Monday, 31 October 2016

Hospitalists: functions and competencies

Don’t panic, it’s not about defending a new specialty, it’s about thinking what should be the roles and responsibilities of the physicians in charge of hospital wards if they want to improve safety, quality and continuity of admitted patients’ care.

In 1996 Dr. Robert Watcher and Dr. Lee Goldman described for the first time the term hospitalist as a doctor specialized in the practice of hospital medicine. This matter was experienced then as necessary for the organization of hospital wards in the US, due mainly to the multitasking of specialists who caused that the management of admitted patients was often disorderly. Almost twenty years later the Society of Hospital Medicine reports that there are more than 30,000 hospitalists working in 3,300 hospitals.

In the video, you can see Dr. Chris Addis explaining the main contributions of hospitalists to the admitted patients’ care, in summary: a) assume the coordination of specialists, b) know how to communicate the patient's clinical information in a simple manner, c) ensure continuity of care, and d) be the referent for family doctors both during admission and during the transfer.

Monday, 24 October 2016

Modern clinical management: the basics

In recent decades, clinical management has had a couple of conceptual disruptions that have generated interest in the welfare act as an object of study. The first was when, in the early 90s a group of epidemiologists moved clinical epidemiology from the academy to the consultation and developed evidence-based medicine; and the second came when governments and health professionals became knowledgeable about the clinical work’s ability to do harm. The "To err is human" from the Institute of Medicine report in late 1999 was the turning point of patient safety programs. Now, in the second decade of the century, starting from those two fundaments (security and evidence), all the interest is in knowing what is the value that clinical practice brings to the health of people.

The conceptual foundations of modern clinical management

Monday, 17 October 2016

Professionals are important, but so is good governance

Professionals in health services are important because without their dedication and enthusiasm patients do not receive the necessary care, especially in times of cutbacks. However, we should not forget that for these professionals to work properly they need their organizations to be well governed and I will exemplify this with two publications, the first of which is the last book of the veteran professor of McGill University Montreal, Henry Mintzberg, and the second is an article on this subject in the New York Times.

One of Professor Mintzberg’s best known lessons has been the conceptualization of the third sector as a balanced element of democratic societies. One sector, he says, called to serve as a counterweight between public and private spheres. Its key differentiator is property that is either collective, such as in cooperatives or is diffuse, such as in foundations or associations, apart of course of their altruistic purposes and their natural space: community services. All this makes the third sector is specially equipped to manage health services in a well weighted basis between the despotic temptations of political power and the interests of private companies.

Monday, 10 October 2016

Are we all mentally ill? About Allen Frances

Allen Frances, psychiatrist professor emeritus at Duke University (USA) led the working group that developed the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders). I follow the author’s activity, always critical and always documented, on twitter (@AllenFrancesMD) and, unaware of the framework of psychiatry, a question started spinning in my head. How could it be that someone who had led the fourth edition of the DSM was now the most lucid voice against the excesses of modern psychiatry? If I wanted to know the answer, I had no choice, but to read his latest book: "Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life".

Monday, 3 October 2016

Saving Blood; Strategies to Shatter Resistance

The evidence is clear: avoiding unnecessary transfusions saves lives and generates savings with clinical criteria. Nature echoes this aphorism in an article that collects research insisting that regarding blood transfusions less is more. This issue of blood is very awkward and contradictory. Not surprisingly, for modern nations, having a system of voluntary donation is a matter of pride. Many people believe it and when there is a disaster, the first reaction of many people is lining up to give blood. And it should be noted that the evidence favours the popular intuition: transfusions work better for the injured with major bleeding and for more complex patients, but can also be harmful for patients with smaller problems.

Transfusion = transplant?

The transfused red blood cells have two problems: the first is that in the storage process they lose flexibility, which can make them less effective in transporting oxygen, and the second is that they are actually foreign cells containing antigens (beyond ABO and Rh) that arouse immunological reactions of varying intensities. On these physio-pathological issues, there is still not enough research, but many believe that the origin of the transfusion problems is in these two points.