Archivi delle etichette: Health promotion

Smokers will be asked to quit before undergoing surgery under new medical guidelines @Medici_Manager

Grant McArthur

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

“Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections,” Dr Roberts said.

“When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

“It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

“From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery.”

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack – prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college’s quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

“This is not about banning people, this is about giving them the best chance to benefit,” Dr Parnis said. “When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that.”

Partnering with patients @Medici_Manager @bmj_latest

Fiona Godleeeditor, BMJ

Last month we published a plea from Dave deBronkart (also known as e-Patient Dave) to “let patients help.” As a survivor of stage IV, grade 4 renal cell carcinoma, he described how the online patient community helped save his life (BMJ 2013;346:f1990). His aim is nothing less than to revolutionise the relationship between patients and healthcare providers. “Please,” he wrote, “let patients help improve healthcare. Let patients help steer our decisions, strategic and practical. Let patients help define what value in medicine is.”

This week we hear from another e-Patient, Kelly Young, who tells us why she became “a rheumatoid arthritis warrior” (doi:10.1136/bmj.f2901). Her blog,, was born of the realisation that her doctors were stumped and that she needed to take responsibility for understanding her condition and deciding about her care. The blog now reaches nearly 2% of all patients with rheumatoid disease in the United States and, according to Young, is changing the way doctors as well as patients think about the disease.

The language of revolution and war may seem excessively violent, but it reflects the sense that even internet empowered patients feel they must fight to be heard, to get access to information, and to have their say in treatment decisions.

The BMJ is a journal for doctors. Over the years we have resisted the temptation to widen our sights to include patients among our target readership, although we know that many of our online readers are patients and members of the public. Despite its name, our series of Patient Journey articles is not designed for patients. As recently summarised by the BMJ’s patient editor, Peter Lapsley (BMJ 2013;346:f1988), these articles aim to give our medical readers new insights into patients’ experiences of illness and treatment in order to improve care.

But Young, deBronkart, and others like them are looking for something more than simply more empathetic doctors. They want partnership on an equal footing. And it’s this shift that the BMJ now wants to champion, working with colleagues at the Mayo clinic and others. As several of us ask in an Editorial this week, how better to improve care than to enlist the help of those whom the system is intended to serve?

Achieving such a partnership is a challenge. Years of paternalism have left doctors and patients unprepared for a different type of interaction. Time and other pressures may seem to justify current ways of working. But what if taking steps to bridge the divide between doctors and patients really did result in better, less costly, more effective care? There is a growing evidence base to suggest that it will. Ten years ago, we published a theme issue on partnering with patients (, and other articles published before and since are now gathered in a collection on To encourage further research and thinking in this area, the BMJ plans a call for papers for a conference and theme issue on participatory care next year. More information will follow shortly. Meanwhile, we are recruiting a panel of patients and doctors to help us think about how we can reflect the shift to patient partnership. I’d welcome your thoughts.

Cite this as: BMJ 2013;346:f3153

Sette domande che ti farai alla fine della tua vita @Medici_Manager @silviogulizia

E se prendessimo un attimo per rispondere ora a queste domande? Giusto per cercare di arrivare in fondo con le risposte pronte, che in fondo per prepararsi a morire ci vuole una vita, ma a volte non hai a disposizione tutta la vita per prepararti.

  1. Sono orgoglioso di come ho vissuto?
  2. Cosa ho scoperto?
  3. Come ho sfruttato le opportunità che si sono presentate?
  4. Mi sono preso abbastanza responsabilità od ho lasciato correre troppo spesso?
  5. Che battaglie ho vinto per raggiungere i miei obiettivi?
  6. Quanto ho amato davvero?
  7. Quanta parte della mia storia l’ho scritta di mia mano?

Antimicrobial resistance—an unfolding catastrophe @Medici_Manager @bmj_latest

Fiona Godlee, editor, BMJ

At the end of the 1960s, the then US surgeon general William H Steward famously declared: “The war against infectious diseases has been won.” His optimism might well have been justified at the time. The discovery of antibiotics and their widespread introduction had transformed both medical practice and life expectancy.

Antibiotics still transform lives, but—as with so many of the world’s resources—we now know that they are not limitless, and that unless we are careful, their beneficial effects will run out. We have become so accustomed to the availability of antibiotics that a world without them is almost inconceivable. Yet this is the world that England’s chief medical officer, Sally Davies, demands we contemplate in the second volume of her annual report (doi:10.1136/bmj.f1597). The causes of this unfolding catastrophe are many: overuse of existing antibiotics, increasing resistance to them, a “discovery void” regarding new drugs, and a change in the types of organisms presenting the greatest threat. “If we don’t get this right we will find ourselves in a health system not dissimilar to the early 19th century,” she says.

Is Davies being overdramatic? Sadly not. Her decision to focus on antimicrobial resistance has been broadly welcomed. And this week we publish a report from Richard Smith and Joanna Coast, long term analysts of the economics of resistance (doi:10.1136/bmj.f1493). They suggest that the picture she paints may even be too rosy. “Resistance is said to present a risk that we will fall back into the pre-antibiotic era,” they say. “However, this is perhaps optimistic.”

Their argument is that we have badly underestimated the cost of resistance. Studies that have tried to estimate the economic impact have looked at the extra cost of treating a resistant infection compared with a susceptible one. But this ignores the bigger picture. The whole of modern healthcare, including invasive surgery and immunosuppressive chemotherapy, is based on the assumption that infections can be prevented or treated. ”Resistance is not just an infectious disease issue,” they say. “It is a surgical issue, a cancer issue, a health system issue.”

Their revised assessment of the economic burden of resistance encompasses the possibility of not having any effective antimicrobial drugs. Under these circumstances they estimate that infection rates after hip replacement would increase from about 1% to 40-50%, and that about a third of people with an infection would die. It seems likely that rates of hip replacement would fall, bringing an increased burden of morbidity from hip pain.

The CMO’s 17 recommendations include better hygiene measures and surveillance, greater efforts to preserve the effectiveness of existing drugs, and encouragement to develop new ones. As Anthony Kessel and Mike Sharland point out, only one or two new antibiotics that target Gram negative organisms are likely to be marketed in the next decade (doi:10.1136/bmj.f1601). Recognising this as a global problem, the CMO’s report also calls for antimicrobial resistance to be put on the national risk register and taken seriously by politicians internationally.

As for the cost of such action, Smith and Coast see it as an essential insurance policy against a catastrophe that we hope will never happen. And they share the CMO’s urgency. “Waiting for the burden to become substantial before taking action may mean waiting until it is too late.”


Cite this as: BMJ 2013;346:f1663

Footnotes Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

@ProfAlanMaynard on NICE approval: Lucentis for Macular Oedema why not Avastin? @Medici_Manager

NICE approves eye drug for diabetes

By James GallagherHealth and science reporter, BBC News

A drug that can save the sight of people with diabetes may now be made available on the NHS in England and Wales – reversing an earlier decision.

At least 50,000 people in the UK have diabetic macular oedema which can leave people unable to read, work or drive.

In 2011, the National Institute for Health and Clinical Excellence (NICE) said ranibizumab, which is sold as Lucentis, was too expensive.

A final decision will be made in February.

Macular oedema occurs when fluid leaks from the small blood vessels in the eye.

Diabetes can trigger changes to the blood vessels leading to fluid collecting in the central part of the retina called the macular area.

Saving sightProf Carole Longson, from NICE, said the manufacturers had agreed to reduce the price which led to a review of the guidance.

“NICE is pleased to recommend ranibizumab as a treatment option for some people with visual impairment caused by diabetic macular oedema in new draft guidance.”

Clara Eaglen, eye health policy and campaigns manager at the charity RNIB, said: “We believe NICE has thrown a lifeline to the growing number of people with diabetes facing blindness.

“Currently people are needlessly losing their sight from diabetic macular oedema.”

Barbara Young, the chief executive of Diabetes UK, said: “We are delighted that NICE have reconsidered their previous decision, and that this draft guidance recommends that Lucentis is made available on the NHS, as this would mean more people with diabetes would have a better opportunity to preserve and possibly improve their vision.”

The case for slow medicine @Richard56 @Medici_Manager

The characteristics of health systems are complexity, uncertainty, opacity, poor measurement, variability in decision making, asymmetry of information, conflict of interest, and corruption. They are thus largely a black box and uncontrollable, said Gianfranco Domenighetti of the Università della Svizzera Italiana at a meeting in Bologna on La Sanità tra Ragione e passione (Health through reason and passion). The meeting was held to celebrate the life and work of Alessandro Liberati, the founder of the Italian Cochrane Centre, who died last year.

Only 11% of 3000 health interventions have good evidence to support them, said Domenighetti. A third of the activity in the US health system produces no benefit, said a recent study in the New England Journal of Medicine. Half of all angioplasties are unnecessary. Some €153m a day is lost through corruption in health systems in the European Union. Four fifths of new drugs are copies of old drugs. Screening is creating diseases like ductal carcinoma in situ. Most doctors (80-90%) have taken “bribes” from pharmaceutical companies, although many may not see their free pens and lunches and subsidised travel as bribes (but if they are not bribes what are they?). Between 15% and 40% of articles in medical journals are ghostwritten. Half of clinical trials are not published, and there is systematic bias towards positive results, hence suggesting that treatments, usually drugs, are more effective and safer than they actually are.

Yet against this backcloth more than four fifths of people in most countries think medicine is an “exact or almost exact science.” In a study published in the Annals of Internal Medicine nearly 90% of patients undergoing percutaneous coronary intervention (PCI) thought that it would reduce their chances of having a heart attack, when it doesn’t. Asked about various scenarios almost half of cardiologists questioned would go ahead with a PCI even when they believed there was no benefit to the patient.

It is time, said Domenighetti, to open up the black box of healthcare. Encouraging “health literacy” seems to be a way to do this, but Domenighetti thought that this was “old wine in new bottles.” We need, he said, to encourage a healthy skepticism about the medical market and to help people understand that medicine is far from being an exact science. Data should be published exposing variations in practice, corruption, and conflicts of interest. We should explain that health depends mostly on exogenous factors not the healthcare system. And people should be given practical tools to promote their autonomy—tools like access to evidence based information.

Domenghetti ended his talk by pointing people towards the Choosing Wisely campaign in the US where professional organisations are identifying interventions that offer little or no value. A similar but broader campaign of Slow Medicine is underway in Italy, and I have little doubt that slow medicine—like slow food and slow lovemaking—is the best kind of medicine for the 21st century.

We need to pull back from what Ivan Illich called the hubris of medicine.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interest: RS spoke at the meeting and had his expenses paid by the health department of Emilia-Romagna.

Approaching Illness as a Team @Medici_Manager @Doctor4Quality

The New York Times

Opinion Twitter Logo.

The Cleveland Clinic, long considered a premier medical system, is gaining new renown for innovation in improving the quality of care while holding down costs.

For Op-Ed, follow@nytopinion and to hear from the editorial page editor, Andrew Rosenthal, follow@andyr

In its most fundamental reform, the clinic in the past five years has created 18 “institutes” that use multidisciplinary teams to treat diseases or problems involving a particular organ system, say the heart or the brain, instead of having patients bounce from one specialist to another on their own.

The Neurological Institute, for example, provides both inpatient or outpatient care for those with strokes and brain tumors, as well as those with epilepsy, multiple sclerosis, depression and sleep disorders, among other conditions.

On a recent visit, we observed one such team, consisting of a neurosurgeon, a neurologist, a neuroradiologist, a neurologist with advanced training in intensive care, a physical and rehabilitation doctor, a medical resident, a physical therapist and a nurse. As they made rounds from patient to patient, they had a portable computer that displayed electronic medical records so that the whole team could see how the patient was doing and plan the course of care for the day.

This team approach can improve the quality of care because all the experts are involved in deciding the best treatment option, which can save time and money. The neurological team, by consensus, has been better able to determine which acute stroke patientsneed a risky and expensive treatment that involves threading a catheter through an artery in the leg up into the brain to destroy a clot. It cut the use of that treatment in half, reducing costs and deaths and improving outcomes.

The Cleveland Clinic has strong leverage to drive such reforms because its staff physicians are salaried and are granted only one-year contracts and subjected to annual performance reviews. Those reviews apply measures of quality, like patient improvement, patient satisfaction and cost reductions. It raises the pay of those who get high marks, reduces the pay of poor performers and even terminates some doctors who fall short. This approach could become more widespread as more hospitals and doctors move toward the salary-based model.

Data analysis to evaluate how well treatments work is also a big part of the medical practice. For instance, the clinic analyzed outcomes for heart surgery patients and found that those who had received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate. As a result, it has adopted strict guidelines that limit the use of transfusions.

Such judgments about a treatment’s effectiveness are made by doctors, not by financial administrators, so they tend to be accepted. One analysis found that suturing could be done as well with a $5 silk stitch as with a $400 staple, leading to a big drop in the use of the staples. At the same time, the clinic has also carried out simpler reforms, like improving sterile conditions, which has reduced catheter-related bloodstream infections by more than 40 percent and urinary tract infections by 50 percent. All this has happened in a remarkably short time. Patients seem to like the treatment they get. A federal government survey of patient opinion last fall found that 80 percent of the patients gave the Cleveland Clinic a high rating over all and 84 percent would recommend it to others, well above the state and national averages in the 69 percent to 71 percent range.

Still, many patients are clearly unhappy. A series this year about confusing medical bills and unexpectedly high charges by The Plain Dealer of Cleveland elicited hundreds of patients’ complaints mostly directed against the clinic, because it had reclassified off-campus physician practices and health centers as hospital outpatient facilities and tacked on a “facility fee” for services previously billed at lower doctor’s office rates. The clinic says the added fees are justified because it provides better quality controls and health information technologies in its outpatient units than that available in a typical doctor’s office.

Medicare’s spending per patient at the clinic for an episode of illness that requires hospitalization is below the national median, suggesting that the clinic’s cost-cutting efforts are working. The University HealthSystem Consortium, an alliance of the nation’s leading nonprofit academic medical centers and teaching hospitals, gave the clinic one of its “rising star” awards in September for significant improvements over the previous year in quality, patient safety and clinical effectiveness, an indication that its quality efforts are taking hold.

The Cleveland Clinic’s progress in restructuring itself, said Michael Porter, a Harvard professor who analyzes health care delivery and organizational change, is “light speed” compared with other institutions. The clinic is “a model of where we need to go,” he said, “Not perfect, not done, but far along.”

A version of this editorial appeared in print on December 25, 2012, on page A26 of the New York edition with the headline: Approaching Illness as a Team.

Una giornata particolare. In ricordo di Alessandro Liberati @Medici_Manager

Luca De Fiore  7 gennaio 2013

“La Sanità tra ragione e passione”.  Questo il titolo dell’affollato convegno tenuto a Bologna lo scorso dicembre per ricordare Alessandro Liberati. Cinquecento persone attente e ciascuna a suo modo impegnata in un tifo personale per il relatore preferito: chi ammirato dalla presenza scenica di Richard Smith, chi concentrato su Domenighetti; tanti colpiti dalla visione di Sir Iain Chalmers, vera guidaconsistente per tutti i presenti; molti sedotti da Gianni Tognoni e dal puntuale richiamo a riportare in un contesto di ordinaria sofferenza ogni ragionamento troppo astratto o dimentico della scelta radicale tra i sommersi e i salvati…

Ai primi di dicembre, due sessioni del congresso della American Society of Hematology (ASH) ad Atlanta sono state aperte da una grande fotografia di Alessandro Liberati, medico, ricercatore e fondatore della sezione italiana della Cochrane Collaboration, scomparso il 1 gennaio dello scorso anno. Ho chiesto a S. Vincent Rajkumar responsabile di questa scelta – e delle due “educational sessions” dell’ASH – le ragioni della sua decisione; così mi ha risposto:

It was an honor for me to open my two education session presentations at the ASH meeting talking about Dr. Liberati – ha spiegato il clinico ematologo della Mayo Clinic -; I told the audience that Dr. Liberati worked all his life for evidence based medicine, and pointed out in his Lancet letter weeks before his death of the major problems with clinical trials in myeloma today.

I chose to do this because Dr. Liberati pointed out what so many of us in the myeloma field should realize – the trials we are doing are often not the trials that patients need. We are not testing strategies. We are no doing head to head trials comparing drugs. We are doing mostly small clinical trials, and the phase III trials we are doing are asking questions that are not strategic. And we continue to rely on surrogate endpoints instead of overall survival. The fact that a person who worked his life for evidence based medicine and one who struggled with myeloma bravely for so many years chose to provide a much needed insight in his letter was very inspiring to me. I am a strong believer in EbM, and very much agree and echo Dr. Liberati’s thoughts in this regard.”

Raramente sono state sintetizzate in modo così efficace le “ragioni” alle quali Alessandro ha dedicato gran parte della propria vita ed è ancora più bello che queste parole siano giunte da una persona che non lo conosceva personalmente.

Sebbene molto qualificato, quello di Atlanta era un convegno tradizionale, per così dire. Raccogliendo la sollecitazione della moglie Mariangela a pensare ad una giornata di riflessione in ricordo di Alessandro, è stato immaginato qualcosa di diverso dalle consuete occasioni congressuali, pensando che anche le “passioni” dell’amico rappresentassero elementi capaci di infondere energia per ripartire per una nuova stagione con un entusiasmo rinnovato. Passioni legate alla letteratura, alla politica, alla musica, al calcio e alla pittura: ambiti evidentemente quasi senza confini così che per garantire all’incontro un riconoscibile filo conduttore si è deciso di discutere le sei parole chiave scelte da Italo Calvino per le sue Norton Lectures alla Harvard University. Six memos for the next millennium raccolti incompleti nelle Lezioni americane: leggerezza, rapidità, esattezza, visibilità e molteplicità. Termini ai quali si sarebbe dovuto aggiungere coerenza, concetto che lo scrittore non riuscì a sviluppare a causa dell’improvvisa e prematura scomparsa.

È apparso subito chiaro come la sfida fosse quella che Alessandro aveva costantemente ricordato: sperimentare. Non si dovrebbe mai perdere l’occasione di fare ricerca, con la fiducia di trovare nuove strade che ci motivino al cambiamento. Così è nato un evento originale, forse straordinario, sicuramente non irripetibile, la riuscita del quale può offrire più di una riflessione a quanti hanno a cuore la crescita professionale e umana del personale sanitario del nostro Paese.

Leggerezza – Il taglio del convegno, il modo col quale sarebbe stato articolato, le forme con il quale sarebbe stato gestito sono stati discussi e concordati durante incontri informali, il primo dei quali svolto intorno alla tovaglia a scacchi di una trattoria bolognese. Lightness anche nei costi: poco più di 15 mila euro, nonostante il pranzo leggero offerto a tutti i partecipanti e la traduzione simultanea. Interamente finanziato da enti e istituzioni pubbliche.

Rapidità – È quella ottenuta dai 21 relatori intervenuti consecutivamente dalle 9,30 del mattino alle 17, quando Renato Balduzzi ha concluso la giornata. Per garantirla,  i curatori delle diverse “parole” hanno interagito continuativamente con i relatori, scambiando punti di vista, invitando alla sintesi, suggerendo immagini capaci di sostituire l’esposizione di concetti complessi.

Esattezza – Non era raccomandata, nelle linee guida fornite agli autori delle letture. Al contrario, aderendo alla convinzione dello stesso Calvino, ciascuna parola non avrebbe dovuto escludere il suo contrario. Così, più che della rapidità si è detto dell’opportunità di rivalutare una giudiziosa, sobria lentezza; allo stesso modo, chi avrebbe dovuto parlare di exactitude ha finito col confrontarsi con l’incertezza, più o meno evitabile, col quale convive la medicina.

Visibilità – Il desiderio di sperimentare ha innescato da subito un meccanismo per cui ci si è divertiti a far vivere il convegno ben oltre la giornata del 14 dicembre, anticipandone i temi con video interviste, proponendo approfondimenti e alimentando una pagina Facebook che ha molto contribuito al precoce “sold out” dei 500 posti disponibili nella sala degli Istituti Rizzoli di Bologna. La scommessa è oggi quella di proseguire, così come sta accadendo, mantenendo vivo un prezioso spazio di dialogo e di confronto.

Molteplicità – Meta-promemoria per la sanità dei prossimi anni, ha felicemente riassunto molti dei temi discussi nelle letture che l’hanno preceduta. Oltre che alla parola, i relatori hanno affidato le loro riflessioni a brani musicali, a immagini di dipinti, a video riprese di sculture, fino ad una vera e propria performance teatrale che significativamente ha aperto la strada all’ultima lettura.

Coerenza – Come sostiene David Weinberger nel suo bel libro La stanza intelligente, un gruppo è efficace se è composto da persone eterogenee che condividono un obiettivo. In questo caso, oltre all’intesa sulla finalità, c’era coesione sui valori e i principi che avevano ispirato la giornata. Laconsistency è dunque quella che aveva legato tutte le presentazioni, pur formalmente così diverse e personali.

L’originalità della forma non soltanto ha sorpreso e convinto ma è probabile riesca anche a rendere più duratura la memoria dei contenuti trasmessi in un convegno che, per le sue caratteristiche, non ha potuto offrire ai partecipanti gli agognati crediti ECM: mancata rispondenza a specifici obiettivi formativi nazionali, multidisciplinarità, audience ampia e (teorica) assenza di interattività. Come è stato ricordato il 14 dicembre, ancora ragazzo Alessandro non esitò a discutere di metodologia epidemiologica con Alvar Feinstein e di filosofia della medicina con Hans Gadamer. È molto probabile che in conclusione della giornata col suo sorriso dolcissimo avrebbe chiesto al Ministro: “Possibile, Renato, che tutto questo non abbia valore per l’educazione continua della sanità del Paese?”

Luca De Fiore. Pensiero Scientifico Editore

La Sanità tra ragione e passione”.  14 dicembre 2012, Bologna, un convegno per ricordare Alessandro Liberati.

Part of medical education is to learn limitations @Medici_Manager @kevinmd


There is a strong relationship comparing sports to the military, business, and also to medicine.  Young athletes, in their late teens and early 20s, are mostly brawn and use their strength and speed to achieve success early in their professional careers.  As the athlete matures in their late 20s and early 30s, the physiologic processes slowly decrease and efficiency and maturity and other cerebral skills emerge.

There are 2 rainbow arcs that describe this brawn-brain interaction.  The arc of brawn rises earlier than the arc of brain-based skills, which appear later only when brawn starts on its down slope and intersects with the rising arc of experience that peak performance occurs.

The same 2 arcs probably take place in every medical doctor’s career.  Young doctors are full of energy and knowledge.  It is only after years in practice that the doctors develop maturity of their clinical skills that makes them peak performers.

When I was a newly minted urologist in 1978 I was referred a Crohn’s patient who complained of foul smelling urine and passing “bubbles” in her urine.  I worked her up and diagnosed a colovesical fistula.  I called the referring doctor and told him that I could surgically correct this with the assistance of a general surgeon.  The gastroenterologist said, “Neil, I am going to do you a favor and not allow you to operate on her.  She has terrible nutrition and has a history of multiple fistulae and would not heal and she would likely be made worse by the surgery.”  What a valuable lesson that was helpful in my early maturation as a physician.  I was able to learn that I couldn’t cure everything and that were times when keeping the scalpel on the shelf was in the best interest of the patient.

I think part of our medical education is to learn our limitations.  My best lesson I learned was to always think of our actions appearing on the front page of the paper or on 60 Minutes.  Always ask yourself, “Would I want my decision to appear in public?” or “Is this decision or action in the best interest of the patient?”  If the answer to both questions is yes, you will not be making an error where your brawn gets in the way of your brain.

Neil Baum is a urologist at Touro Infirmary and author of Marketing Your Clinical Practices: Ethically, Effectively, Economically. He can be reached at his self-titled site, Neil Baum, MDor on Facebook and Twitter.

10 macro trends that will shape health of the future according to Rockefeller Foundation @Medici_Manager @IlonaKickbusch

One of the major components of The Rockefeller Foundation’s “Dreaming the Future of Health” convening will be the consideration and discussion of the macro, health-related trends that will shape our world over the next 100 years. In advance of the convening, The Rockefeller Foundation asked select attendees and other experts to identify ten trends that may dominate the global landscape into the future. This list is the result of that “crowd-sourcing” exercise.We invite you to take a look and scroll down to share your thoughts with the Foundation.

1. Climate Change and Disasters.
The future will include increased frequency and severity of climate-related shocks, disasters and pandemics (likely with zoonotic origins). What needs to be done to better understand the health impacts of climate variability and build more resilient social and health systems to be prepared, respond and adapt?
2. The Demographic Revolution.
According to the UN, the population aged 60 years or older is estimated to be nearly 2 billion by 2050 when it will be as large as the population of children age 0-14. With this shift, there will be accompanying changes in disease patterns such as growth in non-communicable diseases and associated risk factors. What actions are needed in the context of these epidemiologic and demographic shifts? How will we address aging populations, changes in the socioeconomic composition of societies (will the middle class grow or the proportion of those at the Bottom of the Pyramid persist or expand?) and an estimated world population of 10 billion by the year 2100?
3. The rise of mega cities.
More than 50% of the world’s population currently lives in urban areas and this is expected to increase to 70% by 2050. According to the WHO, the majority of this urban population growth will occur in cities of developing countries. How can cities develop to ensure the health of all residents
4. Social and economic development converge.
The relationship among the state, citizens and business is increasingly dynamic and systems are changing. The correlation between social and economic development has been reflected in the inclusion of health in development policies and in other intersectoral approaches to health. What mechanisms will promote the convergence of national and international social policies to improve governance and solidarity and decrease economic, social and health inequities?
5. Frontiers of public sector reform.
In the future, there will be increased interaction by and amongst institutions in various sectors as well as heightened informality within global labor. Silos will be broken down leading to a deeper complexity of mixed (public and private) systems – particularly in the health and education sectors. What will be the health effects of this complexity and lack of appropriate regulatory structures? What interventions will be needed to mitigate risks and work effectively within both formal and informal systems to prevent increasing inequalities?
6. Our Social Future.
Individuals’ connectivity and access to vast information will continue to explode. Changes in the access to information and modes of communication will continue to empower citizens yet also raise major privacy concerns along with concerns of growing social isolation and exclusion. What are the new governance structures needed where the community’s health interests and expectations are explicitly represented? What effects will this complexity have on health? How can we take advantage of the benefits of increased connectivity while mitigating its risks?
7. The Budget Crunch.
What will countries and governments look like in the next century, and what do possible changes in governance mean for health? In the shorter term, how will leaders develop sound health policies in a time of austerity and limited financial resources? How can the perspectives of local communities be included?
8. Technology Races Ahead.
For example, nanotechnology may become more important than immunizations in preventing and curing disease. Health technology and real time information access offers many opportunities for treatment and prevention of disease as well as health promotion. Communication technologies will also continue to change the ways in which individuals engage with the health system and could reduce the need for hospitalization. What are the challenges and opportunities in scaling up existing interventions to take advantage of the game changing advances in science and technology that are certain to occur? How might access to information change patterns of individual self-treatment?
9. Game-changing advances in science.
Advances in scientific research, and medical science more specifically, will continue to transform the health care landscape. What will be the ground-breaking discoveries in fields of biology, immunology, virology, zoology and related fields such as ecology that will impact health for the next 100 years? What are the critical questions and threats that these fields must address to ensure well-being in the future?
10. New ways of learning.
Massive open, online courses offer new opportunities for scalable, sustainable and profitable forms of training and education. How will new technologies transform the accessibility and effectiveness of higher education and training for future health professionals and leaders?

The Future of Health – World Economic Forum @Medici_Manager @IlonaKickbusch

The future of health is being shaped by many global transformations, of which technology and connectivity are the most salient. Hence, “digital technologies and personalized medicines” was an appropriate tag line for this Annual Meeting session.

As an emerging domain – at the intersection of heath and technology – this should be viewed in two contexts:

The first one, centred on personalized technologies, is transforming the way in which patients engage with healthcare in chronic disease management settings; people in general enhance wellness independence. These are important objectives given the likely emphasis on non-communicable disease prevention and incentive-based wellness in the foreseeable future. By linking big data in the cloud with mobile applications, new engagement mechanisms and social media connectivity, a number of health endpoints can now being pursued – from safety, adherence and compliance, to improved access and healthy behaviour change.

The second emerging domain is digital health (eHealth, mHealth, tHealth and cHealth), where its context-specific applications can help achieve broader health systems goals: data management and information for policy can be transformed; e-learning can be enabled; costs and errors can be mitigated through e-solutions in healthcare settings; and transparency and efficiency can be institutionalized in health governance.

Digital health can be the single most important lever to lift heath systems out of their existing systemic problems. By linking entitlements with health data repositories, it can additionally help in the attainment of wider social objectives and universal health coverage goals, which are fast gaining traction as a policy agenda; at the international level as an umbrella post-MDG health goal and at the domestic level as a deterrent against Arab Spring type of social unrest.

The promise within these approaches underscores the need for policies to harness their potential and creates imperatives for global and domestic normative action. Recognition that this promise can only be fulfilled by leveraging the strength of technological tools, which are outside of traditional healthcare, necessitates multisectoral action and effective engagement with the private sector.

An out-of-the box domestic policy appetite needs to be generated for the establishment of an enabling environment for innovation and research. Capacity needs to be built for translating evidence into policy and taking pilots to scale. Governments need to appreciate the “business case” for investment in this area and should create enabling regulations, incentives as well as the necessary infrastructure.

Appropriate investment and partnerships can help achieve double bottom line objectives and a win-win situation for all stakeholders within and beyond the health sector.

INEPTOCRACY @Medici_Manager

Definition: a system of government where the least capable to lead are elected by the least capable of producing, and where the members of society least likely to sustain themselves or succeed, are rewarded with goods and services paid for by the confiscated wealth of a diminishing number of producers.

The end of the hospital as we know it? @Medici_Manager

How profoundly do hospitals need to change and will there be a place for the hospital as we currently know it in the health system of the future?

I want to answer this question by reflecting on the current way in which the NHS thinks about this question in theory and acts on it in practice.

There is a growing chasm between what the NHS thinks should be done to change the hospital model and what it is actually doing on the ground.

Nearly every board or leading doctor or manager in the NHS thinks that the current model of hospital care should and will be radically different in the next decade. Most people would say that this has to happen if the NHS is not going to run out of money. So the driver for change is a powerful one. Change might take the form of:

  • developing integrated care pathways that have the bulk of the pathway outside of hospital moving some categories of outpatients and day surgery out of hospital, or
  • removing the demand for emergency beds out of the hospital.

Sometimes this is backed by the idea of developing whole new models of care; sometimes it is backed by specific restructuring of current models of care.
But all around there is talk of radical change in the way in which hospitals operate. Most hospitals agree with this theoretical vision.

If you look at the long-term vision of most hospital boards, it contains a lot of change. If you add up the commissioning intentions of clinical commissioning groups (CCGs), together they create very different models of care for England’s hospitals.

Change – very radical change – in the nature of hospitals is in the air. The problem for the NHS is that it might just stay there – in the air. For in many parts of the country the moment a CCG starts to put this into operation a very different set of motivations comes into play.

In some of the CCG authorisation sessions that I have heard about, the second or third question that the panel asks the CCG is why they aren’t more worried about the way in which their commissioning intentions might ‘destabilise’ the hospital. Under those circumstances CCGs are puzzled. They look at the commissioning intentions that have just been marked green by the panel. They will have been congratulated because they have developed radical new approaches to integrated care in the home and the community.

But the moment they actually DO something they are told they should be more worried about destabilising the hospital.

This is backed up the possible action by the hospital at the moment when any of these intentions are put into effect. Hospitals still say that if you move these clinics out of the hospital, the hospital will collapse and it will be your fault.

In some parts of the country the old strategic health authority (SHA) (now a part of a new cluster and soon to be a part of the brand new NHS Commissioning Board) will then challenge the CCG about whether they really know what they are doing in moving this work out of the hospital.

  • How would they cope if the hospital fell over?
  • What plans have they got to replace the entire hospital when this happens?

It takes a brave CCG to say ’Actually whilst of course we have an input into that, it is not our prime concern.’

The brave CCG points to the new architecture and says that luckily Monitor will have the responsibility to the public ‘to ensure the continued provision of services.’ It is Monitor that will have the responsibility to look at the whole of England and see which providers are becoming unsustainable. It will be Monitor whose responsibility it will be to have plans to ensure that those services are maintained irrespective of the nature of the organisation.

My point here is that the NHS has a pretty good analysis of how the question at the top of the page should be answered. Of course it could be better; of course we probably need more fluidity in the thinking and more knowledge from other jurisdictions.

But the theoretical answer is not the problem. The problem is the practice of making the vision happen. Practically there are real road blocks placed in the way of putting that vision into reality.

Great CCGs and great provider trusts can and will get round and through those road blocks. But to radically change the hospital model in the NHS we need more than heroines and heroes.

To change something this big the whole system needs to encourage the change so that ordinary organisations can make it happen.

Professor Paul Corrigan CBE is an an Independent Consultant and Executive Coach.

Recommended Reading: Reflecting on the Choosing Wisely Journal Articles of 2012 @Medici_Manager @ABIMFoundation

Written by Amy Cunningham on December 21, 2012

Since nine medical specialty societies announced their lists of “Five Things Physicians and Patients Should Question” in April, 55 published journal articles have referenced the Choosing Wisely® campaign. For the final Recommended Reading post of 2012, we’ve culled a selection of those articles, and will share more in the new year.

In order of publication date:

  • In From an Ethics of Rationing to an Ethics of Waste Avoidance, Howard Brody argued for a stepwise strategy to eliminate unnecessary care given the limitations of comparative-effectiveness research, saying, “it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit.”
  • In Application of “Less Is More” to Low Back Pain, the authors found strong evidence supporting the American Academy of Family Physicians’ recommendation as part of theChoosing Wisely campaign, “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.” The article was accompanied by a commentary by ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson.
  • In the New England Journal of Medicine article, A Systemic Approach to Containing Health Care Spending, Ezekiel Emanuel, MD, PhD and co-authors outlined a number of recommendations for bending the health care cost curve, including the development of credible practice guidelines.
  • British Medical Journal piece on unnecessary care said that a “newly launched movement lead by prominent doctors is challenging the basic assumption in U.S. healthcare that more is better” and cited Choosing Wisely as part of the movement
  • Authors of a JAMA commentary mentioned the Choosing Wisely campaign as one of several recent initiatives addressing the physician’s role in health care expenditures. They then call for a new model of medical education that celebrates restraint in ordering health care tests and procedures.
  • An Annals of Internal Medicine piece discussed the potential impact of Choosing Wisely recommendations for radiology and argues, “Current campaigns that draw attention to overuse of imaging studies coupled with greater physician knowledge and use of the criteria for appropriate imaging can help to ensure a further reduction in unnecessary testing—a result that would benefit both patients and our health care system.”
  • In Choosing Wisely: Low-Value Services, Utilization, and Patient Cost Sharing, researchers from the University of Pennsylvania reflected on the Choosing Wisely campaign and asked, “But if it is difficult in many situations for patients to choose wisely, and if there are significant challenges in getting physicians to choose wisely, then who should be doing the choosing?”

We look forward to continuing the conversations on professionalism and Choosing Wisely in 2013, and wish our readers a happy and healthy new year.

Private healthcare: the lessons from Sweden @Medici_Manager

On Kungsholmen, one of the islands on which the Swedish capital Stockholm is built, stands what some consider to be the future of National Health Service under David Cameron: St Göran, a six-storey redbrick hospital that makes profits from the state by treating patients.

Emblazoned with the name of its corporate manager, Capio – rather than the Swedish state, which constructed it – the hospital has for a decade been the mascot of pro-market Scandinavian policies that are widely admired by the coalition in Westminster.

Despite its reputation as a leftwing utopia, Sweden is now a laboratory for rightwing radicalism. Over the past 15 years a coalition of liberals and conservatives has brought in for-profit free schools in education, has sliced welfare to pay off the deficit and has privatised large parts of the health service.

Their success is envied by the centre right in Britain. Despite predictions of doom, Sweden’s economy continues to grow and its pro-business coalition has remained in power since 2006. The last election was the first time since the war that a centre-right government had been re-elected after serving a full term.

As the state has been shrunk, the private sector has moved in. Göran Dahlgren, a former head civil servant at the Swedish department of health and a visiting professor at the University of Liverpool, says that “almost all welfare services are now owned by private equity firms”.

Thanks in part to the outsourcing of the state, Sweden’s private equity industry has grown into the largest in Europe relative to the size of its economy, with deals worth almost £3bn agreed last year. The key to this takeover was allowing private firms to enter the healthcare market, introducing competition into what had been one of the world’s most “socialised” medical systems.

Business-backed medical chains have sprung up: patients can see a GP in a centre owned by Capio, be sent to a physician in the community employed by Capio, and if their medical condition is serious enough end up being treated by a consultant in a hospital bed in St Göran, run by Capio. For every visit Capio, owned by venture capitalists based in London and Stockholm, is paid with Swedish taxpayers’ cash.

The company’s Swedish operation now has 4,500 employees, with a turnover of about £500m. Westminster wonks have monitored Capio’s success closely ever since St Göran was allowed to be taken over in 2000. There are now six private hospitals funded by the taxpayer in Sweden, about 8% of the total.

In Britain the coalition has mimicked this approach. Circle, backed by private equity firms, runs Hinchingbrooke hospital in Cambridge. Serco, a FTSE 100 company, is eyeing the George Eliot hospital in Nuneaton, and two hospitals may be privatised in south London as a result of bankruptcy.

Dahlgren says: “The difference between Sweden and England is thatprivatisation of a hospital was only considered when you had big financial problems. St Göran was considered one of the best when it was sold.”

Capio’s executives dispute that they have simply “made the best better”. They say they focus on improving standards, arguing that only by attracting more patients and managing costs can they make money from healthcare.

During an hour-long presentation to the Guardian, St Göran’s chief executive, Britta Wallgren, says the 310-bed hospital, serving 430,000 people, outperforms state-owned rivals inside and outside the country.

She says emergency patients see a doctor within half an hour, compared with A&E waits of up to four hours in the NHS. “We took an A&E department that dealt with 35,000 patients a year and now treats 75,000,” Wallgren says. “As admissions grow and we have an increasingly elderly population so must our performance improve.”

Capio stresses that St Göran has low levels of hospital-acquired infections, and patient surveys record high levels of public satisfaction. It has also produced year-on-year productivity gains – something the state cannot match. Thomas Berglund, Capio’s president, says the “profit motive works in healthcare” and companies run on “capitalism, not altruism”.

He adds: “We have just won the right to run the hospital again and will have to reduce costs by 120m Swedish krona [£11.2m] over 10 years. That’s our profit gone unless we keep reducing costs here.”

At the busy entrance to the hospital, Swedish patients appear resigned to the end of state ownership in health, once a cornerstone of the country’s generous welfare system.

“I am one of those Swedes who do not agree that private hospitals should exist,” says Christina Rigert, 62, who used to work as an administrator in the hospital but resigned “on principle” when it was privatised a decade ago.

Now back as a patient after gastric band surgery, she says: “The experience was very good. I had no complaints. There’s less waiting than other hospitals. I still do not think there should be private hospitals in Sweden but it’s happening.”

Since 2010 private companies have had the right to set up large GP-style services anywhere in the country – and to be paid for it out of taxpayers’ money. Corporates have set up 200 healthcare centres in two years, although critics point out that the majority have been in wealthier urban areas.

Dahlgren says that inequalities are growing, adding that the law is “fundamentally antidemocratic”. Sweden, he explains, has a long history of local governments deciding where GPs should be sited to ensure poor or rural areas do not lose out.

“The local councils can now neither determine the number of for-profit providers to be financed by taxes nor where these tax-financed services are to be located,” he says. “This is determined by the private providers on the basis of profitability rather than the health need for these tax-financed services. It is remarkably antidemocratic.”

There are distinct differences between Sweden and Britain. Swedish political culture is much more consensual than in Britain, and strongly centred on people choosing where to get healthcare.

Leftwing governments in Sweden, who ran the country for 65 of the last 80 years, promoted patient choice between state-owned hospitals. The real shock was when centre-right governments argued in the 1990s that for patient choice to work, competition and privatisation in healthcare were needed.

The Social Democrats, the main Swedish opposition party, have given up the idea of renationalising the health service and instead argue that profits should be capped and quality of care more tightly regulated. With hardline opposition to private healthcare limited to the far-left parties, Swedes are likely to see more changes.

In Stockholm, more than 500 beds are being removed from the country’s best known health centre, the Karolinska University hospital, and the services are being moved into the community to be run by private companies, a policy that in England would almost certainly lead to demonstrations.

Pro-marketeers argue that companies can improve patient experience at a reduced cost, and expand provision at a time when the state cannot afford to do so. This view was challenged last year when a business-backed research institute, the Centre for Business and Policy Studies, looked at the privatisation of public services in Sweden and concluded that the policy had made no difference to the services’ productivity. The academic author of the report, who stood by the findings, resigned after a public row.

There have also been scandals involving claims of shocking treatment of some patients. Last year Stockholm county council, which controls healthcare for a fifth of the Swedish population, withdrew contracts from a private company after staff in a hospital were allegedly told to weigh elderly patients’ incontinence pants to see if they were full or could be used for longer.

Stig Nyman, a Christian Democrat member of the council instrumental in ushering in a pro-market health policy for 20 years, says he still believes private business is necessary.

Over coffee and biscuits in his modern office amid the 19th-century neoclassical columns of the council building, Nyman dismisses the allegations of mistreatment. “We have hundreds of contracts with private firms. In this case journalists found five or six mistakes. It’s not a big deal.

“In healthcare, companies drive up standards. We pay 5,000 Swedish krona [£465] a patient on average. We force people to compete on the quality of service and treatment.”

Perhaps most damaging for private investors drawn by the potential profits to be made from the state has been the probing of their affairs by tax inspectors. The industry has been under scrutiny since 2007, when a spate of high-profile deals, including the buyout of Capio, led to investigations into financiers.

The charge is that private equity firms siphon profits out of the state’s coffers while avoiding their fair share of taxes. Berglund, of Capio, says: “It is always thrown about that we are not paying taxes but it is not true.”

Swedish tax authorities are, however, taking some companies to court because pay in private equity groups is often linked to the profits made on deals and has been incorrectly taxed for years, it is said, at rates lower than that required for income in Sweden.

Earlier this month one of Capio’s owners, a private equity firm called Nordic Capital, lost a court case against the Swedish tax agency, leavingit with a bill of 672m Swedish krona [£63m]. The authorities, it is reported, will also slap a tax bill collectively of 2.6bn krona on another 34 individuals.

“There has been a strong reaction in Sweden. These people have been paying themselves enormous sums of money,” says Dahlgren. “It should be a worry for every health system where you have competition and private firms arriving.”