Archivos para mayo, 2011

I recently read a wonderful article in the New Yorker which is a very poignant reminder of our values in health care. Many health care professionals start out with high ideals and a deep desire to help every patient. However, unfortunately this often quickly dissolves into disillusionment, cynicism and in an isolated hospital/clinical environment into ignorance of the real underlying problem and needs.

Ask any doctor about their worst or “heart-sink” patients and they will easily identify the frequent flyers, the poorly controlled diabetics that visit the ER every other week, the ones that don’t take control of their physical illness – often those with social issues and little social support.

In the isolated world inside a hospital it is all to easy for management and health care staff to focus on the numbers, the physical illness, the test results, the hospital outcomes and performance in terms of mortality and discharge rates. But without leaving our comfortable safety net of the hospital indicators and biomedical medicine we can not understand nor identify the actual underlying problems and make a difference to those patients that need it the most. And ironically, those patients we are treating inadequately and dismissing as frequent flyers are costing us the most.

Sometimes the more cost-effective solution to a patients poorly controlled diabetes is not frequent readjustments to their medication, frequent admissions due to decompensation but linking them in with social workers and community support to assist with obtaining adequate housing, understanding their medication and autocontrol of their illness and improving social support.

To quote Gawande in the New Yorker – Lower Costs and Better Care for Neediest Patients

… You might decide to increase his insulin dose and change his blood-pressure medicine. But you wouldn’t grasp what the real problem was until you walked up the cracked concrete steps of the two-story brownstone where he lives with his mother…

Gawande further develops his argument by saying that

…“Emergency-room visits and hospital admissions should be considered failures of  the health-care system until proven otherwise,” he told me—failures of  prevention and of timely, effective care….

This last statement is slightly provocative and thought-provoking, but has an element of truth. There is much scope for preventative measures and health promotion. Social and community issues are vital parts of an individuals and community health and should not be forgotten. Although arguably we can shift responsibility for this from the hospital to primary care medicine or public health. We can and should be using the ER admissions and re-admissions as indicators of areas of need in the community and identify social and health needs of a community. In treating each patient we need to remember the importance of the psychosocial factors influencing their health.  And ultimately in economic and managerial terms it may be beneficial for a hospital identify problem areas and to invest in their catchment zone – either directly or indirectly.

We need to get out of our doctors office and reconnect with our community. We should try to identify and understand the underlying issues of our patients remembering that the solution to a health problem may be better solved from a social context,

and ignoring this is costing us more.

— MT —

Pequeños pasos para grandes cambios

Publicado: 2 mayo, 2011 en Uncategorized
Etiquetas:

Durante mi primer año del Master en Salud Publica, escuché varias charlas, presentaciones y debates grupales donde se idealizaba los sistemas de salud de los denominados “países desarrollados”; y como era de suponer siempre se buscaba las falencias e inequidades de los sistemas de salud de nuestros “países en desarrollo”.

Y al principio de ese año yo también creía y deseaba que mi país tuviera un mejor sistema de salud como los que estudié. Pero a medida que pasaron los meses y fui conociendo más y más acerca de este mundo interminable que es la Salud Pública, me di cuenta que el problema no son los sistemas de salud (bueno si lo son pero no en su totalidad); el principal problema que veo yo es que tenemos la mala costumbre, los seres humanos, de tratar de imitar a otros. Se nos mete esta idea en la cabeza de que tal sistema de salud es muy bueno en el país “X” o de que tal política funcionó en el país “Y”, y tratamos a toda costa de aplicar esos mismos conceptos a la realidad de cada país y el resultado es obviamente muy diferente a lo que se obtuvo en los países “X” y “Y”. Como consecuencia de este resultado tan opuesto a lo esperado, tenemos la tendencia a resaltar todo lo malo que hay en nuestros países y desvalorizar los pocos y pequeños cambios que se han ido dando.

Lamentablemente ya no estamos en la era de las hadas madrinas ni de los genios que cumplen deseos, es por eso que al ver cambios tan “insignificantes” no los valoramos como debe ser, pues estamos siempre comparándonos y a la espera del cambio radical que no vendrá en un abrir y cerrar de ojos.

No estoy justificando lo atrasados que estamos en varios aspectos, no sólo a nivel de salud, sino mi deseo es que reflexionemos sobre el hecho de que los cambios llevan tiempo y que la suma de todos estos pequeños esfuerzos eventualmente nos llevarán al gran cambio que todos anhelamos.

Por lo tanto, no miremos al resto para compararnos o imitarles, sino miremos a nuestros pequeños cambios que nos han llevado hasta donde estamos ahora, que es indudablemente mucho mejor que antes.

-ElianaMD-