MPH – Thought Integration

Authors

Medical education, Practice and Health

…thought integration

Healthy Lifestyle Is THE Mantra – Deviation From It Itself Is Disease

Whenever there is a deviation, which happens without our complete knowledge, select an appropriate medical advice and medication JUST TO PUT YOU BACK ON TRACK.  Become aware of the deviation and self-correct it where possible and as soon as possible.

Medication is like ‘breakfast’ and can we live with ONLY eating BREAKFAST, throughout the day and every day?.

The main purpose of the medication I believe is to ‘break-deviation’. Thus Healthy Lifestyle Is THE Mantra and whenever there is a deviation take the best out of the medical sciences (every system has its merits, weigh them and use it for your benefit just to put you back on track only) and realize & continue with the healthy lifestyle.

If you allow me, I would like to add this….

Medical Education & Training

We have been continuously and relentlessly educating the patients and bombarding with various information as far as the health is concerned and they are the only ones’ left on the face of the earth to listen to. Now I would like to look at the problem from a different perspective, i.e.,

TGI_healthAs far the medical education is concerned, every medical practice in reality is having their mode of teaching and practice across the continents. And this is not bridging the gap in terms of understanding and practices.

Taking into account the trend in the 21st century, I strongly believe, there should be one school, one curriculum, one unified rigorous training to teach medical sciences and surgery as well because human body and its anatomy, physiology and pathophysiology is the same regardless the mode of practice and location. The only thing that differs from each other is the medicine/remedy part. Therefore, across the medical practices, there should be an unified medical teaching method to integrate first the minds, medical knowledge & training, including at least one year surgery training to all. And then next comes the medicine part.

Medical Practice

Medical bags

As far Medical Practice is concerned, after successfully going through the above mentioned education and training, the qualified doctors can individually select the application of the evidence based medicines/remedies as per their interest across the medical practices and apply them judiciously for the benefit of the patient . The message that we wish to share this morning is – WIN BACK THE PUBLIC TRUST.

Industry

The above message is mainly and obviously to the physicians and policy makers, but not to the pharmaceutical industry. Why because industry is industry, to the maximum extent they do business mainly with in the frame work of the available policies and regulations. Regulatory system in place takes good care of it. In fact, the highly vigilant regulators are relentlessly pursuing non-compliance action against a large number of companies all over the world.

However, the industry should continuously make efforts to supplying quality medicines and also has to adopt policies that make sure no counterfeiting in the market. As a person worked at Sanofi, I congratulate and appreciate their efforts in combating counterfeiting. And I hope that every company (in all walks of medical practices) will adopt the same and fight against counterfeit medicines to assure the health of millions of people worldwide.

These policies clubbed with the approach suggested in the recommendations section (Hyper Quality Loop) would further strengthen the bonds across the chain and unite the minds for good of humanity.

Public Health

The entire thing goes in this direction: policies, regulations, pharma, supply-chain, physicians and then to patients. So,

  • it is the policy makers responsibility to prepare concrete strategies, leave no room for excuses by continuously reviewing and updating. Also it is important to adopt a unified policy making system, at the highest level in the state, to maintain uniform quality standards across the industries.
  • it is the regulators responsibility to strictly regulate the activities at ground zero level itself by increasing frequency of spot audits and reviewing the issuing of and/ or extending the manufacturing licenses.
  • it is the pharmaceutical industries responsibility to develop, and manufacture only the evidence based medicines as per the guidelines. 
  • it is the supply-chain managements responsibility to supply as per the guidelines the manufactured evidence-based medicines
  • it is the physicians (practitioners) responsibility to educate the patients and ameliorate, treat, cure, eradicate, and prevent the disease.
  • and last but not least, it is the patients responsibility to think twice before deviating from the Healthy Lifestyle. In case of deviation, consult your GP immediately and take necessary precautions and medications.

Since every patient may not be as educated or clever as others, the sole responsibility lies on the shoulders of the practitionerswho are the direct contact to the patients – who have to strike the BALANCE to correct the IMBALANCE in the patient.

Dr. Vinay Prasad, MD, Medical Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, MD, Who Recently Conducted The Following Study:

Title: A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices

Mayo Clinic Proceedings
Volume 88, Issue 8 , Pages 790-798, August 2013

published online 22 July 2013

says that, “While the next breakthrough is surely worth pursuing, knowing whether what we are currently doing is right or wrong is equally crucial for sound patient care.”

This study reviewed ten years (between 2001 and 2010) of original articles published in the New England Journal of Medicine testing standard of care and has presented very shocking findings. This study was conducted from August 1, 2011, through October 31, 2012. The study summary is as follows (source).

Study Method:

Articles were classified on the basis of

  1. whether they addressed a medical practice,
  2. whether they tested a new or existing therapy, and
  3. whether results were positive or negative.

Articles were then classified as 1 of 4 types:

  1. replacement, when a new practice surpasses standard of care;
  2. back to the drawing board, when a new practice is no better than current practice;
  3. reaffirmation, when an existing practice is found to be better than a lesser standard;
  4. reversal, when an existing practice is found to be no better than a lesser therapy.

This study was conducted from August 1, 2011, through October 31, 2012, to outline broad trends in medical practice and identify a large number of practices that don’t work.

“Identifying medical practices that don’t work is necessary, says Dr. Prasad, because the continued use of such practices wastes resources, jeopardizes patient health, and undermines trust in medicine.”

The study included:

– assessment of a screening, stratifying, or diagnostic test, a medication, a procedure or surgery, or any change in health care provision systems.

– reviewed 2044 original articles, 1344 of which concerned a medical practice, Of these,

    • 981 articles (73.0%) examined a new medical practice,
    • whereas 363 (27.0%) tested an established practice.
      • A total of 947 studies (70.5%) had positive findings,
      • whereas 397 (29.5%) reached a negative conclusion.
  • A total of 756 articles addressing a medical practice constituted replacement,
    • 165 were back to the drawing board,
    • 146 were medical reversals,
    • 138 were reaffirmations, and
    • 139 were inconclusive.
    • Of the 363 articles testing standard of care, 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it.

i.e., :

  – Only 27% (363/1344) of articles that tested a practice tested an established one

  – 73% (981/1344), tested a new medical practice.

Conclusion:

Dr. Prasad’s major conclusion concerns the 363 articles that test current medical practice — things doctors are doing today.  His group determined that

 – 146 (40.2%) found these practices to be ineffective, or medical reversals.

 – 138 (38%) reaffirmed the value of current practice, and

 – 79 (21.8%) were inconclusive — unable to render a firm verdict regarding the practice.

Based on his work, Dr. Prasad comments that, “A large proportion of current medical practice, 40%, was found to offer no benefits in our survey of 10 years of the New England Journal of MedicineThese 146 practices are medical reversals.  They weren’t just practices that once worked, and have now been improved upon; rather, they never worked.  They were instituted in error, never helped patients, and have eroded trust in medicine.”

Dr. Prasad adds, “Health care costs now threaten the entire economy.  Our investigation suggests that much of what we are doing today simply doesn’t help patients.

He is of the opinion that “Eliminating medical reversal may help address the most pressing problem in health care today.”

According to him, key examples of medical reversal include the following:

  1.  – Stenting for stable coronary artery disease was a multibillion dollar a year industry when it was found to be no better than medical management for most patients with stable coronary artery disease.
  2.  – Hormone therapy for postmenopausal women intended to improve cardiovascular outcomes was found to be worse than no intervention.
  3.  – The routine use of the pulmonary artery catheter in patients in shock was found to be inferior to less invasive management strategies.

Other instances pertain to the

  1.  – use of the drug aprotinin in cardiac surgery,
  2.  – use of a primary rhythm control strategy for patients with atrial fibrillation,
  3.  – use of cyclooxygenase 2 inhibitors, early myringotomy procedures, and
  4.  – application of recommended glycemic targets for patients with diabetes.

“To our knowledge, this is the largest and most comprehensive study of medical reversal. The reversals we have identified by no means represent the final word for any of these practices. But, the reversals we have identified, at the very least, call these practices into question,” Says Dr. Prasad.

In an accompanying editorial, John P. A. Ioannidis, MD, DSc, of the Stanford Prevention Research Center, Department of Medicine and the Department of Health Research and Policy at Stanford University School of Medicine, comments on the work of Prasad and his team and evaluates it within a broader context.

“The 146 medical reversals that they have assembled are, in a sense, examples of success stories that can inspire the astute clinician and clinical investigator to challenge the status quo and realize that doing less is more,” notes Dr. Ioannidis. “If we learn from them, these seemingly disappointing results may be extremely helpful in curtailing harms to patients and cost to the health care system.”

According to Dr. Ioannidis, it is just as important to promote and disseminate knowledge about ineffective practices that should be reversed and abandoned. Given the widespread attention that practice guidelines typically receive, particularly when published by authoritative individuals or groups, he questions whether a generally higher level of evidence should be required before these guidelines are recommended and can impact clinical practice.

“Finally, are there incentives and anything else we can do to promote testing of seemingly established practices and identification of more practices that need to be abandoned? Obviously, such an undertaking will require commitment to a rigorous clinical research agenda in a time of restricted budgets,” concludes Dr. Ioannidis.  “However, it is clear that carefully designed trials on expensive practices may have a very favorable value of information, and they would be excellent investments toward curtailing the irrational cost of ineffective health care.”

Our Recommends

1. Adopt Hyper Quality Loop

Taking this study and also “the additional responsibility and accountability by the individual practitioners, who took oath to balance the imbalances in the patients in to consideration, we think that individual practitioners should adopt a mechanism to monitor and control the quality and quantity of medicine prescribed to their patients.

In such a case, the medical associations may adopt a program (called PROMISE: Physicians’ Regulatory Overview of Medicines, Investigation, Selection and Enlighten) in addition to their regular control activities in the health care sector. “A PROMISE made by the clinician is a PROMISE kept by the physician” is the way forward.

This program (PROMISE) utilizes cutting-edge analytical tools and techniques to evaluate product quantity & quality. This will proactively address quality & quantity questions. If any non-compliance, the findings can be directly presented/reported to the manufacturer for withdrawing the batches from the market, while requesting to replace them with the appropriate ones.

Knowledge gained from PROMISE increases the certainty and consistency of medicines in the market and contributes to the implementation of best practice standards for pharmaceutical manufacturing. In case of further non-compliance by the industry, the regulatory authorities will step in and will take appropriate measures.

Thus the following “HQL” system (Hyper Quality Loop) may be adopted and standardized.

PROMISE_TGI

2. Establish Philanthropists Club

“sharIre jharjharIbhUte vyAdhigraste kalevare |
auShadhaM jAhnavItoyaM vaidyo nArAyaNo hariH ||”
danvantri

meaning

When the body is suffering with disease, medicine is like the sacred water of the Ganga and the Doctor is protector (Narayana) himself”

When I was in K-12, I thought I would go to medical school, learn everything possible and serve the humanity. Instead I ended up in a research laboratory mixing and fixing the chemical bonds that in turn (hopefully) strengthen the bond between body and mind. So, instead of a prescriber of medicines I became a subscriber of medical and chemical journals which is not bad either taking into account, on one hand, the highest level of satisfaction and enjoyment when a molecule is thru the market and helping the needy, and on the other hand the enormous costs incurred in getting educated as a medical doctor especially in countries like India (for Indians).

Most young people enter medical school with the same intention as of mine above and put their best skills to practice medicine. They all at the beginning want to work for the good of humanity, but in reality, the things may work against their ideals. The reason for that primarily is the high costs involved in medical education. On this line, I am just throwing an idea to see its practicality. The idea, what I call “Philanthropists Club To Catalyze the Medical Education and Practice”.

The concept is that if philanthropists in the world join hands and form a club and work with UN to unify and support the medical education across the continents and bare the costs involved to educate and train the dedicated practitioners who would respect the profession and oath and serve the humanity with humility. In this case, the club can adopt the medical schools across the continents and prepare a common medical education system that the interested should complete before adopting the medical practices mentioned above.

Benefits of this approach:

1. It will help young doctors focus solely on studies, training and ultimately on practice

2. It will integrate the minds and practices for the good of humanity

3. It will lift the financial burden on state/central governments alike and that money can be used to develop/improve the infrastructure as part of public health program (needs to be improved a lot)-

    1. Attack on poverty
    2. Clean drinking water to every household
    3. Closed efficient drainage system
    4. Recycling waste (kitchen/sanitation) and generate energy etc.
    5. Health for all (focus should be on child nutrition-fundamental to economic (internal & external) development)
    6. Expansion of education
    7. Housing for all
    8. Eradicate slum concept
    9. Protection of the environment

4. Last but not least, it will fulfill/ satisfy the zeal of philanthropy

***

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