Article Type : Review Article
Authors : Nina Bjelogrlic-Laakso
Keywords : Health care management; Pharmaceuticals; Health professionals
Three most important determinates for a profitable invest on
a real estate business are commonly thought to be ‘location, location and
location’. This makes one to ask what would be the equivalent contributors in
health care business. Could ‘attitude, attitude and attitude’ play such role in
health care management, which is largely dependent on health professionals and
finance? The undeniable fact is that both our health care costs and chronic
neurodevelopmental diseases are continuously on rise. This commentary discusses
what it would require from health professionals, authorities and pharmaceutical
companies perspective to stop this unfavourable trend.
Logistics in health
care can be irrational from patient’s perspective. In clinical settings various
routine protocols are meant to reduce a physician’s workload, but paradoxically
they can result in undesired outcome. Specialized clinics may not have the capacity
to manage patient’s multifaceted diseases and symptoms belonging to many
different medical fields. Patients end running from one door to another before
they can expect to obtain what they need. The kinds everyday unfortunate events
rise a question of shouldn’t the system be changed? Yes, it certainly should,
but it would require a change in attitudes of all players in the medical field.
Professionals attempt to work for the best of their patients while avoiding to
cause harm to them. In spite of these genuine aims, something has gone wrong
since the burden of intractable chronic diseases keep increasing already at
young age [1-3]. Thus, it is time to seriously think what has gone wrong and
why.
Clinicians
and multidisciplinary teams
Multidisciplinary teams
have taken more and more significant role in clinical decision making in
conservative medicine even though physician is still usually the one, who is
responsible of the final decisions. More experts do have better chances to make
the right conclusions in complicated cases than a single doctor working by himself
in his office. However, pitfalls are possible. It is easy for any team member
to hide behind multi-professional expertise when no solutions can be found. In
the worst scenario, solving the problem is on nobody’s responsibility and the
team keeps repeating itself. Furthermore, the time spent in meetings may
“steal” experts’ time from patient work. From an educational perspective team
work may have deleterious effects on physician’s capabilities for independent
medical practice when he/she gradually starts to rely more and more onto team's
advice. Therefore, self-supervision should become an essential part of
multi-professional team-work.
Clinical skills and
their maintenance should be placed at the heart of all health care. No lab
tests or protocols can overcome ”doctor’s eyes” and clinical evaluation; i.e.
the first hand shake, eye contact and general looks of the patient is extremely
informative to an experienced physician. Thorough interview and clinical
examination will guide further to make a work hypothesis, which is then
confirmed or excluded by ordering appropriate laboratory tests or radiological
examinations. This requires that physician has enough time per patient and also
importantly that electronic records are functioning normally (unlike they
frequently are). It is also self-evident that each physician needs to update
his / her medical knowledge at regular intervals. To conclude, routine
protocols, teamwork and electronic records should be set to serve patients’
needs, not to make physician’s work more difficult and time consuming. Mutual
feeling among many physicians is that this evident order of functions
importance does not always happen.
Multifaceted
role of health authorities
The main task of
authorities is to supervise researchers, clinicians and drug companies as
neutral experts in order to make it possible for citizens to obtain the best
evidence-based treatments available. The core purpose of regulatory institutes
is good, but they have failed to prevent the cascade of events leading to not
so good situation where we are now. However, it would be unfair to blame
authorities alone for increased chronic diseases and health care costs. Most
authorities just like health professionals do wish to do their best to promote
health.
Regulatory agencies
hire experts from different medical fields in order to have as wide
understanding and expertise as possible to be able to fulfil all its duties. On
surface, everything looks fine, but there are problematic caveats that may
weaken authorities' independence whether they realize it themselves or not.
There are several reasons for this. Firstly, the longer an expert works for a
regulatory agency the further away he may drift from his own expertise and at
the same time he becomes more and more dependent on the information coming from
authorities themselves. Secondly, it is difficult to find experts without any
conflicts of interest. This problem is usually acknowledged in a commendable
way in medicines agencies; experts are required to inform all their conflicts
of interests, but this practice does not necessarily eliminate the core problem
of not having qualified experts without any personal connections with drug
companies. Regulatory agencies do their best to keep their neutrality in order
to succeed in their important task in between health professionals and drug
companies. However, only when the above-mentioned potential weaknesses are
acknowledged, can our inevitably somewhat biased regulatory system be improved
to serve citizens as neutrally as possible. Open discussions and transparency
in decision making are essential pedals to this path.
Patients need efficient
and safe medicines, which means that drug development is costly and intensive
process. Of all compounds investigated for use in humans, only a small fraction
is eventually approved following preclinical development, clinical trials and
safety monitoring. This long process is subject to a variety of laws and
regulations the numbers of both of whose has had an increasing trend along
time. While trying to keep up with emerging regulations pharmaceutical industry
has attracted praise and controversy as being one of the most profitable and
influential players in today's existence. People working for pharmaceutical
companies do most likely wish to promote health just like any other worker in
the health care. Many, however, may be too involved and/or financially tied to
their work to see the bigger picture, which may not always be idealistic. Thus,
as with the above discussed routine protocols, multidisciplinary team work and
health regulations, also pharmaceutical industry's core purpose is good but the
outcome may, however, be unfavourable. In order to improve efficacy and
tolerability of medicines pharmaceutical industry has shifted its research
focus during the past decade toward personalized medicine aiming to find
biomarkers, which would help in clinical decision-making [4]. This reform has
been a natural continuum to advances in neuroscience, but it does have one
weakness; the translation of research findings into clinical practice has been
challenging [5,6]. In other words, biomarkers cannot be translated into
clinical practice without a pertinent case-by-case knowledge on drug response
and adverse reactions. This is of uttermost importance particularly when
treating patients with complex neuropsychiatric disorders [7]. To make the best
out of emerging scientific data health professionals’ role and possibilities to
follow and record clinical efficacy and tolerability of patients’
pharmacotherapy should be emphasized [8]. This might ease also the somewhat
troubled relationship between Big Pharma and clinicians.
The complex relation
between medical treatments and pharmaceutical industry is and most likely will
be subject to heated disputes until used for constructive new developments. The
choice is ours. 'Attitude, attitude and attitude' belongs certainly to one of the
key elements that all parties need to adopt if we wish to improve the quality
of the public health care and perhaps, also to cut the costs. Idealistically
that would mean more careful clinical consideration at each step, less routine
protocols and more transparent communication between clinicians, health
authorities and representatives of pharmaceutical industry while keeping in
mind Hippocratic oath “Premium non nocere” (first do no harm).