Mejora de un método de consenso experto para reducir la variabilidad de la práctica clínica: Aplicabilidad y rendimiento de una adaptación del método Dolphi modificado, como instrumento de consenso experto para elaborar recomendaciones en situaciones de incertidumbre clínica

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Psiquiatría. Fecha de lectura: 20-11-201

Towards a person-centered medical education: challenges and imperatives (I)

It is increasingly claimed that modern medicine has entered into crisis —a crisis of knowledge (uncertainty over what counts as “evidence” for decision-making and what does not), care (a deficit in sympathy, empathy, compassion, dignity, autonomy), patient safety (neglect, iatrogenic injury, malpractice, excess deaths), economic costs (which threaten to bankrupt health systems worldwide) and clinical and institutional governance (a failure of basic and advanced management, inspirational and transformational leadership). We believe such a contention to be essentially correct. In the current article, we ask how the delineated components of the crisis can be individually understood in order to allow them to be collectively addressed. We ask how a transition can be effected away from impersonal, decontextualized and fragmented services in the direction of newer models of service provision that are personalized, contextualized and integrated. How, we ask, can we improve healthcare outcomes while simultaneously containing or lowering their costs? In initial answer to such questions —which are of considerable political as well as clinical significance— we assert that a new approach has become necessary, particularly in the context of the current epidemic of multi-morbid and socially complex long term illness. This new approach, we argue, is represented by the development and application of the concepts and methods of person-centered healthcare (PCH), a philosophy and technique in the care of the sick that enables clinicians and health systems to re-introduce humanistic ideals into clinical practice alongside continuing scientific advance, thereby restoring to medicine the humanism it has lost in over a century of empiricism. But the delivery of a person-centered healthcare within health systems requires a person-centered education and training. In this article we consider, then, why person-centered teaching innovations in the undergraduate medical curriculum are necessary, as a first step, to achieving real progress in the integrity of modern undergraduate medical education. Without such innovations, we do not believe that suitable foundations for subsequent innovations in postgraduate training can be laid and, with them, a continuing professional education in PCH that spans entire medical careers. We first review the historical perspectives of relevance to our arguments and then advocate a radical re-think of what we believe to be the urgent imperatives for a modern medical undergraduate and postgraduate training.post-print300 K

Measures to evaluate quality of care in renal cancer: results of a Delphi study in Spain.

Purpose: To review current measures for renal cancer care and develop a comprehensive and updated list of measures for their practical use. Methods: The study was developed by Fundación ECO, a Spanish foundation aiming to improve oncology quality of care. A systematic literature review was carried out to identify measures and knowledge gaps. A scientific committee composed of 9 experts reviewed the literature findings and added measures. A preliminary list of 42 measures was evaluated with the Delphi method to gather feedback from 47 medical oncology experts in Spain. Experts scored the appropriateness of the measures and ranked their priority in 2 consecutive online surveys. The scientific committee reviewed the Delphi results and developed the measures. A technical group from Universidad Francisco de Vitoria conducted and oversaw the Delphi method. Results: The Delphi method led to consensus on all 42 measures. The scientific committee used a prioritisation matrix to select 25 of these measures for evaluating quality of care in renal cancer. These measures regarded structure, process, and outcome and covered general management, diagnosis, treatment, follow-up, and evaluation of health outcomes. Easy-to-use index cards were developed for all 25 measures, including their definition, formula, acceptable level of attainment, and rationale. Conclusions: This manuscript aims to provide healthcare professionals with expert- and evidence-based measures that are useful for evaluating quality of care in renal cancer and cover all aspects and stages.pre-print451 K

Medical students’ perceptions towards learning communication skills: a qualitative study following the 2-year training programme.

Objective: This study aimed to gain an understanding of the perceptions of 4th-year medical students about a training course in communication skills with 'experiential learning' characteristics, completed over the past two years.Methods: Twenty 4th-year medical students were invited to participate in a qualitative study with focus groups. These students were selected randomly, stratifying by gender, from all 4th-year medical students (106) at the Francisco de Vitoria University (Madrid). The students had just completed their communication skills training taught in small groups, with simulated patient interviews and feedback. The focusgroup facilitator used an open-ended discussion guide to explore the students' perceptions. Thematic analysis was used to identify salient themes from these discussions. Results: Sixteen students participated in two focus groups. The discussions revealed two contrasting perceptions: while this learning is considered useful, it nevertheless brings about a great deal of stress, especially regarding student exposure to peers in small-group sessions when interviewing standardised patients, and summative assessment. This generates a range of negative feelings in students that could affect perspective and attitude towards the importance of doctor-patient relationships. Conclusions: Experiential learning is effective in improving students' communication skills. However, these results suggest that use of such strategies requires a strong focus on "student-centred" teaching approaches, in order to minimise some sensitive topics that may arise during the learning. Further research is needed to refine these strategies depending on the teaching situation and to identify different ways of implementing these experiential methods.post-print206 K

Measures to evaluate quality of care in head and neck cancer: Results of a Delphi study.

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Medical students’ attitudes toward communication skills learning: comparison between two groups with and without training.

Objective: The value students give to communication skills (CS), acquiring them, or other related matters can influence the effectiveness of educational programs. In this study, we explored first and fourth year medical students’ attitudes toward CS and their learning, assessing the possible influence they have on programmed experiential training in a medical school. Subjects and methods: Two hundred and twenty first and fourth year medical students completed the Communication Skills Attitudes Scale, analyzing the positive and negative, and affective and cognitive attitude subscales toward learning. Results: Fourth year students trained in CS showed less positive attitudes toward CS than first year untrained students. Cognitive and affective attitudes displayed different patterns in both groups; while affective attitudes decreased in fourth year students, cognitive attitudes did not vary significantly between groups. Accumulated learning experiences seem to be more influential than sex. Conclusion: The findings suggest that students’ attitudes toward CS could decline as a result of CS training. Nevertheless, students’ attitudes at the cognitive and fundamental level stay fairly unchanged. Learning CS with experiential methods seems to be challenging for students at a personal level; so, educators should personalize these methods as much as possible. However, further studies using longitudinal research designs should be performed for exploring students’ attitudes changes over time.post-print182 K

Searching for the erosion of empathy in medical undergraduate students: a longitudinal study.

Objective To analyse the trajectory of empathy throughout the degree programme of medicine in a Spanish school of medicine. Design Longitudinal, prospective 5-year study, between October 2014 and June 2019. Setting Students from a Spanish university of medicine. Participants Two voluntary cohorts of undergraduate medical students from two different school years were invited to participate (n=135 (cohort 1, C1) and 106 (cohort 2, C2) per school year). Finally, a total number of 174 students (102 (C1, 71.6% women) and 72 (C2, 70.8% women) students, respectively) were monitored for 5 years. Each cohort was divided in two subcohorts of paired and unpaired students that were analysed to check possible social desirability bias. Primary outcome measure The Jefferson Scale of Empathy (JSE). Results The cohort of 102 students (C1) monitored between their first and fifth years of study (71.6% women) showed an improvement among paired women of 2.15 points in total JSE score (p=0.01) and 2.39 points in cognitive empathy (p=0.01); in the unpaired female cohort the increase was of 2.32 points (cognitive empathy) (p=0.02). The cohort of 72 students (C2) monitored between their second and sixth years of study (70.8% women) displayed a cognitive empathy increase of 2.32 points (p=0.04) in the paired group of women. There were no significant differences between paired and unpaired results for either cohort. Empathy scores among men did not decrease. Conclusions The empathy of medical students at our school did not decline along grade years. In fact, it improved slightly, particularly cognitive empathy, among women. This paper contributes to enlarge data from Europe, where longitudinal studies are scarce. It supports the idea that there may be global geo-sociocultural differences; however, more studies comparing different school settings are needed.post-print362 K

Health state perception of people close to retirement age: Relationship with lifestyle habits and subjects' characteristics

Aim: Societal ageing increases the need for correct and healthy ageing to ensure the well-being of older adults. Practical strategies are needed to acquire healthy habits for the ageing process. This study aims to analyse the lifestyle habits of subjects who are retired or close to retirement and identify factors that could influence their perceived health and that could be related to these habits. Methods: A Spanish observational, descriptive, cross-sectional study of subjects close to retirement-age. Socio-demographic, family, work, leisure, social, and clinical-psychological indicators were evaluated. Results: 1,700 participants (581 employed; 714 retirees; 405 other-status) were included, average age 63 years, 52% women. Most reported a satisfactory social life (90%), were in live-in relationships (74%), non-smoking (80%), followed a Mediterranean diet (73%), and took medicines daily (70%). Perceived health (EQ-VAS) was 75.9/100, with low disability (12-WHODAS) (7.4/100) and moderate/severe depression. Women reported higher disability (p < 0.001) and depression (p < 0.001), a better social life, and healthier lifestyle, but lower physical/work activity. Retirees reported less depression, better social life, healthier lifestyle, higher physical/work activity, and better sleeping habits. The multivariate model showed a significant association of health-status with disability level, number of chronic diseases, sleep habits, exercise, diet, and alcohol consumption. When depression level was introduced, age and being a woman were also related. Conclusions: Retirement does not mean worse health but rather an opportunity to reinforce favourable health activities and improve lifestyle factors. Incorporating the differences related to gender and employment status in health-perception will facilitate the design of healthy ageing strategies.S

Bioinspired decision-making for a socially interactive robot

Nowadays, robots and humans coexist in real settings where robots need to interact autonomously making their own decisions. Many applications require that robots adapt their behavior to different users and remember each user’s preferences to engage them in the interaction. To this end, we propose a decision making system for social robots that drives their actions taking into account the user and the robot’s state. This system is based on bio-inspired concepts, such as motivations, drives and wellbeing, that facilitate the rise of natural behaviors to ease the acceptance of the robot by the users. The system has been designed to promote the human-robot interaction by using drives and motivations related with social aspects, such as the users’ satisfaction or the need of social interaction. Furthermore, the changes of state produced by the users’ exogenous actions have been modeled as transitional states that are considered when the next robot’s action has to be selected. Our system has been evaluated considering two different user profiles. In the proposed system, user’s preferences are considered and alter the homeostatic process that controls the decision making system. As a result, using reinforcement learning algorithms and considering the robot’s wellbeing as the reward function, the social robot Mini has learned from scratch two different policies of action, one for each user, that fit the users’ preferences. The robot learned behaviors that maximize its wellbeing as well as keep the users engaged in the interactions.The research leading to these results has received funding from the projects: Development of social robots to help seniors with cognitive impairment (ROBSEN), funded by the Ministerio de Economía y Competitividad (DPI2014-57684-R); and RoboCity2030-III-CM, funded by Comunidad de Madrid and cofunded by Structural Funds of the EU (S2013/MIT-2748).Publicad

Indicators to evaluate quality of care in head and neck cancer in Spain.

Purpose This study aimed to develop a set of criteria and indicators to evaluate the quality of care of patients with head and neck cancer (HNC). Methods A systematic literature review was conducted to identify valuable criteria/indicators for the assessment of the quality of care in HNC. With the aid of a technical group, a scientific committee of oncologists specialised in HNC used selected criteria to propose indicators that were evaluated with a two-round Delphi method. Indicators on which consensus was achieved were then prioritised by the scientific committee to develop a final set of indicators. Results We proposed a list of 50 indicators used in the literature or developed by us to be evaluated with a Delphi method. There was consensus on the appropriateness of 47 indicators in the first round; the remaining 3 achieved consensus in the second round. The 50 indicators were scored to prioritise them, leading to a final selection of 29 indicators related to structure (3), process (22), or outcome (4) and covering diagnosis, treatment, follow-up, and health outcomes in patients with HNC. Easy-to-use index cards were developed for each indicator, with their criterion, definition, formula for use in real-world clinical practice, rationale, and acceptable level of attainment. Conclusions We have developed a set of 29 evidence-based and expert-supported indicators for evaluating the quality of care in HNC, covering diagnosis, treatment, follow-up, and health outcomes.post-print998 K