Universitat Internacional de Catalunya
Appropriate Decision Making in Medicine
Teaching staff
This is a compulsory subject that the UIC incorporated in a pioneering way in its curricula of the Degree of Medicine from the beginning. It was designed by Dr. Albert Jovell (e.p.d.), and since 2013 we continue his legacy the current team of teachers. Appropriate Decision-Making in Medicine was awarded the year 2015 in the XIV edition of the Diario Médico awards as one of the best ideas of the Spanish National Health System.
Its main objective is to bring to the 4th year medical students the knowledge of the reality of health systems where they will have to work once graduated, and to offer them a space for structured debate and critical thinking about the decision making that they should make in their medical practice. The subject wants to help future doctors to face the different technological, economic and social conditions that will determine the environments that will be found throughout their professional life, learning how to open their minds, learning how to have a critical vision of health systems, and learning how to understand the professional and human role of doctors and their patients.
For all these reasons, we recommend to attend the classes with interest and willingness to participate, knowing in advance that although the subject is compulsory, the attendance at the lectures and the case methods is voluntary, and no list of attendance in class will be checked.
Students may ask lecturers questions at the end of each class. For enquiries outside of class time, students must make an appointment by email:
Dr. Xavier Corbella xcorbella@uic.es
Dr Esther Jovell: ejovell@uic.es
Dra Candelaria Calle: ccalle@uic.es
Dra Ana Martí Delgado: anamarti@uic.es
Introduction
Making appropriate decisions relating health care is a necessary and essential competence of physicians.
There are many aspects to consider in a decision-making process in medicine (medical decision -making), including those that are determined by our environment, either 1) at the "Macro-management" (Health Policy, health care model and system planning, funding), 2) "Meso-management" (type of institution in which we serve, our place in the organization, type of activity we do), or 3) at the "Micro-management" (role of doctor/physician, level of evidence, available resources, the role of the patient and their wills).
The knowledge of the constraints that determine our decisions in medicine at these three levels (macro, meso and micro) will help us making appropriate decisions, since we should not forget that all of them are part of our medical practice. The "macro" and "meso-management" determine our thinking and our clinical decision-making depending on we work in a public or private health care system, a hospital or primary care setting, the operating room or the emergency department, or the availability of resources assigned or others. At the “micro” level, physicians take medical decisions depending on their level of knowledge of the scientific evidence, their personal experience, the clinical practice guidelines, the degree of recognition of their limitations or the established relationship with the patients and their opinions.
Decision making in medicine is not always done in ideal conditions of access to a complete and certain, knowing fully the predictable effects of our decisions and with enough time available to calibrate the consequences of it. In fact, most of the processes of decision-making in medicine usually are performed under conditions of uncertainty, incomplete information, complex situations, with uncertain consequences and lack of time and resources.
The subject "Appropriate Decision-Making in Medicine" is the scope of the degree in Medicine which teach “how to decide" by knowing the set of agents, variables and indicators that act when we make decisions during medical practice. The knowledge of the health care sector, the value of the so-called evidence-based medicine and the patient opinion will be part of the matter. Beyond uncertainty, variability and limited resources, a proper decision-making will allow us to provide the maximum value possible to our patients, and every euro spent on health care.
Pre-course requirements
1.- Be familiar with our health care system.
2.- Basic knowledge of clinical practice.
3.- Basic knowledge of Catalan, Spanish and English.
Objectives
1.- To understand the determinants of decision-making in medicine from the perspective of the three levels of healthcare management organization ("macro”, "meso“ and "micro-management”).
2.- To understand the basis of health economics and the management and organization of the healthcare system to respond to the health needs of the population.
3.- To know how the different health actors (stakeholders) think and decide (politicians, health planners, funders, providers, professionals, patients) and how to understand their different point of views.
4.- To encourage critical thinking among medical students, facing scenarios in which uncertain and difficult decision-making are needed, either organizing complex health care processes or sharing decisions with patients during clinical practice.
5.- To understand the dilemmas of efficiency, effectiveness, efficiency, equity and access to health care system.
6.- To understand the ethical point of view of the medical decision-making in terms of social justice and benefit to the patient, either individual or collective.
Competences/Learning outcomes of the degree programme
- 01 - Recognise the essential elements of the medical profession, including ethical principles, legal responsibilities and patient-centered professional skills.
- 02 - Understand the importance of central principles, in particular of professional confidentiality for the benefit of patients, society and the profession.
- 03 - Know how to apply the principle of social justice to professional practice and understand the ethical implications of health in a changing global context.
- 04 - Develop professional practice with respect for patient autonomy, beliefs and culture.
- 05 - Recognize own limitations and the need to maintain and upgrade professional skills, with particular emphasis on autonomous learning of new knowledge and skills and motivation for quality.
- 06 - Develop professional practice with other health professionals, acquiring teamwork skills.
- 25 - Recognize the determinants of public health; genetic and sex-dependent lifestyle, demographic, environmental, social, economic, psychological and cultural determinants.
- 27 - Recognize role in multidisciplinary teams, assuming leadership when appropriate, for the delivery of health care, such as interventions for health promotion.
- 28 - Obtaining and using epidemiological data and assess trends and risks in health related decision-making.
- 29 - Understand national and international health organisations, and the environments and conditions of the different health care systems.
- 30 - To acquire basic knowledge of the National Healthcare System and general healthcare legislation.
- 31 - Understand, critically evaluate and know how to use sources of clinical and biomedical information to obtain, organize, interpret and communicate scientific and health care information.
- 34 - Ability for critical thinking, creativity and constructive skeptisim with a focus on research within professional practice.
- 35 - Understand the importance and limitations of scientific thinking in the study, prevention and treatment of disease.
- 36 - Be able to formulate hypotheses, collect and critically evaluate information for problem solving using the scientific method.
- CB-2 - To know how to apply and incorporate knowledge, an understanding of it and its scientific basis and the ability to solve problems in new and loosely defined environments, including multidisciplinary contexts that include both researchers and highly specialised professionals.
- CB-3 - To know how to evaluate and select the appropriate scientific theories and precise methodologies required by their field of study to make judgements based on incomplete or limited information. Where necessary and appropriate, this includes a reflection on the ethical and social responsibility linked to the solution suggested in each case.
- CB-4 - To be able to predict and control the evolution of complex situations through the development of new and innovative working methodologies adapted to the scientific / research, technological or specific professional field, which is generally multidisciplinary, within which they undertake their activities.
- CTP-3 - To develop critical thinking and reasoning as well as self-assessment skills.
- CTS-1 - To know the principles of leadership and decision making in ordinary situations or in conflicts with and between various ethical, legal and professional elements.
- CTS-3 - To promote and ensure respect for human rights and the principles of universal accessibility, equality, non-discrimination as well as the values of democracy and a culture of peace.
Learning outcomes of the subject
1. – Have developed critical thinking about the agents that influence appropriate decision-making in medicine.
2. - Having understood the usefulness of the different tools, methods and indicators that help proper decisions at different levels of performance.
3. - Have learned to apply logical reasoning in solving complex cases.
Syllabus
7 Master Classes (2 h x 7 = 14 hours) and 5 Case Methods (2h x case = 10 hours, for 2 groups)
LESSON 1. - Decision-Making in Medicine
Introduction to thought, reflection, reasoning and critical thinking in medicine, the value of theoretical knowledge, the value of the experience, the concept of sources of evidence and clinical knowledge, moral and ethical approach, meet and communicate with the patient, recognition of our limitations, the guidance and support of other experts, the support of the organization.
LESSON 2. - Decisions on Macro - Management (I-II): Health Policy, Health Systems and Models.
Introduction to Health Policy, difference between health model and health system, functions of a public health system, introducing its history and goals, health care in the current, dysfunctional health systems, national health system and health system in Catalonia, accountability to citizens and control systems.
LESSON 3.- Decisions on Macro-management (V): Health plan
Concept of organisation for delivery settings: primary care, inpatient care, long-term care and mental health. Concept of integrated care organisation. Concept of process: ambulatory, surgical, hospitalization, and emergency. Efficacy, effectiveness, efficiency and quality of care. The Health Plan as a tool of strategic planning.
LESSON 4.- Decisions on Macro-management (VI): Financing and Purchasing Health Services
Systems of Financing and payment of health services: by fix budget, fee for service, capitation fee, and pay per performance.
LESSONS 5 and 6.- Decisions on Meso-management (I): Governance and Leadership in Health Institutions
Description of the types of healthcare providers, councils of government, health institution as a company, stakeholders, functions of the organ of corporate government, corporate social responsibility, and best practices. Concept of Leadership: styles, dimensions, cathegories.
LESSON 7. - Decisions on Macro - Management (III): Bases of Health Economics
Introduction to health economics and health care studies, broad concept of health technology assessment and evaluation of health policies and systems, introduction to the ideas of prioritization, allocation, market, supply and demand care.
LESSON 8. - Decisions on Macro - Management (IV): Social Justice, Bioethics and Resource Allocation
To describe the main theories of social justice, libertarian, egalitarian, utilitarian, and the impact on the organization of health care systems and the distribution of health care resources.
LESSON 9.- Decisions on Meso-management (III): Clinical Management and Participation of Professionals in Healthcare Management
Concept of clinical management, direction by objectives, orientation to results, implication of the professionals on management, autonomy of management and policy of incentives, management agreements.
LESSON 10.- Decisions on Meso-management (IV): Quality Plan and Outcomes Evaluation
Models of management based on Quality of Care. Plan of Quality and systems of quality evaluation. Balanced score card: Indicadors of activity, quality and cost. Concept of benchmarking.
LESSON 11. - Decisions on Micro - Management (I): Professionalism
Description of the physician as a clinician, teacher, researcher and manager, present values of professionalism, involvement in the process of clinical decision-making, concept clinical leadership, clinical decision analysis models as a strategy to provide information for clinical judgment, critical reasoning and decision-making in complex processes and under conditions of uncertainty.
LESSON 12. - Decisions on Micro - Management (II): Clinical reasoning and judgement. Clinical Practice Guidelines
Evidence-based Medicine, sources of evidence, the elements of an economic analysis and valuation techniques applied in the health sciences, particularly cost-effectiveness, concept and description of the methodology of drafting guidelines clinical practice, application and evaluation of specific clinical conditions .
LESSON 13. - Decisions on Micro - Management (III) : Aging and Chronicity
The impact of aging on healthcare system, changes description of epidemiological pattern of acute and chronic illness, strategies to address and manage the challenge of chronicity.
LESSON 14. - Decisions on Micro - Management (IV): Patient Safety
Concept of patient safety indicators, measures of adverse effects and complications of health care, strategies to prevent medical errors
Case Methods (2 hours per case each of the 2 groups)
1.- Case Method 1. Apply Population Screening Programs, yes or no?
The example of early detection programs for breast, prostate and lung cancer.
2.- Case Method 2. RESONANTIA CASE.
A process is a series of interrelated tasks performed by people or machines that, together, transform inputs into a given output. In healthcare systems or organizations, process reengineering should be considered when the results are not good and requires rethinking an action plan to resolve a list of problems. Concepts of costs and results of profits and losses are worked on.
3.- Case Method 3. (English). Transitions of Care.
The example of managing transitions of care in chronic patients by bridging the gap between healthcare providers at different levels, and the gap between inpatient and outpatient worlds.
4.- Case Method 4. Patients' Rights and Shared Decision Making.
Guarantee the rights of patients and share decisions that affect them with health professionals.
5.- Case Method 5. MEGACAR CASE.
A complex situation arises, with a difficult decision that must be made considering the multiple factors and actors involved, without a single solution. The idea is to exercise critical thinking and reasoning in a context of uncertainty.
Teaching and learning activities
In person
Teaching methodologies are basically participatory master classes and case methods where topics are addressed on the basis of real-life examples, and work by groups in class.
Evaluation systems and criteria
In person
1st call: Test written in Spanish with 50 multiple choice questions (4 answers per question), where one point is subtracted for each 3 incorrect questions answered. The pass is 25 points. The duration of the exam is 60 minutes. As in the MIR exam, each student will be called in alphabetical order and will be MANDATORY to identify yourself with your ID, driver's license or passport. All students who arrive more than 15 minutes late will not be able to take the exam.
The performance of the activity proposed in each Case Method is voluntary but serves to raise the score obtained in the test-type exam, according to the following criteria: activity rated as remarkable 0.05 and rated as excellent 0.10. If the student does for example 4 of the 5 activities proposed in the 5 Methods of the Case, and obtains 0.10 points in each activity, the final score adds 0.40 points to the score achieved in the multiple-choice test exam, whatever the note obtained.
According to UIC regulations, there are usually up to 4 possible students who will be qualified as Honors, always at the discretion of the teachers, and they are rigorously awarded to the best scores obtained in the summation between the multiple-choice test 1st call and the Case Methods.
2nd call: Test written in Spanish with 50 multiple choice questions (4 answers per question), where one point is subtracted for each 3 incorrect questions answered. The pass is 25 points. The duration of the exam is 60 minutes. As in the MIR exam, each student will be called in alphabetical order and will be MANDATORY to identify yourself with your ID, driver's license or passport. All students who arrive more than 15 minutes late will not be able to take the exam.
The maximum final score that a student can obtain in the 2nd call exam is 6.9 (PASS), adding the score of the multiple choice exam and that of the activities carried out in the Case Methods. Although the sum of the two exceeds the score of 6.9, the maximum grade that a student can obtain in the second call is PASS.
Bibliography and resources
https://ec.europa.eu/health/sites/health/files/state/docs/2018_healthatglance_rep_en.pdf
https://salutweb.gencat.cat/web/.content/_departament/pla-de-salut/Pla-de-salut-2016-2020/documents/Pla_salut_Catalunya_2016_2020.pdf