CARING FOR THE CARERS. Dr Virgilio Sacchini is a surgeon who specializes in the treatment of breast cancer, with academic experience at Cornell University in New York and University of Milan in Europe. In all his life he was involved in clinical trials increasing curability and quality of life in breast cancer patients. Working and teaching in two of the most important cancer Institutions in USA and Europe: Memorial Sloan Kettering Cancer Center in New York and European Institute of Oncology in Milan, let him to match and take the best from different medical and research culture. Dr Sacchini was for more than 10 years in the Memorial Sloan Kettering Research Review Committee and from 10 years President of the Ethical committee of the State of San Marino. He published more than 190 papers in Medical Journals and in Medical Books.
The world is a very different place now that we have to cope with viruses that cause global pandemia, for which we were unprepared. What is medicine in general doing to try to ensure we are more prepared for this in future?
At the end of the story the world is the same, and it is only our perception of disease that has changed. Diseases are part of humanity, and this pandemic is only a fraction of the causes of people’s morbidity and mortality. The difference with other diseases is that Coronavirus occurred so quickly, and with incredible media coverage. The World Health Organization has estimated that more than 8 million people die from tobacco use every year and we see people smoking without any restriction from governments. In general the best way to be prepared is to put the most competent scientists in charge of the health system with a reasonable budget.
To address such global viral threats do we need to build new hospitals and vaccine facilities, from the richest to the poorest nations? How can this be done?
From this pandemic we learned that science can win, and we won. As never before, excellent scientists with an exceptional budget from governments were able to develop life-saving vaccines. Unfortunately we missed the opportunity to educate the population enough for wide acceptance of the vaccines. Having the vaccines is important, but also very important is having people who want to be vaccinated, and this may be a problem in poor countries where there is scepticism about conventional medicine. There is no doubt that vaccines should be available in poor countries, as well as adequate educational campaigns.
Do we now need to add the threat of ever changing viral pandemic to our list of life threatening conditions such as heart attacks, cancer, leukaemia, stroke?
The pandemic created an exceptional burden on the health system, paralysing “normal” diagnostic and therapeutic clinical activities. Screening was reduced, and we are now facing more late stage cancers. In the last 6 months my surgical activity has become more difficult and challenging for extirpating bigger cancers with a worse prognosis. People are doing less screening tests for cardiovascular, neurologic, ophthalmic and other diseases, putting them in danger of increased mortality and sequelae.
“The burn-out of physicians and nurses were among the highest in the last 10 years, and burn-out of the health workers means that the health system is falling apart.”
How can people in general learn to live with these threats safely and without ongoing fear of their neighbours as they go about their daily lives?
The pandemic has had an incredible psychological consequence on people, especially the young. Men and women are “social animals” who exchange confidences, ask each other for advice, complain together, get angry together, love together. We are now missing the “together”, and social media on the phone cannot replace hugs and kisses. I am confident that sociality would be restored soon after better statistics on the pandemic.
Are vaccines the answer, when they have to be repeated so often and nobody seems to know how long they provide immunity?
We saw that vaccines are the answer, and many lives were saved by vaccines. As we knew by vaccination science, one shot was usually enough to protect against the pathogen for years. Vaccination for flu is different, because the pathogen can change every year and we need a vaccine for the predicted new pathogen. What we saw from the Coronavirus experience was that we need quite a high level of antibody in the blood to be protected, and this can only be reached with several vaccinations with the same vaccine. Probably in the future an annual vaccination would be required, possibly with new vaccines covering different variants.
In such a pandemia doctors and nurses are themselves at high risk. Are there enough trained medical practitioners in the world or do we need many more?
It was estimated by the WHO that 180,000 health care workers died from Covid between January 2020 and May 2021, 4,000 in Italy alone. Poor personal protection with inadequate or unavailable equipment and the unexpected and incredible load of patients were among the causes of this tragedy. We have learned that the protection and education of health workers is a priority in the health system worldwide.
What is you experience working as a doctor in the recent period?
Never as much as now has the world realized how important the health system is, with health operators struggling every day to treat and save Covid patients around the world. But even in the pre-Covid era physicians and nurses were under pressure to treat patients with all diseases: cancer, cardiovascular, immunologic, traumatic, and others. The burn-out of physicians and nurses were among the highest in the last 10 years, and burn-out of the health workers means that the health system is falling apart.
“To decrease the risk of mistakes we need to implement a basis of aviation industry level standard procedures.”
Is this burn-out across the entire healthcare system?
Across all specialties, 42 percent of physicians reported burnout in 2019 with the number increasing every year. Depression, fatigue, family distress, alcohol abuse, and suicidal ideation were the most reported complaints, and a burnt-out physician is neither good for her/him nor for patients.
What is being done about it?
There is an important effort, at least in the United States, to find causes and assist health care workers for burn-out. Questionnaires are frequently sent, to identify early cases of burn-out and take action with psychological counselling and relaxation techniques, as well as identifying systems that can help health workers against burn-out like less paperwork, more informatization, and more human help for the busiest people.
But why are health workers and the health system around the world experiencing this critical situation?
Medicine in the last 20 year has become more and more sophisticated, with improved life span. Treatment protocols are changing every month, based on drug discovery, results of clinical trials, new discoveries of mechanisms of diseases, and physicians need to be on top of the updating which is very time consuming. Fortunately, the patient-physician relationship has changed, and there is more discussion with patients regarding options for treatments, risks and benefits of treatments, side-effects and long-term consequences. But all this is also very time consuming. Quality control procedures have also been implemented more and more in order to reduce medical errors, requiring time consuming verification of check lists. In some parts of the world there is continually increasing competition among hospitals, looking at patients like customers and engaging the healthcare worker in this competition with, for example, demanding extreme availability from medical staff for patients. Health expenses increased a lot for more expensive equipment, incredibly expensive medications (one year of treatment for some malignancies may cost 1 million dollars/euro). Unfortunately, the resources that governments or private administrations put into the health budget were not enough for balancing the last decade of evolution of medicine, without even speaking about the incredible stress on the health system due to Covid in the last 2 years.
What are the priorities to try to limit and reverse the dangerous decline of the health system?
The first thing to implement is a better quality-control, to prevent possible medical mistakes that can be deleterious for patients. In spite of the increase in quality-control in the last 10 years, at least 3,400 wrong-site surgeries likely occurred in the United States in 2020. This represents 2 out of 10,000 surgeries. This seems to be very low; but it is consistent considering the number of surgeries we do every year in the world and it is not in any way acceptable from the individual point of view. Wrong site surgery is the most dazzling in terms of medical mistakes, but is only one of several that may include wrong drug administration, administration of medications for which the patient is allergic, incorrect application of guideline/ procedures, and wrong test orders.
How can the risk of making these mistakes be decreased?
To decrease the risk of mistakes we need to implement a basis of aviation industry level standard procedures. The aeronautical concept of a Swiss cheese model considers human systems like slices of Swiss cheese. The holes in the slices represent weaknesses in individual parts of the system, and these are continually varying in size and position across the slices. The system produces failures when a hole in each slice momentarily aligns, permitting a trajectory of “accident opportunity” so that a hazard passes through holes in all of the slices, leading to a failure. To avoid the holes of the slices aligning we need to implement checklists, electronic automatic systems, double/triple authentications. Partnerships with the aeronautical quality control industry may really help in establishing effective medical models of negative event prevention.
“We need to make the effort to better select people to screen, and to personalize the screening with better screening modalities.”
How can the continuing rapid evolution of information technology and artificial intelligence help?
The electronic informatization of medicine is an important model to implement in order to better manage the hospital system. In many US hospitals the record charts of the patients are now paper free, and accessible remotely by the treating staff. Critical information can be used by different health specialists managing the patient. A good example is information on allergies, preventing all the pharmacists in a country giving a wrong medication to the patient. The Covid experience taught us how real time statistics are so important to act in a preventive measure and better allocate resources. The real time elaboration of statistics is important in all the medical fields, like cancer, heart diseases and others, and can also be used as data for scientific production. The data should be central and managed by a team of specialists, preferably from government agencies.
Is personal family medicine still the best treatment model?
The good fortune of some countries, like for example Italy and Switzerland, is to have a strong family medicine, with a capillary distribution in the territory. This medicine that for years was sacrificed for lack of resources was the first that collapsed during the Covid pandemic. The creation of better base medicine hubs with family doctors with diagnostic and treatment guidelines, able to perform basic tests and correspond in real time with specialists, may relieve the hospitals’ burden from congestion of emergency units and better assist all patients. Governments should facilitate the creation of base medicine hubs, better supporting family doctors with tax deductions and financial help.
How can medical professionals keep abreast of the rapid developments in healthcare in a stress free way?
Education of the health worker is a fundamental process, to keep this important work force up-to-date in such an evolving field. Re-certification and update courses should be mandatory and annual based. Medical Universities should organize these courses and test the workers for a sort of continuing medical education. The Continuing Medical Education system now implemented in some countries, and consisting in gaining continuing medical educations credit by participating in a sometimes not well structured meeting for a focused educational objective, may be not enough to keep this worker category up-to-date.
Are we now seeing as a reality the emergence of personalized medicine based on an individual’s DNA?
Financial resources have to be at last put into precision medicine. We are able now to better predict risk of diseases in the population utilizing personal DNA information and implementing personalized screening. Now we screen for diseases people who would never have some diseases, at the same time as screening people at incredibly high risk of having some diseases. We need to make the effort to better select people to screen, and to personalize the screening with better screening modalities. For instance, identifying women with genetic mutation increasing the risk of breast and ovarian cancer (BRCA mutation genes) would allow us to screen these women earlier and with better tests.
What about personalized treatments?
Precision medicine is also fundamental for the success of the treatments. We can predict the outcome of the treatments with mathematical models called nomograms, and with genomics, based on DNA mutations, especially in cancer. This will allow us to better address successful treatments with better outcomes.
How can these very advanced personal treatments become cost effective?
In the last years we implemented a cheap way to decide treatments, based on expert opinion discussing each case individually in a disease management board (group of experts), but the expertise of the individuals is not so precise as the genomics and predictive nomograms that should be integrated in the expert discussion. Integration of these tools in the patient management decision is definitively more expensive, but rewarding for the outcome.
Is mental illness still too often overlooked in the healthcare system?
Economic crisis may increase the risk of mental diseases and psychological distress, and we should be ready to help these people with state-of-the-art psychological intervention. Drug abuse is incredibly diffuse in rich countries, with a lot of people dying in young age groups. In the 2000s, 100,000 people, especially young, died from opioid overdose. Families are often abandoned, alone, and resources should be made available for better saving these people.
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