Medical virtualists

Is It Time for a New Medical Specialty?The Medical Virtualist

Michael Nochomovitz, MD¹; Rahul Sharma, MD, MBA²

   

¹New York Presbyterian, New York, New York    ²New York Presbyterian, Weill Cornell Medicine, New York, New York

JAMA. Published online November 27, 2017.     doi:10.1001/jama.2017.17094

Medicine has seen a proliferation of specialties over the last 50 years, as scientific discovery and care delivery advanced. Diagnoses and treatments have become more complex, so the need for formal training for specialty competence in cognitive and surgical disciplines has become clear. There are currently 860 000 physicians with active certifications through the American Board of Medical Specialties and 34 000 through the American Osteopathic Association.¹

Drivers of Specialty Expansion

Specialty development has been driven by advances in technology and expansion of knowledge in care delivery. Physician-led teams leverage technology and new knowledge into a structured approach for a medical discipline, which gains a momentum of its own with adoption. For instance, critical care was not a unique specialty until 30 years ago. The refinement in ventilator techniques, cardiac monitoring and intervention, anesthesia, and surgical advancements drove the development of the specialty and certification, with subsequent subspecialization (eg, neurological intensive care). The development of laparoscopic and robotic surgical equipment, with advanced imaging, spawned new specialty and subspecialty categories including colon and rectal surgery, general surgical oncology, interventional radiology, and electrophysiology.

In nonprocedural areas, unique certification was established for geriatrics and palliative care. Additional new specialties include hospitalists, laborists, and extensivists, to name a few. These clinical areas do not yet have formal training programs or certification but are specific disciplines with core competencies and measures of performance that might be likely recognized in the future.

Telemedicine and Medical Care

Telemedicine is the delivery of health care services remotely by the use of various telecommunications modalities. The expansion of web-based services, use of videoconferencing in daily communication, and social media coupled with the demand for convenience by consumers of health care are all factors driving exponential growth in telehealth.²

According to one estimate, the global telehealth market is projected to increase at an annual compounded rate of 30% between 2017 and 2022, achieving an estimated value of $12.1 billion.² Some recent market surveys show that more than 70% of consumers would consider a virtual health care service.³ A preponderance of higher income and privately insured consumers indicate a preference for telehealth, particularly when reassured of the quality of the care and the appropriate scope of the virtual visit.³ Telemedicine is being used to provide health care to some traditionally underserved and rural areas across the United States and increased shortages of primary care and specialty physicians are anticipated in those areas.⁴

A New Specialty

Digital advances within health care and patients acting more like consumers have resulted in more physicians and other clinicians delivering virtual care in almost every medical discipline. Second-opinion services, emergency department express care, virtual intensive care units (ICUs), telestroke with mobile stroke units, telepsychiatry, and remote services for postacute care are some examples.

In the traditional physician office, answering services and web-based portals focused on telephone and email communication. The advent of telehealth has resulted in incremental growth of video face-to-face communication with patients by mobile phone, tablet, or other computer devices.^2,3,5 In larger enterprises or commercial ventures, the scale is sufficient to “make or buy” centralized telehealth command centers to service functions across broad geographic areas including international.

Early telehealth focused on minor ailments such as coughs, colds, and rashes, but now telehealth is being used in broader applications, such as communicating imaging and laboratory results, changing medication, and most significantly managing more complex chronic disease.

The coordination of virtual care with home visits, remote monitoring, and simultaneous family engagement is changing the perception and reality of virtual health care. Commercialization is well under way with numerous start-ups and more established companies. These services are provided by the companies alone or in collaboration with physician groups.

The Medical Virtualist

We propose the concept of a new specialty representing the medical virtualist. This term could be used to describe physicians who will spend the majority or all of their time caring for patients using a virtual medium. A professional consensus will be needed on a set of core competencies to be further developed over time.

Physicians now spend variable amounts of time delivering care through a virtual medium without formal training. Training should include techniques in achieving good webside manner.⁵ Some components of a physical examination can be conducted virtually via patient or caregiver. Some commercial insurance carriers and institutional groups have developed training courses.⁵ These are neither associated with a medical specialty board or society consensus or oversight nor with an associated certification.

Contemporary care is multidisciplinary, including nurses, medical students, nurse practitioners, physician assistants, pharmacists, social workers, nutritionists, counselors, and educators. All require formal training in virtual encounters to ensure a similar quality outcome as is expected for in-person care.

It is possible that there could be a need for physicians across multiple disciplines to become full-time medical virtualists with subspecialty differentiation. Examples could be urgent care virtualists, intensive care virtualists, neurological virtualists, and psychiatric or behavioral virtualists. This shift would not preclude virtual visits from becoming a totally integrated component of all practices to varying extents.

Based on early experience in primary care, one estimate suggests that 30% to 50% of visits could possibly be eligible for a virtual encounter.⁴ This could be amplified when coupled with home care and remote monitoring devices. There are varying data on the influence of telehealth on total health care services utilization and that will be determined with greater adoption. In addition, as the number of emergency department visits continues to increase nationally, health care systems must develop innovative ways to maximize efficiency and maintain high-quality standards.⁶

However, complete replacement of the traditional clinical encounter will not occur. “Bricks and clicks” will prevail for patients’ convenience and value. Physicians will lead teams with both in-office and remote monitoring resources at their disposal to deliver care. This model could be enhanced in the future with digital assistants or avatars.

In the surgical specialties, remote surgery has been more focused on telementoring and guiding surgeons in remote locations. There have been examples of true virtual surgeons who have operated robotically on patients hundreds of miles away.⁷ This approach can be expected to develop further in the coming years.

Critical Success Factors

The success of technology-based services is not determined by hardware and software alone but by ease of use, perceived value, and workflow optimization.

Medical virtualists will need specific core competencies and curricula that are beginning to develop at some institutions. In addition to the medical training for a specific discipline, the curriculum for certification should include knowledge of legal and clinical limitations of virtual care, competencies in virtual examination using the patient or families, “virtual visit presence training,” inclusion of on-site clinical measurements, as well as continuing education.

It will be necessary for early adopters, thought leaders, medical specialty societies, and medical trade associations to work with the certifying organizations to formalize curriculum, training, and certification for medical virtualists. If advances in technology continue and if rigorous evidence demonstrates that this technology improves care and outcomes and reduces cost, medical virtualists could be involved in a substantial proportion of health care delivery for the next generation.

Article Information

Corresponding Author: Michael Nochomovitz, MD, Physician Services Division, New York Presbyterian, 525 E 68th St, PO Box 182, New York, NY 10021 (mnochomovitz@nyp.org).

Published Online: November 27, 2017. doi:10.1001/jama.2017.17094

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank Risa Oliveto, Jonathon Monteiro, Shauna Coyne, and Laura Forese, MD, MPH, New York Presbyterian; Jane Torres, Weill Cornell Medicine; and Peter Fleishut, MD, New York Presbyterian-Weill Cornell Medicine, for providing input on the manuscript, none of whom were compensated for their help.

References

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American Osteopathic Academy of Orthopedics website. http://www.aoao.org/. Accessed August 23, 2017.

2.

Vaidya A. Global telehealth market to rapidly rise to $12.13B by 2022: 7 key trends. Becker’s Hospital Review. July 19, 2017. https://www.beckershospitalreview.com/telehealth/global-telehealth-market-to-rapidly-rise-to-12-13b-by-2022-7-key-trends.html. Accessed August 23, 2017.

3.

Dare  F. Voting for virtual health. https://www.accenture.com/t20170216T205948__w__/us-en/_acnmedia/PDF-43/Accenture-Health-Voting-for-Virtual-Health.pdf. Accessed August 23, 2017.

4.

Ripton  JT, Winkler  CS. How telemedicine is transforming treatment in rural communities. Becker’s Hospital Review. April 8, 2016. http://www.beckershospitalreview.com/healthcare-information-technology/how-telemedicine-is-transforming-treatment-in-rural-communities.html. Accessed August 23, 2017.

5.

There's a growing need to train physicians on how to handle virtual visits with patients. Modern Healthcare. August 27, 2016. http://www.modernhealthcare.com/article/20160827/MAGAZINE/308279981. Accessed September 11, 2017.

6.

Reddy  S. Can tech speed up emergency room care? Wall Street Journal; March 27, 2017. https://www.wsj.com/articles/can-tech-speed-up-emergency-room-care-1490629118. Accessed August 23, 2017.

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Eveleth  R. The surgeon who operates from 400km away. BBC. May 16, 2014. http://www.bbc.com/future/story/20140516-i-operate-on-people-400km-away. Accessed August 23, 2017.

Women's leadership

 

7 challenges women STILL face in higher ed  - and how to fix them

By Laura Ascione, Managing Editor, Content Services, @eSN_Laura

 

Low numbers of women in higher education present challenges the industry must solve.

 

 

 

While more than half of all college students are women, less than one-third of all full-time professors are women–and the troubling gaps in academia are proving difficult to close.

But the low representation of women in higher education isn’t indicative of their qualifications to be higher-ed leaders, according to Higher Ed Spotlight: Pipelines, Pathways, and Institutional Leadership: An Update on the Status of Women in Higher Education.

The pipeline myth, or the idea that there are too few women qualified to hold leadership positions, is exactly that–a myth. While there may be qualified women, are they holding higher-ed leadership positions at a stead rate?

The report offers an update on women in higher education and sheds some light on the positions and degrees they hold, salary gaps, and more.

1. New data indicate there are more than enough qualified women in higher education who can fill available leadership positions, and women are being prepared at a greater rate than men. Women have earned more than 50 percent of all doctoral degrees since 2006, more than 50 percent of all bachelor’s degrees since 1982, more than 50 percent of all master’s degrees since 1987, and more than 50 percent of all associate degrees since 1978.

2. But despite these encouraging statistics and despite women’s availability for higher-ed leadership positions, they do not hold associate professor or full professor positions at the same rate as men.

3. The higher the academic rank, the fewer women present. Women of color often outnumber men of color in lower-ranking faculty positions, but men of color hold full professor positions more often than women of color.

4. Perhaps one of the biggest indicators is the pay gap between men and women who hold the same faculty rank. During the 2015-2016 academic year, male faculty members made an average of $89,190, and female faculty members made an average of $73,782. Men are more likely than women to earn a higher salary and to hold a tenure track position.

5. The number of women presidents has increased since 1986, but as of 2016, women only hold 30 percent of presidencies across all higher-ed institutions. However, women presidents are more likely to have a PhD or EdD than their male peers.

6. Women presidents are more likely to have served as a chief academic officer, provost or other senior executive in academic affairs. Male presidents are more likely to come from outside higher ed or have had a different senior campus executive role than women presidents.

7. The percentage of women serving in a chief academic officer position has declined from 2008 to 2013 in public doctoral degree-granting institutions.

Benchmarking Women’s Leadership in the United States, a report published by the University of Denver’s Colorado Women’s College, suggests areas of future action to help close the leadership gap:

1. The governing board and the senior staff should annually review the institution’s commitment to diversity to evaluate how well it is working.

2. Identify, support, and advance women and women of color to become chief academic officers, provosts, and senior executives. These positions are stepping-stones to the presidency.

3. Look beyond sitting presidents in order to increase the pool of potential presidential selections. Because women are more likely to have followed a nontraditional career path, the best candidates may come from farther afield.

4. Review hiring and promotion policies to ensure they are fair and equitable and do not disproportionately encumber women. For example, if the majority of non-tenure track positions do not have equal standing in promotion, and women predominantly occupy these positions, then the university must critically evaluate its hiring process.

5. Evaluate the lack of tenure track hires and consider how promotion may be re-evaluated.

6. Insist that pools of candidates for faculty and senior leadership positions be diverse. Women cannot get hired if they are not in the pool of candidates.

7. Diversify search committees for presidential, senior leadership, and faculty positions. Often diversification on the committee helps ensure a search will be expanded to the broadest range of qualified candidates.

8. Make certain search committees have data on the status and benefits of women and women of color candidates.

9. If universities hire search firms, they should ensure the firms have a reputation for providing diverse pools of candidates.

10. Public institutions should pay particular attention to the declining number of women leaders. Among all the sectors, academia is the only one that has this trend. Typically, public organizations, entities, and offices have a better representation of women overall.

Erros de medicação

OPAS/OMS apresenta iniciativa para reduzir erros de medicação 

A Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS) apresentou nesta sexta-feira (17/11/2017) um panorama do 3º Desafio Global para Segurança do Paciente. A iniciativa Global Patient Safety Challenge on Medication Safety busca reduzir pela metade, nos próximos cinco anos, os danos graves e evitáveis associados a erros de medicação.

A apresentação foi feita durante o I Congresso Pan-Americano e o VI Congresso Brasileiro sobre o Uso Racional de Medicamentos, que acontece até sábado (18), em Foz do Iguaçu, Paraná, Brasil. Segundo Felipe Carvalho (foto), consultor de desenvolvimento e inovação tecnológica em saúde da Representação da OPAS/OMS no Brasil, os erros de medicação, além de causarem danos ao paciente, prejudicam os orçamentos de saúde.

“Os custos relacionados a erros de medicação representam 42 bilhões de dólares [cerca de R$ 136 bilhões] por ano. E isso é o que conhecemos, a ponta o iceberg. Imagina o que não conhecemos, o que está subnotificado. Essa estimativa da OMS foi feita com base em informações de países que têm esses dados. E esses países são também os que monitoram melhor a segurança do paciente. Então, sabemos que o problema no mundo é ainda maior”, afirmou.

Além disso, estima-se que os erros de medicação causam pelo menos uma morte todos os dias. Somente nos Estados Unidos, aproximadamente 1,3 milhão de pessoas são prejudicadas anualmente por esses equívocos.

Tanto os profissionais de saúde quanto os pacientes podem cometer erros que resultam em danos graves, como prescrever, dispensar, preparar, administrar ou consumir a medicação errada ou de forma inadequada, o que pode resultar em danos graves, deficiência e até mesmo morte.

A maior parte dos danos advém de falhas na maneira como o cuidado é organizado e coordenado, especialmente quando vários provedores de saúde estão envolvidos no cuidado do paciente. Uma cultura organizacional que implementa rotineiramente as melhores práticas e que evita a culpa quando os erros são cometidos é o melhor ambiente para cuidados seguros.

Desafio

O Desafio Global para Segurança do Paciente, lançado em março deste ano pela OMS, convoca os países a tomarem medidas prioritárias para abordar os seguintes fatores-chave: medicamentos com alto risco de dano se usados indevidamente; pacientes que tomam múltiplos medicamentos para diferentes doenças e condições; e pacientes que passam por transições de cuidados, a fim de reduzir os erros de medicação e danos.

Esse é o terceiro desafio global da OMS para a segurança dos pacientes. O primeiro foi sobre higienização adequada das mãos (“Clean Care is Safe Care”), em 2005, e o segundo tratava de procedimentos necessários para cirurgias seguras (“Safe Surgery Saves Lives”), em 2008.

 

Atenção integral ao idoso

Paraná lança Rede Estadual de Atenção Integral à Saúde do Idoso

Foi realizado em Maringá no dia 23/11/2017 o lançamento da Rede Estadual de Atenção Integral à Saúde do Idoso, iniciativa pioneira de ordenamento do atendimento à população idosa do Paraná, uma das prioridades da agenda de Saúde do Estado. 

Na solenidade presidida pelo Secretário de Estado Michele Caputo Neto e contando com a presença de várias autoridades estaduais, municipais e das instituições formadoras, além de representantes da sociedade, foram apresentados os documentos-base da Rede, "Avaliação Multidimensional do Idoso" e "Linha Guia da Saúde do Idoso - 2017".

Estes documentos foram preparados pela equipe técnica da Divisão de Atenção à Saúde do Idoso, coordenada por Rubens Bendlin, com a assessoria de Edgar Nunes de Moraes e contribuições da Sociedade Brasileira de Geriatria e Gerontologia - Secção Paraná .

Clique aqui para alguns flashes da cerimônia.

Predatory journals and publishers

Site mostra que pós-graduação brasileira publica em 485 periódicos predatórios

Lançado neste mês por três professores, Preda Qualis detecta revistas acadêmicas acusadas de não seguirem padrões científicos

MAURÍCIO TUFFANI,

Imagem: Preda Qualis.

 

Pelo menos 485 periódicos acusados de recorrer a más práticas editoriais são usados no Brasil por professores, pesquisadores e pós-graduandos, registra o site Preda Qualis, lançado neste mês por três docentes da USP, Unesp e UFABC. Essas publicações estão na plataforma de dados online Qualis Periódicos, do governo federal, que reúne e classifica cerca de 26,5 mil títulos e serve para orientar pesquisadores, professores e pós-graduandos a escolher de revistas acadêmicas para publicar seus trabalhos.

O objetivo do Preda Qualis, afirmam os autores da iniciativa, é “contribuir para o aperfeiçoamento dos critérios de avaliação dos programas de pós-gradução e do sistema Qualis”, que integra as atividades de avaliação da pós-graduação brasileira pela Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes), do Ministério da Educação.

Dos 485 periódicos “potencialmente predatórios”, 67% foram classificados nos estratos A e B do Qualis, em vez de serem listados no nível C, destinado a publicações consideradas inadequadas, afirmam os autores da iniciativa, Paulo Inácio Prado, do Instituto de Biociências da USP, Roberto André Kraenkel, do Instituto de Física Teórica da Unesp, e Renato Mendes Coutinho, do Centro de Matemática, Computação e Cognição da UFABC.

Embora considerem “baixa” a proporção de periódicos predatórios do Qualis – os 485 títulos detectados correspondem a 1,8% dos 26.477 registrados na plataforma –, os criadores do novo site entendem que “há uma grande vulnerabilidade do sistema de avaliação da CAPES à invasão por este tipo de publicação”.

Ponderações

Logo no início de sua apresentação, os criadores do Preda Qualis advertem que sua lista de títulos potencialmente predatórios “não é uma palavra final e está em constante revisão, devendo ser usada como subsídio para avaliações caso a caso e a critério dos autores e instituições”. E acrescenta:

O fato de um artigo ser publicado em uma revista potencialmente predatória não significa que este artigo seja de má qualidade. Um dos prejuízos causados pelos periódicos predatórios é justamente potencialmente afetar a credibilidade de tais artigos.

O Preda Qualis, está aberto para sugestões de leitores, afirmam Prado, Kraenkel e Coutinho, que também pedem para serem informados sobre quaisquer problemas encontrados no site.

Os periódicos predatórios são revistas editadas por empresas que exploram sem rigor científico o modelo de publicação de artigos acadêmicos em acesso livre, que é mantido por meio da cobrança de taxas de autores ou pelo custeio por parte de instituições científicas.

Tanto no acesso livre como no modelo tradicional, mantido por assinaturas anuais ou pela cobrança por artigo baixado pela internet, os periódicos considerados “legítimos” demoram meses e até mais de um ano para analisar e aceitar artigos, ou rejeitá-los. Os publishers predatórios não só reduzem a poucas semanas o intervalo entre a apresentação e a aceitação de artigos, mas também são menos seletivos e rigorosos nesse processo.

“Quanto mais artigos eles aceitam e publicam, mais dinheiro eles fazem. A prática de autores que fazem pagamentos aos periódicos criou muita corrupção na publicação acadêmica”, afirmou para a Folha em 2015 o biblioteconomista Jeffrey Beall, professor da Universidade do Colorado em Denver, que lançou em 2011 sua lista de “potenciais, possíveis ou prováveis publishers predatórios” em seu blog Scholarly Open Access, desativado em janeiro deste ano.

‘Acontecimento auspicioso’

“Acho essa iniciativa excelente! Espero que seja bem sucedida. O Qualis efetivamente funciona como uma ‘lista branca’. Por isso, é uma grande responsabilidade ter certeza de que exclua periódicos predatórios”, afirmou Jeffrey Beall. “Esses cientistas estão efetivamente defendendo a ciência”, disse ele sobre os criadores do novo site.

“Acho que os autores estão oferecendo um ótimo serviço, ajudando o Qualis a melhorar”, afirmou Beall referindo-se ao Preda Qualis. “O número [detectado] 485, ou 1,8%, é pequeno, mas não demora para que pouco veneno arruine um poço”, acrescentou.

Para o geógrafo Marcos Pedlowski, da Universidade Estadual do Norte Fluminense (UENF), um dos raros pesquisadores brasileiros a se posicionar frequentemente sobre o problema dos predatórios, o lançamento do Preda Qualis é  um acontecimento auspicioso para a comunidade científica brasileira, pois no oferece uma primeira ferramenta para saber mais sobre esse tipo de publicação acadêmica.

“Alguns poderão dizer que este não seria o melhor momento para o lançamento deste tipo de ferramenta, na medida em que enfrentamos uma grave crise de financiamento que afeta a capacidade dos pesquisadores brasileiros de seguir publicando nos mesmos níveis da última década. Eu já penso que este é o melhor momento, na medida em que teremos como ter escolhas claras de onde não publicar pesquisas que custam bastante aos contribuintes brasileiros”, afirmou Pedlowski.

“Ao mesmo tempo, poderemos nos mover da falsa dicotomia entre quantidade e qualidade na publicação de artigos científicos para nos concentrar em publicar nas melhores revistas, sejam elas de editoras tradicionais ou de acesso aberto”, acrescentou.

“Minha expectativa é que os colegas que estão lançando o Preda Qualis não se desanimem com as eventuais críticas e mesmo oposição ao seu trabalho. É que os desafios que estão sendo postos no enfrentamento ao crescimento exponencial das revistas predatórias não podem esperar mais para serem atacados de frente”, disse o professor da UENF.

Quase nada a declarar

Questionada por Direto da Ciência por meio de sua assessoria de imprensa, a Capes laconicamente respondeu com a nota transcrita a seguir em sua íntegra.

São classificados no estrato C os periódicos predatórios identificados na maioria das áreas para que o título permaneça visível e dessa forma deixamos claramente sinalizado para os programas, que a produção publicada nesse tipo de periódico não será considerada.

Research funding

Governo vai criar fundo privado para financiar pesquisa e inovação

O governo federal vai criar um inédito fundo privado com o objetivo de apoiar a pesquisa de alto nível no país e qualificar universidades e institutos nacionais a fim de que alcancem maior projeção e visibilidade internacionais.

O fundo deverá ser lançado oficialmente em dezembro e seus recursos – que podem chegar a R$ 2 bilhões por ano –, serão oriundos sobretudo de empresas dos setores elétrico, de bioenergia e petróleo, de telecomunicações e de mineração, que têm de investir ou por contrato ou por dispositivos legais cerca de 1% da receita líquida em pesquisa e desenvolvimento.

Segundo o modelo atual, essas empresas têm a incumbência de construir projetos e encontrar instituições para desenvolvê-los. Muitas vezes, porém, tal processo encontra obstáculos e parte desses recursos acaba não sendo investido na área. Transformam-se em multas das agências reguladoras ou são transferidos para o Tesouro Nacional.

A ideia é alimentar o fundo com parte desse dinheiro, além de oferecer a oportunidade de que outras empresas também contribuam com ele.

Seu formato não será o de um fundo patrimonial – como o do Instituto Serrapilheira, iniciativa privada de apoio a pesquisa –, no qual os rendimentos de uma dotação inicial servem para financiar projetos. A ideia do governo é provê-lo anualmente com os recursos das empresas e distribui-lo por meio de editais.
A previsão é que ele comece a funcionar em 2018 e distribua recursos a partir de 2019.

"A proposta é muito interessante e, por suas características, traz um novo alento aos pesquisadores brasileiros", diz Sandoval Carneiro Júnior [membro titular da Academia Brasileira de Ciências - ABC], professor emérito da UFRJ e diretor-executivo do Instituto Tecnológico Vale.

Marco Antonio Zago  [membro titular da Academia Brasileira de Ciências - ABC], reitor da USP, também elogia a iniciativa, pois considera que ela "pode trazer abruptamente uma quantidade considerável de recursos novos para a ciência e tecnologia, num momento de grande aperto.


Excelência

Embora a Capes, entidade ligada ao Ministério da Educação, seja a responsável por estruturar o fundo, ele será independente e contará com administração privada, com a participação de organizações como a Academia Brasileira de Ciências, a SBPC e a Confederação Nacional da Indústria, além de órgãos como a própria Capes e o CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico).

O fundo será atrelado ao Programa de Excelência de Universidades e Institutos, que está sendo criado pelo MEC. Para evitar a contratação de um grande corpo burocrático, ele utilizará a Capes e o CNPq para executar o programa, que deve durar dez anos. E que conta com as seguintes iniciativas:

1) Desenvolver e internacionalizar as instituições de ensino superior.
2) Dar apoio a grupos de excelência em pesquisa básica e aplicada que possam projetar as universidades brasileiras entre as melhores do mundo.
3) Melhorar o relacionamento da academia com o setor privado e com a sociedade, com vistas à inovação.

Este último ponto é crucial, na visão de Carneiro Júnior. "Esse modelo pode propiciar uma interação bastante profícua e necessária entre o que pesquisamos na academia e o setor produtivo."

Com o caráter privado do fundo, busca-se evitar que ele seja contingenciado pelo governo federal ou esteja submetido à lei do teto de gastos, que limita a aplicação de recursos públicos ao Orçamento do ano anterior mais a inflação.

O reitor da USP rechaça a ideia de que a criação do fundo poderia significar uma privatização da área de ciência e tecnologia - crítica comum a iniciativas desse tipo.

Os órgãos governamentais devem ficar responsáveis pela elaboração dos editais e pela avaliação do uso dos recursos distribuídos.


Diagnóstico

Dirigentes da Capes vêm apresentando a ideia do fundo e discutindo-a com membros de dentro e de fora da academia há cerca de três meses.

O diagnóstico que embasa a iniciativa é que o Brasil tem crescido nas últimas décadas em produção científica e tecnológica, mas que a qualidade não acompanha essa marcha. Ademais, as universidades não possuem projeção que corresponda à importância da economia nacional.

Por fim, a capacidade de inovação do país vem decaindo em comparação com a de outras nações. No Ranking Global de Inovação, o Brasil despencou da 47ª posição em 2011 para a 69ª em 2017.

Assim, o componente fundamental do fundo e do programa de excelência é a tentativa de aprofundar a internacionalização da pesquisa brasileira, associando-a aos melhores grupos do mundo.

Pesquisa feita pela Elsevier, empresa que é referência na área de ciência e tecnologia, mostrou que 63% dos pesquisadores brasileiros nunca deixaram o país para fazer pesquisa. O impacto (a quantidade de citações) dos artigos desses cientistas é 24% menor do que a média mundial.

Já os artigos dos 28,6% de pesquisadores que regularmente fazem ciência em colaboração com estrangeiros têm, em média, o dobro do impacto da média mundial.

"É claro que é necessário um apoio básico, permanente e distribuído ao qual todos os pesquisadores tenham acesso", afirma Marco Antonio Zago. "Por outro lado, grandes avanços da ciência exigem recursos vultosos e que têm de ser concentrados em algumas iniciativas que tenham mais substância."


Questionamentos

Carlos Américo Pacheco, diretor-presidente da Fapesp, também vê com bons olhos a iniciativa, mas diz que pode haver resistência de agências reguladoras e setores econômicos, inclusive com questionamentos jurídicos sobre a destinação dos recursos. "Essa iniciativa é boa. Ela abre debate sobre alternativas para financiar a pesquisa."

Ele afirma que um dos méritos do projeto é ir além da busca por recursos. "Envolve também solicitar planos para a universidade acerca do que ela pretende fazer na área de internacionalização e pesquisa de qualidade."

Mas a comemoração pelo "dinheiro novo" para a pesquisa nacional, diz Marco Antonio Zago, "não exclui outros movimentos para aumentar o orçamento do CNPq, ou para eventualmente descontingenciar fundos setoriais".


Iniciativas envolvidas no programa: os três eixos

1. Inovação
    Melhorar e agilizar o relacionamento entre as universidades e as empresas
   Incentivar a geração de produtos e processos de interesse nacional

2. Internacionalização
   Universidades e instituto de pesquisa devem apresentar plano para internacionalizar a pós-graduação
  Ênfase na mobilidade de doutorandos, pós-doutorandos e professores para o exterior e do exterior para o Brasil

3. Excelência
   Apoio a "clusters" (grupos de pesquisa de uma mesma universidade ou instituto de pesquisa ou locais próximos)  de excelência em pesquisa básica e aplicada
  Pesquisas devem se concentrar em áreas competitivas internacionalmente.




A Diretoria da Academia Brasileira de Ciências esclarece que ainda (17/11/2017) não recebeu nenhuma informação oficial sobre o assunto, e que se manifestará quando da notificação.


Veja a matéria original da Folha de S. Paulo com infográficos.

(Fernando Tadeu Moraes e Phillippe Watanabe para Folha de S.Paulo)

Physician's words

The Iatrogenic Potential of the Physician’s Words

Arthur J. Barsky, MD¹

 

 

Article Information

 

JAMA. Published online October 31, 2017.  doi:10.1001/jama.2017.16216

 

 

Some of the information that physicians convey to their patients can inadvertently amplify patients’ symptoms and become a source of heightened somatic distress, an effect that must be understood by physicians to ensure optimal management of patient care. This effect illustrates the iatrogenic potential of information, as opposed to the iatrogenic potential of drugs and procedures.

Somatic symptoms and underlying disease do not have a fixed, invariable, one-to-one equivalence. Symptoms can occur in the absence of demonstrable disease, “silent” disease occurs without symptoms, and there is substantial interindividual variability in the symptoms resulting from the same pathology or pathophysiology. One mediator of this variability between symptoms and disease is the patient’s thoughts, beliefs, and ideas. These cognitions can amplify symptoms and bodily distress. Although cognitions may not cause symptoms, they can amplify, perpetuate, and exacerbate them, making symptoms more salient, noxious, intrusive, and bothersome.

Several common clinical scenarios exemplify the iatrogenic potential of the physician’s words—for example, instituting a new medication regimen, reviewing an informed consent document, presenting ambiguous laboratory test information, and preparing patients for painful procedures.

Knowledge of the nonspecific, diffuse, ambiguous adverse effects of a drug (such as fatigue, difficulty concentrating, nausea, dizziness, headache) increases the frequency with which they are experienced and reported.¹ Whether the information is imparted through discussion with the physician or when obtaining informed consent, patients who learn about the common, nonspecific adverse effects of β-blockers, statins, estrogen-containing oral contraceptives, and agents for obstructive urinary symptoms report more of these putative adverse effects than comparable patients not informed of them. For example, in a study of 76 patients who received β-blocker treatment for hypertension, erectile dysfunction occurred in 32% of the 38 patients explicitly informed of this adverse effect and in 13% of the 38 patients not specifically warned about it.² Likewise, in a double-blind trial of statins, the incidence of muscle-related adverse effects increased from 1.00% per year to 1.26% per year when patients (n = 9899) were subsequently unblinded and given the active drug.³

The nocebo phenomenon (the development of adverse effects to placebo) strongly supports that patient knowledge of adverse effects influences the reported incidence of these symptoms. Thus, the frequency and profile of adverse effects manifested by patients randomized to receive placebo in controlled, double-blind clinical trials are similar to those they have been told may occur with the active comparator drug.

Providing test results of dubious clinical significance also can lead to increased symptoms. For example, in a randomized study of acute low back pain, one group (n = 210) underwent spine imaging, whereas the other group (n = 211) did not. A treatment plan of conservative medical management was implemented in both groups. At 3-month follow-up, the former group had significantly more pain, greater functional impairment, and more physician visits.⁴ The problems involved in conveying equivocal test results or anatomical abnormalities of unknown clinical significance (“incidentalomas”) are likely to increase in importance as the volume and resolution of diagnostic testing accelerate.

Pain is particularly sensitive to the beliefs, thoughts, and expectations of patients. The specific language used in describing and preparing patients for painful procedures can affect the pain experience. For example, in a randomized study of women receiving epidural anesthesia or spinal anesthesia (n = 140) for childbirth, those told that the intradermal injection of a local anesthetic would “feel like a bee sting: this is the worst part of the procedure” reported significantly more pain than did those told “the local anesthetic…will numb the area and you will be comfortable during the procedure.”⁵ The importance of cognitions in the experience of pain is particularly timely, given the current crisis in opiate treatment for chronic, nonmalignant pain.

The Mechanism of Viscerosomatic Amplification

Viscerosomatic amplification has been proposed as an explanatory mechanism whereby information can affect the perception of symptoms.⁶ The information conveyed by the physician does not cause somatic symptoms but rather amplifies symptoms—symptoms that may be due to the underlying medical condition or to normal physiology (eg, ectopy, orthostatic hypotension), common benign dysfunctions (hoarseness, bloating, cramps), transient and self-limited ailments (rashes, upper respiratory tract infections), stressful life events, lack of exercise, insufficient sleep, or dietary indiscretion.

New medical information can initiate a self-perpetuating and self-validating cycle of symptom amplification (eFigure in the Supplement). Learning that a symptom may be more noteworthy or medically significant amplifies it. Reattributing the symptom to a new and more serious and more concerning source then causes the patient to monitor and scrutinize the symptom more closely, and this heightened attentional focus amplifies the symptom, making it more intense and intrusive, more disturbing and distressing.^6,7 The misattribution also launches a selective search for additional symptoms to corroborate the suspicion that something is wrong, resulting in a heightened awareness of other diffuse, transient, or ambiguous symptoms that were previously ignored, minimized, or dismissed as insignificant. The seeming emergence of these “new” symptoms (along with dismissal of observations that do not confirm the suspected cause) is taken as further evidence of seriousness. The cycle of amplification is also fueled by mounting anxiety: Increasing worry and concern about the symptom’s medical significance, and its apparent worsening, make it more threatening and ominous.

 

Modulating Symptom Amplification and Minimizing Undue Distress

Careful attention to what and how information is conveyed can minimize the inadvertent fostering of excessive, disproportionate, and unduly bothersome symptoms. The initial therapeutic step is an exploration of the patient’s ideas about the symptoms: What is the suspected cause of the symptoms and their putative significance, what is the future course expected to be, what is most worrisome and troubling about them? The answers to these questions can lead to more realistic and reassuring discussion of the patients’ specific concerns.

Explaining the process of viscerosomatic amplification can be beneficial. Understanding that the interpretation of medical information can exacerbate and perpetuate symptoms, and learning about the processes of misattribution, selective attention, increased bodily scrutiny, and secondary anxiety, can have a palliative effect by providing patients with a more benign and reassuring explanation for their discomfort. The reassurance that the symptoms, however bothersome, are not medically harmful makes them less intrusive and more tolerable. The nocebo phenomenon provides a vivid, helpful, and nonpejorative illustration of the power of beliefs to amplify symptoms. This discussion also helps by emphasizing and encouraging adaptive coping to increase the tolerance of discomfort. It may be useful to prospectively identify patients at increased risk of disproportionate or undue nonspecific medication adverse effects, so that the amplification process can be explained to them in advance. This can be done with the Perceived Sensitivity to Medicines scale,⁸ a 5-item self-report questionnaire with demonstrated validity and reliability.

In addition to exploring the patient’s ideas and explaining the process of amplification, physicians need to use care in their choice of words. For example, in discussing potentially painful procedures, physicians can emphasize what will be done to alleviate the pain (such as simple relaxation techniques), use neutral language to describe the experience, and give the patient as much choice and control over the analgesic regimen as is medically feasible. Likewise, language is important in discussing nonspecific drug adverse effects, for example, focusing on the proportion of patients who do not have the adverse effects being enumerated, rather than on the proportion who do, and closely coupling information about benefits with information about adverse effects.

When obtaining informed consent, physicians must absolutely provide complete and truthful information and must avoid fostering a “paternalistic” patient-physician relationship. But balancing the requirement for full and complete disclosure with the iatrogenic potential of some information is problematic. “Contextualized informed consent” has been proposed as an ethical way of balancing these competing imperatives.⁹ When prescribing a medication, all serious and medically significant adverse effects are of course described, and the patient is instructed to report all adverse effects; however, if the patient agrees, benign, nonspecific symptoms are not enumerated in advance because it is explained that doing so makes them more likely.

Unusually distressing symptoms may point to difficulties in the patient-physician relationship, because symptoms can be a nonconfrontational and less explicit way of expressing doubts or concerns that patients feel and are unable or too embarrassed to voice openly. Symptoms can then become a covert, nonverbal communication of anxiety about pain, misgivings about medications, concerns about the meaning of a diagnostic test result, or concerns about the physician’s care or expertise.¹

Conclusions

Information is an important mediator of the variability in the relationship between disease and symptoms. Some nonspecific drug adverse effects, undue pain from procedures, and symptoms exacerbated by learning about test results of unclear medical significance can be understood to share similar pathogenic mechanisms and respond to similar strategies of medical management.

Article Information 

 

Corresponding Author: Arthur J. Barsky, MD, Department of Psychiatry, Brigham and Women’s Hospital, 60 Fenwood Rd, Boston, MA 02115 (abarsky@bwh.harvard.edu).

Published Online: October 31, 2017. doi:10.1001/jama.2017.16216

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

 

 

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