Alberto E Tozzi
Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it
We are living in a time of reflection suspended between the glorious history of pediatrics, the great goals and the progress achieved over time, and a future yet to be discovered. Any pediatrician champions children and ever since they visited a child for the first time, they dream of discovering any useful tool to improve their patients’ health. In recent decades we have witnessed a constant and progressive improvement in healthcare thanks to new discoveries in the fields of diagnostics and therapy, and to the creation of infrastructures that painstakingly, but inexorably, pursue the continuity of care. But we are insatiable. We look or solutions to the endless list of big and small problems that dot the patient’s path, as they strive towards the optimum level of health. Therefore, in addition to being proud of the goals achieved, we must look forward.
Theme 1: In the beginning it was EBM
One of the great achievements in medicine has been the understanding that clinical decisions should be based on data. The evidence based medicine (EBM) revolution took time to take place but, finally, we can no longer renounce it. EBM should guarantee patients the right to enjoy the best possible care, ideally being an instrument of equity. It is worth remembering that clinical epidemiology, the foundation of EBM, is a medical science and it would be a serious mistake to think that pediatricians can do without the ability to critically appraise scientific studies that guide their decisions. Unfortunately, the amount of scientific publications has increased exponentially, making it impossible to keep up with systematic reading. Moreover, data streams are submerging us and we are not yet able to make a timely and rational use of them. Finally, we still need to develop evidence for complex patients and those with multi-morbidities. Pediatricians have the unprecedented opportunity to use artificial intelligence and epidemiology to revitalize EBM to address these challenges, and to lead technological advancements for the best use of data and of medical knowledge supporting clinical decisions.
Theme 2: The eternal confusion between scientific research and innovation
There is still great confusion between the concepts of scientific research and innovation. In scientific research, resources are used with the aim of increasing knowledge. Clinical trials are carefully planned with detailed protocols in order to minimize the risk of failure. Although innovation is closely linked to scientific research, its intent is to introduce a new value and bring it into clinical practice and, if possible, onto the market, so that everyone can benefit from it. Innovation does not pass through linear experiments but rather through continuous cycles that allow the creation of prototypes of products or interventions that, in the final form, meet the needs of its end users. It is a process where the risk of failure is much higher than in research. On the other hand, in case of success, the gain in terms of the process is very high. While scientific research and innovation are complementary, innovation products may become applicable in routine clinical practice in the short term. We are familiar with scientific research methods but we often believe that innovation should be left to other disciplines and we disregard its methodology. Educational programmes focused on innovation methods should be integrated into pediatric curricula.
Theme 3: Super specialist or interdisciplinary pediatrics?
The super specialist approach is no longer sufficient to satisfy the thirst for medical progress and, indeed, imposes numerous limitations. Much of the pediatrician’s work still remains in the comfort of the specialist bubble, where we hear the echo of our voices and feel safe. We continue to pursue the improvement of quality of care which has contributed to enormous progress, but which, applied incrementally, is no longer sufficient to solve the great problems of large-scale populations. There is scope for the development of new high impact solutions for pediatrics which is closely linked to the collaboration between different disciplines. We must challenge ourselves and open pediatrics to interdisciplinarity more than ever to tackle complex problems of child patients through collaboration and contamination between different skills and expertise.
Theme 4: The role of child patients
Is it possible to consider pediatric patients not only as allies, but also as collaborators? Children continually teach us a great deal but we have not yet adopted a systematic approach to working with them. In citizen science, children may act as principal investigators of their own projects, planned and conducted with standardized methods. The step from educational to patient centered innovation projects is short. Design thinking is a powerful tool that relies on empathy with users to develop innovations based on a deep understanding of what they really need. This methodology, still uncommon in healthcare, can radically transform the relationship with patients and their families. We, as pediatricians, have the opportunity to develop solutions for treatments never before considered, with patients, rather than only for patients, through co-creation. Embracing a participatory model will push forward research and innovation focusing on patient centered care and leveraging the creativity of children.
Theme 5: Changing is tough
Eric Topol, in his review for the English National Health System, reaffirmed three principles that still remain neglected: patients must be considered our partners in affecting change with particular attention to vulnerable populations; health professionals must learn to evaluate new technologies based on evidence; technologies must be interpreted as tools to increase the time available in the personal relationships between doctor and patient. Applying these principles in the existing health systems often means going out of our own comfort zone. Change is difficult, which is why great changes are often associated with emergencies or other traumatic events. There is space, however, to break down the barriers of scientific individualism and pool the enormous resources that are still unused. Change is typically a team sport and, although it is often triggered by a few leaders who are ahead of their time, it cannot be accomplished without participation, from within the walls of one’s own clinic, to policies on a national or international scale.
Crossing the pandemic portal
Is using these tools for innovation still pediatrics? Certainly yes, if pediatricians will be able to guide strategic choices in these fields for the good of the child. At the beginning of the last century, the most important causes of illness and death were represented by infectious diseases and malnutrition. Pediatrics focused on these and on gastroenterological problems and, at that time, only primitive tools were available for antibiotic treatment and vaccine prevention. Since then, we have developed vaccines for serious and fatal diseases that have radically changed the health of populations. We have learned how to lower the risk for SIDS. We have found effective therapeutic strategies for acute lymphatic leukemias and we have very good hopes of making treatments for other pediatric cancers more effective. Chronic patients live better and longer. We keep on discovering the causes and mechanisms of genetic diseases while developing possible therapies to cure them. More recently we have gained ground in the field of resuscitation techniques, in regenerative medicine and in surgery. We are also focused on medical complexities, and finally, as pediatricians, we always work towards prevention.
While contemplating our successes, the COVID 19 pandemic arrived and uncovered all our weaknesses in strategies to promote child health and inexorably accelerated some decisions that seemed uncertain. Despite the enormous progress, we are using methods of containment for the pandemic, such as quarantine, which we have inherited from biblical times. The emergency has stimulated attention on novel tools for medicine that can be developed and implemented very quickly, as new vaccines for SARS COV2, and has made us discover that we strongly need innovation for developing new health strategies for patients. As Arundhati Roy recently wrote, pandemic is a portal. Let’s cross it fast and let’s put innovation at the service of children who are the future of humanity.
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