20 May Julio Mayol: “Research is one of the key points in the response to this pandemic”
Interview Julio Mayol – Professor of Surgery at the Complutense University of Madrid and Medical Director of the San Carlos Clinical Hospital
Julio Mayol is Professor at the Complutense University of Madrid and Medical Director of the San Carlos Clinical Hospital, where he was Head of the Colorectal Surgery Section until 2016. Since 2010 he is Director of the Innovation Unit of the San Carlos Health Research Institute (IdSSC), board member of the Centre for Surgical Studies of the Department of Surgery of the UCM and patron of the San Carlos Biomedical Research Foundation. Furthermore, he has been a member of the BJS (British Journal of Surgery) editorial board joining the board of directors in 2015.
The COVID-19 pandemic has been a severe ordeal for hospitals around the world. Nobody was prepared for a situation like the one we have experienced. Are we now better prepared to face a new pandemic? Have we learned anything?
The pandemic was something predictable that the entire global public health system was waiting for, although only Asian countries such as South Korea and Taiwan had done their homework, because they had already suffered from SARS. Australia and New Zealand decided to copy their elimination strategy versus the mitigation strategy we chose in Europe and America. We have prepared ourselves for a new outbreak, although not entirely, of a very similar virus to SARS-CoV-2 or for a reactivation of one of its variants, but it is very unlikely that as a system we have learned to prepare ourselves to attack new pandemics.
What changes must be made in our healthcare model to be effective?
A total transformation. Faced with a crisis like this, you only have two options: introduce enormous transformative changes or take a conservative position of “we are going to consolidate what we have because it is what we have.” Changes must be made in funding in the business model. Right now, we are funded by a fee-for-service payments and we have to move on to pay-by-value models. As for the current business model, it was already depicted in the Talmud: “the patient gives money to the doctor, he might be cured, and he might not be cured”. We are in the 21st century and we are using exactly the same model. We also have to be able to make decisions based on data, not narratives.
Right now, both politicians and system operators, who are the professionals, base all their decisions on three narratives: fear, envy – as professionals we compete because they have chosen us to compete-. And thirdly, fantasy or wishful thinking: if we do this, we will get better. But since we never measure when we get better, we don’t know why we are better and we don’t know if we are really better. Another change must be technological innovation: taking full advantage of the advances that are produced in technology to embed them in new healthcare processes, and abandoning the organisation in silos, in professions, in specialties, and think about processes.
Although the focus has always been on the importance that telemedicine could have, it seems that it has not finished catching on. One consequence of the pandemic has been the need, especially during the first wave, to establish telemedicine as a first-order resource. Has it come to stay or will we return to the old face-to-face model when all this will be over?
It seems that our model is built around the face-to-face medical consultation; therefore it will be difficult to make a leap towards telemedicine. We have jumped to telemedicine, or something similar to telemedicine, not as a reengineering of the process but rather as a resource to the fear of contagion and lack of access to the system, but we have not modified our healthcare processes. Therefore, the most normal thing is that as soon as we lose fear of these SARS-CoV-2 waves we will return to the face-to-face model. Changes are undoubtedly taking place, but it doesn’t seem that they will come about, at least in the short term.
The pandemic has also shown the need for a healthcare model where primary care has more weight in order to prevent the collapse of hospitals in crisis situations. How is this valued from the hospitals?
In the current model, primary care is one of the keys and for many reasons, such as under-funding, it has not worked. This pandemic has bypassed all filters to reach hospitals and hospital ICUs. The truth is that the whole model would have to be transformed: without primary care-hospital levels and taking in account the healthcare process during the complete cycle. Public health should be the retaining wall in a pandemic situation like this one, but it was not. Primary care served as containment for a time but there is a complexity and sophistication in the need to use technology that cannot be solved, and then we reach saturation levels. This depends on the quantity, on the inflow of patients and the system may or may not be able to deal with this, that is why we should transform the entire system and not only strengthen primary care.
The entire model is insufficient to respond to increases in demand of this magnitude. There is no system that is capable of doing so. The first mistake was to choose mitigation as a strategy and that was a public health decision, and a political one. It was the first mistake. There is no system capable of absorbing this, neither in Spain nor in the United Kingdom nor in the United States nor anywhere else. You have to change the entire system because if we keep doing the same thing, even if there are more resources, exactly the same thing will happen again.
Drawing positive conclusions from the pandemic, what has been evident has been the importance of research and also the role that hospitals play in it. To what extent is it crucial for a hospital to have its own research centre so as to have a continuous flow of feedback between the two of them?
Research is one of the key points in response to this pandemic. The biotechnological capacity of the scientific system has been colossal and has made it possible, on the one hand, to generate vaccines very quickly and, on the other hand, to quickly rule out through well-organised clinical trials which treatments did not work. For example, our hospital participated in the first study involving the WHO to test whether any of the existing treatments worked, for example remedesvir or hydroxychloroquine.
Therefore, a strength of the system has been its ability to answer key questions through clinical trials. But, have we been able to transfer the knowledge generated to clinical practice? It is a new line of research development, but above all, of innovation. How to use knowledge to improve the health outcomes of our patients even during a pandemic?
We have just published 600 cases of pneumonia that were not physically admitted to hospital and that we manage remotely at the patient’s home because in the first wave we learned with the data, we trained algorithms to help in decision-making and we have applied those decisions based on data from real life to clinical practice, and that has been beneficial. The question is how to transfer it throughout the system. It is not easy and that is where we have a lot of potential to advance innovation. Innovation is about taking knowledge and using it to generate value.
Top-level biomedical research has been underway in Spain in recent years and the transfer of this research to the market is starting to be carried out. What role are hospitals playing in this transfer?
The role of hospitals is unequal because we don’t have a legal framework that facilitates the transfer of research results to generate new products and new services. We don’t have a framework that allows efficient and quality exploitation of the knowledge generated within the system.
To what extent can the transfer be an important source of income that helps in the sustainability of our hospitals and the healthcare system?
Our country is not a leading power in the marketing of products. Therefore, it is unlikely that with the current system we will be able to generate enough income to improve their sustainability. Without a doubt, it should not be the main pillar in the exploitation of the transfer of research results; it is only a part of it. It is about learning the system: how the system works better by making this transfer, how hospitals function better as primary care, and it also serves to motivate professionals within structures that don’t favour excellence.
What do you think will be the main strategic lines to be developed in the coming years in terms of technology transfer in the healthcare sector?
It is very difficult to predict this: Innovation would be necessary in those areas that have a greater burden on the healthcare system and on society. Secondly, where we have the knowledge and experience to be able to carry it out and where we also have a critical mass of innovators and the productive and industrial fabric in the country to be successful. Interesting areas? For example, regenerative medicine. There was an initial impulse with all the cell therapy lines that has not been sustained over time, in addition to the area of transplants and their research, which, being very transversal, involves many other areas within biomedicine. On the other hand, gene editing: everything related to manipulating our genome is also very important.
And, finally, all this related to data: how to use the large amount of data we have in healthcare systems, much of it of valuable quality, to generate artificial intelligence, to generate both machine learning and deep learning solutions that help professionals and patients to make the most correct decisions possible about their own health, or about the clinical decisions they must make.
Work is now being carried out on another ”Science Law”, will the technology transfer of research environments be taken into account to transform this knowledge into innovation and in products that will reach the market?
We believe that just by changing legislation we have already achieved substantial effects, and furthermore immediately, but it is not enough. We hear that research is supported in Spain. But how many millions of euros support research or innovation? It is not about changing the legislation, it is about changing the country. And that is not done through a law of science, it is done through a strategy that is not immediate, that does not offer immediate results and that has multiple levels of action not directly related to science or research.
As well as being the medical director of the San Carlos Clinical Hospital, you continue to be closely linked to the field of surgery. What are the great challenges for the future in the medium and long term for surgery?
The two great challenges for surgery: digital transformation to obtain greater knowledge of what happens in the surgical area among professionals and with patients, how to help in decision-making, increasing not only effectiveness but also patient safety. Also the automation and robotisation of surgical processes, both preoperatively and intraoperatively and the follow-up of patients to evaluate the result.
In recent years there have been great technological advances in the field of surgery. Has there also been adequate progress in the training of surgeons so that they can take advantage of all these advances?
We still have a great dissociation between education, training, and the technological advances that occur in surgery. It is logical that there is a certain transition, but all these changes driven by technological innovation should lead us to rethink the training of surgeons: from how they acquire and manage knowledge, how it is learned, how skills and abilities are acquired and how they are maintained over time, as training a surgeon is not a unique or time-limited process. As surgeons we have to know how to direct our learning over time, evolving with changes in context, both social and technological and, on the other hand, we must bear in mind that we do not perform surgery individually. Today, surgery is a team effort, and we must also include patients and their families in that team.
You are now part of the GENESIS Biomed Business Advisory Board. How do you think you could contribute with your experience to the projects we work on and how do you value this type of initiative?
GENESIS Biomed is an example of a key agent in an R+D+i ecosystem. We need translators, we need experienced teams to coordinate actions within healthcare systems and the bio-health R+D+i ecosystem. And that all this is translated into real actions so that the knowledge ends up being something actionable for the end user. Downstream users who are health professionals’ benefit from the work of GENESIS Biomed because they improve their ability to carry out actions that are of great interest. In the end, the basic issue is to improve the health of citizens. And GENESIS Biomed is one of the major players in that ecosystem that we have not taken into account for a long time, the role played by organisations like GENESIS Biomed has been ignored.