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Sistema de seguridad social Colombiano (clase 2) — Transcript · YTtoTranscript

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Sistema de seguridad social Colombiano (clase 2)

Clases medicina · 8,800 words · 44 min read · EN

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TRUE? Let's do this to relax with your little finger. We

will use our finger to follow the presence of the image. Ready. I see them with my little finger.

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[music] Well, for those who enjoyed it at home, for those who feel like they're making a fool of themselves, well, that too. Okay, then let's pass my chicken. Pass me my chicken, please.

Why risk tomorrow? What is risk? We saw it yesterday. And we saw it. What? Silence. That is the probability of an unfortunate event occurring. And speaking of health, what could that unfortunate event be? Getting sick, right? Or worsen the condition I already have. OK? Okay. Hey, keep going with the pol, please.

with the chicken. Who has the chicken? Yes, it was you. Yes, I saw it. Okay, come here, please.

Last class, we talked about risk management in our health system, and I presented that to them about halfway through and at the end of the class . Ready? What does that sum up? Tell us. Oh, so you beheaded the chicken. [laughs] Well, the risk also has to be taken into account depending on the

person. In other words, a young person like me, I don't know, is not going to have the same risk as a person of the same age, but with other resources, an older person. Okay, so that's how we start the class. Okay. Well, it also has to be taken into account that, as it says there, we

also focus on cardiovascular risk. Uh, well, I don't really remember exactly what it was about, what it was about, and also what other diseases could develop from it. Okay. Like the 16 risk groups that Colombia has. Alright. Sit down. Oh, no. Continue with the chicken. Yes, sit down and keep going with your colleagues. Already.

Who has the chicken? You. No, not anymore. every day. Come. And you show me why I told you that this seems to me a graph that can exemplify everything we did in class. Silence. Please, the idea is that you explain to me why I told them that this slide was very important as a summary of what we saw

happen. Well, because here are all the things that can represent, like, all the risks to the person. Okay. Where? For example, in a patient throughout their life course, they also decide how much time they have or not, how, where they live, with whom they live, what their home is like, and what needs they have

as they grow up, as they reach adulthood, and in their old age. The general promotion and maintenance route is more like, I mean, I see it more as the one that is accessible, you know? as specifically as cardiovascular brain, as where there may be more diseases that can be had or the risks that can be most

common, such as the special route of hypertension or diabetes, since I feel that it is as in addition to the topics that we have talked about a lot, as diseases that could be said to be more repetitive. So I feel that this graph is like what the risk is and also how one could

prevent it, taking it into account. Okay. Okay. Stop over there and let's go for the last chicken rotation.

The top rotation. Okay, so summary. That shows us the risks that each individual faces. We see that the little ones are protected from that welfare world. Uh , okay. And yes, well, the risks that each person has in their life in general. Okay. Nothing. Someone here wants to help me make a slightly more accurate summary of

what I've said here, right? Okay. Well, let me tell you that they have... Yes, it's true that my topics are deductive, but no. What we're talking about is that in order for me to do risk management, I need to have different scenarios. Within those scenarios, I clearly need to have a care model that tells doctors,

paramedics, and others how to care for people, how to care for people throughout their life course. So, this isn't because the little umbrella is more or less effective, but because whatever the healthcare system's care model may be, it has to provide care from childhood to old age and from health promotion to end of

life. And that means this part as well as the entire network it has. But these individuals have particular needs. Since they have particular needs in Colombia, there is something we do to prevent them from getting sick, which is the promotion and maintenance route. For practical purposes, for those who have always had prepaid insurance, it was their mother

taking them to Mexico every 6 months. Yes, the health promotion and maintenance pathway is a technical document, like a guide, with a protocol written in Colombia that tells doctors, "How often do you have to see a newborn? How often do you have to see a child between 5 and 10 years old? How often do you

have to see an adolescent? How often do you have to see an older adult for health promotion and prevention activities? But since we all get sick and have risks, right? And last time we were talking about a balloon, uh, I do n't remember if it was a woman or a man who had multiple

sexual partners. So, it turns out that we, depending on our particularities, conditions, lifestyles, and habits, cause those risks to materialize, right? And then the possibility of treating an individual comes into play. Here, in the case of cardiovascular diseases, most have a multidimensional etiology, like hypertension, right? Because it occurs, we don't have a

clear understanding. We know that there are multiple risk factors that cause me to get high blood pressure, right? Like being obese, for example." For example, if I'm Black, for instance, then I might be more susceptible to developing hypertension. But when I do get hypertension, my doctors should be trained to treat me for it

. This means that this step requires the healthcare system to create mechanisms to efficiently treat these patients with high blood pressure . But it turns out that patients with high blood pressure also have heart attacks and other associated illnesses. So the healthcare system should be able to treat everyone, right? With all these different circumstances and

characteristics, right? We were also talking about how, in order for me to do this, I have to stratify the risk; I have to know my population. So, we were talking about how you told me there were 108 of you, right? And if I wanted to know the population, I would have to ask Dr. Malda or the

dean's assistant to tell me how many of you are men, how many are women, your ages, and if you reported any type of condition that I should be aware of, for example, right? And that's how it was last time. I showed a pyramid there with many arrows and interactions, explaining that when I go to meet this

population, the idea is to be able to determine everyone's priorities, right? If I wanted to do an intervention, then I've already met them, now I have to group them. Ah, look how many are men, how many there are here. Some of you said that some of you vape. So, there you go . Yes, I already have this whole

picture and now I have a pyramid that tells me, listen, if there's someone who hasn't had their BPH DNA tested, for example, who smokes, who uses active substances, I'm definitely going to prioritize them. Why do I prioritize in risk management? Because I'm never, ever going to have enough money or enough human resources to treat

everyone. So I have to do it like when, I don't know, you get your allowance and you want to buy something and go to a concert, well, you prioritize: do you go to the store or do you take the TransMilenio and you can go to the concert? Right? That's how I do risk management.

Obviously, at a macro level, those priorities depend on many things, and the health system is organized this way, from the care model, with the 16 risk groups I explained last class, to be able to provide people in a democratic country with the rights they want. And then, this is where people with rare diseases, their mothers, tell me, "Doctor, they have

n't given me my medication." How much does your medication cost? Let's talk about Agra? What is this disease? What does it sound like? Agra. It's an autoimmune disease, they say around here . But what are its characteristics? Neuromuscular. Okay. And what happens with that? Yes, it turns out it's a neuromuscular disease that causes people to lose the

ability to contract all their muscles, right? And it has, let's say, various presentations. When I say various presentations, I mean it can range from someone who is tired all the time, right? Usually in the afternoon. And that can be normal, right? Because everyone gets more tired in the Afternoons, right? And if you work

from 5 in the morning, you get more tired, but it has its own particularities, and it's in these particularities that crises appear. In crises, this contractile capacity of the muscles compromises the person so much that they experience respiratory failure, and it's necessary to manage the genuine... well, let's say there are several options. One

is called Flex, which is through a catheter, right? To do plasmapheresis and try to get rid of those antibodies that, let's say, are n't working. The other is called immunoglobulin. Do you know how much the immunoglobulin treatment costs for these patients for just 5 days?

30 million pesos. And then that's when each patient is in a bad situation, and it turns out that, like, I have cystic fibrosis, and thousands of other pathologies that can have high costs, right? And then, like the system of greeting each other, well, to give everyone what they need. That's the problem that

the next minister and the next president will have to solve. It's not a problem, not even for the next one, because our democratic state, with a statutory law, allows us to claim our rights to... to be treated for any pathology, even for those that have, let's say, a high level of involvement. Right. Summary of the last class.

So, how do I proceed knowing that I have all of that in an institution like San Claio Java Health, which has them close by, to manage risk? So, what do I say? Diagnosis. Diagnosis. I need to know my population, know what they have, how often they consult, their ages, their pathologies, if I

have patients with serious conditions, if I have patients with epilepsy, if I have patients with cardiovascular disease. Then, like everyone else, I act. And how do I act? Come on, look, look at what regulations must be followed. And then, look at what regulations must be followed. Colombia has something called a risk management system, and we

need to know what changes. For practical purposes, at this point in your academic life, it's not necessary to read the 300 pages of the risk management system. The important thing is that you are familiar with it and know that there are certain procedures and activities that must be followed. It's very likely that

you won't talk about this again for a long time, but when the rural Uh, they're probably going to do it, because when you start working in the field, you have to comply with the regulations, and within those regulations are the technical protocols that will tell you how to treat hypertension or how to carry out health promotion and

prevention activities. Importantly, when I have and know my regulations and I do everything I did in the previous slide, I have to evaluate, I have to follow up. And how do you imagine one does follow-up in healthcare ? Oh, that's great. Why with medical records? What's so important about medical records? Patient development,

everything, but to see how this is useful, some of them have the patient's socioeconomic status because it's risk management. So if you know that the patient lives in a certain area , you could say, okay, they live in Girardot or whatever. And there could be advanced risk management , well, regarding some way that can be done for them.

Okay, it's very important. Why? Because these evaluations help us see where we're going, right? And generally This is done through indicators. So you 've seen, or saw last semester with Luis, for example, all the statistics, right? And maternal mortality, infant mortality, what the external causes are, what people die from, right? And what

those indicators are like and why those indicators mean the same thing. And I could compare the maternal mortality rate in Colombia with the maternal mortality rate in Haiti, for example. Right? What is the maternal mortality rate in Colombia? Someone mentioned that I know the technique of children of fluctuating births. Which one? I do

n't know, maybe 20, right? A little more. Who knows what the maternal mortality rate in Colombia is?

2,024,000 live births, more or less. Let's say it's around 36. However, in the last one or two years, it increased and reached almost 64 per 100. My God. But here, Google the maternal mortality rate, it 's eight, and here, maternal mortality is higher. Silence.

Yes, confirmed. France 8th. I have 7th in my head. Yes. Yes. Okay. Gana has 300,234,239 deaths. Imagine that. We have 8, more or less 30, and 239 to 200,239. If I didn't do an evaluation and didn't follow indicators, I wouldn't realize that Gana is clearly in the worst-case scenario, right? And patients are dying

from 1,000 causes, including because it's a low-resource country and so on, right? But that's the purpose of the indicators, to be able to make decisions and say, "Okay, we have to invest more in Gana, and okay, let's learn from France to see what they 're doing, why they're doing it well." With these indicators, I

can do two types: prospective, a prospective assessment, or evaluations, let's say, post-care evaluations. When I do post- care evaluations, I look at all the processes that tell me how the care was delivered, such as complaints, user satisfaction, and the patient's history. Clinic. And within the medical record is included something called an audit. What is

that? You. Yes, you. Yes. What is an audit? What do you imagine that is? Wait a minute . [snort][clears throat] Thank you. But, what's this? Look, Google it, please, and tell me what an audit is. And it turns out that whatever an audit is, as they'll tell us, it's important because it allows,

as a colleague here was saying, to review all the care provided and know if we made a mistake, if we made a mistake, yes, if we made a mistake or if we didn't make a mistake with the patients, but it also allows us, for example, to start seeing if what we were doing was right.

And this audit is the epidemiological methods or something to improve a health service, maybe you didn't understand that either. The audit process is used not only in health, but in the entire production chain, in aviation, in my field, right? And what it does or what it means is being able to go in and review

all the processes. So, the Auditors are the ones who stand next to the doctor to see if they're prescribing correctly or not. And then, I don't know, a doctor I admire, my dad, your dad, what's his name? And the alternative medicine doctor. He's an alternative medicine doctor. So, the doctor does alternative consultations,

right? And then I go and stand next to him . You knew that co-culture is in my post and that I could access alternative medicine through the post. Well, imagine that this doesn't really go beyond the post. Not much, not many people know about it , but it's one of the benefits we have. I can

sit next to Dr. Carlos and say, "Come on, but why are you doing that?" He's doing it this way today because he used acupuncture therapy and not neural therapy and not the other, let's say, wide variety of alternative therapies, right? Or a doctor you admire, like Dr. Cañadas. Dr. Cañadas, the gastroenterologist. Okay, I

can sit with Dr. Cañadas, As a gastroenterologist, I review the colonoscopies, endoscopies, and other procedures he ordered for the 18 patients he sees each day, checking if they are appropriate. Right? And why do you think that's important after he's already seen the patient? To improve, well, to improve, but what else? To see how resources are being used.

Why? To see that resources are being used. Of course, to see that resources are being used. And that's what I'm getting at because we think that everything we do in medicine is just about saving lives, right? But it turns out that we save lives, but under a cushion, so to speak, which is the

financial one. And if Dr. Cañadas sees 18 patients and orders endoscopies for all 18 of them that they didn't need, what will happen? What will happen? Well, he would spend the resources that should be used for something else. Of course, they could be denied. Of course, that too. But there's another very important thing, and that's safety

and stress. Do you know what percentage of a procedure can become complicated? Endoscopy? Google it. What complications could an endoscopy have? Yes, yes, yes. Okay. Esophageal perforations. And when a patient perforates during an endoscopy, it will almost certainly end up very, very complicated, and they could die. So, imagine if they die, and I go and

do an audit—my colleague already knows what that is—and I review it and say, "Oh, but this was a 15-year-old patient, and I only made a couple of copies for the doctor, right?" Because if a patient is wearing a monitoring device, what will happen to the two locks? They're getting themselves into serious trouble. Important because they're going to

sue him, right? This is important because San Ignacio will surely say, "Doctor, you didn't act very ethically, did you? You were rationalizing services, and it resulted in a patient dying, and that's called an unsafe act, right?" And it turns out—I don't know if you've already seen this—that we doctors are liable both civilly and criminally. That is,

we can go to jail, and beyond that, in short, right? With very long processes and so on, but the idea is that it's not Dr. Cañadas, but it can happen to him, right? And he tells me, well, one of the examples that can be much easier because procedures in rheumatology can get complicated, and we can't do

anything about it. That's why it's important that in everything we see, it's not just about spending money and ordering the latest test, but about knowing the cost, the risk, and the benefit that I'm going to provide to my patient. Of course, this applies to everyone. And so it's important that from the third

semester onward, students can learn that everything we do in medicine, even the counseling I give to a patient, can have consequences. Secondary issues. I can sit down with the doctor and tell him, for example, not to practice a high-risk sport. Last time we were talking about a thing that was terrifying, and it

seemed like the most extreme thing in the world to me. Now there are even more extreme things, right? The doctor is so Mejía-like from my time. I say, "Come on, I mean, slow down on the motorcycle, wear a helmet, right?" Let them do those things they did at the Gasca Circus, right? Uh,

but it turns out that if I scare Tarragona Mejía and he doesn't do anything again, and then he tells me, "I'm sinking, they can send me because of the advice I gave you." Right, that's right. The same thing happens if I'm talking about generating habits, right? About lifestyle, because sometimes doctors consult with patients not only for

physical pain, but for emotional pain. And if after a talk a patient commits suicide, who's going to do it? Very important. So, everything we doctors do has a consequence, right? What do we have to do? A balance to prevent that consequence from being negative. Now, it's not that I'm scaring you and now you shouldn't give advice to

anyone, right? Nor that we can't practice medicine freely, right? What happens is that you always have to do it with all the supporting evidence, and the medical record is going to be the most important supporting evidence because, since you don't record the patient, right? But you simply talk, everything that is documented in the medical record will be... So, it's about

justifying what we did. Okay? Well, that's what causes all health institutions to face these challenges. One of these challenges is the comprehensiveness of care, because it turns out that patients— we were talking about this last class, for example, cardiovascular patients—who should ideally have the same doctor throughout their lives, someone who gets to know them,

right? And who can understand a bit about that patient's context, well, that doesn't happen, right? So, for example, the 15-year-old patient that Dr. Cañadas saw, he saw him because he was a 15-year-old patient with peptic ulcers that seemed to be functional, but he had been complaining for 5 years, and the general practitioner hadn't

interpreted that what he had was, well, bullying he was experiencing at school, for example, right? And so those are the most basic cases. But in cardiovascular patients, for example, here in San Ignacio, patients arrive with heart attacks, the heart attack is treated, they They undergo cardiac rehabilitation and then return to their communities, but they never

get a follow-up appointment. And then what happens? Their condition worsens, and they're readmitted. So, this is a significant challenge for the healthcare system. Another important challenge closely related to this is follow-up, which is what I was saying. Look, the hospital isn't the most important thing for the patients. The most important thing is patient follow-up,

allowing them to leave the hospital and continue receiving care and treatment. Let's go back to the free myasthenia gravis. A patient with Penalis should be taking some kind of immunosuppressant or immunomodulator. If that patient isn't taking it, right? They're going to have more myasthenic crises, right? On average, some patients have two or three in

their entire lives, right? What happens with myasthenic crises? Because they cause significant respiratory distress , the patient can die. If that patient doesn't receive specialized follow-up , they'll be among the 108, right? On the other hand, if I, as an EPS (Health Promoting Entity) or IPS I say, "Ah, this patient of mine, I have to

attend to him faster, I have to give him appointments, I have to call him, because I do risk management and prevent that patient from reaching a crisis. " Sufficiency of resources." And here it's important that you learn from now on that everything we do in medicine generates a cost, right? That cost... and we were talking about iPhones, and

we were talking about how someone here was telling me that the latest iPhone, which one was it? You told me, the 17. Having the iPhone 17 means spending more money, but the iPhone 17 theoretically serves to communicate just as well as an iPhone 13. So, the same thing happens in medicine, right? There are medications, supplies, and

other things that could generate the same beneficial effect for patients. And that's what epidemiologists are for , you have great professors of epidemiology, who do pharmacoeconomic studies and who tell us if we definitely have to spend 30 million on the patient with myasthenia gravis or if we could spend 2 million every month.

Human talent turnover. This is very important because it turns out that when I, as a health insurance provider, for example, have a staff of general practitioners, which I think must be about 40 or 45 general practitioners at the moment, and I have them with good salaries, with training; these doctors are very good,

so good that these doctors from the Health Department almost always pass when they apply for residency, because they do some training in primary care. We already know them here, these doctors who are studying every week, they have a blocked hour, like at university, where they have classes and review material, they review different topics. So this

makes the Health Department run out of resources in Mexico. It's bad, it's not very good because it's a platform, for example, for you to move on to [unclear - possibly "public health"]. But it's very bad for the Health Department because it has to train and train and train, and that in health could be problematic with

all the high- complexity institutions like USIS and others, because training a person in specific processes and protocols as specialized as those of the ICU is very complicated, and you can't find people, you can't find nurses, for example, who can do it and do it well. Monitoring indicators. It turns out that before, we would go, sit down, and

see the patients And we thought that was the most important thing, but it turns out it's not, folks. Then there's the audit we administrators do to find out if, for example, the 18 patients referred by a cardiologist are properly seen, have appropriate prescriptions, if the medications they were prescribed are safe, and if, for example, in the case of

hypertension and diabetes, they are well controlled. That means you're also going to have audits to see if your patients are properly controlled. And that's what should be done, because ultimately, what do we study for? To improve people's quality of life . So, how can I know if I'm doing my job right? Well, if they have a better quality of life and

if the clinical indicators—I'm referring to biometric hemoglobin or blood pressure levels, in the case of hypertensive patients—are controlled. Additionally, since I'm looking at data, it's important to see the quality of the data. I don't know if any of you have experience reviewing medical records, I don't know, has your father had a consultation, and what in-

depth medical record software does he have?

Okay. Anyone? Does your dad have a doctor who knows medical histories or who has managed medical records? No. Okay. Cheers. Cheers. No, it's not him. Okay. Why is that important? It turns out that doctors no longer do manual medical records, right? Or at least not in Bogotá. But when you go to do your rural service, you'll surely

encounter that. That's what should happen, isn't it? Because all of Colombia should be connected, and we should have electronic medical records . Imagine that what I do through auditing is, I mean, after the patient's care, there are many fields in the medical record, and then it's like when you fill out those forms when you make

purchases online, right? You'd like to have an automated system where you just tell it to, and everything appears and you make the purchase, right? It turns out that the records don't have automated systems, and you have to write absolutely everything, and then we laypeople are very... well, and then, for example, they ask for the place of birth.

What do we put in the "place of birth" field? Well, logically, no, imagine that we are so... Creatives that we put together, and then when I go to do it and look at where the entire population came from, it turns out that I download the report in an Excel spreadsheet and it shows me

where the population that is learning was born. Where? The point, right? Because we were never taught the importance of filling in all the data in the medical history. And because we think that a class, right? After lunch, 2 in the afternoon, is unimportant, and that makes risk management fail, doesn't it? And just

as it's a long point as silly as the origin, there are guessing points about what parameters, ah, blood pressures. So I'm going to help with blood pressure, and there's technician one. So it's very important to follow up on this, on the quality of the cat, so that if you see a patient and

your patient has 13085 blood pressure, you can put 130 85. Well, later you'll understand when you 're doing critical histories. It's important that I also have to get the data for risk management from different sources. Why? Because it is important to know the origin of the people I'm seeing in I consult and I have the points in the

medical record, well, great, right? I have to draw from other sources to get that information. And now, as a result of changes made by the former president, but by President Petro's ministry, there's something called basic teams, which are really good and have yielded good results in countries like Costa Rica and Brazil . These

basic teams are led by general practitioners with therapists, psychologists, and others who go into patients' homes and see what's happening to them. Then they sit down and talk with them and find out what they're suffering from, how they're suffering, if they have running water, if they have electricity , if their medications aren't arriving

. All that information should be reaching medical centers so that healthcare decisions can be made. Regarding information systems, you mentioned that your father had a medical record system that you didn't know about. Regardless of the medical record software, I have to make sure that the information system is robust, that it doesn't allow

data leaks, that I made sure to have that data, uh, let's say, very well guarded. Why? Because, just like when you tell them, "You authorize the data here in health," we also authorize, when we sign up to an EPS (Health Promoting Entity), that all that data be known and that I can call you, right? That I can

call you and say, "Have you had your Pap smear yet? You're getting pregnant. I'm inviting you to a session to stop your habit of...

" It's important that we have to implement innovative processes, interdisciplinary work, the patient and their family must be involved, and there must be coordination. And so, let's understand that doctors aren't the most important people in care; we're one piece that makes up the whole of care. It's likely that in the community, who are more

important? Nurses, social workers, psychologists. Well, with all this context, let's look at programs focused on risk. Who is our president? Let's observe. Let's listen. What we have done. Silence. He is prepared. He is not listening. Right? Silence

A child's physical condition is not [sighs]. It's a matter of prevention. Knowing the classroom systems doesn't teach, the rules don't come out, the educational systems are very deficient. Well, you remember this. Yes. Let's see, who can give me a summary? Oh, who can give me a summary of this president? Let's see, a summary.

What happened with this case?

What happened? And now, the reason it's important that I want to talk about this is that it really gave me the perfect opportunity to talk about how our child was already diagnosed with hemophilia and all that, and the mother had taken him to the treatment center several times . Yes, but in the end, without further problems

with paperwork, they were never able to receive the medication, and the child ended up dying. Okay. And the president made these statements, right? That he says that we have to prevent it, right? That the mother acted in a way that was, let's say, uncontrolled, right? And that the child shouldn't have gotten on a bike,

right? That was the summary. So, why am I bringing this up? Here? Because it turns out, yes, of course, I have to do prevention, which is what I do, [clears throat] but it turns out that hemophilia is a disease, right? It's one of the main, let's say, most frequent orphan diseases in Colombia,

with very sad and unfortunate stories like this one, but also with complex stories associated with corruption. And then, when the whole issue of recognizing orphan diseases in Colombia began, it turns out that many resources were freed up . Why? Because most orphan diseases are very expensive. Being very expensive, the Ministry and the nation allocated

specific resources that can be spent on them. What happened about 15 or 20 years ago? The "backpack cartel" was created, and it turns out that in some regions of Colombia, more cases began to be diagnosed than before, and so it turns out that we no longer had 10 people with hemophilia, but 100 people with it. And

why? Because each hemophilia patient is worth a lot of money, right? And they are worth a lot of money, and so... They stole the money. So, the issue of mophilia has always been there, in a dark and shadowy way. And the latest news was, what are we doing as a health system to prevent Kevin's risk?

Well, in part, what the president says is to provide support to families, to educate families so they adopt habits that complement the treatments. Okay? What else? Uh, in the medical aspect, the most appropriate treatment that allows him to develop a healthy lifestyle. Okay? And then it turns out that risk, what is it

? A probability of something happening to his health, right? And that it could increase the condition I have. This patient had a risk factor that could lead to complications, right? As I identified it, right? And the new EPS (Health Promoting Entity) identified it, they should have had him in close contact with a team, very

closely, very frequently, right? Where an interdisciplinary team with nurses, doctors, and psychologists supports the patient and his family, explaining the risks, educating them, but We were also monitoring him and watching him, right? But the problem here isn't that the preventative measures didn't work, it's that he wasn't getting the medication, right? A child, I think he was 10

years old, normally, what should he be doing in terms of basic functions? And what else? Playing. And so it's inappropriate for him to be riding a bicycle. It's not a risk that would happen if Tatán Mejía got on and those motorcycles crashed, right? Because a child can't play dangerously or ride a bicycle.

So, the issue here wasn't the bicycle, with all due respect to the president, right? The problem wasn't the bicycle, nor was it the mother whose son died and he came out and said that he also killed him by letting him ride that bicycle. Right? That's not the problem. The problem is that he has a

risk factor that we should intervene and block so that it doesn't become established. Now , if this patient had had the medication, he could have ridden a bicycle. Yes. Yes. Because the idea of all the pathologies that Whether we're dealing with children, teenagers, or older adults, the goal is for them to try to lead their normal lives,

and for us to support them in doing so . So, limiting a child and putting them under a mattress to protect them is impossible. What we should have done is follow up, which we didn't, and that's why Bueno died. And then, something very Colombian: "How am I going to go?" You're going to go

because you explain things to the patient, you have to attend to the patient, right? And you're going to have to do things for the patient. I don't know if you know that there are doctor cutoffs, and for example, there are EPSs (Health Promoting Entities) where the doctor is contracted for 6 or 8 hours, and of those 6

hours, two are left free to manage their patient population. And what does "managing their patient population" mean? Well, if you have 3,000 patients, a general practitioner should generally have between 2,500 and 3,000 assigned patients to see what's happening to them. And so They create Excel spreadsheets, dashboards, and data for him and tell him,

"Doctor, you're going to review those histories and tell me how many of those patients you have to see and how you're going to see them, right?" So, we doctors go all out in addition to everything else. When I do the care processes, I do that—plans, programs, or projects—because when I talk about Kevin, who was a child with hemophilia, I

see Kevin with hemophilia. But there are doctors who see entire populations. So, when I see entire populations, I have to give them a line, a plan, a program, a project, as if it were a care protocol. Those plans are nothing more than one thing, something other than organizing care processes. So, for example, uh, do any of

you know what diabetes is? Square the sketch is one of the most important publications in diabetes, it's a magazine that comes out every year, right? In its December or January supplement, it publishes recommendations for the treatment of diabetes. So you already know that throughout December or January you will have to read that

diabetes supplement because it is the one that starts all, let's say, the latest developments in diabetes treatment and explains to you how it is diagnosed, how it is prevented, how it is treated, and even provides recommendations for patients. So, more or less, that's what a flan is: a structured document that tells me

what to do in certain situations. This plan leads to programs that are a little more detailed and specific. And so, for example, diabetes G has specific supplements for diabetes and pregnancy. So, think of the programs as a slightly clearer detail of a health situation or a health problem in a community. For example,

we have programs to promote healthy habits, to prevent illness, the onset of diseases, to treat diseases that are already established, or to rehabilitate diseases that are already established and have caused some organic damage. When I do those programs, right? I do something called the HPVA cycle: do, plan, check, and act. And so what I do is always start

with a diagnosis, then I see what I'm going to do, how I'm going to do it, and always evaluate. This applies to public policy, to different activities. Now, when I have a plan, a program, I have to make a project. We were talking, for example, about diabetes in pregnant women. So, diabetes in

pregnant women has different topics, such as, for example, how do I diagnose seasonal diabetes, right? And why do I do it? And why does the test differ from that of adults? And so that's the project. Since I already took a problem, a diagnosis which was diabetes, I got something specific which was diabetes in

pregnant women and how, of all the things I can do about diabetes in pregnant women, I am going to focus on one focus. That's a project, something a little more specific to a population. For example, let's look at this. Teenage pregnancy. Teenage pregnancy is defined as pregnancy in a minor age range. A pregnant patient is under

18 years old, right? But it turns out that teenagers also have different levels, and having an 18-year-old pregnant girl is different from having a 14-year-old pregnant girl. Because? Because the ranking is 14 and 15. Okay. At 18 because they are more appropriate, there has been a homosexual. Okay. And that's important because from

the age of 14 I can already have a capacity for discernment that is supported by the law. But below 14 years old, right? So, that's rape, right? And it has some important legal components, depending on the type of abuse and so on. Ready? So, it's very important, right? And it is so important

that the ODE countries give us, through indicators, one of the indicators being teenage pregnancy. And then I can say, "Ah, well, I'm going to watch a program for teenagers and I'm going to make sure they don't get sick, right? Let's see what happens and if they have risk factors, and give them information, right?

And you know, something like this.

I'm your future self and I'm writing this letter to say thank you. You might be wondering. Thank you. Your life could be surrounded by your sisters, becoming a mother, and falling in love for the first time with one of them. However, you chose to graduate from high school and become the professional you dreamed of being.

Now you return home and realize that not being a very mobile mother allowed you to prepare yourself to help your community. That's why I thank you because you remember when you attended those workshops for teenagers with your friends; there you understood that making your dreams come true takes time and effort. And you met places and people you

never imagined. Emil, being a mother is undoubtedly something she wants to be, but today I'm clear that if I had been very young, the path would have been different. Now I I can also teach others to dream without limits and, in such a way, return to life the fortune it gave me. Okay, what catches your attention in that

video? We're talking about preventing teenage pregnancy. How? Another perspective. Right, another perspective. So, it turns out that when we make programs, plans, and projects, we don't just think about it in the biomedical area, right? But particularly, and let's say that teenage pregnancy gives us that range of thinking about how I efficiently care for a girl who is

pregnant, but how do I prevent it? What is the method of choice to avoid teenage pregnancy? One for each. Yes. I mean, like the fact of finding it in a short video. Okay. But let's say that if we could call it a contraceptive method, the most effective one for teenagers, what is it?

Which one?

Okay. Let's say it goes well, but for teenagers, the main method is education. To the extent that women are more educated and reach higher levels of education, We decided in a slightly more sustainable and independent way, and that means that you address the beginning of sexual relations, or when you decide to use them, you have the ability

to use the method. So, uh, even though it may seem different to you, these campaigns in Cartagena seek to give women greater access to training, to learn about the world, to have more intellectual capacity to prevent pregnancy. So, as I was saying, teenage pregnancy brings me the possibility that you also think that I'm not only going to prevent pregnancy by talking about

sexuality, not only by having infrastructure to care for pregnant women. That means that even though when I have a teenager in consultation, I have to talk about the topic, I can also, supported by all the intersectoral collaboration and public policy, on TikTok, in whatever way, intervene to prevent pregnancies. So, I was already telling you that this

is important in public policy, but it's important how to differentiate it. And so, how can I differentiate a plan, a program from a project? I can differentiate it through, For example, time. I'm going to create a national plan to reduce teenage pregnancy. That's not short-term; it's long-term, far-reaching. Why? Because by the time

all our women attend and complete high school, at least, we're going to spend at least a decade, right? The program, being a bit more specific to that project, can be medium-term, while the project itself is very specific and has, let's say, less scope. It's important to consider that when I want to address general

population problems, I have to think far beyond the biomedical aspect, to see, for example, in pregnant women under 18, what they want to do, what vocational activities they need, what their well-being is, right? And that allows me to think about different ways to address health problems. Important in health is to see what

we saw in the first semester, and these are all these disparities and inequalities that we have in our population, right? And here I want you to think... This, right? For example, obesity. Um, the last article in Lancers that came out last December acknowledges that the issue isn't obesity itself, and that it shouldn't be

treated, for example, as obesity, but rather, like Gutiérrez, who has obesity, or Betizo Pérez, who has obesity, as a disease, but not as a disease that a person has, right? Starting from the person. Why? Because otherwise, we're going to end up doing that. Two points. Eat more vegetables. Exercise 30 to 60 minutes a day, but without acknowledging this. Is

there money to eat fresh food and vegetables? Is there time to cook? Why? Are there safe parks? Is there access to checkups and follow-up? Have you seen the Discovery Channel program about obesity treatment and follow-up? No, where there's a doctor, data, right? Yes, no. Well, okay. So, it turns out that if you don't see it, obesity is a

multidimensional problem, and it's not just about surgery, but about seeing the patient's context . What's wrong with them? Why are they eating? Um, food compensates for something, some deficit in their life. So, uh, what I want you to take away here is that when I give a recommendation to a patient for something,

for a pathology that's on the rise, right? Yes, I have to think that this patient has to be different, they have different risk factors, they have different contexts, and they're definitely not going to be able to follow all the recommendations. And in that sense, I have to consider that not all our patients may have

the same capacity to understand, right, what's happening to them in their health context. And that differential approach isn't just about race, I 'm Black, I'm Indigenous, no, I have to see all those processes, all the diversity that I need to see to be able to understand a little beyond the patients' illnesses. It's

not true that vulnerable people are the ones with the highest rates, right? Of course, if I see that we saw that they had about 230 maternal mortality rates, right? Well, I say, "Uh, this population is clearly at risk." They're at risk because they 're poor patients. But risk isn't defined solely by... It's not that

vulnerability, right? But rather exposure. I could be living in the United States, and we saw this in the first semester, which is a high- income country, right? And have a higher risk of cardiovascular disease and obesity, right? Because it's the type of exposure, the environment, the food, the way of life and the context

that leads to obesity. Let's look at this to finish up, and the situations will only take 10 seconds.

It's something you should have seen: individuals from disadvantaged populations have a lower state of health than those from privileged populations. This difference in health, according to an individual's position on the vulnerability scale, is called the social gradient of health. With the goal of reducing these inequalities, various approaches to public policy are used, such as the

universal approach, the targeted approach, and proportional universalism. To begin, a universal program offers the advantage of being open to the entire population. However, the big drawback is that, in practice, many obstacles prevent access for people at higher risk. In contrast, targeted programs are aimed at specific populations. Those at greater risk are generally excluded from universal programs.

However, certain vulnerable individuals are also found in populations not initially identified as being at risk. To ensure that the entire population has access to prevention and care programs, proportional universalism seeks to combine a universal approach with a specific approach. To reduce health inequalities between socially advantaged and disadvantaged groups, actions must be universal

and therefore distributed across the entire social spectrum. But these actions must also give particular attention to the groups at greatest risk. Furthermore, the intensity of these actions increases proportionally according to the level of social disadvantage within the population.

Proportional universalism thus seeks to reduce social inequalities in health and strive for equity.

So, what is it? A probability of something that specifically affects health. The World Health Organization

defines health risk as the probability of an unwanted, preventable, and negative event occurring in a population or individual's health, which can also be the worsening of a pre-existing condition. A pre-existing condition or the need to require more consumption of goods and services that could have been avoided. Okay. What did we say the PDSP was?

Public health. Okay. And what did we talk about? Public health plan. What? That it's one of the most important population health policies that Colombia has? Well, let's review. For tomorrow. What is the main purpose of risk management? No, of risk management. Let's see, well, to prevent that risk from occurring, right? I don't know, let's say, to prevent it from

happening. But for that, what do we do? Where do we start? Oh, no, from the diagnosis. Do you remember that we always said we're going to start with a diagnosis, and that diagnosis... we start by identifying and analyzing what's happening to the population? Yes? Of course. Okay. If I have a group of patients, for example, with diabetes,

hypertension, for example, right? What would be the first thing I would do to manage risk? Prioritize. Prioritize. And prioritize What? Well, for example, patients with high blood pressure, differentiating between those who are already being treated or those who are newly diagnosed and have n't been treated. Okay. And we saw that pyramid where

we said low risk, high risk, medium risk, right? But to get there, what do I have to do? A diagnosis and a characterization. Yes. And perhaps these could be the judge's questions tomorrow. Um, let's see what I can do starting today, from your consulting work, right? To manage the risk of a population you

're seeing in your practice, what could you do? Well, yes, what else? We talked about, and as I was saying here, they talked about the case of... and what other education, right? For the patient and for whom else? The family. Okay. Well, what will you know so that all the questions tomorrow are well-prepared?

If I, for example, have a group of patients that I know are being hospitalized, let's take an example, a patient with chronic obstructive pulmonary disease and they are... What would I do if I were a doctor at Sura, and they told me I'd have a daily appointment to see, and I was told, "Look,

what are you going to do because patients are being hospitalized with serious illnesses?" I would audit their medical records . No, we're going to do a medical history audit, review their progress, and look for possible causes of this recurrence. And if the causes, for example, are that they haven't been vaccinated against influenza or

pneumococcus, or that they aren't receiving their medications, what would you do? Well, create a program to encourage them to come to the health center and get vaccinated. Okay, very good. Why a program and not a plan or a project? Because it's a smaller population, and it's something that's needed more immediately, and it's not a plan.

So, it's a plan or a project. What would it be? A project. Why? Because it's short-term. Because it's short-term and more specific. Right. Yes. For everyone. Well, that's it. I hope you have a good day tomorrow. See you next time. [applause]

project.