Charles Nisz
Um organograma da estratégia. Assim podemos definir o Estrategirama, ferramenta para análise de Parques Tecnológicos, uma metodologia criada pelo espanhol Luis Sanz, diretor da IASP (Associação Internacional de Parques Tecnológicos). A palestra Estratégias para criar e desenvolver parques tecnológicos teve a apresentação do caso do Porto Digital no Recife (PE).

Segundo o diretor do IASP, a ferramenta pode ser diversos usos: investigadores sociais podem mensurar o impacto de um parque tecnológico, diretores dessas entidades podem utilizá-la para verificar a evolução estratégica e promotores de parques tecnológicos podem usá-la para tomar decisões sobre como e onde construir um parque tecnológico.

Sanz explicou os sete eixos fundamentais na avaliação desses parques:
- localização (urbana x não-urbana)
- uso da tecnologia (criadora ou utilizadora de tecnologia)
- fomentar empresas ou desenvolver empresas existentes
- foco num ramo empresarial ou diversidade
- escolher empresas locais ou atrair empresas de outras regiões/países
- como avaliar a utilização do trabalho em rede e networking nos parques
- como escolher o melhor modelo de gestão e governança desses centros tecnológicos

A ferramenta tem um índice que varia entre 10 e -10. Cada item é determinado por esses indicadores e o índice pode ser verificado empiricamente. Isso permite aos parques tecnológicos planejar mudanças em médio e longo prazo, alterando seu perfil.

Podemos tirar conclusões ao analisar dados de vários parques tecnológicos usando as ferramentas do Estrategigrama, explicou Sanz. : “Parques Tecnológicos tem a ver com Universidades”, No início o foco eram as chamadas start-ups e hoje muitos desses arranjos já trabalham exclusivamente com o desenvolvimento de empresas já consolidadas.

O Porto Digital de Recife é um caso de parque tecnológico que utiliza o Estrategigrama. Guilherme Calheiros, diretor da incubadora do Recife mostrou o impacto econômico do Parque: “São 4 mil profissionais de TI com salário médio de R$ 2500 – três vezes a média do Recife”. O Porto Digital, fundado em 2000, tem 120 empresas e foi o único projeto brasileiro na publicação Learning by Sharing do IASP.

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The War on Drugs Sold so Well That Persons With Pain

Often Cannot Get Pain Medication or Treatment

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Don’t read this. It will upset you.

The federal government has always been more interested in addicts than in persons who are disabled with intractable pain. Billions are spent to imprison addicts rather than pay for addiction programs which would be far less expensive.

Only 3% of medical schools have a course in pain management, Yale announced in 2008. According to the International Association for the Study of Pain, the IASP, education on pain is poor “at either the preclinical or clinical levels and information is poorly integrated.” Fewer than 3% of recent graduates have had a few hours of training. This means that unless your doctor is among that small 3% that has recently graduated, they have had no training in pain control. None. And the FDA ignores the extensive training of pain specialists when approving limitations on new medications.

Worst of all, NIH spends 0.67% of its budget on pain research – less than 1% – though 10 to 20% of the population in the US suffers from chronic pain, an estimated 60 million Americans, and the conditions are more prevalent among the elderly. Addiction funding is the only reason neuroscientists in the early 1970’s were able to identify opioid receptors and then to clone them, which legitimized pain in cancer patients and led to use of opioids for cancer pain in the 1970’s and for noncancer pain in the 1990’s.

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Pain Epidemic:

Does Pain Management Have a Place in American Healthcare?

Today, there is too much reliance on opioids for pain because there is little or no NIH research on alternatives. Or maybe because your doctor does not know any other treatment than to prescribe an opioid. Or because Medicare will not pay for the amount of physical therapy you need. Opioids are overprescribed. This increases the risk of opioids being diverted and falling into the hands of addicts, leading to deaths and headlines that will no doubt limit your ability to be treated for pain. How many of you know Medicare has been limiting physical therapy for years? If you use all your treatment by mid February, they will not pay for more no matter how often you fracture your hip or herniate a disc. Is it right for them to pay for opioid pain medication and not physical therapy?

Just think of it. Before the early 1970’s, we had no pain societies, no hospices, no use of opioids for cancer patients (unless they happened to be hospitalized), no oral opioids, no oral morphine — why the very thought that oral morphine could work was argued against vehemently by the chief of the pain service at Memorial Sloan Kettering Cancer Center in NYC, in December 1975 at the first meeting of the IASP. The first meeting. 1975. Think of it. He argued that oral morphine would be metabolized so rapidly that it would pass out of the body and not be there to help.

William Lamers, Jr., MD

In the early 1970’s if you had pain, you were not legitimate because we simply did not know there were such things as opioid receptors nor did we have oral opioid medication.

Now re-imagine that vehement argument in 1975 again, knowing that my dear friend William M. Lamers, Jr., MD, was the first in the world to use oral morphine when he founded home hospice in America 5 or 6 years before that date. He invited Dr. Cicely Saunders to California to teach her how to use oral morphine at her hospice, and following that, St. Christopher’s Hospice in London stopped using the ineffective Brompton’s Cocktail that caused so many side effects with so much less pain relief. Their research a few years later enabled Dr. Robert Twycross from St. Christopher’s Hospice to stride to the stage in 1975 at the IASP meeting, and report their work with oral morphine, to the applause of the Brits.

Let me be clear, I am gravely concerned that the use of opioids for nonmalignant pain will lead to a dire problem with opioid induced hyperalgesia in our large population of pain patients. Opioids create pain at the same time they relieve pain.

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We Are Not Getting Access to Effective Nonopioid Treatments

Worst of all, unless opioids are low cost, your insurance – PPO, Medicare, Medicaid – will not authorize several profoundly important nonopioid medications that I find has helped and/or relieved intractable disabling pain in many of my patients:

• Namenda an NMDA antagonist that was shown in European research in 2001 to be effective for severe pain at a dose of 55 mg per day; in the US it is approved only for dementia at a dose of 20 mg per day. Insurance will not cover the dose needed; patients cannot afford it.
• Compounded capsules and ointments may be the only thing that helps others, but are often not approved.
• Naltrexone and other morphinans – see my post on naltrexone -  may relieve disabling pain, but compounded medications are often not approved
• Medical marijuana research has been forbidden by the federal government despite active research and use of approved compounds in Canada and UK for severe intractable pain. Marijuana is in a class of chemicals called cannabinoids. Our brain makes cannabinoids and has receptors where they act. A synthetic cannabinoid  is FDA approved in the US for chemotherapy induced vomiting. The cost of one mg capsules is $400 for 20 – who can afford that?  In Canada, it is used for pain patients at bedtime to relieve severe pain that prevents sleep. Yet in California where inexpensive medical marijuana is legal, the Obama Department of Justice has continued the prosecution of Charles Lynch, a legitimate marijuana dispensary owner.  He was convicted on federal drug charges despite carefully following state and local law in setting up and running his business and being fully licensed by the state. He had the full support of the mayor and city council, yet he was sentenced to a year and a day in jail last week – the Obama DOJ pushed for a mandatory 5 years jail. Federal law prevented him from testimony in his own defense, presumably because federal law excludes states rights and the issue that marijuana sales may interfere with interstate commerce. For discussion of this and the bill introduced Thursday by Rep. Barney Frank, HR 2835, to legalize medical marijuana, see here. There was a time in the recent past when hospice doctors in the US made marijuana suppositories to relieve severe pain and nausea in dying cancer patients. In Mexico, marijuana is used in ointments by the elderly to relieve arthritis pain. 100 years ago, it was mentioned in some medical textbooks in America. And U.S. Rep. Mark Kirk calls for 25 years in prison for first time trafficking offense.
• Marijuana: Effective for severe pain, safe, nontoxic, inexpensive and illegal.
• The legal status of prescribing as well as the legal status of using marijuana is needlessly complicated. The Federal Government is clear… prescribing and use are both criminal offenses. Nothing is for certain except that the legal status is a mess.
• Unrelieved suffering leads to an intensification of pain that may result in depression, withdrawal, irritability, anger and sometimes even hostility to caregivers.

NSAID –  nonsteroidal anti-inflammatory drug – use is discouraged in the elderly.  NSAIDs pose severe risk to the elderly and cannot be used in others due to heart disease, gastric intolerance, ulcers, GERD, anemia, bleeding, kidney disease, asthma, and those who are on various medications such as Plavix or Coumadin. Further, heavy NSAID use leads to higher dementia risk (see my post on this).

Some nonopioid alternatives cannot be used in those with liver or kidney conditions, men over 50 who still have a prostate, persons who wish to avoid suddenly becoming obese (Lyrica), those with allergies or intolerance to their side effects because the drug makes the fall backwards or suppresses their bone marrow.

Worse than those issues, we have only a few opioids which work on specific opioid receptors, some are more specific for neuropathic pain or for allodynia, yet since September 2008, the FDA has removed several of the older opioids from the shelf with no reason given to pharmacists or MD’s. I have spent hours calling pharmacies to see if they stock a medication I wrote for a patient hours before they left the office holding their specialized prescription. You know very well that if a patient called asking about opioids in stock they’d be looked upon as an addict, and many pharmacies will not stock opioids with the excuse they would be robbed. No matter you are in severe pain, you must wait 72 hours until they stock it. 

Even with insurance, your PPO will not authorize many if not most of the medications I prescribe and the cost of medication is surely the #1 reason.  That is true for opioids and nonopioid medication I use for pain control. Many are off label for pain, others are off label for anyone  who does not have cancer despite severe disabling pain, therefore not covered. If you are wealthy, you can purchase any medication prescribed.

Opioids are a distinct issue and outrageously expensive compared to the pennies cost of the raw drug. There is never a discussion of reducing costs of new drugs. Imagine $45 per unit, used 12 or 20 times per day in extreme, rare cases. Then imagine your PPO allowed prior authorization for 1 year, but then it was 6 months, then 2 months. What will happen next month? Hours and hours of non-reimbursed physician time is spent on these.  They could just save us all time if they published a list telling us what they will never ever ever reimburse no matter what. No wonder a radiologist or cardiologist or a doctor who does procedures makes millions every year. They don’t have to deal with the deafening “no.” The California law is never enforced that guarantees continuation of medication that is being used and that has been approved in the past for years. Requesting an independent appeal is a sham, the fox guarding the henhouse, paid by the same company that refused authorization.

The FDA has limited use of short acting fentanyl to cancer pain, thus PPO’s will often not authorize it without a cancer diagnosis.  News flash: there is no such thing as cancer pain. Patients without cancer have the same categories of pain that you do: involving abberent signals from nerve, viscera or other tissues. At the American Pain Society’s annual meeting in San Diego, May 2009, an FDA official admitted there were only 3 pain specialists on a panel of 11 MD’s that reviewed short acting fentanyl. It is likely the other 8 had no training in use of opioids.  Fewer than 3% of medical schools spend less than 30 hours over 4 years teaching pain management to medical students, and that is only in recent years, which means almost all physicians in practice today have had no training in use of opioids. Oncologists included. Do they think that pain specialists who have spent decades in the field have no understanding of opioids? If so, then why do they not limit all strong opioids to persons with cancer? or is this coming? Politicians do not like headlines about addicts who overdose themselves.

The special case of Subutex and Suboxone which is buprenorphine alone or with naloxone. Buprenorphine is an old drug, a long acting opioid that has unique effect at kappa opioid receptors and it is said it may help allodynia better than other opioids. PPO insurance will not authorize Subutex (buprenorphine) for my patients with pain, or if they do, they will authorize only one of the two, Subutex, but not the other, even though the one they will pay for causes intractable migraine but not the other. In Europe, both are approved for pain or for addiction, just like we use methadone here.  But our FDA has limited use to addicts, though it is an important opioid that we might use for pain. This means PPO insurance will not pay for it. This new formulation of Suboxone or Subutex in a sublingual tablet means it is very expensive, and I have patients in pain, weeping that they cannot afford it and must go back on their Oxycontin that works less well.

Unique issues for oral short acting fentanyl and Subutex or Suboxone: both will absorb directly in the mouth which is important for some persons with colitis, abdominal surgery, bariatric surgery, other conditions with poor GI absorption of tablets such as celiac disease, and those who are unable to use fentanyl patches due to skin allergies.

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Need for Balance between Risk of Substance Abuse

vs  Suffering and Disability Caused by Untreated Pain?

The FDA and Congress voice concern about addiction, but how much do they care about pain? Actions speak louder than words and the lack of NIH funding for pain research is shocking. Pain does not make newspaper headlines though pain is the #1 reason people seek medical help, more so as the population ages.

Here are more policy and headline issues that will make it harder for people with pain to get the care they need:

FDA, Pain Docs Look to Cut Abuse of Pain Killers “FDA said it was working on a plan to make it tougher for people to abuse certain prescription painkillers….” From the comments: “Regardless of great efforts to reverse this trend, physicians who legitimately prescribe opioids for pain may still feel ‘damned if they do and damned if they don’t.’ It seems as though we have simultaneously raised consciousness of the need for pain control and increased the risks to physicians of being part of the solution. If this dilemma is not resolved, advancing the cause of pain management as a fundamental human right may, in part, serve to polarize the medical community.”

F.D.A. to Place New Limits on Prescriptions of Narcotics “This is going to be a massive program,” according to Dr. John K. Jenkins, director of the F.D.A.’s new drug center.”  ”…a law passed in 2007 gave the agency a new, intermediate weapon — Risk Evaluation and Mitigation Strategies. Known as REMS, these programs allow the agency to place strong restrictions on the distribution of certain drugs.”

Increased Scrutiny of Opioids Could Alter Prescribing Practice “If a formal risk reduction plan for opioid painkillers increases the regulatory burden on physicians, they may simply stop prescribing such drugs, to the detriment of patients in severe pain, the FDA was told Thursday.” Most physicians have no training in pain management, yet instead of requiring more education, regulation of doctors makes it harder to treat persons with legitimate pain and may have no effect on addicts and illegal diversion that they are really trying to regulate. Suggestions were made at a public hearing, quoted here:

• If a REMS does end up imposing requirements on physicians, positive incentives should be put in place to fund and support training in pain management, such as waiving the fee clinicians now must pay to the DEA for the privilege of prescribing Schedule II drugs
• But clinicians do not currently have the tools to enforce proper distribution and use of narcotics, and need more support and training, said Jennifer Bolen, founder of the Legal Side of Pain and the Pain Law Institute. ”It’s dangerous and irresponsible to use physicians to teach the law,” Bolen said. She said state medical licensing boards, health insurance plans, and law enforcement officials must play a big role in enforcing the REMS.
• But the FDA is not a criminal enforcement agency, said John Jenkins, M.D., director of the Office of New Drugs at the FDA.
• One suggestion from a number of speakers is that the FDA require opioid manufacturers to put serial numbers or microchips in opioid tablets, linked to the prescription that released them to a patient. That way, if law enforcement officials seize pills, the prescriber and patient can be easily traced.
• The FDA is already considering serial numbers on some classes of medication for a different reason — to confirm the integrity of the supply chain.
• Other speakers suggested creating opioid medications that are “less abusable” such as crush-proof pills. However, formulations intended to thwart abuse have been tried before. That was the original intent behind Oxycontin, the brand of extended-release oxycodone that ended up widely abused.While it’s up to the FDA to decide what a REMS will look like, it’s the responsibility of drug companies to enforce the new regulations.
• the two-day hearing was peppered with emotional testimonies from people whose family members overdosed on opioid drugs that they obtained illegally.
• the FDA might convene an advisory committee before any REMS is finalized.

Addiction is a very important issue. Families are best in a position to see what is happening to members who have addiction problems, but addiction programs are poorly funded and many Americans are uninsured, especially the young who are most vulnerable to chemical dependency. Can families help someone who does not want to be helped?

I want to make it very clear that all of us, myself included, are responsible for reducing addiction, misuse of prescription drugs, and diversion in this country. Yes, that means anyone who gives someone else a pill from their prescribed medication, no matter how harmless it may seem. If that is a pain drug, your pain specialist can go to jail for 30 years even if he or she did not know about it. Never give one of your prescription pills to anyone else.

Designing high tech remedies to prevent opioid tablets from being injected or inhaled by addicts will increase the cost of your pain medication.  It is already difficult to afford without new technology, and why is it so expensive since many are now old drugs and the raw material costs pennies?

If we become disabled or develop chronic pain, there is often no money for the multidisciplinary approach to pain management that is essential for treatment: extreme limits on physical therapy, no cognitive behavioral therapy, no coverage at all for many medications that I prescribe. Some of my patients who are still working are afraid they will be laid off at work if they limp, are slow or show they have pain. This is not unlike my cancer patients who fear public knowledge they have cancer. But the rising insurance cost to their employer is Darwinian evolution at its cruelest, untouched by the human mind and heart. Free for the rich, for profiteering off the most vulnerable.

Cost of high tech pills to deter addicts. We thank the FDA for their guidance in requiring opioid manufacturers to make it more difficult for addicts to abuse these drugs, but does the cost of that new technology make these medications unaffordable for the average person, especially the disabled and elderly who may need them more than others. Is the FDA pulling older and more affordable opioids off the shelf because they do not have this new technology? Is the cost of medical care and denial of coverage being driven by the 5% of addicts in this country, by expensive prison empires to house them, by headlines and politicians?

Cost is the issue that limits care. When Medicare & PPO coverage is cut for all of us, will the cost of drugs be one of the major reasons? Answer: it already is.

Remember, the FDA does not have a majority of pain specialists on pain-related advisory committees, only 3 out of 11 MD’s sat on the FDA committee that limited use of short acting fentanyl medication for cancer pain. Opioids may be an essential option for some of my patients yet their PPO will not pay for it — it’s restricted to cancer patients. PPO’s will not pay for many nonopioids used for pain either.

Does the FDA think oncologists know more about treating pain than a pain specialist? The answer is definitely no! Oncologists do not, and some abuse their power to prevent pain relief. Research has shown severe untreated pain in 34% of cancer patients among oncology specialists in the Northeastern US, and likely far more in other areas. There are many untold stories about oncologists who do not treat pain or who use poor practice treating pain, even at major cancer centers. Pain is not their priority and most spend no time learning the needed expertise.

So no coverage for PT, for off label medication, for compounded medication, for opioids restricted to cancer pain, for expensive medication, and increasing regulation for older and more affordable opioids if they have not been pulled off the shelf by the FDA.

Cost cuts imposed major losses in pain management. PPO cuts were severe at least as far back as the mid 1980’s. In 1990, UCLA closed its Anesthesiology Interdisciplinary Pain Center, only 15 years after the first international pain society meeting. Laid off with two weeks notice was the President of the American Pain Society and distinguished researchers in the field. Soon after that, in the hallways of the annual pain society meeting, whispered rumors spread that almost all university centers had closed their interdisciplinary pain centers. Only a few remained, but there was silence on the subject from the platforms and leadership and media. UCLA paved over the only therapeutic swimming pool in the greater Los Angeles area in order to build yet another radiology center.

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The Era for Procedures

There has been a rapid increase in interventional procedures with almost all pain specialists shifting to high reimbursement and easily funded techniques, but where’s the science? Procedures bring in money for hospitals and surgery centers. See this weblog for comments from the Academy of Neurology and American Pain Society on epidurals and nerve blocks: Show me the science! Morphine pumps used to be commonplace, but not so much now because a tumor forms at the tip of the catheter. The focus shifted to spinal cord stimulators, but there is no proof they offer any lasting benefit. I have patients whose relief lasted a couple days, then stopped forever, and now the leads are scarred into their spinal cord. Others have failed two or three “stims.” They will never be able to have an MRI again  even if they have cancer or stroke. One distinguished Anesthesia Pain colleague refuses to put them in because patients are soon on the same opioid medication they used before, with no improvement in pain control. Show me the science! No one looks at those costs. But Medicare and PPO’s will pay for procedures which are inversely proportional to the time needed for pain management. The rationale for some of those procedures is to limit access of drug to addicts. Where is the science? Where is the research on pain control?

What if you get pain? if you are disabled? Will you be able to afford care? Will your PPO cover the cost for your pain medication? Will it be available to you if you don’t have cancer? From what I see, the answer is increasingly no. And it looks like politics may make the treatment of pain subject to more and more irrational or unaffordable choices.

Corrections 6/15/09:  3% of medical schools teach a course in pain management, not 6%. Yale 2008 reference, above and next post.

The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

To Find My Home Page, click here:  Welcome to my Weblog on Pain Management!

]]> http://jabertolin.wordpress.com/2009/06/07/xxvi-worldconference-iasp-2009-raleigh-nc-%c2%bfinnovamos-en-las-conferencias/ Sun, 07 Jun 2009 09:20:32 +0000 jabertolin http://jabertolin.wordpress.com/2009/06/07/xxvi-worldconference-iasp-2009-raleigh-nc-%c2%bfinnovamos-en-las-conferencias/

(english below)

Durante esta semana he asistido a la XXVI World Conference of Science and Technology Parks en Raleigh, NC (USA) cuyo eje principal giraba entorno a

He intentado analizar la conferencia desde un marco crítico (de forma constructiva) dado que después de las ponencias a las que he asistido puedo decir que el balance neto es negativo y quisiera que en próximas ediciones fuera positivo

Primero, y antes de evaluarla, hay que plantearse: ¿Cuál es el objetivo de una conferencia de este estilo?

Por una parte una conferencia, y esto es una interpretación personal y por lo tanto discutible, es un evento que pretende reunir a personalidades de un área de conocimiento para que compartan con el resto de los participantes sus experiencias, conclusiones o visiones de su futuro.

Desde este marco habría que preguntarse sin una conferencia ha de ser interactiva o no, es decir si tiene que ser unidireccional o bidireccional, si el ponente espera aprender de la audiencia o sólo que sean los demás  los únicos susceptibles de aprender.

Si es unidireccional y no existe interacción entre los participantes, el valor añadido de la conferencia se pierde pues se centra únicamente en el protagonismo del ponente, como  único generador de conocimiento válido y contrastado, y no de los participantes a los que no se les considera fuentes de conocimiento.

Este es el modelo que se ha seguido en el IASP, al igual que la mayor parte de las conferencias y por tanto al finalizar tienes la sensación no tanto de haber perdido el tiempo (visión negativa) como de no haberle sacado suficiente partido al tiempo invertido.

Charlando con mi buen amigo Anthony Townsend, sacó a relucir un concepto que me pareció muy interesante: la “Unconference” (http://en.wikipedia.org/wiki/Unconference), es decir una aproximación completamente opuesta al habitual y que se apoya en métodos como el Open Space Technology (http://en.wikipedia.org/wiki/Open Space Technology) o Barcamp (http://en.wikipedia.org/wiki/BarCamp).

Un entorno tan innovador como lo es el de los Parques Científico-Tecnológicos (en adelante PCT) debería dar ejemplo a la hora de interactuar, y en este caso ha quedado de serlo; no ha sorprendido salvo de forma muy puntual (al menos de todas las presentaciones que he visto)

Curiosamente, después de escribir mi post en un pequeño bloc dada la dificultad que tuve en conseguir conexión a internet durante mi viaje a USA -increíble pero cierto-, me encontré un post de fecha 7 de Mayo en el blog de Stefan Lindegaard titulado “Innovation conferences: Are they worth attending?” donde varias de sus reflexiones coinciden con las mías (se supone que hasta las conferencias que versan en temas relacionados con PCTs son conferencias que giran entorno a la innovación) y haré mención a él cuando se produzca la coincidencia).

Siempre con un ánimo constructivo,  he echado en falta varios aspectos:

• Casi todas las presentaciones han girado alrededor de exposiciones endogámicas de cada PCT: quién soy, qué hago y qué bien lo hago (información que hoy por hoy es fácilmente accesible por internet y cuyo valor añadido es mínimo o nulo). Por tanto a la hora de preguntas no cabe discusión salvo peticiones de aclaraciones (son como las preguntas cerradas dónde sólo se admite un SI o NO). Entiendo que hubiera sido más efectivo lanzar cuestiones abiertas que incitaran a la discusión, a la reflexión, …. al que podríamos llamar el “acto de constricción”. C.K. Prahalad suele hablar de la co-creación y la importancia de de proporcionar una experiencia (y eso podría decir que es responsabilidad de los organizadores ser consciente de la información que se está transmitiendo).
• No he visto ponentes jóvenes (salvo el casto de Townsend y alguno más). Es obvio que la “seniority” es importante por la experiencia acumulado a lo largo de los años pero también hay que tener en cuenta que el mundo está cambiando a una velocidad trepidante y las nuevas tendencias van imponiéndose a las antiguas y obsoletas, y eso requiere nuevas concepciones, nuevas formas de innovar (lo que podríamos llamar “innovar la innovación”). Son las nuevas generaciones de emprendedores y visionarios que buscan y necesitan modelos de espacios diferentes (tal y como apuntó Ilkka Kakko en su intervención de la sesión paralela Beyond Borders: The Geography for Innovation), de gestión diferente que exigen más dinamicidad y los modelos tradicionales dejan de tener sentido.
• La presencia de una representación de empresas de todos los estados de creación-crecimiento y maduración de una empresa: spin-off, startup, grow-up, tractor que pudiera tener voz sobre cuáles son las necesidades básicas y no tan básicas que tienen (y que no son siempre las mismas debido a la naturaleza de la actividad de las empresas). Parece que cando se presentan los modelos de gestión de PCTs éstos se asumen infalibles (y hay que tener en cuenta que casi hay tantos modelos como PCTs luego … ¿dónde está la infabilidad?
• No existen KPI objetivos que permitan establecer la calidad del valor generado por el modelo de gestión que ha implementado un PCT (así podrían identificarse los mejores y aplicarlos exportándolos a todo el mundo con sus matices). Estos KPIs (que serían un buen tópico a tratar por su grado discutibilidad) permitirían evaluar el trabajo que están haciendo todos los PCT aunque ello diera lugar a una clasificación y por tanto a un nivel de competencia entre ellos, pero por otra parte forzaría a que los PCT mejoraran su gestión (con este planteamiento es probable que muchos de los PCT creados por mera especulación urbanística por el acceso a subvenciones -por su carácter de parque-  renombrándose como simples polígonos industriales). También permitiría saber si la inversión realizada (en términos públicos o privados)  para poner en marcha un PCT compensa la generación de riqueza realizada y el impacto en la economía local-regional.

China hizo una presentación de un diseño e implementación de KPIs muy complejos matemáticamente pero acabó concluyendo que sólo 4 KPIs eran necesarios para evaluar un parque: número de empresas ubicadas, su facturación, metros cuadrados utilizados y, sinceramente, creo que está lejos de permitir conocer la viabilidad y eficiencia de un parque. Voy a indagar más en el modelo completo… tengo interés.

• Un verdadero proceso de networking y para ello, para comenzarlo es necesario que la lista de los participantes se distribuya entre todos ellos con suficiente tiempo como para que se establezcan pre-contactos que se hagan efectivos y consoliden durante el evento.

Por tanto, el modelo actual de conferencias del IASP (y de cualquiera relacionada con parques) debería reorientarse hacia un modelo más interactivo donde una parte (la plenaria) recogiera visiones estratégicas de expertos de alto nivel (y que permita la interacción con la audiencia de forma directa) y una segunda donde el networking activo e interactivo fuera el protagonista. En esta segunda parte, se tratarían temas específicos con expertos seleccionados escrupulosamente y en los que los participantes interactuarían entre ellos y con los expertos planteando nuevas estructuras de gestión o modelos a seguir: por ejemplo, temas financieros, actuaciones innovadoras dirigidas a empresas instaladas, KPIs a definir…etc. Para su ejecución se podrían conformar equipos multidisciplinarios, constituidos por miembros de diferentes PCTs y donde se pudiera exponer conclusiones, visiones y debatirlas.

Otra sesión que podría ser muy interesante en la de presentación de conclusiones de interacción entre parques dentro de la iniciativa INTRA-STP networking o de la INNOGATE que comentaré en un siguiente post como triggers de la colaboración internacional entre parques.

Finalmente, es necesario establecer un conjunto de KPIs asociadas a la calidad de las conferencias (yo ya he elaborado una propia para conocer el grado de efectividad de mi tiempo invertido versus lo obtenido por asistir) donde permita evaluar al ponente, calidad de presentación y contenidos con el objetivo de incrementar el nivel de calidad de la misma.

Para concluir, resaltaría un conjunto de reglas que Ed Bernacki detalló en su libro “Seven Rules for Designing More Innovative Conferences” y que giran entorno a la necesidad de que se creen estrategias de aprendizaje antes de desarrollar el plan logístico de un evento de estas características:

Regla 1: Los Expertos de la conferencia son los que forman parte de la audiencia no sólo los ponentes
Regla 2: Piensa en el Retorno de la Inversión aunque a veces es difícil de medir
Regla 3: Diseña una conferencia con Logística y Aprendizaje
Regla 4: El aprendizaje objetivos debe marcar el contenido de las presentaciones.
Regla 5: Siempre utiliza el poder y capacidad de la audiencia a la hora de crear algo.
Regla 6: Ten en cuenta la estructura en las oportunidades de networking que generes.

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(translation to english in progress)

La douleur, faire-valoir du plaisir de vivre ?
Ou bien phénomène toujours autant psychique que physique, presque toujours excessif, disproportionné, inutile et nuisible ?
Essayez d’abord de vous replonger courageusement dans l’univers de la douleur, cette préoccupation, ce thème si cher à Juan-David Nasio.

Le sous-titre de l’ouvrage sur la douleur physique a sans doute plus d’importance que le titre lui-même :

La douleur physique
Une théorie psychanalytique de la douleur corporelle

La douleur physique n’est pas que la conséquence, la réponse, le retentissement de la simple information d’une lésion physiologique, physique, d’une atteinte corporelle.
Le retentissement est aussi psychique, on le sent bien, et les spécialistes des neurosciences pensent que la part psychique est importante dans l’émotion douloureuse et qu’il peut même y avoir une douleur « psychogène » effectivement ressentie bien que sans cause physique repérable.
L’IASP (International Association for the Study of Pain) définit ainsi officiellement la douleur :
« une expérience sensorielle et émotionnelle désagréable, associée à une lésion tissulaire réelle ou potentielle, ou encore décrite dans des termes évoquant une telle lésion »
Donc l’émotion douloureuse est sincère, peut être vraiment éprouvée sans forcément qu’il y ait une atteinte organique.
La douleur physique, corporelle, n’est pas que neurophysiologique. Elle ne l’est parfois pas du tout. Cela suffirait à motiver la recherche psychanalytique pour élucider cette dimension psychique parfois seule, en tout cas toujours présente, et nous le verrons, souvent excessive.

Pour J.-D. Nasio, « la douleur (physique ou psychique) est toujours un phénomène de limite…, un phénomène mixte surgissant entre corps et psyché »
- Il y a bien sûr la douleur de la lésion, du choc, de la commotion : une douleur neurophysiologique perçue instantanément.
- Cette atteinte corporelle est localisée (vue ou imaginée), et le « blessé » souffrant a une « vision », en partie réelle, mais aussi très vite fantasmée des dégâts physiques perçus ou imaginés. Ainsi, lors d’un infarctus, la malade se fait une « idée », une image fantasmée de son cœur souffrant, brisé… Les « images » de nos organes intérieurs ne sont jamais objectives, et l’intolérable douleur, souvent disproportionnée, contribue pour beaucoup à cette distorsion de l’imaginé et du ressenti.
Et c’est cette « représentation », cette mise en scène mentale et non objective des lésions, qui se forme instantanément, et qui le plus souvent va accentuer le ressenti douloureux. La douleur sera sentie comme émanant de la blessure, comme localisée à l’emplacement de la douleur, à cette zone lésée qui agresse comme un être étranger, comme quelque chose dont il faut se débarrasser.
« …très vite [après la commotion], s’élève du tréfonds de l’être une autre douleur, bien différente, essentielle et profonde. Cette douleur, je ne la possède pas, c’est elle qui me possède : je suis douleur. » : en état de choc.

Et nos pauvres tout petits, face à l’énorme agression de la douleur physique ?
Ils n’ont pas les moyens, pas l’expérience ni le recul nécessaires pour analyser objectivement, pour comprendre ce qui leur arrive, pour éventuellement savoir relativiser.
Submergés par une douleur sans nom venue ils ne savent d’où, ils ne peuvent que hurler leur souffrance, clamer leurs cris de détresse.
Il leur arrive, à mesure qu’ils grandissent, quand déjà ils comprennent un peu les mots de l’entourage venu à leur secours qui leur désigne le coupable – « le vilain caillou qui a coupé le genou de Pierrot », « le méchant couteau qui fait saigner le pauvre petit doigt », – quand ils sentent et apprécient cette compassion des grands, quand ils se laissent un peu rassurer et consoler par les « là…c’est rien…c’est fini », par maman qui souffle sur le bobo pour le faire envoler (nos mémés saintongeaises appellent ce souffle de tendresse et de compassion « de l’eule de thieur » – « de l’huile de cœur », un geste « affectif » comme un baiser à distance sur une blessure qu’on ne peut encore toucher, un souffle de rien qui à la puissance d’une anesthésie locale.

Mais alors, nous aussi, adultes, pourtant si forts, si aptes à l’objectivité, face à la douleur physique, nous redevenons donc de tout petits enfants désemparés et paniqués.
Nous vivons cette blessure physique comme une atteinte narcissique qui touche notre Moi le plus profond.
Et très vite, quand la blessure est grave et que nous sommes conscients, nous voyons se profiler les ombres sinistres de la mort, du handicap.
C’est sans doute pour cela que nous surinvestissons la représentation que nous nous faisons de l’atteinte subie, et c’est justement ce surinvestissement psychique qui accroît démesurément notre ressenti douloureux.
Il nous faudrait avoir le détachement du soignant qui lui permet, avec sa compétence et ses savoir-faire de secouriste, d’urgentiste, une évaluation rapide et néanmoins objective des dommages, et donc des procédures efficaces à suivre.
Mais face au Mal, nous sommes tous tout petits, tout faibles, tout désemparés : nous avons tous eu un jour le spectacle affreux d’un adulte sur le bas-côté d’une route hurlant à pleins poumons sa souffrance, comme un nourrisson. Et la télé se délecte – améliore son audimat – de ces détresses en gros plan et aux heures de grande écoute.
Il y a tout un apprentissage de l’expérience douloureuse : apprendre à l’évaluer au premier coup de dent comme on jauge une bête malfaisante et dangereuse.
Une école de la douleur, en quelque sorte :
- Pour ses victimes, qui la subissent ;
-Pour les professionnels qui eux doivent savoir au plus vite la juguler ou tout au moins la contenir, et ce d’autant plus que les souffrants sont jeunes et/ou vulnérables.
Il ne s’agit surtout pas de nier la douleur, celui qui souffre est toujours de bonne foi – même si parfois rien encore de la science médicale ne permet d’en repérer pour le moment une quelconque trace physiologique.
En tout cas, une souffrance psychique, une simple appréhension de douleur physique, quand elles sont négligées, ou niées, ou pire, moquées, finissent toujours par avoir un retentissement corporel. Les blessés du cœur n’ont pas que des bleus à l’âme et très vite il leur vient des séquelles bien physiques. Freud, cité par Nasio (pbp 609 p 37) affirme :
« Rien dans la vie psychique ne peut se perdre, rien ne disparaît de ce qui s’est formé, tout est conservé… et peut réapparaître. »
Et J.-D. Nasio explicite à sa façon, magnifiquement, la formule géniale du grand Freud, cette mémoire pour ainsi dire génétique que nous gardons de la sommation des expériences douloureuses endurées depuis la nuit des temps :
« Assurément, nous ne savons pas de quelle souffrance immémoriale nous sommes issus, mais nous pouvons être sûrs qu’elle ressurgit à l’occasion de toutes les douleurs physiques et psychiques, et transmet à chacune sa qualité spécifique d’affect pénible. Cette douleur primordiale et intemporelle revient sans cesse dans le présent pour communiquer à toutes les autres la marque du déplaisir intolérable que nous éprouvons lorsque nous sommes malades ou affligés. »

On Monday, I attended the first day of the International Association for the Study of Pain®’s (IASP’s) World Congress on Pain at the Scottish Exhibition & Conference Centre (SECC) in Glasgow, along with Daniel Austen, of the UK FM Clinics, and Jo Fisher, the development officer for the Surrey & Sussex Support Group.

Dan, Jo and I travelled to Glasgow separately over the weekend and attended the conference on the Monday. The conference venue, the SECC, which is huge, was a relevation in itself, as was the information that there were 5,000 delegates attending – pain is obviously big news in the international medical community.

There were a huge numbers of stands on everything from drugs to pain associations and rows and rows of poster displays (363 on Monday). The one of most interest to us was ‘Fibromyalgia: Impaired Top-Down Control during Anticipatory Pain Relief’, describing a study by Canadian researchers showing that, although anticipating pain can lead to greater perceived pain levels, the physical pain response in patients with Fibro is extreme, maintained and unaffected by whether patients think that something will hurt or not – more proof that Fibro is a real condition that causes increased levels of pain physically. The researchers concluded that:

“…[the pain reading in Fibro] cannot be reduced to a psychological epiphenomenon, but rather suggest a true neurological disturbance.”

We got the opportunity to talk with the researcher presenting the poster and we were delighted to find that he had a fantastic in-depth knowledge of Fibro.

Many of the posters weren’t relevant to Fibro, being more concerned with acute pain, opioids and CRPS. But there were 3 other posters directly relevant to Fibro being displayed on Monday.

The highlight of the conference for the Fibro community, and our reason for attending on Monday, was Daniel Clauw MD’s talk on ‘Stress and Chronic Pain: Lessons Learned from Fibromyalgia’. Dr Clauw, a Professor of Medicine at the University of Michigan, USA, is an internationally renowned expert on Fibro.

Hearing Dr Clauw’s talk was amazing. It backed up everything that FibroAction have been saying about Fibro and it was incredible to sit in a 3,000 seat auditorium, listening to an accurate, evidence based lecture about Fibro – what this must have done for the credibility of Fibro in the midns fo the thousands of doctors and researchers present!

After the talk, Dan, Jo and I met with Daniel Clauw, and also with Patrick Wood. It was fascinating to talk to both of them about Fibro and the situation in the UK, where we are years behind the US in terms of awareness. That evening we took also Patrick Wood to dinner, which really make the Congress for me. As the originator of the Dopamine Theory of Fibromyalgia, Dr Wood’s theories and the research that has come from them are responsible for the use of dopamine agonists in Fibro. I take a dopamine agonist and owe my ability to attend such events as the Congress to the improvement I have found whilst on this med. I feel that I personally owe Dr Wood (and Dr Andrew Holman who investigated the use of Pramipexole as a treatment for Fibro) a great deal and it was a real honour to sit across a dinner table from him and have the opportunity to ask and answer questions.

Olá,

Hoje estou postando as gravações da Big Band da escola em que trabalho como professor de violão e guitarra. O trabalho da Big Band é desenvolvido com alunos de diversos instrumentos da Escola de Artes do IASP (www.iasp.br). A big band conta com os arranjos e regência do professor Cristiano Frank, que é auxiliado por outros professores da Escola de Artes: Pablo Pezoa (bateria e percussão), Rafael Thomaz (violão e guitarra), Douglas Vieira (trombone) e Israel Calixto (trompete). 

(clique aqui para baixar)

As músicas, gravadas em Dezembro de 2007 no Estúdio Vitrola Digital em Campinas, são:

The Chicken

Solos: Rafael Thomaz (guitarra) e Bruno Cabral (saxofone)

Cartoon Simphony

Eye of the Tiger 

 Solos: Paulo Victor (saxofone) e Wismar Zanella (trombone)