Prac­tis­ing medicine

From ex­pe­ri­enced-based to ev­i­dence-based to the in­ter­per­sonal

The Irish Times - Tuesday - Health - - Front Page - Muiris Houston mhous­[email protected]­

For years we had ex­pe­ri­enced based medicine. Then ev­i­dence-based medicine (EBM) came along and has in­flu­enced doc­tors’ de­ci­sion-mak­ing for the last 20 years or so.

But now it’s time to wel­come a new par­a­digm – say hello to the world of “in­ter­per­sonal medicine”.

EBM was an im­por­tant ad­vance over the in­tu­ition-based medicine that pre­ceded it, but its lim­i­ta­tions are be­com­ing clear even as it is in­creas­ingly ac­cepted as an as­pi­ra­tion. Writ­ing in the New Eng­land Jour­nal of Medicine last month, Drs Stacey Chang and Thomas Lee say there is now a need for some­thing be­yond EBM.

“EBM placed new em­pha­sis on the re­la­tion­ship be­tween clin­i­cal re­search and clin­i­cians’ prac­tice pat­terns, but shifted medicine’s ‘cen­tre of grav­ity’ away from the space be­tween clin­i­cian and pa­tient to some­where be­tween re­search and clin­i­cian,” they write.

What’s needed now, in their view is “in­ter­per­sonal medicine,” – a dis­ci­plined ap­proach to de­liv­er­ing care that re­sponds to pa­tients’ cir­cum­stances, ca­pa­bil­i­ties, and pref­er­ences. In­ter­per­sonal medicine, they main­tain, is not just about be­ing nice – it is about be­ing ef­fec­tive.

I have prac­tised both ex­pe­ri­ence­based and ev­i­dence-based medicine. Be­fore the rise of EBM, ex­pe­ri­ence gained from a life­time of prac­tice was the most re­li­able ba­sis for clin­i­cal de­ci­sion mak­ing.

I was com­fort­able prac­tis­ing what might be termed in­tu­ition-based medicine but have to ac­knowl­edge it was lim­ited by the data to which I had ac­cess as well as my prior ex­pe­ri­ence. And in fair­ness to EBM, it al­lowed doc­tors to still draw on their own ex­pe­ri­ences and in­stincts, while en­abling them to en­rich these with broader data sets and less bias.

But the world has moved on and with it the type of ill­ness most of us will ex­pe­ri­ence. Rather than hav­ing a sin­gle dis­ease, as we live longer, most of us will have mul­ti­ple mor­bidi­ties. So­cial and be­havioural fac­tors as­so­ci­ated with dis­ease will be­gin to out­weigh pure bi­o­log­i­cal con­sid­er­a­tions. And so ef­fec­tive treat­ment will have to move be­yond “a pill for ev­ery ill”.

Which is where in­ter­per­sonal medicine be­comes in­creas­ingly im­por­tant. In­ter­per­sonal skills are peo­ple skills and in­clude the abil­ity to mo­ti­vate, com­mu­ni­cate, solve prob­lems and, per­haps most valu­able of all, em­pathise.

In­ter­per­sonal com­mu­ni­ca­tion skills fa­cil­i­tate pa­tient-cen­tred care. De­fined as com­mu­ni­ca­tion that oc­curs face-to-face, it is shaped by the in­di­vid­ual char­ac­ter­is­tics, so­cial roles and re­la­tion­ships of the peo­ple in­volved. It en­ables the ex­change of mes­sages be­tween doc­tors and pa­tients in or­der to es­tab­lish shared goals and un­der­stand­ings.

In­ter­per­sonal medicine re­quires skills that place clin­i­cians along­side their pa­tients, as fel­low trav­ellers and ex­pe­ri­enced guides. But most of all it re­quires a fun­da­men­tal shift in how we or­gan­ise our health sys­tem.

The days of fee-per-item, pro­ce­dure-fo­cused medicine are num­bered. In­flex­i­ble rules and tech­nol­ogy-driven pro­duce prompts care that is man­age­ment driven rather than pa­tient-cen­tred.

We need to com­pletely re­struc­ture the health ser­vice so that time spent along­side the pa­tient be­comes the most im­por­tant met­ric. In my opin­ion it’s the only way we can de­liver em­pa­thetic, co-or­di­nated care.

We need to com­pletely re­struc­ture the health ser­vice so that time spent along­side the pa­tient be­comes the most im­por­tant met­ric

There is any amount of ev­i­dence to back this up. Bet­ter physi­cian com­mu­ni­ca­tion is as­so­ci­ated with sig­nif­i­cant gains in pa­tients’ ad­her­ence to rec­om­mended ther­a­pies and to im­prove­ment in a va­ri­ety of out­comes.

Ef­fec­tive doc­tor-pa­tient in­ter­ac­tion has been shown to im­prove pa­tient sat­is­fac­tion, de­ci­sion mak­ing, emo­tional health as well as im­proved blood pres­sure con­trol.

But if we keep do­ing what we are do­ing then two-thirds of pa­tients will con­tinue to be dis­charged from hos­pi­tal with­out un­der­stand­ing their di­ag­no­sis. And if these trends con­tinue, pa­tients will re­ceive care that isn’t com­pre­hen­sive and doesn’t ad­dress the root cause of their symp­toms. Pa­tient read­mis­sion rates will in­crease, re­sult­ing in a spi­ralling cost to the health ser­vice.

We must change the sys­tem to en­sure in­ter­per­sonal medicine be­comes the norm. Oth­er­wise, we will con­tinue on the “ham­ster wheel of health” – go­ing around in cir­cles to less and less ef­fect.

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