Against cookbook medicine

"How can modern medicine be so dehumanized?" is a question posed by Dr. Leana Wen and Dr. Joshua Kosowsky in “When doctors don’t listen”. According to them, with a few exceptions, the practice of medicine is subjugated by the dictatorship of guidelines, algorithms, codes, protocols and rules. "Cookbook medicine" they call it. Everyone is aware that many requested tests are unnecessary and that many people are subjected to anxiety induced by the prescribed manual diagnostic processes to rule out infrequent pathologies. The theory of the book is based on the fact that the process to arrive at a diagnosis is complex, requires an interview in which the patient can frankly express the story of what is happening to him, a physical examination according to the hypotheses that arise and a clinical reasoning participated by the patient himself; all this, very far from a manual practice.

The ancestral optimism and the perfect storm

The optimism of patients

When people get ill, or are afraid of being ill, as a rule we tend to trust doctors and by extension, health systems. But do we really benefit? A systematic review, developed by researchers from the Centre for Research in Evidence-Based Practice of Bond University (Australia), based on 35 surveys (27,323 patients as a whole) concludes that 88% of people overestimate the real benefits of the clinical actions, while 67% underestimated the adverse effects.

See for example, the expectations of people in being able to reduce the risk of dying from secondary prevention programs for breast, prostate and bowel cancers are far above the real data. The dark part of the bars corresponds to the percentage of respondents who overestimate the benefits of the respective preventive tests, and the crosses on the right indicate for which of them this percentage is equal to or greater than 50%.

Effective communication for planning living will

Glòria Galvez

Planning living will is a key element for the care and attention of people with advanced chronic diseases and their families. In recent years, models and proposals have been developed throughout the Spanish territory, such as in Andalusia or Catalonia, based on respect for the person and framed in quality care, taking into account their wishes, expectations and preferences.

The communication within planning living will has been shown to have important benefits when a terminal process of the patient is expected, since a shared decision-making process is established in a trusting environment, at the same time as it’s incorporated in to the family and relatives care planning. Addressing these issues effectively involves doing so at the moment when the patient still retains his decision-making capacity, that is, at the earliest time of his hospitalization. Doing it later may pose a greater risk of aggressive and unnecessary treatments.

Despite their high therapeutic value, professionals report great difficulties in maintaining a fluid communication with a terminally ill patient. In a recent Canadian study published in the journal JAMA some of the reasons for this difficulty are described as: uncertainty of the prognosis, fear of causing distress or perception of patients being unprepared to talk about it.

The Catalan Institute of Oncology (ICO), a world reference centre in the design and evaluation of public palliative care programs for the WHO, with Dr. Gómez Batiste at the helm, has designed a new model of palliative care at the Institute in which it is proposed that communication with the patient follow a strategy based upon open questions, considered key to detecting their basic needs: How do you feel? How do you perceive your current state of health? What are you worried about? What do you think may happen in the future? What do you think would help you fight this situation? What do you need us to do for you?

Dr. Gawande, in his book Being Mortal, also proposes some key questions that can help professionals have a quiet conversation about the end of life process. Faced with this open approach, there are those who propose a closed script with previously prepared themes. This can be quite a challenge due to the different barriers that have been expressed by professionals, such as the fear of eliminating all hope that the patient may have regarding his illness.

Both strategies have advantages and disadvantages: the open format allows the patient to express fears or questions that the professionals had not foreseen, and the closed format could facilitate professionals in asking potentially difficult questions. To illustrate the post, I leave the video in which Dr. Meier, a doctor at Mount Sinai Hospital and director of the Centre for the development of palliative care (CAPD) in the USA explains the 10 essential steps in communicating with patients and family members receiving palliative care:

1. Review the patient's clinical situation.
2. Prepare a decent, comfortable space with privacy and confidentiality.
3. Present the attendees and comment with simplicity on the objectives of the meeting.
4. Find out what the patient knows about his illness.
5. Explore what the patient wants to know: ask/explain/ask. Ask about the required information.
6. Explain the thorniest details required by the patient.
7. Ask if they have understood the terms used and encourage them to repeat them in their own words.
8. When faced with difficult questions such as: Am I going to die? Simple and clear answers: Yes, you will die and we will be permanently by your side, watching over your welfare to the maximum.
9. Analyze the therapeutic options, without deceiving but without denying reasonable hopes.
10. Organize and plan the next visit.

Communicating is also being able to know how to listen; it’s a key aspect in knowing what the patient's situation is at each given moment. For active listening to work, it’s better to move away from paternalism and facilitate the patient's participation in the decisions that best preserve their dignity and freedom.

Clinical practice guidelines versus shared decisions

In the April post I was talking about the call for the end of clinical practice guidelines. This is an issue that is generating controversy and I think it’s worth revisiting, especially following the publication of “Making evidence based medicine work for individual patients” by Margaret McCartney and collaborators, where they say that there is concern because the guidelines, instead of reducing variations and improving the quality of assistance have managed to bureaucratize medicine, while at the same time reinforcing historical authoritarianism. This happens because, according to the authors, based on the evidence, the guides encourage doctors to ignore the real needs of the people they serve. In addition and to top it all, a review concluded that 62% of the guidelines were based on irrelevant evidence for health problems affecting people visiting the family doctor.