The Family Physician of the Future
This post is part of our forum on David H. Freedman's July/August story, "The Triumph of New Age Medicine." Follow the debate here.
Any discussion of complementary and alternative medicine inevitably polarizes people. Both sides feel very strongly that they are "right" and can provide dramatic examples of the benefits of -- or serious harm caused by -- whatever approach they support or challenge. However, it is unlikely that anyone will change his or her mind based on an article or expert opinion.
Regardless of which view one holds, it is well documented that patients do things that physicians do not prescribe, and they benefit from mechanisms we might not expect. We have evidence that good communication skills result in improved health outcomes. An article published in March's Academic Medicine correlated higher empathy scores in physicians with objective improvement in their patients' ability to control diabetes. As we learn to measure the variables of the physician-patient relationship, bridges can be built between seemingly disparate treatment modalities.
In this forum, Steven Salzberg states that only one kind of medicine exists -- "the kind that works." I agree, but we don't always know how to measure success. Research suggests a significant part of our care might depend more on placebo than we'd like to admit. All controlled trials recognize the power of the placebo effect, which has always been and will always be a part of medical care. Rather than controlling for it, we could work to augment its benefit to our patients.
Moreover, despite careful clinical trials, the outcomes of medical treatments are not always what we expect. The Institute of Medicine reports that 100,000 deaths per year occur from the right drug being used for the right reason in the right person. These are not mistakes, but consequences of our therapy. And research shows that long-accepted procedures such as coronary artery stenting may not ultimately extend a patient's life.
Based on this new data, should we say such treatments do not work and therefore stop doing them and paying for them? These are the huge questions created by unexpected evidence-based evaluations.
In order to fix what is wrong, we have to make informed decisions rather than ones based on fear and politics. As noted in this discussion, lifestyle and behavior choices are key, and prevention is important for promoting health. But as a faculty member at a primary-care-focused allopathic medical school, I can state that we do not teach about health and healing. Instead, our focus is anti-infectious, anti-hypertensive, anti-depressant, and so on.
We must recognize that times have changed. Our tremendous successes in handling issues such as infectious disease pale with our difficulty in managing chronic pain, depression, obesity, and other epidemics of modern life.
Sadly, our healthcare system is not about health. We spend more per capita on healthcare than any other country on earth, yet we're far down the list when it comes to patient outcomes. Our current system of basing care on fee for service not only leaves millions of Americans un- or under-insured (people rob banks in order to get health care!). It also encourages physicians to "do something" -- to order more tests and prescribe more pills -- even though more and more evidence shows that what we do may not be as important as how we do it.
When we had fewer things that we could do, we focused on being present for our patients. We need to find ways to do this again -- to provide care that focuses on each person. All physicians must recognize what Hippocrates stated, that it is more important to treat the person than the disease, as diseases manifest differently in every person.
Fortunately, new models are beginning to emerge. The patient centered medical home allows doctors to organize their practices around their patients, creating a functional system that is based on health and healing. Doctors must also make meaningful use of electronic health records and delegate tasks to other members of the team, allowing many of the necessary parts of patient care to occur online and even after hours. This can free us up to focus more closely on our patients' lifestyles and behaviors, their joys and sorrows, and address their most important issues face-to-face.
In this, we can learn from complementary and alternative providers, who recognize the value of good bedside manner and individual attention. Patients and providers have trouble finding that in our current system.
It is difficult when experts disagree. And meanwhile, the territory continues to shift. Not long ago, osteopathic physicians were felt to be on the fringe. Hypnosis used to be alternative, but is now seen even by one of the critics of this article as mainstream care. On the other side, medications we've prescribed with full confidence have been suddenly pulled off the market because of adverse reactions that were unexpected -- or worse, not revealed when first known.
This sort of change is part of medicine: something that is "true" today may suddenly not be "true" tomorrow, and vice-versa. What is always true, however, is that the blending of the art and science of medicine has less to do with being a doctor than with being a healer. Freedman's article is a call to those of us in the health professions to put our hearts back into the art of medicine.
The debate continues here.