Patient-centered vs. Lab-centered "Personalized Medicine"
Treat the patient as a person, not as a bunch of lab test results.
Posted Jul 24, 2017
"It is more important to know the patient who has the disease than the disease the patient has."—Hippocrates
Personalized medicine was invented 2500 years ago when Hippocrates put the patient at the center of medical care—not the gods or the practitioner or the treatment.
To the detriment of patients, Hippocrates' brand of patient centered, personalized medicine has been eroded by 150 years of increasingly high tech medicine. Sadly, the laboratory tests, the technical tools, the medical record, the billing system, and the computer are now too often at the center of medical care- all at the expense of the crucial healing that has always come from the doctor/patient relationship.
The modern and misleading use of the term "Personalized Medicine" began 20 years ago as an outgrowth of the enormous enthusiasm engendered by the human genome project.
The concept was grand. Rather than diagnose and treat people based on very broad and nonspecific features (like shared symptoms or signs), perhaps doctors could use the powerful new genetic tests to determine which specific genes were causative of each individual's disease and then fashion a treatment specific to each person's underlying genetic defect.
There have already been a few dramatic successes of this modern form of "personalized medicine," and hopefully with time there will eventually be many more.
But scientifically informed personalized medicine mostly remains a distant hope for the future and has instead become a crude form of marketing hype in the present.
Hospitals, drug companies, doctors, the National Institute of Health, even President Obama have used the misleading term "personalized medicine" as a branding advertising tool to sell medical services and to gain support for enhanced research funding.
Extravagant promises are made that most certainly cannot possibly be kept. The sell is that magical cures for a whole variety of diseases are just around the corner- especially now that we have the extremely powerful tool of gene editing.
The reality is much more uncertain and difficult. Most diseases have remarkably complex genetic roots involving hundreds of genes, each making tiny and complexly interacting contributions. There are few simple genetic targets; there will be few magical cures. Gene editing will likely be helpful only for the relatively few diseases that have simple causation.
Surely, we should march on with sophisticated research to find them, but mustn't be so dazzled by the potential of the science of medicine that we lose the magic that has always come from its art and humanity.
Nicholas Capozzoli, a neurologist, is the wisest and most humane doctor I know. He will help us recapture the simple things, now so often lost, that have made Hippocratic medicine so effective for so long.
Dr. Capozzoli writes: "The once-glorious doctor/patient relationship is being cheapened into a commercial contract—like buying a car or filling out tax forms with an accountant. In my view, the tie between doctor and patient should be a powerful relationship of trust, empathy, and healing.
Personalizing medicine by focusing on the patient is an extension of the ancient and time honored tradition of hospitality. The magic of healing in the doctor-patient relationship begins with the first phone call and continues through every contact.
Your patient should be welcomed like an honored guest, not made to feel like an annoying intruder. Greeting someone in the waiting room and escorting them back to your office seems to be a lost art, but should be as natural as greeting people at the door of your home when they arrive for dinner.
Similarly, apologizing for being late is a simple courtesy that should not be forgotten just because the meeting occurs in a professional setting.
While these gestures may seem small, patients often tell me how surprising and comforting they are. They are much more likely to engage in the intimate conversation that informs medical diagnosis when they feel at home with the doctor.
The onerous demands of protocol-driven medicine and electronic medical records have made the filling out of checklists more important to many doctors than really getting to know the person and understanding the context surrounding his symptoms.
Casual conversation is intrinsic to all human relationships and essential in setting the stage for meaningful history taking. The physician paying close attention to the little details can make an accurate differential diagnosis that usually obviates the need for frequent, expensive, and unnecessary fishing-expeditions of extensive laboratory testing that often turn out to do much more harm than good.
Call me old-fashioned, but referring to patients as healthcare consumers and physicians as healthcare providers degrades their relationship and under-estimates the healing it provides.
I take my own vital signs. Patients are surprised by this and tell me it indicates my interest in them.
I take my notes on a yellow pad and only enter what's required for electronic medical records after the patient has left the office. Patients say that other doctors are so focused on the computer screen, they never once make eye contact.
Ushering people into a metallic 8 x 8 room and asking them to undress before the physician even enters seems to be an awkward and humiliating way to start a relationship. My examining table is in my office where I sit down with them for the first time. My office is folksy and filled with conversation pieces. My home becomes temporarily their home.
Arguments that this sort of personalized medicine does not take into account the current business demands of modern medicine simply do not hold water. The quality of the doctor-patient relationship is not identical with the time spent, but rather the way it is spent.
Patients also tell me of rude staff, long waits in the waiting room, and then long waits in the examining area before the physician comes in. This sabotages the doctor-patient relationship and creates a terrible context for care and cure. Administrative handicaps to care can and must be eliminated with careful selection of personnel, ongoing training, and close attention to effective office or clinic management practices. The patient's convenience should take priority over staff convenience.
A strong doctor-patient relationship is essential to good diagnosis, to good treatment decisions, to carrying out the treatment plan, and is the royal road toward patient confidence, comfort, and healing. As physicians, we are allowed into a sacred space and must honor our obligation to personalize and humanize all our contacts with patients."
Thank you Dr. Capozzoli for your precious advice on recapturing old fashioned personalized medicine- how best to form a healing doctor/patient relationship.
Which brings us back to the current spate of fake claims for a scientific personalized medicine. Some researchers and leaders of major cancer centers have made the ridiculous promise that all cancers will be cured in 10-20 years. The advertising pitches made by some medical providers are even more outrageous- they make it sound as if personalized medicine has already arrived at their particular hospital.
There has always been a tendency for medicine to overpromise and under deliver. Often enough the treatments offered are more harmful than the diseases treated.
That's why the Hippocratic "First do no harm" is the most important commandment in medicine. The second is: "Cure sometimes, treat often, comfort always." We shouldn't neglect the bedside art of medicine as we become overly enamored by its laboratory science.