Tuesday, January 10, 2012

Honor Thy Patient

The New Therapeutics: Ten Commandments (From the British Medical Journal) 1
  1. Thou shalt treat according to level of risk rather than level of risk factor.
  2. Thou shalt exercise caution when adding drugs to existing polypharmacy.
  3. Thou shalt consider benefits of drugs as proven only by hard endpoint studies.
  4. Thou shalt not bow down to surrogate endpoints, for these are but graven images.
  5. Thou shalt not worship Treatment Targets, for these are but the creations of Committees.
  6. Thou shalt apply a pinch of salt to Relative Risk Reductions, regardless of P values, for the population of their provenance may bear little relationship to thy daily clientele.
  7. Thou shalt honour the Numbers Needed to Treat, for therein rest the clues to patient-relevant information and to treatment costs.
  8. Thou shalt not see detailmen, nor covet an Educational Symposium in a luxury setting.
  9. Thou shalt share decisions on treatment options with the patient in the light of estimates of the individual’s likely risks and benefits.
  10. Honour the elderly patient, for although this is where the greatest levels of risk reside, so do the greatest hazards of many treatments.
Many of these address drug therapy.  In today's medical climate that seems to be the therapy of choice.  Well, and surgery.  It's worth bringing up this study that Stephanius posted in comments:

Sociodemographic And Lifestyle Statistics Of Oldest Old People (>80 Years) Living In Ikaria Island: The Ikaria Study, Cardiology Research and Practice, February 2011
"The majority of the oldest old participants reported daily physical activities, healthy eating habits, avoidance of smoking, frequent socializing, mid-day naps and extremely low rates of depression.

Conclusion: Modifiable risk factors, such as physical activity, diet, smoking cessation and mid-day naps, might depict the “secrets” of the long-livers."
Modifying risk factors through lifestyle changes can be as effective, if not more effective, than drug therapy. It may not be as lucrative.

There is so much in this list that I like, not least of which the warning against medicating to a surrogate endpoint instead of a hard endpoint. That is, the warning against medicating to, say, reduce cholesterol or blood glucose (surrogate endpoints) instead of to reduce heart attacks or strokes or premature death (hard endpoints).

I really like that last commandment, although I wouldn't single out the elderly. I would apply it to all patients. Just "Honour thy patient."
1 From Gary Schwitzer at Health News Review, via British Medical Journal (BMJ) Blogger Richard Lehman, via Yudkin et al. at BMJ: "The Idolatry Of The Surrogate".

The sketch is by Rembrandt, a self-portrait, from RembrandtPainting.


Dr. Mel said...

These are great principles, but, as you point out, not lucrative for Big Pharma, which runs the show so to speak. (Have to say I don't understand some of the terminology but I think I get the general gist.) My old college roommate recently was prescribed a cholesterol-lowering drug by her doc for a total cholesterol count of 280. She refused the drug (never had the scrip filled) and went on a vegan diet. Within the 6 weeks since then, her chol count has already dropped 30 points & HDL is much higher! Good thing she didn't take the drug, what w/ this new study showing that statins can cause diabetes!

Bix said...

Alice Dreger posted a translation:

Get Your Doctor to Treat You Right,
Train your doctor to be your doctor, not your salesperson.



caulfieldkid said...

I wonder how these things weigh on doctors. Do they struggle with the issues, or have they been taught one method (such as medicate symptoms or what have you)? I have to assume some would rather cycle through everyone. Sitting down and really getting to know someone's lifestyle has to take more time than staring a chart then making a recommendation/prescription. Are some of them so bound to their student debt that they don't feel able to take the time? There is so much information out there now. Do they feel threatened when a patient comes in having done a lot of research on their specific situation?

I guess I'm just trying to look across the table a little bit.


Bix said...

The first line of treatment for high cholesterol is lifestyle. I interpret that to mean, if you go to a doc and she discovers high cholesterol, she sends you away with an eating and activity plan. After 6 weeks if that doesn't work, she encourages the lifestyle changes more. It's the third visit where drugs may be initiated, right?

Look at Figure 1. in this:

National Cholesterol Education Program 3rd Report



Bix said...

Shaun, we had a new doc in our practice several years ago who took one hour, one hour!, to get to know a new patient. My god, it was hard. No one supported him doing this, not the scheduler, the other docs, the other patients, and probably not his family since he was always late getting out of the office. But the patients loved him!

Dr. Mel said...

Thanks for the links!

Gladys said...

I am agree with you Dr. Mel, this are good principle and patient must come first.

Dr. Mel said...

Love the Rembrandt self-portrait, btw!