The stakes of patient-based medicine

It is understood that this new therapeutic approach, which takes on different shapes in different medical specialities, fits particularly well any chronic disease. Its purpose is, by means of a literal revolution in the doctor-patient relationship, to restore liberty to the patient in the face of the relative incarceration engineered by his illness, and to which the doctor occasionally contributes. Particularly in skin disorders, the deterioration of the self-image has often a serious effect on all social relations, and patients feel very keenly this plight of imprisonment inside a distorted image of themselves. But this largely transcends the bounds of dermatology ; any illness impairing an organ destabilizes a life based on relationships. And even if the organ requires obviously to be taken care of, the relationship also needs to be nursed in return. This cannot be done without the active and informed, and hence accountable, participation of the patient : no one can be liberated against his will. With this approach, there are naturally far fewer compliance problems, since the patient has been able to take hold of his illness, to regain control of it.

For thousands of years, medicine has only had the patient as target, empathy as treatment and fate as companion. The development of evidence-based medicine and more and more outstanding therapeutic tools has focused everyone’s attention on the illness, and on diagnostic and therapeutic tools of exceptional effectiveness. More particularly, this progress has made it possible to discover the role of the nervous system (and hence of the emotions) in controlling immune, inflammation, growth and cellular differentiation responses in numerous organs. It is only natural, then, that organ-based medicine centring on the fight against illness and disease should rediscover the patient in his or her individuality. This realization should be the starting point for a much more efficient and status-enhancing division of tasks between specialists and GP en route to a system of global management in which the patient, not the illness, is put at the centre. The very advance in evidence-based medicine therefore emphasizes the urgent need to put in place techniques whereby general knowledge can be applied to a particular individual as best as possible, thus encouraging the development of what we call patient-based medicine.

Is this new approach simply a restatement of medical humanism ? On no account ! It is a matter of medical techniques that are needed for the effective management of all chronic illnesses, whatever the nature of the doctor, whatever his or her ability to show empathy, and whatever the patient’s wish for dependence. These techniques can and must be taught, and the artificial distinction between technician doctor and humanist doctor should merge amid global approach techniques. Today’s doctor must make use of all scientific knowledge available in databases, drawing from his experience and integrating the patient’s life pattern in order to help the latter to choose whatever means will allow him to find his indivisibly physical and mental balance. It is interesting to note that more and more often patients are attending consultations armed with plentiful documentation about their illness obtained over the Internet. The request is clearly worded : “Here’s what I’ve been able to find out about my illness and treatment for it, and I’ve come to discuss it with you, doctor”. Today’s patient lines up directly at the third stage, the negotiating stage, what does not exempt the doctor from going back over to the first two stages with him again, rather on the contrary, but allows a much greater avail.

Is such management possible ? Under the current conditions for practising medicine, the answer is no. In fact, these techniques take time, and medical time is absolutely not valued these days. If management of chronic illness is to be improved, it is paramount to take spent time into account and to allow every doctor, one day or half a day a week, to bill for his consultation, not on the number of consultations but on the basis of spent time. Needless to say, this will not increase health costs in any way, since the ‘takings’ for this particular day or half-day will remain unchanged.

Does this management alter the way medicine is taught ? It is already beginning to do so : an initial endeavour, called patients-partners, originating in rheumatology, consists of having small groups of students meeting patients who have accepted special teaching. These encounters are designed to heighten students’ awareness of managing not only the illness, but also the patient in every aspect.

Yet, it is doubtlessly in postgraduate medical training where this revolution in care strategy will have the greatest impact. It is effectively a matter of elaborating new training techniques whereby classic lecture-based teaching, in which an expert comes to teach practitioners, can be supplemented with a totally different approach. Practitioners are asked to tell others about hands-on management situations. Each situation is presented during the postgraduate training session, and each person suggests different management solutions, providing reasoning for them through the information presented and gathered thanks to the technique of global approach to the patient. The conclusion is delivered by the practitioner, who explains what management he has selected, for what reasons, and what the results were. This postgraduate training technique allows medical education to be developed not only for the illness but also for the patient. The first trials based on this new approach are already under way.

Through this new initiative, the patient becomes once again the owner of his illness and hence of his medical records, taking the responsibility for his health on his own shoulders. Does patient-based medicine whittle down medical power ? I do not believe so, quite the contrary. By developing patients’ knowledge and freedom, medical power recovers its true meaning : that of taking care of an equal. By gradually becoming technically useless as the patient frees himself from his illness, the doctor becomes humanly indispensable.