[|Patient centred medicine is by
no means new! In my view there has been always a knowledge of basic,
scientifically proven facts in medicine, formerly found in schools of medicine,
then in textbooks, and today maybe in databases of systematically reviewed
literature. However, this has always been the basis of treatment, followed by
analysis of the specific situation
of a given patient. At this situation, the doctor has to use his general
knowledge in a special, unique
situation not described in any textbook. There are some doctors who are
particularly capable in doing so, and this complex process is called the art of
medicine. As in all other field, there are outstanding artists and their
untalented counterparts. However, the art of medicine has existed as long as
medicine exists.|auteur195]

The exceptional progress in medicine during the 20th century has been made possible by two complementary research pathways: the creation of tools providing insight into comprehending and changing the living; and the application of those tools to the diagnosis, prevention and treatment of illnesses.

The object of this research is, then, the illness. By definition, it targets broad populations having in common a certain number of clinical and biological anomalies whose origins must be understood. The effectiveness and tolerability of the treatments proposed will also be gauged on broad populations. The level of certainty of the differences observed can be evaluated by means of statistical methods.

By definition, this “evidence-based” medicine disregards the individuality of the sick person, what makes him different from others. It allows a diagnosis to be reached by characterizing the symptoms that the patient shares with those patients and that have enabled this illness to be individualized.

Though needed for diagnosis and supreme in the management of acute situations, this scientific medicine can only bring genuine benefits to patients whose illness is expressed in terms of duration if supplemented by other medical techniques that allow this knowledge to be applied to a particular individual. Each patient, even if suffering from a common illness, differs in the way his illness is expressed, in his response and tolerance to treatment. He differs also in the way the illness impinges on his day-to-day life, in the way he perceives the treatment and he is or is not capable of adapting to it. These new medical techniques, which I propose to gather together under the term “patient-based medicine”, begin to develop in Europe. This doubtlessly represents the most significant advance in therapy of the early 21st century.

These new therapeutic techniques have first developed in medical specialities managing chronic illnesses whose impact on the length of life is minimal, but whose gravity is related to their - sometimes very serious - effect on the quality of life. Indeed, the quality of life cannot be called forth without shifting the focus from the illness to the patient. In dermatology, these management techniques originated naturally in the context of illnesses like psoriasis. This illness does not actually shorten life expectancy, but sometimes impacts very severely on social life, illustrating what is called the skin disability. European experts working on this illness have reached a consensus to consider that the severity of psoriasis is connected primarily with the degree to which the quality of life is impacted, then with any resistance to available treatments and finally, and only in third position, with the extension of skin surface involved, whereas this measurable factor has long been considered the main severity criterion.

In the majority of acute illnesses, it is the doctor who knows how to assess the gravity of the illness. In quality-of-life diseases, the patient alone is qualified to assess the gravity of this impact and hence of the disease. Assessing this gravity is vital, since this is what will sanction the use or non-use of drugs that are powerful and efficacious but that may possibly entail adverse effects. As always in therapeutics, it is the benefit/risk ratio that needs to be assessed, but only the patient, with the help of his dermatologist and GP, can truly judge the reality of that benefit, as it boils down to the quality of his life. Moreover, specifically with chronic illnesses, the use of topically or systemically administered drugs will always entail some restrictions and unwanted effects. These restrictions and secondary effects may have an altogether negative effect on quality of life. Though it is too often the case, it would be absurd to replace the troubles associated with the disease by those even more distressing that would be due to the treatment.

It is not possible, then, to treat a chronic illness without the informed and responsible participation of the patient. However, a patient coming for a consultation in 2008 is coming to seek a solution, a formula, a prescription; he is not prepared to assess the way in which his life is disrupted by his illness, nor to really even take a critical and constructive look at the treatments he can be offered. He experiences his illness like an external strain, of which medicine must rid him of, just as one is cured of an infectious disease or appendicitis.

Then, in the course of his consultations, this misunderstanding will need to be dispelled and the patient allowed to take control over his illness and the available treatments. This in order to lay down the foundations of a true therapeutic negotiation that will end not in a prescription but in a choice made by the patient aided by his dermatologist or GP, in a care contract, ideally signed not only by the doctor but by the patient too.

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