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Simplicity in Medicine: For a Return to Patient-Based Care

  • Alain Putot
    Correspondence
    Requests for reprints should be addressed to Alain Putot, MD, PhD, 97 Avenue du Président Mitterrand, 97410 Saint Pierre, Réunion, France.
    Affiliations
    Unité post Urgence Gériatrie, CHU Sud Réunion, Saint Pierre, France

    Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires, Université de Bourgogne, Dijon, France
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Published:February 06, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.01.038
      The recent Intergovernmental Panel on Climate Change (IPCC) report has highlighted the extent to which what was foreseen is becoming clearer: a rapid degradation of the environment due to our unbridled overconsumption of the planet's resources.
      Only a profound change of paradigm in the way we understand our relationship with the world seems to be able to significantly change the course of things. We should not wait passively for this change to occur at the level of our governing bodies. Individual behaviors must be modified, not toward a forced restriction of our consumption but, rather, toward a philosophical change—toward a “happy simplicity” as proposed by the late philosopher Pierre Rabhi, which is capable of raising humans to a more enviable condition while preserving our environment.
      • Rabhi P.
      Vers La Sobriété Heureuse.
      Such considerations have a particular resonance for us physicians. One cannot help but draw a parallel between the climate crisis and the current health care crisis, both of which have shaken the entire planet this year. In addition to having a number of common causes, these climate and health threats have both found the scientific community unprepared.
      It is clear that the constant increase in health costs in industrialized countries is not associated with a parallel improvement in the health of the population. One could argue that this could be due to the aging of the population, but it appears that current medicine concentrates many of its resources on offering care that is increasingly technical and, therefore, increasingly expensive. New technologies, although certainly essential for medical progress, are too often presented as the determining factor for quality of care. And yet, few of our patients benefit from these costly techniques. Human care, on the other hand, remains an essential element that unifies and structures our health care systems. Technological investments have been made possible through constant increases in the means allocated to health care
      • Johnson PT
      • Pahwa AK
      • Feldman LS
      • Ziegelstein RC
      • Hellmann DB.
      Advancing high-value health care: a new AJM column dedicated to cost-conscious care quality improvement.
      but, above all, by cutting back on the cornerstone of the health care system: the primary care and hospital staff who provide in-person care.
      Just as the climate crisis urgently requires a change of mentality, the health crisis should be an opportunity to refocus resources, which are anything but negligible in our Western countries, on what really matters to our patients. Among the biggest health care spenders in the world, the United States and France devote respectively 16.9% and 11.2% of their gross domestic product to health, and yet both countries have fewer health care workers per capita than the Organization for Economic Cooperation and Development (OECD) average.
      Organization for Economic Cooperation and Development (EOCD)
      Health at a Glance 2019: OECD Indicators.
      This may suggest a need to examine taxpayer priorities relative to their own health care systems. The patient, not the disease, must find its rightful place at the center of care. Despite strong long-standing evidence of the clinical and psychological benefits of doctor-patient relationships, there has been a recent transformation within health care resulting in a “new normal” in which patient contact with caregivers is de-emphasized; disruptive innovations that emphasize transactional speed and convenience are now routinely used in service delivery.
      • Hoff TJ.
      Doctor-Patient Relationships and Our Expectations. Vol 1.
      In a brilliant article in the Green Journal, Arbab-Zadeh et al
      • Arbab-Zadeh A
      • Zeger SL
      • Blumenthal RS
      • Weintraub WS
      • Boden WE.
      The rising urgency to pivot back toward Hippocratic medicine.
      share, through the example of coronary artery disease management, the observation that medicine is increasingly focused on the relentless search for a diagnosis. This often results in a loss of the primary meaning of care, which should be centered on the person. The authors describe a drift in the resources allocated to technology at the expense of local and preventive care. I can only agree with this observation of a deplorable situation that extends well beyond North America. It is up to all of us to reaffirm the meaning we wish to give to our profession and to refocus our attention on patient care rather than the technical fight against a given disease.
      Centering care on patients' complaints and not on their presumed disease is not only an ethical necessity, but it is also a guarantee of the scientific quality of medical care. Indeed, the diagnostic process needs to be based on a hypothetical-deductive strategy.
      • Elstein AS
      • Shulman LS
      • Sprafka SA
      • et al.
      Starting from the diagnosis is becoming an unfortunate new norm in medicine, even if this ethically questionable attitude that reduces individuals to their disease, completely sclerotizes the diagnostic process, and is thus a source of frequent diagnostic errors.
      • Frishman WH
      • Alpert JS.
      Twenty common mistakes made in daily clinical practice.
      The diagnostic process has not changed since Hippocrates: It should result from a unique and holistic interaction with the patient, seeking, through questioning and physical examination, to understand the complaint and to build together a care plan to try to answer it.
      As the authors illustrate, the more technical and disease-focused care is, the more contentious and controversial it is by nature. This can result in head-on clashes between patient values and Western medicine, particularly when its humanistic purpose is obscured. Human patient-based care is, on the contrary, universal and will forever transcend ideological divides. It may be time to restore it to its rightful place in our health care systems.

      References

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