{"id":32749,"date":"2014-11-17T16:36:27","date_gmt":"2014-11-17T15:36:27","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=32749"},"modified":"2014-11-17T16:40:54","modified_gmt":"2014-11-17T15:40:54","slug":"neal-maskrey-treating-the-patient-and-not-the-disease","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/11\/17\/neal-maskrey-treating-the-patient-and-not-the-disease\/","title":{"rendered":"Neal Maskrey: Treating the patient and not the disease"},"content":{"rendered":"

\"neal_maskrey\"<\/a>It was the biggest turnout for many a year. In our small coastal town in the north west of England, 5000\u00a0of us stood together bare headed for an hour on a magnificently clear but cold November morning. The Salvation Army brass band was muted but played beautifully, and there was pomp and circumstance aplenty. But at the 11th hour on the second Sunday of the 11th month, even small children and dogs fell silent, somehow recognising the importance of the two minutes of silence.<\/p>\n

Our own Cenotaph is usually surrounded by the rumble of traffic and the clatter of shoppers. Not so on that\u00a0Sunday. The traffic was diverted, the shops deserted, the deputy lord lieutenant was in town, and no one was going to miss honouring the 100th anniversary of the start of the Great War.<\/p>\n

Why were so many of us there? The 100th anniversary had something to do with it, I\u2019m sure. Perhaps the poppies at the Tower of London had something to do with it too. And, after Iraq and Afghanistan and the 24 hour news cycle, like many I\u2019m probably more aware these days that it isn\u2019t just those who gave their today for our tomorrow; it\u2019s also those who go and come back, and yet carry all sorts of scars for the rest of their lives. It\u2019s personal.<\/p>\n

I saw old\u00a0wives with their jaws set determinedly, pushing even older husbands in wheelchairs; a group of Hells Angels visibly moved; and a little girl who couldn\u2019t have been more than 4 years old, holding a wreath of poppies in one hand and her grandmother\u2019s hand in the other. I\u2019m still not sure who was supporting who. It was personal for them too, and they wanted to mark and share, as did their community.<\/p>\n

Fast forward 48 hours and I\u2019m at a conference about atrial fibrillation (AF). We have presentations on the epidemiology of AF and stroke, the pharmacogenomics of vitamin K antagonists, left atrial appendage occlusion, and, of course, all the technical details of the non-vitamin K oral anticoagulants (NOACs). It was scientifically superb, with amazingly intelligent and committed people driving forward better care. This is an absolute requirement for the audience, because now just the stroke prevention aspect of AF has many aspects, has become explicitly preference sensitive, and is highly complex.<\/p>\n

I got 30 minutes in the slot after lunch to cover individualised decision making. I tried my best to summarise the Cochrane review<\/a>, which shows how much patient decision aids improve patients\u2019 knowledge and reduce decisional conflict. I gently presented\u00a0the data that show clinicians think they do shared decision making already but often they don\u2019t<\/a>, that three out of four people want at least some say in decisions<\/a> about their healthcare, and the data that show\u00a0GPs get the estimate of how much people want to be involved in decisions wrong<\/a> two times out of three.<\/p>\n

I pointed out that patient decision aids were just a tool that\u00a0helps the conversation along the path to shared decision making,\u00a0and that these aids had the same limitations as the evidence from which they spring\u2014if the trials don\u2019t include people like your patient, you can\u2019t be sure how generalisable the data is. Eighty four year old patients with heart failure, osteoporosis, and gout (as well as AF) are unlikely to feature in the RCT population for anything, so don\u2019t underestimate the need for clinical expertise, as well as the evidence and the patient\u2019s values and preferences.<\/p>\n

It was fine. There were thoughtful questions both in the session and afterwards. But my heart was heavy. Because, as one of the grateful organisers put it afterwards over tea, during the rest of the day the values and preferences of patients didn\u2019t get a look in. Not once.<\/p>\n

I once shared a platform with Patch Adams<\/a>, an unconventional doctor played by Robin Williams in the eponymous film. His talk was rambling and ill prepared. But he was passionate to the point of spittle, funny, enthusiastic, and completely inspirational. I had to speak after the star of the show, and in case you\u2019re interested I was well prepared, entirely coherent . . . and deadly dull. I learned a lot that day.<\/p>\n

One of Patch\u2019s quotes sums up his message. \u201cTreat a disease and sometimes you\u2019ll win, sometimes you\u2019ll lose. Treat a person, and I guarantee you\u2019ll win every time.\u201d So when will conference organisers (also kind, intelligent, and hardworking people) allocate an equal amount of time to the evidence on the one hand, and then for attendees to discuss and practice the communication of that evidence on the other? Only then will patients stand a decent chance of consistently getting conversation and support, which enables them to optimally understand the risks and benefits of their options if they wish to. Then, and only then, will we be true to Patch, and Sir William Osler<\/a>, and many others, and be treating the person and not the disease.<\/p>\n

Back to Remembrance Sunday. The presiding minister at the Cenotaph had jerked my head back with his opening remarks. \u201cWhat does the Lord require of you but to do justice, and to love kindness, and to walk humbly with your God?\u201d It\u2019s gone round and round my head all week. I had to go and look it up. It\u2019s Micah, chapter 6, verse 8.<\/p>\n

So OK, I\u2019ll stiffen my resolve, and keep turning up at workshops and conferences, and use whatever time I\u2019m allocated to encourage the treatment of persons, not diseases, because we and what we do unselfishly many times every day should indeed be all about justice, and kindness, and walking more humbly. In healthcare, even when there are just two of us in a consultation, we\u2019re a community.<\/p>\n

Neal Maskrey’s<\/strong>\u00a0early career was as a GP before spending seven years as a medical manager and part time GP. After 12 years as a director of the National Prescribing Centre and programme director at NICE, he is now honorary professor of evidence informed decision making at Keele University, and consultant clinical adviser in the Medicines and Prescribing Centre, NICE.<\/em><\/p>\n

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I hereby declare the following interest: Employed part time by the National Institute for Health and Care Excellence.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

It was the biggest turnout for many a year. In our small coastal town in the north west of England, 5000\u00a0of us stood together bare headed for an hour on […]<\/p>\n

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