Tuesday, December 26, 2017

“We see this sometimes”

“We see this sometimes” is a phrase doctors use now and then to “reassure” patients. I find it disturbing and paternalistic and hope it is soon purged from our vocabulary, made archaic by precision medicine.

I first heard the phrase in 1986 as a medical student on rounds at Duke University School of Medicine. The rounding team included an attending physician — an internationally prominent neurologist — along with a second-year neurology resident, an internal medicine intern, a pharmacist, and a physician assistant student. As was the culture of the time, we moved from patient to patient and stood around the bedside while the medical student presented the case to the attending physician, who then led a discussion of the case in front of the patient.

On this morning, as I described the case of one of our patients, we focused on a physical finding I wasn’t familiar with: the patient had a white hairy tongue. I rapidly reached the limit of my knowledge of this finding, and the attending physician began grilling the team on the differential diagnosis of a white hairy tongue versus a black hairy tongue, the possible causes of fungal infections in the mouth, and risk factors for squamous cell carcinoma of the mouth and jaw.

As our discussion plunged deeper into the potential implications of this particular physical finding, the patient became increasingly distressed and finally blurted out, “But what does this mean for me?”
The attending physician looked over at the anxious man and simply said, “We see this sometimes.”
We quickly finished our discussion and moved out of the room. In the hallway, the attending explained his comment to the patient. “When you do not have a clue as to what is going on when a patient asks you, just say to them, ‘We see this sometimes.’ That preserves your authority and reassures the patient.”

We see this sometimes? The truth was that in 1986 we were beginning to see white hairy tongues with increasing frequency, as the early years of the AIDS epidemic created an influx of patients with manifestations of weakened immunity that, up until then, had been rare and poorly understood. For these conditions, such as pneumocystis pneumonia, Kaposi’s sarcoma, and toxoplasmosis, effective therapy was nonexistent…

We see this sometimes. The attending physician’s words were supposed to provide reassurance to a frightened patient by implying that an unusual symptom is within the range of known experience, rather than being something entirely unknown. It aims to preserve a physician’s authority based upon his or her possession of special knowledge. Although this paternalistic approach to health care is increasingly inadequate and irrelevant, it remains prevalent in the medical culture.

The persistence of this excuse may be a byproduct of how scientific discovery is translated into medical practice. A group of patients with a particular condition and common characteristics are studied to define the disease. Drugs are developed in a process that determines safety and effectiveness at the population level, all the while identifying acceptable ranges of side effects and treatment outcomes that vary from individual to individual. Evidence-based guidelines and quality benchmarks for a particular condition are built upon what is determined to be the standard of care for prototypical patients. Health plans develop payment policies around actuarial science built upon statistical methods focused on average outcomes and predictable variance.

As an internal medicine physician in practice for more than 30 years, I am very aware of a crucial fact in medicine that this process ignores: patients are not prototypes, and no one is average. Some patients experience muscle pain from taking a cholesterol-lowering statin. We see this sometimes. Some patients don’t respond to sertraline in treating their major depression. We see this sometimes. Some patients develop the Stevens-Johnson reaction when they take a sulfa drug. I saw this one time. A patient of mine received a sulfa antibiotic, the evidence-based medicine treatment of choice for his condition. Soon afterward, his skin began to blister and peel; he ended up in a burn unit for six months and nearly died.

Even as we develop increasingly effective therapies for cancer, heart disease, and other modern plagues, we still struggle to develop a health care system designed around individual needs even as it addresses the population as a whole. What we are calling precision medicine or personalized medicine is essentially the antidote: a model of care built upon differentiation at the individual level that will ultimately be the disruptive force that accelerates change in health care by driving waste from the system as it improves outcomes.

Delivering on the promise of disrupting and improving health care depends upon designing models of care at the intersection of population health and precision medicine. Technologies that deliver solutions at the level of the individual, including artificial intelligence and genomic-focused insights for the medical exposome — everything an individual has been exposed to over a lifetime — will create personalized treatments and consumer-driven products that are essential components of a new health care model.

The physician of the future will not be a primary care physician, a specialist, a hospitalist, a procedurist, or an extensivist. She will be a precisionist and she will never say, “We see this sometimes.” She will say, “I see you now.”

Courtesy of:  https://www.medpagetoday.com/psychiatry/addictions/70097

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