Il British Journal of General Practice pubblica un decalogo per il medico di medicina generale che rievoca le tavole della legge, per un trattamento che non perda mai di vista la prospettiva del paziente.
Articolo condiviso dal British Journal
1. Thou shalt have no aim except to help patients, according to the goals they wish to achieve
When deciding on a treatment, the first diagnosis you need to reach is about the nature of the illness. The second diagnosis you need concerns what the individual would like to achieve.1 Both are of equal importance and this is as true in simple one-off encounters as in complex lifelong illness. But the balance needs particularly careful thought when beginning long-term treatment.
Always make sure that you understand your patient’s aims before you propose a course of action. It may require 3 minutes in a situation like an acute sore throat, or years of ongoing dialogue in a situation like multiple sclerosis or heart failure. Do not assume that you know what your patient has come for, and do not assume that the treatments you have on offer meet the goals of everyone in the same way.
2. Thou shalt always seek knowledge of the benefits, harms, and costs of treatment, and share this knowledge at all times
Both health professionals and lay people tend to overestimate the benefits of treatments and underestimate their harms. The traditional way to express these is as the number-needed-to-treat (NNT) and the number-needed-to-harm (NNH).
It is important to have a ‘ball-park’ idea of these figures in common clinical situations, but also important to bear in mind their limitations. First, patients mostly find NNTs and NNHs hard to understand.2 Second, the numbers do not apply to individuals equally but are just average figures across the populations of clinical trials. Third, people vary widely in how they would balance a given benefit against a given harm.3
So we need better ways of a) knowing the true NNT and the NNH in the populations we treat; b) sharing this knowledge with people in ways they can understand; and c) applying this knowledge to the goals and preferences of the individual in front of us.
3. Thou shalt, if all else fails or if the evidence is lacking, happily consider watchful waiting as an appropriate course of action
The first commandment assumes that there will be two diagnoses in each consultation. But often there will be more, or none.
Many consultations consist of a complex dialogue of exploration, attempted understanding, and partial uncertainty. Unless there is a clear diagnosis, it is usually better to keep the offer open of another consultation rather than issue a prescription.
Other situations where it is often better not to prescribe include acute self-limiting illnesses where symptomatic treatments are available over the counter (OTC). This also applies to some more chronic conditions such as irritable bowel syndrome and chronic back pain, which characteristically fluctuate and for which prescription-only treatments are usually no more effective than cheap OTC alternatives.
The temptation to prescribe rather than offer a timely reassessment should always be resisted. continua a leggere