Treating
the Individual, Not the 'Average' Patient
The new
trend is to strictly embrace evidence-based medicine (EBM) with the
perception that the patients will do better and one can avoid legal
consequences. In chart reviews, EBM looks easy: diagnosis A means use drug
B and C.
Late David
Sackett, MD, a pioneer in EBM, reveals the challenge: Evidence-based
medicine is the conscientious explicit and judicious use of current best
evidence in making decisions about the care of individual patients.
But in
practice we do not treat patients but an individual patient.
Anyone with
internet access can look up the guidelines or the results of a randomized
controlled trial, but the challenge comes when deciding whether or not the
patient in front of you is similar to those enrolled in the clinical trials
underpinning the evidence.
Let’s take
the example of the best blood pressure goal for a patient with multiple risk
factors, hypertension and diabetes: Strict application of the evidence will
be in ACCORD-BP trial, which showed that a systolic blood pressure target
of 120 mm Hg, compared with a target below 140 mm Hg, did
not reduce the rate of the composite outcome of fatal and nonfatal major
cardiovascular events. And patients who received intensive treatment had more
adverse effects. Evidence, therefore, points to the higher target.
But there is
also the SPRINT trial, which showed that treatment to a lower BP goal
resulted in serious reductions in cardiac events. But SPRINT excluded patients
with diabetes
Is my
patient closer to SPRINT or ACCORD? A trial's inclusion/exclusion criteria and
the actual characteristics of enrolled patients may often differ greatly. The
patient in the clinic might technically meet a trial's inclusion criteria but
be poorly represented by the actual baseline characteristics of the patients
enrolled in the study. Or, the patient might have a single exclusion criterion
(e.g., diabetes) but resemble the trial population in many other ways.
My answer to
this would be to treat the individual patient based on my experience of
clinical practice.
When
deciding on the line of management, I would take into consideration the social
determinants of health, my past experience and not treat my patient as per the
findings of any trial.
WHO has
defined health has as “not just the absence of disease, but a state of complete
physical, mental and social well-being”. This clearly indicates that the
conditions we live in and work also affect our health.
So, it is
not enough to address just the immediate presenting complaint, it is also
important to treat the person as a whole in context of his/her social
circumstances. Treatment has to be tailored to each individual patient taking
into consideration their individual characteristics, culture, personal
preferences, expectations etc.
Also many
times I will use the harm reduction approach and
keep the BP control on the higher side just to reduce the harm.
Dr KK
Aggarwal
Padma Shri Awardee
President
Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP
Publications
President Heart Care
Foundation of India
Immediate
Past National President IMA
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