The idea that there can be ‘too much medicine’ may not seem compatible with a world driven by technological and medical advances. But in a public discussion at Summerhall, Dr Caroline Whitworth, consultant nephrologist and Medical Director of Acute Medicine, challenged the dogma that a doctor’s sole aim is to treat illness with medicine. Hosted by Professor Derek Bell, President of the Royal College of Physicians, the discussion began with an introduction to the concept of personalised medicine. The availability of “big data”, including genomics, epigenomics and national patient databases, has vastly improved our understanding of the way individuals respond differently to disease and treatment. This, combined with the latest advances in technology (such as stem cell treatment, biological therapies and gene therapy), means that we are now facing the prospect of being able to very precisely tailor treatment to the patient’s needs and that personalised medicine is an ever-approaching reality.
These advances can hugely advance medical care and improve the ability of doctors to fulfil their traditional role, which is to improve the health of the patient. However, Dr Whitworth argued that this definition of personalised medicine may be missing a key aspect of patient needs. While the average life expectancy continues to increase linearly, the perceived ‘healthy life expectancy’ – the length of life for which people feel healthy – has decreased by 17 years since 1980. By the age of 85 years old, 98% of the population will have been treated for 1-8 chronic conditions. These figures indicate that, while as a population we are living longer, our quality of life in those extra years is compromised.
Dr Whitworth proposed that healthcare professionals should allow patients to make an informed decision about their own treatment. 38% of patients in the last 6 months of life receive treatment that does not improve their condition; and in many cases, the treatment can be aggressive and can have unpleasant or painful side effects. Statistics indicate that palliative care can be more beneficial for patients than medical treatment: for example, lung cancer patients who opted for early palliative care lived around two and a half months longer than those who received treatment, and rated their ‘happiness score’ higher. In many cases, patient choice can be age-dependent. For example, patients with kidney disease with low comorbidity (i.e. no or one other chronic condition) have a good prognosis with dialysis, while patients with high comorbidity (i.e. multiple other chronic conditions) have a better prognosis without dialysis. In these cases, the decision is left to the patient, and consequently the number of patients who opt for dialysis significantly drops in the over 80 age group. However, in other areas of medicine, patients diagnosed with a life expectancy of less than 6 months aren’t given the chance to discuss their preferences and are more likely to receive aggressive treatment.
Psychologists define ‘suffering’ as a mismatch between expectation and reality or a loss of control. Therefore, Dr Whitworth reasoned that reducing patient suffering isn’t just about improving treatment, but also about improving the patient’s understanding of the limitations and benefits of the treatment and giving them control in the decision-making process. Current UK and worldwide campaigns, such as Realistic Medicine (NHS Scotland), Choosing Wisely (UK), and Less is More (Journal of the American Medical Association), aim to promote this strategy.
Five questions were listed that patients should ask when deciding on a treatment: Do I need this treatment? What risks are associated with this treatment? What are the side effects? What other options are there? And what will happen if I do nothing?. Dr Whitworth believes that there should be a focus on more compassionate healthcare and said that it’s important to “diagnose the patient preference as much as diagnosing the patient condition”. In her clear and well-reasoned argument backed by international campaigns, Dr Whitworth seemed to have convinced the audience that personalised medicine should not only be personalised to patient condition, but also personalised to patient choice.
This report was written by Bonnie Nicholson and edited by Teodora Aldea.