preventive thinking — a contradiction to individualised doctoring

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PENS~E Preventive thinking - a contradiction to individualised doctoring Heinz-Harald Abholz Preventive thinking as a medical concept is more than prevention as we know it from immunisation, fighting infections (hygiene) or screening. But these are the very activities that are the model for the preventive thinking that has infiltrated into our daily work. This concept has developed over the last 30 to 40 years. Preventive thinking is especially well developed in risk-factor pre- vention for coronary heart disease and other forms of arteriosclerosis. But there are many other risk factors for many other diseases, such as polyps in the large bowel, leucoplacias in the mouth, pathological glucose tolerance, sunburn in childhood, oesophagitis and Helicobacter. And we give proton inhibitors to pa- tients being treated with NSAIDs to prevent ulcers and to those with reflux even without symptoms; we refer patients with polyps for surgery; we give antidepres- sants for at least a year even though a shorter period of treatment would be fine. The characterising topics for preventive thinking as a concept are: 1 A statistical risk which tells us that a proportion, usually a very small proportion, of those having the risk will actually develop the diseasdcomplication. 2 Time between finding the risk and the possible dis- easdcomplication is usually a period of years. 3 It is usually orientated towards ‘zero-risk’. From these three points it is clear that the effects of treatment in this concept cannot be ‘experienced’ by a doctor because positive or negative outcomes are rare and there is a large timespan between action and a possible result. Preventive concepts can only be evalu- ated by statistics and over a long period of time. So any intervention within the concept has to be an action based not on the personal experience of doctors, but on ‘recipes’, i.e. guidelines resulting from large, high- quality studies. Heinz-Hacald Abholz MD, professor, head of department Abteilung @ Allgemeimmdizin, Uniuersik%&lini&m Diisseldd, Heid-Heine-Uniwrsitiit Disseld~. Moorenstrape S, Geb. 14.97, 0-40225 Diisseldor$ Gennmry E-mail: [email protected]&sseldotfde Public health and personal doctoring The concept of preventive thinking originated in epi- demiology, from the risk factor concept. This tells us that risks or preclinical states of a disease (Pap IV in cervical smears, for example) are associated with later diseases or complications. The relationship between risk on the one hand and a disease or symptom on the other is linear, curvilinear, log-linear but usually there is no real biologically well-defined border between being ‘problematic’ or ‘not problematic’.’ It is rather a distinction between being more or less problematic. This is shown for instance in the number needed to treat (NNT) which is low (1:12) in very high blood pressure, but very much lower in slight blood pressure elevation. But even in slight elevation there still is a NNT, even if it is only 1:800. In its application to therapeutic strategies, the epidemi- ological risk concept is orientated more or less towards zero-risk, because of the lack of a ‘biologically defined step’ between risk and non-risk. The consequence is quite often that all those at risk are treated, because some of them will gain from it. Otherwise, we would have to decide for which patients treatment is justified and for which it is not, and we do not feel happy having to make these decisions without a medical ba- sis. Sometimes our decision to treat or not to treat will be based on well-founded motives, and sometimes not. So we start to become inconsistent in the public health concept. Behind the risk-factor concept lies a public health per- spective: the most effective way of ‘treating’ a medical problem in a population is to treat that part of the population where the largest amount of the disease- burden is located. This is the larger group of low-risk people, not the smaller group of high-risk people.’ According to the public health perspective we have to treat all those patients at risk. But seeing a patient in front of us from a low-risk-group, we quite often have to ask if it is worth starting treatment. If we ask these patients, they usually decide against treatment which is not in line with the public health directi~e.~.~ The only ‘limitations’ to treatment in that contexx are the side effects of interventions and the patient himself 148 European Journal of General Practice, Volume 9, December 2003 Eur J Gen Pract Downloaded from informahealthcare.com by University College London on 11/14/14 For personal use only.

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Page 1: Preventive thinking — a contradiction to individualised doctoring

P E N S ~ E

Preventive thinking - a contradiction to individualised doctoring

Heinz-Harald Abholz

Preventive thinking as a medical concept is more than prevention as we know it from immunisation, fighting infections (hygiene) or screening. But these are the very activities that are the model for the preventive thinking that has infiltrated into our daily work. This concept has developed over the last 30 to 40 years. Preventive thinking is especially well developed in risk-factor pre- vention for coronary heart disease and other forms of arteriosclerosis. But there are many other risk factors for many other diseases, such as polyps in the large bowel, leucoplacias in the mouth, pathological glucose tolerance, sunburn in childhood, oesophagitis and Helicobacter. And we give proton inhibitors to pa- tients being treated with NSAIDs to prevent ulcers and to those with reflux even without symptoms; we refer patients with polyps for surgery; we give antidepres- sants for at least a year even though a shorter period of treatment would be fine. The characterising topics for preventive thinking as a concept are: 1 A statistical risk which tells us that a proportion,

usually a very small proportion, of those having the risk will actually develop the diseasdcomplication.

2 Time between finding the risk and the possible dis- easdcomplication is usually a period of years.

3 It is usually orientated towards ‘zero-risk’.

From these three points it is clear that the effects of treatment in this concept cannot be ‘experienced’ by a doctor because positive or negative outcomes are rare and there is a large timespan between action and a possible result. Preventive concepts can only be evalu- ated by statistics and over a long period of time. So any intervention within the concept has to be an action based not on the personal experience of doctors, but on ‘recipes’, i.e. guidelines resulting from large, high- quality studies.

Heinz-Hacald Abholz MD, professor, head of department Abteilung @ Allgemeimmdizin, Uniuersik%&lini&m Diisseldd, Heid-Heine-Uniwrsitiit D i s s e l d ~ . Moorenstrape S, Geb. 14.97, 0-40225 Diisseldor$ Gennmry E-mail: [email protected]&sseldotfde

Public health and personal doctoring The concept of preventive thinking originated in epi- demiology, from the risk factor concept. This tells us that risks or preclinical states of a disease (Pap IV in cervical smears, for example) are associated with later diseases or complications. The relationship between risk on the one hand and a disease or symptom on the other is linear, curvilinear, log-linear but usually there is no real biologically well-defined border between being ‘problematic’ or ‘not problematic’.’ It is rather a distinction between being more or less problematic. This is shown for instance in the number needed to treat (NNT) which is low (1:12) in very high blood pressure, but very much lower in slight blood pressure elevation. But even in slight elevation there still is a NNT, even if it is only 1:800.

In its application to therapeutic strategies, the epidemi- ological risk concept is orientated more or less towards zero-risk, because of the lack of a ‘biologically defined step’ between risk and non-risk. The consequence is quite often that all those at risk are treated, because some of them will gain from it. Otherwise, we would have to decide for which patients treatment is justified and for which it is not, and we do not feel happy having to make these decisions without a medical ba- sis. Sometimes our decision to treat or not to treat will be based on well-founded motives, and sometimes not. So we start to become inconsistent in the public health concept. Behind the risk-factor concept lies a public health per- spective: the most effective way of ‘treating’ a medical problem in a population is to treat that part of the population where the largest amount of the disease- burden is located. This is the larger group of low-risk people, not the smaller group of high-risk people.’ According to the public health perspective we have to treat all those patients at risk. But seeing a patient in front of us from a low-risk-group, we quite often have to ask if it is worth starting treatment. If we ask these patients, they usually decide against treatment which is not in line with the public health directi~e.~.~ The only ‘limitations’ to treatment in that contexx are the side effects of interventions and the patient himself

148 European Journal of General Practice, Volume 9, December 2003

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with his own views, wishes and values, which are often not in agreement with the preventive concept. So pa- tients start to help us in our problem of deciding be- tween the public health and the individual health ap- proach. But with time, even patients - following their doctors - will be ‘defeated’ by the logic of preventive thinking.’ From the background of that public health perspective, referred to here as ‘preventive thinking’, a medical practice emerges that makes us follow rules about what should be done, in what situation, under what risk constellation etc. using the whole population as a reference, not the one patient in front of us. So indi- vidualised doctoring, seeing that patient in that situa- tion in the centre of our actions, is abandoned.‘J

What charaaerises a GP’s thinking? In contrast to this trend, it is claimed by doctors that personal experience is important in doctoring.S*6 But this is quite often disqualified by pointing out that there are no empirical data to prove whether this doc- tor with this kind of experience in this situation can be better than the rules, the guidelines. With this in mind, we can consider what distinguishes a GP’s thinking from that of a specialist: 1 The individual patient is seen in his social, cultural

and psychological as well as medical context. 2 The individual patient and the special experience

the doctor has with him is used for decision-mak- ing. Continuity and comprehensiveness of care are important factors allowing this experience to de- velop.

3 A number of therapeutic interventions are based on experience in the sense that they are usually fo- cussed on a symptom, a disease or an illness, which is treated in a certain way, allowing positive or neg- ative results to be experienced in a short period of time and in relatively high frequencies.

4 Resulting from the first three points, a GP’s think- ing is strongly orientated towards individualised treatment decisions, which can be ‘tested’ by ob- serving the results during the coming daydweekd months.6-*

To live with the contradiction Today, we have to serve these two concepts: individu- alised doctoring and preventive thinking. The problems start when these two ways of thinking get mixed up. One example is treatment of heart rhythm disturbances which, for a while, was orientated towards the symp- toms and reducing the rhythm disturbances. This al- lowed the doctor to gain experience, i.e. to wait and see if the arrhythmia decreased within a certain period of time. But we learned that judging a preventive activity according to ‘our experience’ is not good: the aim of the treatment was to reduce mortality, which was not achieved by this approach: instead, more people died from lethal arrhythmias caused by the drugs used to

treat them9 A finding which only large studies, but not the doctor’s personal experience, could reveal. Another example for that ‘misuse’ of experience is il- lustrated in the following finding. In most of the stud- ies comparing doctors and nurses in providing pre- ventive care, for example in coronary heart disease, di- abetes, hypertension or psychiatric medication, nurses are better than doctors at reaching the goals of ‘normal values’ and even mortality reduction.I0 And they are probably better because they do not try to incorporate their experience into this process of decision-making and treatment, as doctors always do.

On the other hand, there are examples showing that de- cision-making based on experience is superior to fol- lowing rules. We learned in the 1980s and 1990s that sophisticated computer programmes, for example for finding indications for surgery in patients with acute ab- dominal pain or for admission to a coronary care unit in patients with chest pain, were not as good in diagnosing and predicting as experienced doctors were.”

From these examples it is clear that all complex clinical situations need experience to find adequate solutions. Reasons for encounters in general practice are quite often complex. Looking at the patients we see each day, we quite often wonder if the guideline-orientated medicine, which would have been necessary according to the concept of preventive thinking, is really best for the quality of life of the patient in front of us. Often this is because these patients have very small risks and the ‘necessary’ interventions - even if not dangerous - are spoiling their quality of life.6-8 We should realise that for a couple of years an unseen division in the content of our work has emerged: guideline-based and complex work. We must accept these two concepts, but we should identify and differ- entiate in each case. We need preventive thinking, which makes us follow guidelines in all those situ- ations not ideal for using personal experience. And we need individualised doctoring, which allows us to work on the basis of experience and using the experi- ence we have gained with a certain patient over the years.

Don’t mix it up If both concepts of thinking are important and neces- sary for a GP today, where is the problem? The prob- lem starts when a certain patient in a certain situation needs care and counselling, and we must work out which concept is the right for that patient in that situ- ation. Preventive thinking stands for a public health perspec- tive, the rules are described above: mostly small risk, small win and, necessarily, there should be only few side effects. But patients quite often expect large wins with small side effects or, if the symptoms are severe, even accepting larger side effects. So it can happen that

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patients misunderstand us, when we suggest screening such as a cervical smear or regular blood pressure checks; they expect more than we can give them. Under the ethical direction of ‘doing our best for our patients’, we have to find out what is the best for him, from his perspective. So, before doing anything, we have to inform the patient about the dimensions of win and harm.&’ But doing this quite often results in pa- tients abstaining from measures based on preventive thinking, because they came for a different kind of gain. Under a public health perspective this is ineffective. Therefore, with a disease management programme that expects us to do this and that in a certain situation, we are forced to be successful in following a public health perspective. And doctors who are paid according to the percentage of patients served in a certain way (e.g. having their blood pressure checked, their smear taken), will notice this even more directly.

All this is also true the other way around. If a patient asks us explicitly to care for him in a preventive way, for instance by looking after his cardiovascular risks, and we do not do it according to the guidelines or risk formulae but try to ‘individualise’ our treatment sugges- tions, we start being ineffective in the preventive field. So in each situation we have to decide what the patient wants and where the problem is localised to serve him appropriately. The patient can be partly involved in the decision, which sometimes makes it easier for us to find a solution.

Two medical cultures Behind these two concepts, ‘preventive thinking’ and ‘individualised doctoring’, we can identify two medical cultures within one country and - in different balances - between different countries. On one hand, there are doctors who like to system- atically identify all known risk factors for all known diseases to start early treatment. Examples other than coronary heart disease are chronic obstructive pul- monary disease, impaired glucose tolerance, silent gall stones, hints for possible juvenile suicide or preclinical psychosis. In the other culture, doctors more or less abstain from using these instruments and organise their work according to what the patient asks for or according to the disease a patient has.’,* It is quite ob- vious that this differentiation is not always easy to make. Where does treatment of a disease end and pre- ventive activity begin? But astonishingly often we can distinguish these two worlds of medical thinking, these two kinds of doctors, quite easily. Even in research, one can differentiate between re- searchers who are more fascinated by studies on the control of wide areas of health-attacking risk factors, by evaluating treatment regimes and programmes, for example. On the other hand, there are researchers in general practice who prefer looking at such aspects as

the caring process, communication, and the role of trust and continuity of care.

T h e future There are two possible directions of development. General practice can develop further in the direction characterised here by the term of ‘preventive thinking’ which is actually following a community/public health orientation. If development progresses in this way, we should face the fact that trained nurses or technicians will usually do a better job for less money in wide areas of that field. Individualised doctoring is left for us, which would not be the worst solution. But we should see that ‘individualised doctoring’, even if highly valued by patients, is not greatly valued by politicians because it is so difficult to bring into handy terms of success. The other possible development is that GPs accept that the two ways of thinking, ‘preventive thinking’ and ‘individualised doctoring’, are both part of their work. But this will only work if GPs recognise that these two concepts have different sets of rules and the rules for the one concept are not appropriate for the other. In a concrete situation this kind of differentia- tion is a real effort and requires reflections in a large number of decisions to be taken when caring for pa- tients. The central question should always be: ‘What is best for my patient?’ and then, almost as an after- thought: ‘What is the best for society?’ But this rank order could even be the litmus of differentiation with- in general practice. = References 1 Rose G. The Strategy of Preventive Medicine. Oxford University

Press: 1992. 2 Misselbrook D, Amstrong D. Patients’ responses to risk information

about benefits of treating hypertension. Br J Gen Prud 2001;Sl:

3 Walter FM, Britten N. Patients’ understanding of risk: a qualitative study of decision making about the menopause and hormone replacement therapy in general practice. Fum Prud 2002;19:579-86.

4 Fiepamdc M. The tyranny of health. London Routledge, 2001. 5 Greenhalgh T. Intuition and evidence - uneasy bedfellows? Br] Gen

Pruct 2002;52:395400. 6 Bradley GW. Disease, Diagnosis and Decisions. Wiley, Chichester

1993: Chapter 3. 7 Fraser RC. Clinical Method - A General Practice Approach. London:

Butterworth, 1987. 8 Stewart M, Brown JB, Weston WW, et al. Patient-Centred Medicine

-Transforming the clinical method. Thousand Oaks, CaUJUS: Sage, 1995. [Especially in chapters 2 and 3.1

9 Echt DS, Liebson PRY Mivhel LB, et al. Morbidity and mortality in patients receiving encainide, flecainide, or placebo. N Engl J Med

10 Campbell N, Murchie P. The international perspective of structured disease management programmes for secondary prevention in coronary heart disease. in: Grundlagen einer evidenz-basierten ambulanten Versorgung von KHK-Patienten. h e n : Medizin Dienst der Spitzenverbande, 2003.

11 Berg M. Rationalizing Medical Work. Cambridge (MA): h4lT Press, 1997.

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