THE DOCTOR, THE PATIENT AND THE

TREATMENT

Toulouse 2009

MEDICINE IS A SCIENCE BUT ALSO THE ART OF ADJUSTING TO A SPECIFIC, UNIQUE, DIFFERENT PATIENT, THE SCIENTIFIC KNOWLEDGE ACQUIRED BY DEFINITION FROM POPULATIONS.

LIKE FOR ANY ART MEDICAL IT RELIES ON A TECHNIQUE THAT MUST BE LEARNT AND NEEDS TO BE PRACTICED THROUGHOUT A LIFETIME

THIS TECHNIQUE, PRACTICED IN MANY MEDICAL SPECIALTIES, WAS DEVELOPED AROUND A REFLEXION ABOUT PSORIASIS BUT IS ALSO USED FOR ACNE, VITILIGO, ATOPY, VERNEUIL’S DISEASE, T CELL LYMPHOMAS…

IT INVOLVES

MEDICINE CENTRED AROUND THE PATIENT:- IT CONCERNS EVERY CHRONIC DISEASE

- AT THE HEART OF ITS PREOCCUPTATION: THE EVALUATION OF THE SEVERITY OF THE DISEASE AND ITS IMPACT ON THE QUALITY OF LIFE

A RECENT STUDY CONSISTED OF COMMUNICATING A QUESTIONNAIRE TO DERMATOLOGISTS ON THE QUALITY OF LIFE OF PATIENTS COMING OUT OF CONSULTATIONS. AFTER HAVING SEEN THIS QUESTIONNAIRE, OVER 60% OF DERMATOLOGISTS INDICATED THAT IF THE LATTER HAD AVAILABLE BEFORE THE CONSULTATION, THEY WOULD HAVE CHANGED THEIR THERAPEUTIC STRATEGY.

*

IN A EUROPEAN STUDY INVOLVING MORE THAN 23 000 PATIENTS, THE MAIN COMPLAINT WAS THAT THE SEVERITY OF THEIR PSORIASIS WAS NOT TAKEN SUFFICIENTLY INTO ACCOUNT.

The therapeutic strategy must be chosen according to the severity of the

disease and

The physical and psychological tolerance to different treatments.

IRP

THE SEVERITY OF PSORIASIS DEPENDS ON:

1/ THE IMPACT ON THE QUALITY OF LIFE

2/ THE RESISTANCE TO TREATMENTS PRESCRIBED WITH A GOOD STRATEGY

3/ THE EXTENT OF THE LESIONS

IT IS THE SEVERITY OF THE PSORIASIS AND THEREFORE THE

PATIENT’S EXPERIENCE THAT AUTHORISES OR NOT THE

PRESCRIPTION OF SYSTEMIC DRUGS

THE QUALITY OF LIFE AND THE IMPACT OF TREATMENTS ON THE

QUALITY OF LIFE ARE NOT EVALUATED BY THE DOCTOR BUT BY

THE PATIENT

IRP

THEREFORE THE SEVERITY OF THE DISEASE: MAIN

COMPONENT FOR CHOOSING A THERAPEUTIC

STRATEGY,

IS EVALUATED NOT BY THE DOCTOR AS IN EMERGENCY

MEDICINE BUT BY THE PATIENT WITH THE HELP OF

HIS DOCTOR

IN PRACTICE, HOW TO ADAPT IN THE BEST WAY TO A

REQUEST THAT IS OFTEN NOT FORMULATED?

AND OF COURSE, DRUGS THAT CAN BE USED TOPICALLY OR SYSTEMICALLY

IN ISOLATION OR IN ASSOCIATION

IN MOST CHRONIC DISEASES OF THE SKIN, THE MAIN AIM OF THE TREATMENT IS TO IMPROVE

THE QUALITY OF LIFE OF EACH PATIENT.

TO ACHIEVE THIS, THE THERAPEUTIC TOOLS ARE:

QUESTIONSEXPLANATIONS

NEGOCIATION

QUESTIONSQUESTIONS

WHAT IS THE IMPACT OF PSORIASIS ON - PERSONAL?

- FAMILIAL? - SOCIAL?LIFE

WHAT IS THE IMPACT OF PSORIASIS ON MOOD AND BEHAVIOUR?

WHAT IS THE IMPACT OF TREATMENTS THAT HAVE ALREADY BEEN GIVEN TO THIS PATIENT ON HIS OR HER QUALITY OF LIFE?

WHAT IS THE REASON FOR THE CONSULTATION?

1

HOW DOES THE PATIENT EVALUATE THE

EFFICACY OF PREVIOUS THERAPEUTIC

STRATEGIES?

WHAT ARE THE MOST IMPORTANT ASPECTS

OF QUALITY OF LIFE FOR THIS PATIENT?

QUESTIONSQUESTIONS 2

AT THE END OF THESE

QUESTIONS IT OFTEN SEEMS THAT:

A LIMITED PSORIASIS CAN BE VERY SEVERE AND JUSTIFY A MAJOR

TREATMENT

A WIDESPREAD PSORIASIS CAN BE WELL TOLERATED

EXPLANATIONS

THE AIM IS TO MAKE THE DISEASE SOMETHING OBJECTIVE, THAT WE CAN UNDERSTAND AND ON WHICH

WE CAN ACT

EXPLANATIONSEXPLANATIONS

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ON PSORIASISON PSORIASIS

A CONGENITAL DISEASE

WE CAN THEREFORE NOT PROMISE A PERMANENT CURE BUT WE MUST PROMISE TO IMPROVE THE

QUALITY OF LIFE

WHAT IS THE OPINION OF THE PATIENT ON THE CAUSES OF DISEASE OUTBURSTS?

PSORIASIS IS A NON SPECIFIC REACTION TO EXTERNAL AND INTERNAL AGGRESSIONS

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EXPLANATIONSEXPLANATIONS ON PSORIASISON PSORIASIS

THE RENEWAL OF THE EPIDERMIS IS CONTROLLED IN ALL HUMANS BY:

* Scratching

* infectious diseases

*weight gain, stopping sporting activities

* alcohol and tobacco

* drugs (treatments for hypertension)

* seasons

* the brain:

any danger signal, immediately or in a delayed manner leads to the acceleration of the renewal of the epidermis

Psoriasis is in itself a danger

THE CONTROL OF THESE FACTORS, WHEN THEY ARE IMPLICATED IS AN IMPORTANT PART OF THE TREATMENT

THE RENEWAL OF THE EPIDERMIS IS STRONGLY ACCELERATED

THE TREATMENT INCLUDES TWO PHASES:

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A PHASE OF BLEACHING THAT WILL SLOW DOWN THE EPIDERMIS AND WHICH IS EASY TO TRIGGER

A MAINTENANCE PHASE THAT WILL CONTINUE ON AN APPARENTLY NORMAL SKIN AND WILL BE DIFFICULT TO ENSURE

A BLEACHING PHASE

EXPLANATIONSEXPLANATIONS PSORIASISPSORIASIS

A MAINTENANCE PHASE

EXPLANATIONSEXPLANATIONSON THE TREATMENTSON THE TREATMENTS

THE TREATMENT STRATEGY IS AS

IMPORTANT AS THE DRUG THAT IS

USED

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FOR EACH TREATMENT OR EACH TREATMENT ASSOCIATION YOU MUST EXPLAIN:

THE CONSEQUENCES OF A GOOD THERAPEUTIC STRATEGY ON EVERYDAY LIFE

SIDE EFFECTS

CLINICAL AND BIOLOGICAL SURVEILLANCE

EXPLANATIONSEXPLANATIONSON THE TREATMENTSON THE TREATMENTS

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SYSTEMIC TREATMENTS ARE VIRTUALLY DANGER-FREE

IF

WE RESPECT THE RULES OF USE

(INDICATIONS, CONTRA-INDICATIONS, SURVEILLANCE)

EXPLANATIONSEXPLANATIONSON THE TREATMENTSON THE TREATMENTS

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NEGOCIATIONNEGOCIATION

DEPENDING ON THE QUESTIONS

AND EXPLANATIONS

AND THE REACTIONS OF THE PATIENT,

WE MUST NEGOCIATE WITH HIM OR HER

TO CHOSE THE BEST REASONABLE

THERAPEUTIC STRATEGY

Consider with the patient an adaptation of

the treatment baring in the mind the

history, associated diseases, way of life

and character of the patient.

Consider the therapeutic strategy as long-term depending on the available

treatments and therapeutic progresses.

NEGOCIATIONNEGOCIATION

A PART (developing from one consultation to the

next) OF THE THERAPEUTIC CHOICE MUST

BE MADE BY THE PATIENT.

HE MUST LEARN, STEP BY STEP THAT HE

IS CAPABLE OF CONTROLING HIS OWN

PSORIASIS WITH THE HELP OF THE

DOCTOR.

AT THE END OF THE NEGOCIATION, THE PRESCRIPTION IS NEVER JUST A

WRITTEN PRESCRIPTION BUT A CONTRACT THAT MUST IDEALLY BE SIGNED BY THE DOCTOR AND THE

PATIENT

IRP

We cannot treat a chronic disease to the best of

our capacity if the patient does not want to

progressively take control of his disease

This phenomenon of appropriation is different

depending on the education, age, and culture but

remains a condition of observance and

mysteriously of therapeutic efficacy

THE EDUCATION OF THE PATIENT AND THE QUALITY OF THE THERAPEUTIC NEGOCIATION ARE THE KEYS TO THERAPEUTIC SUCCESS.

THIS SUCCESS TAKES TIME (45 MINUTES FOR THE FIRST CONSULTATION) AND REQUIRES A REVOLUTION IN THE BEHAVIOUR OF DOCTORS BUT ALSO PATIENTS.

THE PATIENTS ARE NOT READY, IN MOST CASES, TO TAKE PART IN THE THERAPEUTIC CHOICE.

THE RELATIONSHIP OF A PATIENT WITH HIS DISEASE (AND WITH THE

DOCTOR) CHANGES OVER TIME:

NEGLIGENCE

WORRY

REFUSAL

RESIGNATION

ACTION

The dermatologist must avoid several traps:

1) 1) Over or under estimate the severity of the Over or under estimate the severity of the

diseasedisease

2) 2) Be scared of side effects and not propose Be scared of side effects and not propose

systemic treatmentssystemic treatments

3) 3) Over or under estimate side effectsOver or under estimate side effects..

4) 4) To not take into account the affective To not take into account the affective

relationship between the patient and the relationship between the patient and the

drugsdrugs

IN CASE OF A POOR THERAPEUTIC OBSERVANCE

THE FIRST PERSON RESPONSIBLE IS THE DOCTOR

THE RHEUMATOLOGIST AND THE DERMATOLOGIST

OUR EMOTIONAL RELATIONSHIPS WITH DRUGS…

AND WITH THE RULES: PRESCRIPTION OUTSIDE OF

MARKET INDICATIONS

Words that are pronounced or unspoken, listened to, heard, are drugs that induce the secretion of several

cytokines and are not devoid of side effects that can sometimes be severe

HOW TO EVALUATE THE EFFECT OF

WORDS?