S'occuper du patient ou de la maladie -le texte

à la demande de certains d'entre vous, le texte qui a servi de base à ma présentation lors du débat sur la motion: "Il est mieux de traiter la maladie que le patient" lors du 12ème symposium de recherche de l'Hôpital St-Mary's  J'avais la chance de défendre le point du vue en désaccord avec la motion, en compagnie de Rosetta Antoniacci, une infièrmière exceptionnelle qui travaille au département de médecine interne.  Nos opposants éatient Dr Peter Steinmetz, un médecin de famille intensiviste, et Annie Chevrier, infirmière en soins critiques.
Le débat était en anglais, et si je n'ai pas suivi le texte/plan suivant à la lettre, ça résume quand même assez bien ce que j'ai dit...

Since my colleague Rosetta quoted a great nurse who said that “the focus of nursing was health”, I feel it is my duty to quote the Florence Nightingales of physicians, Sir William Osler, who said “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” It is almost common sense. When I talked to friends and relatives about participating in this debate on how it is more important to treat the person than the disease, I was received by blank stares. Wait, people would say, is that a debate? That type of a reaction always makes one nervous, when everybody thinks that what you say is common sense, it might mean that there are not many arguments on the subject…
 
And it so happened that I sat down in front of the TV series “House MD”. Dr House is the most obnoxious physician on TV; he is rude, gives the impression that he doesn't care, but is often the only one to diagnose what the patient has. And in most cases, he doesn't even talk to the patient. At first glance he seems to care only about the disease, not the patient. But the more you watch the show the more you realize that it is the opposite. He has his team going through volumes and volumes of charts, question the patient on what they felt emotionally right before the symptoms were triggered; he even sends his minions to the patient's house to explore in details the patient's environment and draws all sort of conclusions on how he/she lives. He really lives according to Osler’s aphorism. He gets to know what sort of a patient has a disease...
 
I'm not House. I talk to my patients. And as a family practitioner, my focus has to be the patient, because the disease that afflicts them is not always known, or treatable, as Rosetta mentioned. Also, many studies have shown that the patient's personal beliefs change how they feel pain and how their body reacts, and definitely change their compliance with treatment. . Often, the disease cannot be separated from its bearer. Many chronic diseases are not treatable, barely controllable, and one has to know his/her patient to help them cope with the burden of such disease. Everybody knows that exercise and calorie reduction is what is needed for an obese patient to loose weight, but you can't help a patient achieve these goals without knowing their environments, their specific biology and focusing on their way of life instead of the bare scientific aspect of obesity. Instructing a person to do that sort of behavioral change is never effective without a therapeutic alliance.
Disease does not occur outside of a patient. Even when there is a pathogenic organism, such as a virus, disease only occurs when there is an interaction between the patient and the organism. Since patients vary, identical pathogenic organisms can cause significantly different responses/disease in different patients. Disease is even more patient specific when it occurs as an interaction between the patient and environment and/or as an internal process ..
 
So ‘focusing on disease’ is a set up for treatment failure First, a given set of signs and symptoms in a particular patient may or may not fit in the ‘correct’ diagnostic box. Given enough time in practice, every clinician will see a ‘classic case’ that turns out to NOT be the presumed problem.
On top of the uncertainty in diagnosis, every patient responds to treatment in different ways. Sometimes you get the diagnosis right, prescribe the ‘right’ treatment, and the patient still doesn’t get better. On the flip side, sometimes you get the diagnosis wrong, and the recommended ‘wrong’ treatment appears to help the patient anyway.
 
We argue that the best way to treat a patient is to practice patient-centered care. It treats the patient with dignity and respect, as one capable of making informed decisions and with the rights to express needs and preferences in treatment and expected outcome. Care that is truly patient-centered considers patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. Disease do not stem only from pathological agents or condition, but from interaction between the biological, the psychological and the social environment. A good patient-centered approach should focus on all these aspect, and not only on the final diagnosis of a disease that they produce.
 
( ad lib on family medicine and need to focus on the patient while dealing with these issues:

• Prevention
• Most efficient, less painful, less costly
• Primary/secondary
• Act on risk factors
• Chronic disease
• DM, obesity, HTN
• Dementia
• How can you treat the disease when you don't know what it is?
• It is not because the x-ray is normal that you don't have pain)

As Rosetta said, we often come to a point where treating a disease seems futile to the treating team or to the patient. The patient’s values, expectation and baseline state need to be considered as a whole. Even when you can’t cure, you can always care, and by negotiating a therapeutic alliance with your patient and not with his disease, you can help relief suffering.

Finally, to quote again William Osler, I can only say that “The good physician treats the disease; the great physician treats the patient who has the disease”. Thank you
In conclusion, we argue that it is impossible to treat diseases and not patients because the disease is rooted in who the patients are, in how they live, and the treatment to their ailments varies depending on how their bodies react to them, on what they beliefs are, and how they envision their choices of life and death. Also, for the patient to feel cared for, he or she has to feel heard as a human being, not just as a bearer of a virus, bacteria or condition.