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Procrustes and Primary Care

Procrustes and Primary Care. Dee Mangin. Effective Care. Recognition of the patients needs Consideration by professional and patient of the best that medical science has to offer Context a relationship that will maximise the therapeutic effect of using or not using treatments.

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Procrustes and Primary Care

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  1. Procrustes and Primary Care Dee Mangin

  2. Effective Care Recognition of the patients needs Consideration by professional and patient of the best that medical science has to offer Context a relationship that will maximise the therapeutic effect of using or not using treatments

  3. Dr. Cabot employed new diagnostic techniques in his practice with patients, techniques that were sometimes ignored by his patients

  4. Evidence based medicine risks becoming Scientific - bureaucratic medicine

  5. Unmet need

  6. Unrecognized Erectile Dysfunction

  7. The Consultation “The occasion when in the intimacy of the consulting room or sick room, a person seeks the advice of a doctor, whom she trusts. This is a consultation and all else in the practice of medicine derives from it.” Sir James Spence

  8. Real populations In primary care 40% of new presentations never fit criteria for any known diagnosis In primary care 40% of patients have multiple comorbid conditions

  9. Infectious diseases Heart disease Proportion of total deaths Cancer

  10. “hypertensive DISEASES, ischemic heartDISEASES, rheumatic fever, pulmonary heart DISEASE and DISEASES of the pulmonary circulation, other forms of heart DISEASE cerebrovascular DISEASES or stroke, DISEASES of veins, lymphaticvessels, and lymph nodes, OTHER AND UNSPECIFIED DISORDERS OF THE CIRCULATORY SYSTEM, AND congenital MALFORMATIONS, or birth defects of the circulatory system.”

  11. 14

  12. drew blood from his body forced him to vomit violently gave him a strong laxative shaved his head applied blistering agents to his scalp put special plasters made from pigeon droppings onto the sole of his feet fed him gallstones from the bladder of a goat made him drink 40 drops of extract from a dead man's skull

  13. Hypothetical >70 year old woman COPD Type 2 diabetes Hypertension Osteoarthritis Osteoporosis

  14. 19 doses of 12 different medications Taken at five times during the day 14 non pharmacological activities 10 different possibilities for significant medicine interactions either with other medicines or other diseases

  15. Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing ever happened

  16. Intermediate indicators as quality targets

  17. Machado de Assis

  18. Clinical state and circumstances Research evidence Patients’ preferences and actions Improved health outcomes

  19. Patient priorities “Life itself is not the most important thing in life. Some cling to it as a miser to his money and to as little purpose. Some risk it for a song, a hope, a cause, for wind in their hair.” Sir Theodore Fox

  20. Professionals relying on epidemiological knowledge to guide their enquiries about unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients Drennan V et al Fam. Pract. 24:454-460, 2007

  21. What characterizes illness is its variability, not its average manifestations. Virtually all of the conclusions of randomized controlled clinical trials are based on the average response. Variability, which underlies the genesis and progression of illness, the role of risk factors, and the impact of interventions, goes unrecognized.

  22. Not Doing Well?

  23. Not Doing, Well

  24. The Art of Not Doing, Well “It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.” Philippe Pinel Treatise on Insanity

  25. Technological brinkmanship and the therapeutic imperative Daniel Callahan

  26. Discriminatory Prescribing “It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.” Philippe Pinel Treatise on Insanity

  27. Discontinuation BP lowering 35 - 40% remained normotensive Bain K et al. JAGS. 2008; 56: 1946-52 199 ‘disabled’ patients in residential care Stopped 332 medicines (mean 2.8 / patient) Garfinkel D Israel Medical Association Journal 2007: 9:430-4

  28. Overall mortality and morbidity indicators

  29. Arch Intern Med. 2010;170(18):1648-1654

  30. 311 medications in 64 patients (58%) of drugs discontinued • 4/5 didn’t have to be restarted • 80% reported a global improvement in health • No adverse events from the discontinuations

  31. Effective Care Recognition of the patients needs Consideration by professional and patient of the best that medical science has to offer Context a relationship that will maximise the therapeutic effect of using or not using treatments

  32. The evidence is strong that no matter how technically correct a medical transaction might be, patients do not get better at the same rate, if they did not feel that their needs were heard and understood over the course of their medical encounters.18, 160-167

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