Excerpt from P-value Primer
Physicians and the Patient Perspective
Physician training focuses on the individual patient to the exclusion of the population. We may call this the “single patient perspective”. The single patient perspective is embedded in medical students from their first year introductory courses. The detailed instruction in anatomy, histology, biochemistry, and physiology we received was not so much to enhance our understanding of the constitution of the population, but to deepen our understanding of the structure of the individual. It was a discussion about facts. Exams were on facts, not on variability.
As medical students, we are trained to develop thorough and exhaustive differential diagnoses, compiling a complete list of possible explanations for the symptoms and signs the individual patient presented, with little thought given to the frequency of the disease in the population. In my medical education, a seemingly disproportionate emphasis was placed on rare diseases (e.g., Whipple’s disease, or Tsushugamuchi fever). This exposure trained us to identify the one unexpected patient who might have that unusual disease. In essence we were taught to bring “the rare to bear” in developing a patient’s diagnosis.
We remember the first time that we had responsibility for performing a history and physical.[1] Each of these experiences inculcates the “single patient perspective” i.e., our focus must be on the one patient before us.
Occasionally, during a short course in either epidemiology or biostatistics in the middle of medical school, we faced another point of view. General discussions about measuring effects in populations presented a perspective that suggested that there was a larger context for our work. However the concept was already a foreign one. After all, wasn’t the best way to mend the health of a population to allow well educated, individual physicians to treat individual patients, one at a time? Trained to place the patient in the position of pre-eminence, the new population-perspective was alien. Upon graduation, we took a patient-based, not a population-based, oath.
As house officers, we focused not on populations of patients, but on the few (although at the time it seemed like the many) patients on the wards, floors, and units that we covered. We attended lectures to learn how we might better help the patients directly under our care. Private practices were built one patient at a time, one family at a time. Every patient interaction offered a potential surprise or pitfall, and therefore required our complete attention. Since the most important patient that we would see is the one we were currently treating, all of our skills and energy had to be focused there.
Research and the Population Perspective
The patient-perspective remains preeminent for good and undeniable reasons. Examining, identifying and treating the patient for his or her benefit alone is a tremendous burden for which we are disciplined and trained. We should not turn our faces from this challenge.
Yet the principles of research are different from those of the medical practice. In fact, many physicians believe that in order to understand research tenets, they must embrace concepts that they have been specifically trained to shun..
One example of this disconnect between research and medical practice principles is the concept of the “average” patient. The average blood pressure produced by the active group in a clinical trial may be only two or three mm/Hg lower than in the control group, a finding heralded as an important advance by the research community. However, physicians treating patients in the community are not impressed with the change, asking how a 2-3 mm Hg reduction could possible matter in a patient where the daily stresses of work and family living generate changes in blood pressure that are more significant.
Another confusing message for the physicians laboring to understand research issues is the concept of variability. Treating physicians clearly understand that patients are very different from one another, unique in an infinite number of ways. We take this into account, adjusting the patient’s visit schedule in accordance with the patient’s stability or our concerns.[2] We never think of modifying variability. Yet, researchers become experts at controlling, adjusting, or even removing variability.
The difference between the two groups of workers is perspective. Physician views develop from the patient-based perspective, while researchers are commonly population-based. Each perspective uses different tools because their goal’s are different.
The Need for Integration
The two examples cited above reflect the difficulties that complicate the physician’s attempt to integrate relevant research findings into their body of knowledge. The different points of view between the population and patient perspective induce a tension in physicians because their goals are different. Yet it is up to us to integrate these disparate points of view, accepting the best of each while simultaneously understanding their limitations.
We can begin this incorporation process by repudiating the idea that individual patient preeminence is negotiable. In a practice, the patient must come first ─ subjugating our primary concern for the patient to any other perspective leads to unethical, avoidable damage to patients and their families. However, embracing the patient perspective blinds us to an objective view of the effect of our interventions.
We as practicing physicians often cannot see the results of our own interventions in an objective light [[i]]. For example, if patients who respond well to our treatments return to see us, while the poor responders drift away, we are lulled into a false sense of confidence in the positive utility of the intervention. On the other hand, if patients who are invigorated by our treatment do not return, while only the dissatisfied come back to demonstrate the inadequacies of our therapeutic approach, we may prematurely abandon an important and promising therapy. The fact is that some patients improve (or deteriorate) regardless of what we do. By concentrating on what we observe, to the exclusion of what should be considered but is unobservable, we lose sight of an unbiased view of the intervention.
Thus, while we require evidence-based medicine, the evidence we collect from our daily practices is subjective and therefore suspect. The focus on the individual patient, while necessary, blinds our view of the true risks and benefits of the therapy.
[1] For me, it was an adult, deaf-mute male at North Shore Hospital on Long Island, New York, in March 1976.
[2] The simple, often mocked monitory “call me in the morning,” is a maneuver acknowledging that the doctor, not knowing in precise detail what will happen to the patient, insists on new information to determine if any unexpected event has occurred.
[i]. Moore T. (1995) Deadly Medicine. New York Simon and Schuster.