In an essay in The New York Times, Dr. Kent Sepkowitz writes about the value of evidence-based medicine and the Cochrane Collaboration’s process of systematic review to assess the body of evidence on challenging medical questions and offer guidance for clinicians. Dr. Sepkowitz points out that skeptics of evidence-based medicine suggest that the practice of medicine cannot be reduced to algorithms and needs to consider the individual patient. “Some critics fear that evidence-based care may create a type of RoboDoc, a model of bloodless efficiency equipped with a 256-gig tablet containing the latest analyses. He may make the correct diagnosis but never will learn to say hello.” We believe that there is room in evidence-based medicine to consider the individual’s goals, preferences, and unique medical needs. Evidence-based medicine and compassionate, individualized care can coexist. Reviews such as Cochrane’s evaluate the breadth of the evidence but still leave room for shared decision-making between physicians and patients.
Dr. Don Dizon writes in an ASCO Connection column about the importance of understanding a patient’s goals and preferences for their treatment and the particular challenges faced by a patient who came to the United States from Laos for her treatment. Dr. Dizon concludes, “I must always remind myself that living for the sake of living cannot be the ultimate goal. It has to be informed by quality of life. Only one person can tell me what quality means though, and ultimately, it is that patient. Understanding the social circumstances of our patients can be as informative as understanding their tumor.” We agree that the individual with cancer has to define what “quality of life” means, and patients want to be seen holistically, as a person not just a tumor. NCCS recently launched two simple tools to help patients communicate with their doctors about their goals and wishes for their treatment and ask the essential questions that will help inform treatment decisions.
In “Should Doctors Take Care of Their Relatives?,” on Slate.com, Dr. Barron Lerner questions the ethics of some of his father’s actions, particularly as he advocated for less treatment and better palliation for terminally ill family members and even helped to hasten their deaths to avoid suffering. Dr. Lerner points out that his father practiced before the age of patient autonomy, when the prevailing belief was “doctor knows best,” and physicians embodied a “paternalistic ethos.” Yet, he acknowledges that his father was “ahead of the cure” in providing less treatment to patients with a poor prognosis, and his actions helped to better manage pain and relieve suffering. Clearly, medicine has moved in the right direction, with a generally accepted belief in patient autonomy. But we could still do better for patients by engaging patients in decision-making about their care, including honest discussions about prognosis, the level of aggressiveness desired, and end-of-life care.