“Our healthcare managers still have all their hopes for technology”
Vitaly Lekhtsier about fundamental and other medical problems
“According to our data, almost every second doctor in the hospital prescribes not what is best for a particular patient but what is available, and every fifth doctor recommends informally to purchase the best drug to patients on their own. So, the question of the ideal doctor today is mainly the issue of creating conditions for high-quality medical work," says Vitaly Lekhtsier, the Doctor of Philosophy, Professor at the Samara National Research University named after S.P. Korolev, Member of the Council of the Association of Medical Anthropologists of Russia. In the interview with Realnoe Vremya, he spoke about the flawed view that medicine is only technology, doctors who are forced to “hide” from their patients, and why people who regularly take pills continue to do so despite their fears about it.
“Today, the main form of self-administer treatment — and it is very common — is self-medication”
As you know, there is another modern mindset of contemporary people — that it is enough to take a pill and the disease will go away, and contra indications, incompatibility with other drugs, problems from long use do not particularly bother them.
That's not quite true. Empirical studies show that people who regularly take pills are very anxious about this, understand all the risks of side effects, but continue to do so, as they say in an interview, “out of desperation”. That is, many patients see the danger of drugs but also believe that biomedicine is the only solution, they do not see any alternatives.
Today, the main form of self-administer treatment — and it is very common — is self-medication. Especially among chronic patients who already have experience of the disease, prescribed and tested treatment regimens. Patients, in this case, self-medicate and just buy drugs at the pharmacy on their own. This happens as long as self-medication negates the symptom, but as soon as it stops working, the patient goes to the doctor. I must say that self-medication is also promoted by the Internet, where people today are willing to search for information about the drug and symptoms.
Today, the main form of self-administer treatment — and it is very common — is self-medication. Especially among chronic patients who already have experience of the disease, prescribed and tested treatment regimens. Patients, in this case, self-medicate and just buy drugs at the pharmacy on their own
“The problem is that medical education is focused on teaching medicine as a technology”
In your book 'Illness: Experience, Narrative, Hope (Essay on social and humanitarian research in medicine)', you touched on the topic of overdue fundamental changes in our medicine. Would you tell us briefly what needs to be changed in it?
If you mean Russian medicine, it has too many problems to cover them in one answer. It seems to be falling apart before our eyes. But I would highlight a problem related not to fatal underfunding and not to healthcare management system but to its basic goal setting and policy. In the book, I write about this as a universal problem that is relevant to modern healthcare in principle. And it is important what practitioners and theorists themselves write about this, for example, a well-known German doctor like Klaus Dorner.
We are talking about that the structure of modern pathology is definitely dominated by chronic diseases, and they should be considered a typical medical case. However, the infrastructure of chronic disease medicine, the adopted formats of interaction between the doctor/medical institutions and the patient should differ from the corresponding formats of acute disease medicine. In acute illness, the doctor is required to make accurate clinical decisions, instant effective technological interventions aimed at the diseased organ, as in case of toothache or poisoning.
Our healthcare managers still have all their hopes for technology, although it is clear that the development of medical technologies by converting many previously fatal diseases into chronic ones has only led to the expansion of the “remission society”
But chronic diseases that last for years, sometimes for decades, diseases that grow together with biographies, occurring in cycles of remissions and exacerbations, irreversibly changing the way of life of a person, requiring constant attention to symptoms and interaction with medical institutions, often drug intake — are something completely different. Here, medicine is not so much a technology, even state-of-the-art one, as an individualized practice of caring for, accompanying the patient, paying attention to his lifestyle, and how to ensure the patient's adherence to treatment.
Unfortunately, there is no such understanding yet. Our health managers still have high hopes for technology, although it is clear that the development of medical technologies by converting many previously fatal diseases into chronic ones has only led to the expansion of “the remission society” (Arthur Frank), which means that the importance of reorienting medicine to the management of chronic pathologies will only increase.
How important is it for a doctor to understand how the patient interprets pain and illness himself when treating chronic illness?
That's what's important. Because the semiotic conflict between the doctor and the patient, that is, the conflict between how the doctor interprets the disease and its causes and how the patient does it can significantly reduce the effectiveness of treatment, sometimes making it impossible. But this conflict is often hidden, not spoken, and if we are talking about chronic diseases, it can last for a long time. That is why the doctor should know how the patient understands what is happening to him, how the disease has affected his life world, what values he gives it. This will necessarily contribute to the individualization of treatment, the relationship of trust between the doctor and the patient. And also to ensure that side symptoms and many circumstances of the patient's life are not missed, which in turn can affect the disease and treatment.
This topic becomes all the more relevant in the modern megalopolis where patients from a wide variety of ethnic cultures come to the doctor with their own ideas about the acceptability of medical interventions, the causes of diseases, and how to behave after doctor's appointments. Many prominent doctors and medical anthropologists, representatives of narrative medicine such as Rita Charon, Arthur Kleinman, or Klaus Dorner, believe that the doctor during a consultation must necessarily give a narrative impulse, that is, the request for the patient's story about his illness and about the meanings that he puts into it. Another thing is that in the allotted time in public clinics for a doctor's appointment (and it is scanty), such medical practices are almost impossible, but in private clinics, they happen, although not always — much depends on corporate policy.
That is why the doctor should know how the patient understands what is happening to him, how the disease has affected his life world, what values he gives it. This will necessarily contribute to the individualization of treatment, the relationship of trust between the doctor and the patient
What needs to be changed to return the individual approach to the patient?
First of all, let us remember that they speak about the individualization of treatment not only constantly, but periodically, since the time of Hippocrates or — in Russia — starting with the activities of outstanding doctor Matvey Yakovlevich Mudrov. In the last twenty years, the new and, I must say, unprecedented hope for the personalization of therapy and prevention has been given by discoveries in genetics and molecular biology, human genome decoding, the emergence of full-genome screening technology, and various genetic tests for predisposition to certain diseases. The emergence and ongoing institutionalization of genomic medicine (or 4P medicine — predictive, personalized, participatory and preventive) promise in the near future not only the administration of treatment that takes into account your personal genetic profile, which, according to the plan, is the maximum efficiency and minimum side effects but also personalized prevention of diseases long before their clinical manifestation.
But again, medicine is not technology, or, as Charon says, medicine understood as technology, it is half medicine. The problem is (and this is typical for many countries) that medical education is focused on teaching medicine as a technology. This is why when technologies are no longer in effect, even advanced doctors sometimes seem to “hide” from their patients and give up, as research shows, this is why the situation with palliative care is so difficult in our country, the care of patients in general, with the rehabilitation and support procedures.
The doctor is closest to the patient, he is a witness to his suffering, this is the ethical basis of medical experience, which only in the second step requires technology. Not the other way around. The presented conflict can also be interpreted as a dispute between clinical and laboratory medicine. Either you distance yourself from the patient and he is objectified into a set of indicators on the screen or under a microscope, or everything is still solved at his bedside.
Of course, only the most humanized medical education can contribute to the return of medicine to its immanent ethical essence. It is necessary to introduce medical anthropology (which is currently being worked on by the Association of Medical Anthropologists of Russia), and the sociology of medicine, and to train the narrative competence of the doctor, and to read medical ethics not as a ready-made set of legal and deontological (moral — editor's note) principles, but as a reflection of the ethical foundations of medicine.
“The doctor often invents tricky prescribing schemes in the interests of the patient at his own risk”
What skills, knowledge, and qualities should the ideal doctor have? And does he have the opportunity to approach this ideal today?
In interviews, patients usually say that they want doctors to not only “give the impression of qualified specialists” but also explain their prescriptions and try to inspire confidence. It is interesting that recently patients have started talking not just about “a good doctor” but about “your doctor” — someone who can be trusted, who combines professionalism and care. Patients often look for not the “ideal doctor” but rather “their doctor”, and follow him if he changes his place of work. “Your doctor” in many cases, especially those related to chronic pathologies, becomes more important than a conditionally good hospital.
Patients often look for not the “ideal doctor” but rather “their doctor”, and follow him if he changes his place of work. “Your doctor” in many cases, especially those related to chronic pathologies, becomes more important than a conditionally good hospital
The question of the ideal in connection with the medical profession has a special character because it is by definition a “moral profession” — doctors know what duty is. I think that it is a reason why to the question of what factors influence the doctor's decision on what treatment to prescribe today, the top factors in our study in Samara included, along with “the doctor's own experience” (82%), the important factors such as “orientation to international and Russian clinical recommendations” (75%) and “ethical principles of the doctor” (73%) — both factors are slightly more represented in private clinics. The federal state standard for specific nosology already follows behind as a significant factor.
In other words, doctors, of course, know how to do it right, but, unfortunately, the system is such that they cannot always do it right. Sociological studies report an almost unanimous opinion of doctors about the bureaucratization of their work, the lack of time for high-quality consultation of patients and often the necessary medicines for prescription, the inability to treat even under effective protocols if they are not supported by the ministry of healthcare. We also know that thousands of criminal cases have already been opened for medical errors. To act in the best interests of the patient, the doctor often invents tricky prescribing schemes at his own risk, advises something informally, and is forced to bypass inefficient or outdated state standards.
However, according to our data, almost every second doctor in the hospital prescribes not what is best for a particular patient but what is available, and every fifth doctor recommends informally to purchase the best drug to patients on their own. So, the question of the ideal doctor today is mainly a question of creating conditions for high-quality medical work. We must understand that this is a political issue, the question of fighting for modern medicine.