Practising medicine: from experienced-based to evidence-based to interpersonal

For years we had experienced-based medicine. Then evidence-based medicine (EBM) came along and has influenced doctors’ decision-making for the last 20 years or so.

But now it’s time to welcome a new paradigm – say hello to the world of “interpersonal medicine”.

EBM was an important advance over the intuition-based medicine that preceded it, but its limitations are becoming clear even as it is increasingly accepted as an aspiration. Writing in the New England Journal of Medicine last month, Drs Stacey Chang and Thomas Lee say there is now a need for something beyond EBM.

“EBM placed new emphasis on the relationship between clinical research and clinicians’ practice patterns, but shifted medicine’s “centre of gravity” away from the space between clinician and patient to somewhere between research and clinician,” they write.

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What’s needed now, in their view is “interpersonal medicine,” – a disciplined approach to delivering care that responds to patients’ circumstances, capabilities, and preferences. Interpersonal medicine, they maintain, is not just about being nice – it is about being effective.

I have practised both experience-based and evidence-based medicine. Before the rise of EBM, experience gained from a lifetime of practice was the most reliable basis for clinical decision making.

I was comfortable practising what might be termed intuition-based medicine but have to acknowledge it was limited by the data to which I had access as well as my prior experience. And in fairness to EBM, it allowed doctors to still draw on their own experiences and instincts, while enabling them to enrich these with broader data sets and less bias.

But the world has moved on and with it the type of illness most of us will experience. Rather than having a single disease, as we live longer, most of us will have multiple morbidities. Social and behavioural factors associated with disease will begin to outweigh pure biological considerations. And so effective treatment will have to move beyond “a pill for every ill”.

Which is where interpersonal medicine becomes increasingly important. Interpersonal skills are people skills and include the ability to motivate, communicate, solve problems and, perhaps most valuable of all, empathise.

Fundamental shift

Interpersonal communication skills facilitate patient-centred care. Defined as communication that occurs face-to-face, it is shaped by the individual characteristics, social roles and relationships of the people involved.

It enables the exchange of messages between doctors and patients in order to establish shared goals and understandings.These interactions focus on motivation, engagement, empowerment, conviction, and resilience.

Interpersonal medicine requires skills that place clinicians alongside their patients, as fellow travellers and experienced guides. But most of all it requires a fundamental shift in how we organise our health system.

The days of fee-per-item, procedure-focused medicine are numbered. Inflexible rules and technology-driven produce prompts care that is management driven rather than patient-centred.

We need to completely restructure the health service so that time spent alongside the patient becomes the most important metric. In my opinion it’s the only way we can deliver empathetic, co-ordinated care.

There is any amount of evidence to back this up. Better physician communication is associated with significant gains in patients’ adherence to recommended therapies and to improvement in a variety of outcomes.

Effective doctor-patient interaction has been shown to improve patient satisfaction, decision making, emotional health as well as improved blood pressure control.

But if we keep doing what we are doing then two-thirds of patients will continue to be discharged from hospital without understanding their diagnosis. And if these trends continue, patients will receive care that isn’t comprehensive and doesn’t address the root cause of their symptoms. Patient readmission rates will increase, resulting in a spiralling cost to the health service.

We must change the system to ensure interpersonal medicine becomes the norm.

Otherwise, we will continue on the “hamster wheel of health” – going around in circles to less and less effect.

mhouston@irishtimes.com