As noted in my personal blog about a year ago, Rita Maggio, the owner of a community bookstore in a shore town adjacent to ours, invites me to take home pre-publication copies of books in the form of advance uncorrected proofs. The gem that I took with Rita’s blessing last Friday was Extreme Measures: Finding A Better Path to the End of Life. The book won’t be available until February 21, 2017, but consider reserving a spot for it on your reading list. Frankly my initial attraction was that the book addresses a serious void in palliative care, a topic that I addressed (again last year on my personal blog) as my father’s life savings were depleted by a dysfunctional system. Jessica Nutik Zitter, M.D., one of only a handful of physicians board certified in both critical care medicine and palliative care medicine, is a self-described accidental evangelist for patient-centered care that she wasn’t taught in school. She points out the need for de-escalation protocols for those patients at the end of life who do not desire continued aggressive or life-prolonging treatment.
But the pleasant surprise here is that Dr. Zitter doesn’t just confine her remarks to the paradigm shift required for a patient-centered approach in end-of-life care. She urges that a truly patient-centered approach be housed within the entire culture of medicine, in every medical school, residency program, and fellowship. She implores her colleagues to prioritize quality of life, and to understand that good medicine is more nuanced than a single approach or protocol. It has to be individualized to each patient without an over-reliance on population norms or Randomized Clinical Trials. Such measures may be appropriate as a guide or a starting point, but we must not lose sight of the fact that each patient is unique.
The transformation that Dr. Zitter underwent as a result of her experiences led her to suggest the formation of The American Society of Patient-Centered Physicians. She writes that its purpose would be to bring together physicians of all specialties whose treatment philosophy prioritizes patient-specific rather than specialty-specific approaches. Communication, discussing goals of care, weighing benefits and burdens of treatment options, and managing pain and distress would be lauded as essential elements of patient care, at least as important as performing procedures and prescribing disease-specific therapies.
A modern version of the Hippocratic Oath was written in 1964 by Louis Lasagna, Dean of the School of Medicine at Tufts University. Dr. Zitter notes that much of the patient-centered approach is already written into the Oath, if only our system supported physicians intent on re-dedicating themselves to its principles.
A Modern Version of the Hippocratic Oath
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.