THE DOCTOR, THE PATIENT AND THE TREATMENT Toulouse 2009

Doctor/patient/drugs: everything is changing! * Medicine that heals, emergency medicine, or even veterinary medicine Medicine that treats but does not heal must be a medicine that talks * * AIDS and the rise in power of patient associations * Diabetes and therapeutic education * Quality of life * Internet

MEDICINE IS A SCIENCE BUT ALSO THE ART OF ADJUSTING TO A SPECIFIC, UNIQUE, DIFFERENT PATIENT, THE SCIENTIFIC KNOWLEDGE ACQUIRED BY DEFINITION FROM POPULATIONS. LIKE FOR ANY ART MEDICAL IT RELIES ON A TECHNIQUE THAT MUST BE LEARNT AND NEEDS TO BE PRACTICED THROUGHOUT A LIFETIME

THIS TECHNIQUE, PRACTICED IN MANY MEDICAL SPECIALTIES, WAS DEVELOPED AROUND A REFLEXION ABOUT PSORIASIS BUT IS ALSO USED FOR ACNE, VITILIGO, ATOPY, VERNEUIL’S DISEASE, T CELL LYMPHOMAS… IT INVOLVES MEDICINE CENTRED AROUND THE PATIENT: - IT CONCERNS EVERY CHRONIC DISEASE - AT THE HEART OF ITS PREOCCUPTATION: THE EVALUATION OF THE SEVERITY OF THE DISEASE AND ITS IMPACT ON THE QUALITY OF LIFE

A RECENT STUDY CONSISTED OF COMMUNICATING A QUESTIONNAIRE TO DERMATOLOGISTS ON THE QUALITY OF LIFE OF PATIENTS COMING OUT OF CONSULTATIONS. AFTER HAVING SEEN THIS QUESTIONNAIRE, OVER 60% OF DERMATOLOGISTS INDICATED THAT IF THE LATTER HAD AVAILABLE BEFORE THE CONSULTATION, THEY WOULD HAVE CHANGED THEIR THERAPEUTIC STRATEGY. * IN A EUROPEAN STUDY INVOLVING MORE THAN PATIENTS, THE MAIN COMPLAINT WAS THAT THE SEVERITY OF THEIR PSORIASIS WAS NOT TAKEN SUFFICIENTLY INTO ACCOUNT.

The therapeutic strategy must be chosen according to the severity of the disease and The physical and psychological tolerance to different treatments. IRP

THE SEVERITY OF PSORIASIS DEPENDS ON: 1/ THE IMPACT ON THE QUALITY OF LIFE 2/ THE RESISTANCE TO TREATMENTS PRESCRIBED WITH A GOOD STRATEGY 3/ THE EXTENT OF THE LESIONS

IT IS THE SEVERITY OF THE PSORIASIS AND THEREFORE THE PATIENT’S EXPERIENCE THAT AUTHORISES OR NOT THE PRESCRIPTION OF SYSTEMIC DRUGS

THE QUALITY OF LIFE AND THE IMPACT OF TREATMENTS ON THE QUALITY OF LIFE ARE NOT EVALUATED BY THE DOCTOR BUT BY THE PATIENT IRP

THEREFORE THE SEVERITY OF THE DISEASE: MAIN COMPONENT FOR CHOOSING A THERAPEUTIC STRATEGY, IS EVALUATED NOT BY THE DOCTOR AS IN EMERGENCY MEDICINE BUT BY THE PATIENT WITH THE HELP OF HIS DOCTOR IN PRACTICE, HOW TO ADAPT IN THE BEST WAY TO A REQUEST THAT IS OFTEN NOT FORMULATED?

AND OF COURSE, DRUGS THAT CAN BE USED TOPICALLY OR SYSTEMICALLY IN ISOLATION OR IN ASSOCIATION IN MOST CHRONIC DISEASES OF THE SKIN, THE MAIN AIM OF THE TREATMENT IS TO IMPROVE THE QUALITY OF LIFE OF EACH PATIENT. TO ACHIEVE THIS, THE THERAPEUTIC TOOLS ARE: QUESTIONS EXPLANATIONS NEGOCIATION

QUESTIONS WHAT IS THE IMPACT OF PSORIASIS ON - PERSONAL? - FAMILIAL? - SOCIAL? LIFE WHAT IS THE IMPACT OF PSORIASIS ON MOOD AND BEHAVIOUR? WHAT IS THE IMPACT OF TREATMENTS THAT HAVE ALREADY BEEN GIVEN TO THIS PATIENT ON HIS OR HER QUALITY OF LIFE? WHAT IS THE REASON FOR THE CONSULTATION? 1

HOW DOES THE PATIENT EVALUATE THE EFFICACY OF PREVIOUS THERAPEUTIC STRATEGIES? WHAT ARE THE MOST IMPORTANT ASPECTS OF QUALITY OF LIFE FOR THIS PATIENT? QUESTIONS 2

AT THE END OF THESE QUESTIONS IT OFTEN SEEMS THAT: A LIMITED PSORIASIS CAN BE VERY SEVERE AND JUSTIFY A MAJOR TREATMENT A WIDESPREAD PSORIASIS CAN BE WELL TOLERATED

EXPLANATIONS THE AIM IS TO MAKE THE DISEASE SOMETHING OBJECTIVE, THAT WE CAN UNDERSTAND AND ON WHICH WE CAN ACT

EXPLANATIONS 1 ON PSORIASIS A CONGENITAL DISEASE WE CAN THEREFORE NOT PROMISE A PERMANENT CURE BUT WE MUST PROMISE TO IMPROVE THE QUALITY OF LIFE

WHAT IS THE OPINION OF THE PATIENT ON THE CAUSES OF DISEASE OUTBURSTS? PSORIASIS IS A NON SPECIFIC REACTION TO EXTERNAL AND INTERNAL AGGRESSIONS 2 EXPLANATIONS ON PSORIASIS

THE RENEWAL OF THE EPIDERMIS IS CONTROLLED IN ALL HUMANS BY: * Scratching * infectious diseases *weight gain, stopping sporting activities * alcohol and tobacco * drugs (treatments for hypertension) * seasons * the brain: any danger signal, immediately or in a delayed manner leads to the acceleration of the renewal of the epidermis Psoriasis is in itself a danger THE CONTROL OF THESE FACTORS, WHEN THEY ARE IMPLICATED IS AN IMPORTANT PART OF THE TREATMENT

THE RENEWAL OF THE EPIDERMIS IS STRONGLY ACCELERATED THE TREATMENT INCLUDES TWO PHASES: 3 A PHASE OF BLEACHING THAT WILL SLOW DOWN THE EPIDERMIS AND WHICH IS EASY TO TRIGGER A MAINTENANCE PHASE THAT WILL CONTINUE ON AN APPARENTLY NORMAL SKIN AND WILL BE DIFFICULT TO ENSURE A BLEACHING PHASE EXPLANATIONS PSORIASIS A MAINTENANCE PHASE

EXPLANATIONS ON THE TREATMENTS THE TREATMENT STRATEGY IS AS IMPORTANT AS THE DRUG THAT IS USED 1

FOR EACH TREATMENT OR EACH TREATMENT ASSOCIATION YOU MUST EXPLAIN: THE CONSEQUENCES OF A GOOD THERAPEUTIC STRATEGY ON EVERYDAY LIFE SIDE EFFECTS CLINICAL AND BIOLOGICAL SURVEILLANCE EXPLANATIONS ON THE TREATMENTS 2

SYSTEMIC TREATMENTS ARE VIRTUALLY DANGER-FREE IF WE RESPECT THE RULES OF USE (INDICATIONS, CONTRA-INDICATIONS, SURVEILLANCE) EXPLANATIONS ON THE TREATMENTS 3

NEGOCIATION DEPENDING ON THE QUESTIONS AND EXPLANATIONS AND THE REACTIONS OF THE PATIENT, WE MUST NEGOCIATE WITH HIM OR HER TO CHOSE THE BEST REASONABLE THERAPEUTIC STRATEGY

Consider with the patient an adaptation of the treatment baring in the mind the history, associated diseases, way of life and character of the patient.

Consider the therapeutic strategy as long- term depending on the available treatments and therapeutic progresses.

NEGOCIATION A PART (developing from one consultation to the next) OF THE THERAPEUTIC CHOICE MUST BE MADE BY THE PATIENT. HE MUST LEARN, STEP BY STEP THAT HE IS CAPABLE OF CONTROLING HIS OWN PSORIASIS WITH THE HELP OF THE DOCTOR.

AT THE END OF THE NEGOCIATION, THE PRESCRIPTION IS NEVER JUST A WRITTEN PRESCRIPTION BUT A CONTRACT THAT MUST IDEALLY BE SIGNED BY THE DOCTOR AND THE PATIENT IRP

We cannot treat a chronic disease to the best of our capacity if the patient does not want to progressively take control of his disease This phenomenon of appropriation is different depending on the education, age, and culture but remains a condition of observance and mysteriously of therapeutic efficacy

THE EDUCATION OF THE PATIENT AND THE QUALITY OF THE THERAPEUTIC NEGOCIATION ARE THE KEYS TO THERAPEUTIC SUCCESS. THIS SUCCESS TAKES TIME (45 MINUTES FOR THE FIRST CONSULTATION) AND REQUIRES A REVOLUTION IN THE BEHAVIOUR OF DOCTORS BUT ALSO PATIENTS. THE PATIENTS ARE NOT READY, IN MOST CASES, TO TAKE PART IN THE THERAPEUTIC CHOICE.

THE RELATIONSHIP OF A PATIENT WITH HIS DISEASE (AND WITH THE DOCTOR) CHANGES OVER TIME: NEGLIGENCE WORRY REFUSAL RESIGNATION ACTION

The dermatologist must avoid several traps: 1) Over or under estimate the severity of the disease 2) Be scared of side effects and not propose systemic treatments 3) Over or under estimate side effects. 4) To not take into account the affective relationship between the patient and the drugs

IN CASE OF A POOR THERAPEUTIC OBSERVANCE THE FIRST PERSON RESPONSIBLE IS THE DOCTOR

THE RHEUMATOLOGIST AND THE DERMATOLOGIST OUR EMOTIONAL RELATIONSHIPS WITH DRUGS… AND WITH THE RULES: PRESCRIPTION OUTSIDE OF MARKET INDICATIONS

Words that are pronounced or unspoken, listened to, heard, are drugs that induce the secretion of several cytokines and are not devoid of side effects that can sometimes be severe

HOW TO EVALUATE THE EFFECT OF WORDS?