key: cord-0729965-u38tlu8m authors: Chapman, Robert title: The Importance of Patient-Centered Care date: 2021-01-06 journal: Chest DOI: 10.1016/j.chest.2020.07.076 sha: c08535e8d0d69176c09b2bf65016f16bbdde1687 doc_id: 729965 cord_uid: u38tlu8m nan The Importance of Patient-Centered Care To the Editor: I am writing in response to the thoughtful insights put forward by Dr Maldonado 1 in the recent editorial introducing the section on Humanities in CHEST medicine. As the coronavirus disease 2019 outbreak sweeps across the globe, it is shining a spotlight on medical practices. The need to treat patients in a holistic manner has become more apparent than ever because we have all been forced to reassure concerned families, broach difficult conversations, and consider ceilings of treatment more frequently than we ever have before. The innovative approaches used to communicate with our patients whilst wearing personal protective equipment and the new ways in which we support patients to communicate with their relatives at home are just two examples of health-care professionals doing their utmost to put their patients first. More Than a Machine Dr Maldonado 1 rightly mentions the drive towards the complete understanding of disease. The use of evidence-based treatment guidelines, diagnostic criteria, and investigation protocols are essential in maintaining patient safety; nobody can doubt that. However, some patients, due to their personal wishes, may need an alternative approach. It is imperative that we continue to treat the patient and not just the disease process. As we share our experiences of holistic care, we can continue to cement the need for a multifaceted approach to clinical care. Whilst we can use guidelines to treat diseases, we must also use other skills to treat the patient as a whole. Where Is the Ceiling? The withdrawal of care or the implementation of ceilings of care for patients is a common area of discussion among clinicians. The importance of a patient-centered approach is unquestionable when we make treatment decisions. In resource-limited scenarios, such as those experienced in some areas during coronavirus disease 2019 outbreaks, the discussions regarding levels of treatment are unequivocally more challenging. However, these decisions must still be taken with a holistic viewpoint, with quality of life and dependency examined together with clinical features. Contrastingly, in resource-rich settings, we must also remember the patient exists beyond their suspected disease, and extensive investigations or treatment may not be best for all patients. As our understanding advances, particularly in critical care medicine, we must limit ourselves to fix what is appropriate, not all that can be fixed. A patient-centered approach to clinical work is a goal that we must all work toward. The dissemination of literature relating to holistic approaches to medicine is integral to the forward movement towards this goal chestjournal.org and vital in prompting us all to reflect on our own clinical practice. To the Editor: We thank Dr Chapman for his insightful response to our editorial in which he highlights the necessity to appreciate the complexity of patient interactions that cannot be adequately grasped by the blind, mechanistic application of evidence-based guidelines, treatment algorithms, or allocation frameworks. 1 The coronavirus disease 2019 pandemic has crystallized the limits of algorithm-based medicine, as illustrated by the debates surrounding allocation of scarce resources during crisis standards of care. Just as the scientific method on which it is based, evidence-based medicine relies on a number of implicit assumptions that constrain its applicability. Models are derived from population-based data and applied to the individual, which is a process fraught with substantial risks at each step: data collection may not include relevant variables and be influenced by observers (ie, theory-laden), modelization may not be possible yet misleadingly capture the general characteristics of the parent dataset, and at any rate cannot possibly pretend to appreciate, even at a basic level, the rich kaleidoscope of distinct individuals for whom we are called to care. Implementing evidence-based guidelines and protocols ensures objectivity and consistency at the risk of sacrificing the individual. Conversely, individualizing care opens the door to subjectivity, biases, and inequalities. Somewhere in between lies the elusive "art of medicine," which we aim to explore in this new section. Perhaps as concerning is the risk to import in decision algorithms inequalities that are inherent in the population from which they are derived, sometimes due to relevant variables (eg, comorbidities) cosegregating with irrelevant ones (eg, social class). 2 This problem is likely to be compounded by the continued integration of artificial intelligence in medical decision algorithms, obscuring these disparities inside the deep learning "black box." 3 These important issues, recently highlighted by controversies over the use of race-correction in clinical scores and physiologic studies and its potential for systematizing and perpetuating inequalities, will be the topic of several articles in the coming year. Finally, we agree with Dr Chapman on the difficulties surrounding the end of life, which have been exacerbated by the current pandemic, and the challenges of implementing ceilings of care when the availability of critical care resources cannot be guaranteed. We are reminded of a quote in the Hippocratic corpus on the Art of Medicine: "Medicine is defined, in general terms, as to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless." The probability of malignancy in solitary pulmonary nodules: application to small radiologically indeterminate nodules CHEST Editorial Board for the Section on Humanities in CHEST Medicine. The humanities in chest medicine and CHEST: the case for a holistic, patient-centered approach to delivering pulmonary, critical care, and sleep medicine in the twenty-first century The "give back": is there room for it Harvard Public Law Working Paper No. 20-03, Informed Consent and Medical Artificial Intelligence: What to Tell the Patient?