Dr. Roytberg vs. " Dr. Google"
How to treat a patient who knows everything about his illness from the Internet
The Department of Therapy and Family Medicine of the Pirogov Russian National Research Medical University celebrated its 20th anniversary. How has the average Russian patient changed? Should a doctor love his patient? How to navigate in the information space, where there is a lot of useful and, alas, dangerous to health? The columnist for "RG" talks about this with the head of the department, academician Grigory Roytberg.
Grigory Efimovich, it seems that now everyone knows almost everything about diseases: what to eat, what medications to take, procedures ... But there are many prohibitions among the information. How can a poor health seeker be?
Grigory Roytberg: We strive to teach future doctors to support the patient's desire to take part in the treatment process. Family doctors need to know that the patient today is not at all the same as he was 30-20 years ago. Indeed, he has already listened to the opinion of "Dr. Google", and therefore sometimes knows about his disease no less than a doctor.
Maybe this is good?
Grigory Roytberg: This is a given. And this must be reckoned with. The doctor must understand that he does not possess sacred, that is, only he and his colleagues know knowledge. He must - and this is more important - understand that the presence of basic knowledge is required, but at the same time there must be a desire and opportunity to constantly learn. What drives the doctor? The Hippocratic Oath, salary, position in society ... And what drives the patient? Lust for life, desire to be healthy. What's more important?
Probably the patient's position.
Grigory Roytberg: And I think so. This is not yet a universal phenomenon in medicine. But if a doctor, in addition to narrow knowledge of the disease, has experience, knowledge about the effect of the disease on a particular patient, intuition, then it becomes obvious: the art of healing has not gone anywhere, but has acquired new nuances. And the ability to love the patient, as the great Russian philosopher Ivan Ilyin wrote about it, has not gone anywhere either. If you cannot feel empathy for the patient, then it is best not to treat him. Let him go to another doctor.
I, like you, believe that Ilyin is not outdated. But ... There are strict standards, there is a time allotted for a patient's treatment, protocols to be followed, and so on. As you, a renowned therapist, feel that the patient's treatment does not always fit into certain, even the most reasonable standards, framework. Call it what you want.
Grigory Roytberg: I do not see any contradictions in this. Both the time and resources of a physician in any country are limited. But we must not forget that the patients of a family doctor, a district doctor, are the most common patients with the most common diseases. In addition, the district doctor, as a rule, knows his patients, knows the conditions in which they and their loved ones live. As for your question about protocols or standards ... We all live by certain rules - the same protocols. You are now writing this article. You know the basics of grammar. For example, the fact that the adverbial turnover should be separated by commas, and so on. And now you don't think that you are observing the spelling standards. Someone, thanks to these spelling standards, wrote "War and Peace", and someone will competently write poetry - good or bad, but write it. But if a person does not know these standards, then both are very problematic.
If you cannot feel empathy for the patient, then it is best not to treat him. Let him go to another doctor
But besides simple diseases, there are those that bring enormous suffering, which are difficult to diagnose, and even more difficult to treat. Let's say a patient has high blood pressure. And then an avalanche of advice begins. The Internet, and not only the Internet, is full of them. Here I read: such and such the most advanced clinic has done a great job. Verdict: Milk is bad. From it, not only the pressure can rise, but also a malignant disease can develop. And many remember that milk is given to those who are engaged in hazardous production. How should a patient be? While thinking about this question, another message comes from another clinic: "Drink two glasses of milk a day. You will be young and beautiful." So what?!..
Grigory Roytberg: You asked a question that is not easy not only for the patient, but also for the doctor. What recommendations can he give? What are his time-tested tips? The doctor is also a man, he also reads Google and Yandex. The doctor attends conferences sponsored by a particular pharmaceutical company with their own interests. He reads medical journals, articles in which are often paid for by certain customers. It is sometimes difficult to resist this stream of "solid" information.
There is the so-called metabolic syndrome, one of the components of which is excess fat deposition on the internal organs of the abdominal cavity. No one wants this syndrome to overtake him. What recommendations on this topic are not voiced today! Eliminate carbohydrates from your diet. Eat only proteins and fats - this is the so-called Atkins diet. It was once followed by millions of people. The final, unfortunately, is deplorable. With prolonged adherence to this diet, atherosclerosis develops rapidly, irreversible changes occur in the liver. And the slightest violation of the diet leads to the rapid formation of body fat. Or: a healthy person should give up sugar and other sweets in order to maintain health, normal weight and good looks.
Well-known recommendation: "Sugar and salt are the main enemies."
Grigory Roytberg: The most dangerous delusion! People who have given up sugar altogether produce the so-called tau protein, which is responsible for Alzheimer's disease. Perhaps the person's appearance will remain. But he is no longer able to remember why, why he lives, to perceive the world around him normally. Today, five times more money is spent on treatment of erectile dysfunction in men and breast augmentation in women than on treatment of Alzheimer's disease. Years will pass and there will be a large number of beautiful and sexually attractive seniors who will not remember what they need it for.
I can tell the same about salt. It has been known since ancient times that any excessive restrictions, as well as any excesses, are harmful. I will refer to the founder of world pharmacology, Paracelsus. He said, "The poison does the dose." There are no absolutely harmful or absolutely harmless products. Unfortunately, we also hear similar recommendations for lifestyle. For example, a patient asks a doctor: "When can I eat in the evening to sleep well?" The usual answer is, "Two to four hours before bedtime." But if a person has a gallbladder disease, gallbladder spasms, then he just needs to eat right before bedtime. That is, any advice must be personalized.
Is the individual approach to the patient outdated yet?
Grigory Roytberg: I am against "bye". It will never become obsolete, even despite the invasion of robotic medicine. Although I am personally against such a term. Medicine is the lot of people, not robots. I'm used to the fact that words should have certain meanings. When you talk about robotic medicine, you need to understand what you mean. If you think that tomorrow a robot will come and say: "Hello Irina Grigorievna, come on, I will operate on you," and will perform all the functions of a doctor, then ... I think today such an opportunity is not foreseen. If you say that a robot or robotics, or special computers help a doctor get information quickly, I’m only in favor. For example, we have developed a decision support program at our clinic. This is an excellent reference book that will set the standards for optimal decision making in seconds.
There are many drugs today. You will come to a therapist, he will prescribe you for the heart, for something else, four medicines. Then you will go to the urologist. He will assign you two more. Then you remember that something else hurt you, and you will be prescribed anti-inflammatory drugs. Then, if the patient has diabetes, he has three more medications that cannot be canceled. There were 12 drugs in total. But, as the famous scientist-therapist, the founder of clinical pharmacology in Russia, Boris Evgenievich Votchal, said: "One medicine and the second medicine are not two medicines, it is the third medicine." Pharmacokinetics is one of the most mysterious areas. And where to get the Einsteins, who can calculate a multifactorial analysis of drug interactions in the body in seconds in their heads.
And now Einstein is not needed: the doctor presses the computer button, and after 0.8 seconds he receives: 1) you have forgotten that this patient is pregnant and that she should not be prescribed this at all; 2) it is impossible to combine two such drugs, because they contain the same component and its dose will significantly exceed the required one; 3) after prescribing this drug, do not forget to check creatinine every day. Robots today are a different kind of reference. Very useful, very useful.
Personalized medicine is an individual approach to the patient. One can not use cottage cheese because ... Others can, it is useful. Physical activity is contraindicated for one. Shown to others. This personalized medicine has always been. Today, medicine is called personalized when medicines for a patient are individually worked out. Perhaps this is the future.
Can. You can't. Absolutely not. And the forbidden fruit is sweet. I usually cite the example of Winston Churchill, who, when asked how he managed to maintain such excellent health, said that "I never stood when I could sit, and never sat when I could lie down," smoked cigars, did not refuse brandy. He lived a long life, maintaining a clear mind and physical health, leading one of the most economically developed and influential countries.
Grigory Roytberg: By the way, about Churchill! He had all the signs of metabolic syndrome. I gave a presentation at the cardiology congress in Munich. We conducted a study, in our department a PhD thesis was defended on the effect of nicotine on the body. So, the harmful effect of smoking on the body has not been proven. We did not investigate cancer, we investigated coronary heart disease. We have proven that there are people who are absolutely not susceptible to nicotine. They may or may not smoke. It doesn't matter to them at all. 40% of people in the population are carriers of the insensitivity gene.
Shocking information, and for sure tomorrow there will be studies that it is incorrect.
Grigory Roytberg: It is possible that they will appear. But we must be reasonable about prohibitions and recommendations.
A club "Academician" has appeared in your clinic, which includes 20 academicians of the Russian Academy of Sciences. For what?
Grigory Roytberg: The opportunity for informal communication is important for us. It is one thing when an academician speaks from the rostrum, and another when we discuss issues of interest to us over a cup of tea.
Over a cup of tea or a glass of wine?
Grigory Roytberg: There is no serious research that people who do not drink, or people who adhere to vegetarianism, live better and longer. A person wants to drink ... This is his right. I am not saying that the truth is in wine. But the fact that wine in small doses reduces stress, improves biliary dyskinesia, relieves intestinal spasm, that's for sure ...
Which wine should you choose?
Grigory Roytberg: Anyone. There is an opinion that red is better. I deliberately became very closely acquainted with the research on this topic. It is written that people who drink red wine live longer. It's true. But who are these people? Red wine is much more expensive than white wine. It is drunk by people who consume certain foods, for example, they eat more meat. There are many factors to consider. Yes, we are constantly informed: "wine is healthy", "not a drop of wine". Because there is no serious data. Therefore, we will adhere to a policy of moderation, avoid excessive excesses. And it's not just about wine and diet.
For example, exercise is beneficial. And excessive physical activity is extremely harmful. For some, a moderate walk or just housework is enough. And you can go to fitness. But those who are trying to pump up muscles with physical education ... These are future invalids, these are any myocardial hypertrophy that we see in an athlete during coronary angiography. Although he does not have atherosclerosis, his large vessels are functioning well, and he dies from the fact that his heart is huge and the small vessels are compressed by the heart muscles. Therefore, no one said that serious sport is good. Therefore, the doctor should be able to determine the balance between moderation and excesses.