1. Procrustes and Primary Care Dee Mangin

4. Effective Care Recognition of the patients needs Consideration by professional and patient of the best that medical science has to offer Context a relationship that will maximise the therapeutic effect of using or not using treatments

7. Dr. Cabot employed new diagnostic techniques in his practice with patients, techniques that were sometimes ignored by his patients

12. Evidence based medicine risks becoming Scientific - bureaucratic medicine

14. Unmet need

15. Unrecognized Erectile Dysfunction

17. “The occasion when in the intimacy of the consulting room or sick room, a person seeks the advice of a doctor, whom she trusts. This is a consultation and all else in the practice of medicine derives from it.” Sir James Spence The Consultation

18. Real populations In primary care 40% of new presentations never fit criteria for any known diagnosis In primary care 40% of patients have multiple comorbid conditions

19. Infectious diseases Heart disease Cancer Proportion of total deaths

20. “hypertensive DISEASES, ischemic heartDISEASES, rheumatic fever, pulmonary heart DISEASE and DISEASES of the pulmonary circulation, other forms of heart DISEASE cerebrovascular DISEASES or stroke, DISEASES of veins, lymphaticvessels, and lymph nodes, OTHER AND UNSPECIFIED DISORDERS OF THE CIRCULATORY SYSTEM, AND congenital MALFORMATIONS, or birth defects of the circulatory system.”

23. 14

24. drew blood from his body forced him to vomit violently gave him a strong laxative shaved his head applied blistering agents to his scalp put special plasters made from pigeon droppings onto the sole of his feet fed him gallstones from the bladder of a goat made him drink 40 drops of extract from a dead man's skull

25. Hypothetical >70 year old woman – COPD – Type 2 diabetes – Hypertension – Osteoarthritis – Osteoporosis

26. 19 doses of 12 different medications Taken at five times during the day 14 non pharmacological activities 10 different possibilities for significant medicine interactions either with other medicines or other diseases

27. Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing ever happened

29. Intermediate indicators as quality targets Adding torcetrapib to atorvastatin ↓ LDL cholesterol Higher death rate in treatment arm HRT↓ LDL cholesterol Higher death rate in treatment arm Adding ezitimbe to simvastatin ↓ LDL cholesterol No change in death rate Rosiglitazone for diabetes Better glucose control Higher rate of heart attacks and deaths in treatment arm Tighter glucose controlLower HbA1CHigher death rate in treatment arm Lower glucose control target Better kidney function More hypoglycemic episodes in treatment arm Adding an ACE blocker to and ACE inhibitor Lower blood pressure Higher adverse events with no change in CV events in treatment arm

30. Machado de Assis

32. Research evidence Clinical state and circumstances Patients’ preferences and actions Improved health outcomes

33. Patient priorities “Life itself is not the most important thing in life. Some cling to it as a miser to his money and to as little purpose. Some risk it for a song, a hope, a cause, for wind in their hair.” Sir Theodore Fox

34. Professionals relying on epidemiological knowledge to guide their enquiries about unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients Drennan V et al Fam. Pract. 24:454-460, 2007

36. What characterizes illness is its variability, not its average manifestations. Virtually all of the conclusions of randomized controlled clinical trials are based on the average response. Variability, which underlies the genesis and progression of illness, the role of risk factors, and the impact of interventions, goes unrecognized.

37. Not Doing Well?

38. Not Doing, Well

39. The Art of Not Doing, Well “It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.” Philippe Pinel Treatise on Insanity

40. Technological brinkmanship and the therapeutic imperative Daniel Callahan

43. Discriminatory Prescribing “It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.” Philippe Pinel Treatise on Insanity

45. Discontinuation BP lowering 35 - 40% remained normotensive Bain K et al. JAGS. 2008; 56: 1946-52 199 ‘disabled’ patients in residential care Stopped 332 medicines (mean 2.8 / patient) Garfinkel D Israel Medical Association Journal 2007: 9:430-4

46. Overall mortality and morbidity indicators P - ValueControl Group Study Group 71119Total no. 0.00132 (45%)25 (21%) Death /yr 0.002 21 (30%)14 (11.8%) Referrals to acute care /yr

47. Arch Intern Med. 2010;170(18):1648-1654

48. 311 medications in 64 patients (58%) of drugs discontinued 4/5 didn’t have to be restarted 80% reported a global improvement in health No adverse events from the discontinuations

49. Effective Care Recognition of the patients needs Consideration by professional and patient of the best that medical science has to offer Context a relationship that will maximise the therapeutic effect of using or not using treatments

50. The evidence is strong that no matter how technically correct a medical transaction might be, patients do not get better at the same rate, if they did not feel that their needs were heard and understood over the course of their medical encounters. 18, 160-167

51. Effective Care Recognition of the patients needs Consideration by professional and patient of the best that medical science has to offer Context a relationship that will maximise the therapeutic effect of using or not using treatments

54. Phronesis

56. Monk T, Mangin D, Stange K, Starfield B

57. Better primary care gives better health outcomes Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htmwww.pitt.edu/~super1/lecture/lec8841/index.htm

58. Fit for Purpose Primary care that meets primary care standards Secondary care that meets secondary care standards

59. Critical Structural Features Accessibility Mechanisms of continuity of care Range of services available in primary care.

60. The evidence-based primary care functions that achieve this are First contact for new needs/problems Person (not disease) focused care (recognition of people’s health problems) The range of services provided in primary care Coordination (of treatment and needs recognition over time)

64. Theseus

65. urpose