Working with what you have in medicine, is it enough?

In modern medicine, perhaps there are two axes that regulate ethical conduct in daily practice: a) evidence-based medicine and b) precision medicine or previously called personalized medicine, but really this term is confusing, since medicine has always has been personalized. In the first concept, in practically the whole world, for some decades now, clinical medicine has been guided by trying to implement the best therapeutic behaviors based on the results of clinical studies, which have strictly followed the steps of the research protocols, in accordance with good clinical practices, and where they have provided benefits in the patients studied.

The results of these clinical studies are published in indexed journals that everyone can theoretically consult, but this is where the problems begin, since not everyone has access to these journals, since their cost is usually high, for this reason, Most of the institutions try to have some subscription to the magazines that they consider most recognized in their field and that can support their staff in their updating.

The concept of precision medicine has recently been introduced, which basically consists of the individualization of each patient with their illness, since we have always known that each person can have different clinical responses and effects of medications. The problem of the individualization of each patient is that one part is based on the determination of molecular tests that particularize the genetic information of each patient, increasing costs, even in many cases, many of these tests can be more expensive than the same treatments. they are trying to select.

With this in mind, our country is no stranger to these demands of current medical practice. However, the differences between public and private medicine are very contrasting. Each administration tries to put its stamp on the health system it inherits and modify it according to the idea that each one has and wants to adopt for Mexico. This administration, despite its good intentions of wanting to provide medicines for the entire population, has lacked good planning in the purchase, distribution, preparation and administration of medicines, causing shortages and bureaucratic delays in patient appointments, forcing many rights holders and patients of hospitals run by INSABI, to have their imaging and laboratory studies done in a particular way to be able to continue their treatments as planned and not suffer delays in them, since these delays can be weeks or months , and also to the purchase of medications that do not exist at that time in their care units.

This situation is not new, since it has been present since past administrations; so much so that some colleagues even said “that their institutional practice was not evidence-based medicine but rather stock-based medicine”, that is, of prescribing only the medications that are available; this, in addition to falsifying the information by pointing out that there is no shortage, since only the medicine that is in stock is dispensed, confusing the health personnel themselves. But in this government, this has been accentuated in a more evident way. It should be pointed out as something positive, that having high-cost medicines in pathologies such as cancer, where the price of many of them are excessively high and that practically almost no patient could afford, in this administration there are more possibilities of treating some more patients , although intermittently, due to the periods of shortages that occur and due to the limited budgets of the institutions, they still have to discriminate patients with the intention of trying to optimize resources in those who are considered to have greater possibilities of better results. Some directors of the government and health institutions try to get doctors to adapt to such circumstances and treat their patients with as much or as little as the hospital can offer them, that is, treat the population with what they have … Sadly, reality trumps talk.

This is where the mentality of the doctor falls into a duality that is sometimes not easy to reconcile. In the public institution, the doctor gets used to prescribing “there is not” or “there is only this or that”, despite being in the understanding that it is not the best option for the patient, and he gets used to that “something is better than nothing”. Physicians who, in addition to working in the public institution, do so privately, will hardly delay procedures or the start of treatment.

Obviously, the institutions try to ensure that their doctors abide by the international management guidelines, but many times, due to the particular characteristics of each of them, they internally allow the “tropicalization” of therapeutic management according to the circumstances that prevail at that time. your institution.

When you live reality or the “real world” as the Americans say, the therapeutic results will be very diverse; each patient will experience the good or bad luck that has befallen him and only he will know of his fortune or misfortune. The doctors will be satisfied with what they believed was the best alternative at that time according to the conditions of their hospital, or that they at least offered something, and finally the government will say that it complied, because no one complained and will presume that its policies have been successful.

*The author is a medical oncologist at the National Institute of Cancerology (InCan), with a master’s degree in Direction and Management of Health Institutions, full professor of the Biological Therapies course, and has been a representative for Mexico of the cooperative group SWOG (South West Oncology Group). Currently in the dissemination project: Science, politics, economics and medicine.

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