BETTER MEDICINES,

BETTER TREATMENT,
BETTER HEALTH,
BUT
LOWER COSTS
Promoting Rational Use of Medicine &
Preventive Measures in the community

Yayasan Orangtua Peduli



Compassion, Courage, Commitment
ROAD MAP
1. Doctors
2. EBM
3. RUM
4. Patient & IT
5. Lesson learnt & Action
1. WHO ARE WE.?
The good physician treats the disease;
the great physician treats the patients
that has the disease.
The great physician UNDERSTANDS the
patient and the context of that patients
illness.
To err is human
Institute of Medicine
PRIMUM NON NO CERE
Above all, do not HARM ....

Who will define what constitutes HARM?
Hippocrates
460-377 B.C.
"he who aspires to treat correctly
of human regimen must first acquire
knowledge & discernment of the nature of man in
general
knowledge of its primary constituents, discernment of the
components by which it is controlled.
though they are made from the same materials,
NO TWO ARE ALIKE
Hippocrates
460-377 B.C.
PRIMACY OF THE PATIENT
CARE
Human understanding, Empathy
Somehow


Do we LISTEN?
Are we humble & trustable?
Human understanding
Empathy
Todays health-care context is highly complex.
Care is often delivered in a pressurized and fast-
moving environment, involving a vast array of
technology and, daily, many individual decisions and
judgements by health-care professional staff.

In such circumstances things can and do go wrong.
PATIENT SAFETY cost-effectiveness
Exhausted, overwhelmed, frustrated, and .
ability to listen & communicate
3 Oct 2012: Reporter Jeanne Lenzer
investigates overtreatment at the heart of
healthcare.
Overly aggressive treatment is estimated to cause 30 000
deaths among Medicare recipients alone each year.
Overall, unnecessary interventions are estimated to
account for 10-30% of spending on healthcare in the US, or
$250bn-800bn (154bn-490bn; 190bn-610bn) annually.

Shannon Brownlee, acting director of the New America
Health Policy Program and author of : Overtreated: How
Too Much Medicine is Making Us Sicker and Poorer,


Harm?
Impact
of
ADRs
THE COST FACTOR
588 million $/year - Germany (1997),
> $ 177.4 billion US - year2000,
$847 million/year - UK (2006, BMJ)
$ 1.4 million/year (exceeds DM, CV); 1/5 hospital death

HUMANITARIAN REASONS:
4-6
th
leading cause of death (Lazarou et al, JAMA; 98)
S/d 19 % inpatients - experience ADR (Davies et al, J
Clin Pharm & Ther; 2006);
2 millions serious ADR, 100000 death/year
up to 70 % are preventable (Pirmohamed et al, BMJ;
2006)
Harm?
US: 2/3 patients Rx
10 drugs/person, year 2000
ADR - 4 drugs
Why . ADR!!
Katanya Autoimmune hepatitis, harus biopsi hati

Bu, makan obat apa sebelum sakit?
Cuma vitamin paru2 . ?????
Harm?
Doctors not medical technicians, mending a human machine
Indonesia: increase 10 13% per year
High cost - sophisticated procedures/tests
65%
Overtreatment -- 56%

Global trend:
Cost shifting of acute in- to out-patient services

Higher utilization of prescriptions drugs.
New drugs are expensive and often over-prescribed.

Utilization of high cost injectables and new treatment
regimes has increased.

COST Out of Pocket?
Harm?
COST 10 TOP CONDITIONS
0
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
350,000,000
Outpatient
Inpatient
31/1
340/6
109/8
Harm?
Each physician must decide if the circumstances of
practice are threatening his or her adherence to the
values that the medical profession has held dear for
many millennia.
APA SIH YANG DIPEROLEH DI SEKOLAH
KEDOKTERAN?
From: "uwi" >To: <sehat@yahoogroups.com>
Sent: Tuesday, July 12, 2005 10:45 AM
Dear dr. & SP's,

Pengen sharing .. mudah2an nggak bete ya bacanya
E... Demam, batuk pilek. ... tumben, barengan. Ayahnya
agak khawatir. Ya udah deh ke dokter ... Oh ya DSA udah 2
kali ganti.
Dokter I yang menangani kelahirannya nggak komunikatif.
Dokter II pasiennya bejibun, seneng banget ngasih obat-
vitamin. Saya dapat dokter III ... katanya RUD... So,
kemaren ke situ.
Diagnosa: radang tenggorokan.
Tanpa penjelasan ABCD, sang dokter menulis resep.
Kemudian : "bu, ini racikan ya, yang ini antibiotik"
"untuk apa ya dok antibiotiknya? ... "untuk radangnya"
"emang radang perlu antibiotik dok?
"iya, tenggorokannya sudah merah begitu"
Ampun! Ya namanya radang kan pasti memerah!
Racikan: Theofilin, Salbuven, Celestamin, Mucopect,
Sirup: -Lapicef Syrup & -Encephabol Syrup

Saya tanya temen yang jaga UGD: "emang perlu AB?"
Jawab: "ya perlu dong untuk mengobati radangnya".

Trus curhat ke teman (sedang ambil spesialisasi syaraf).
Responnya membuat saya shock ... "Makanya lo jangan sok
tau deh! AB tuh emang perlu untuk ngobatin radang. Kita
dokter2 suka sebel ama pasien yang ngotot dan sok tau"
Harm?
Selain angka rujukan yang tinggi, biaya tertinggi - obat - 1x
kunjungan - flu sampai Rp 150 rb asma Rp 300 rb.

2005 - program baru, kerjasama dg klinik dan RS terpilih
Membuat STANDARISASI JENIS OBAT. Masalah: ketidak
setujuan (ketidak sukaan) dan penolakan dari klinik-RS
(terutama); paling banyak - konsultan ahli (merasa
diintervensi). Belum lagi karyawan yang merasa tidak
mendapat obat seperti sebelumnya.

waktu baru lulus - saya sangat HEBOH dg kemampuan saya
mengobati pasien. Kemudian ditempatkan di klinik dg dokter
advisor Alia dan Afrika Selatan. Waduh, saya jadi bahan olok-
olok & merasa sangat bodoh.
Pengobatan yang saya berikan ternyata tidak mempunyai
dasar ilmiah yang bisa dipertanggung jawabkan. Sebagian
besar hanya berdasarkan pengalaman dan nyontek dari senior
atau konsultan semasa kuliah
From: ju@as...id
To: sehat@yahoogroups.com
Sent: Thursday, January 18, 2007 9:30 AM
Subject: [sehat] Tentang resep (was Re: Haruskah Kita
Mengekspor Pasien?)
Docs, Just curious......
Apa memang ada standar/aturan/kode etik agar tulisan dokter
pada lembar resep 'sulit dibaca' awam?? kan baiknya 'mudah
dibaca'......

Sedikit usul, mungkin bisa dijadikan standar prosedur dokter,
agar menerangkan setiap obat yang diberikan ke pasien: dosis,
kegunaan, kapan diberikan, kapan distop, efek samping, dll.
Klo ini dijadikan standar prosedur, kan lebih baik.... walaupun
inisiatif bisa juga datang dari pasien sendiri.

Just my 200rups, Ju. Z..
-still learn to be a father for a son-
Harm?
1. Best clinical
evidence
3. Patients
value
2. Clinical
experience
TO IMPROVE
Outcomes,
Patients safety,
Cost
effectiveness
2. EVIDENCE BASED MEDICINE
(EBM)
Grade of
recommend-
ation
Level of
evidence
Interventions
A 1a Systematic review of RCTs
1b Individual RCT


B
2a Systematic review of cohort
studies
2b Individual cohort study
3a Systematic review of case-
control studies
3b Individual case-control study
C 4 Case series
D 5 Expert opinion
Koleksi Resep?
EBM guidelines
Clinical practice guidelines are systematically
developed statements that aim to help
physicians and patients reach the best health
care decisions. Good guidelines have many
attributes (validity, reliability, reproducibility, clinical
applicability and flexibility, clarity), development
through a multidisciplinary process, scheduled
reviews, and documentation.
More than 2000 guidelines are currently
represented in the National Guideline
Clearinghouse (www.guideline.gov).

GUIDELINES AND RULES:
FRIEND OR FOE?

Dr J onathan Adler, Massachusetts General
Hospital.
Physicians should take the time to be
familiar with the most important guidelines
in their specialty.
They should adopt the best guidelines
because they represent the best practice
and are best for the patient.
DECONGESTANTS: short-term relief of nasal obstruction for
adults, but may not work in children. Are often used, but
evidence that they work is scanty. Trials show that single
doses are moderately effective. Insufficient evidence to show
whether:
repeated doses are effective, or whether
single or repeated doses work in children age < 12. link:
http://www.cochrane.org/reviews/english/ab001953.html

ANTIHISTAMINES: no convincing evidence can relieve the cold.
In combination with decongestives, antihistamines might lead to
some general improvement and relief from a blocked and/or
runny nose although there is not enough evidence to be certain.
link:
http://www.cochrane.org/reviews/english/ab001267.html
OTC cold medicines dangerous for kids
under 2 (U.S. government research)
2005: 3 babies of < 6 months old died
2004 05: more than 1500 children < 2 ys ER
Can any medications help treat the common cold?

Pain reliever such as acetaminophen can reduce a fever and
ease the pain of a sore throat or headache. Remember, however,
low-grade fevers don't need treatment.
Don't give ibuprofen to a child younger than age 6 months, and
don't give aspirin to anyone age 18 or younger. Aspirin has been
associated with Reye's syndrome, a rare but potentially fatal
illness.
Ibuprofen & AKI!
Somehow
URI; 10 months
A doctor will be able to
cure some of the time,
relieve most of the time
but should
comfort all the time.
REALITY . Efficacy, safety, cost
Most prescribers choose drugs on the
grounds of efficacy, while side effects
are only taken into consideration after
they have been encountered.
Sometimes kinetic characteristics which
are of little importance are stressed to
promote an expensive drug while many
cheaper alternatives are available.
Public/private diarrhoea treatment all years
WHO database, ICIUM 2004
0
10
20
30
40
50
60
70
ORS Antibiotics Antidiarrhoeals STG
compliance
%

d
i
a
r
r
h
o
e
a

c
a
s
e
s

t
r
e
a
t
e
d
Public (n=24-50) Private for profit (n=5-23)
URI (55) Fever (43) Diarrhea (27) Cough (41)
Total meds 260 186 83 186
Median 5 4 3 4
Max 8 9 7 11
% Puyer 77.4 72.6 55.4 87
% Antibiotic
(% generic)
54.5
7
86.4
0
74.1
5
46.3
10.5
% Generics 16.9 9.7 3.6 19.4
% prescribed med
-Steroid
-Anti histamine
-Anti Convulsion
-Anti Pyretics
-Supplement
61.8
50.9
16.4
36.4
21.8
41.9
53.5
55.8
79.1
34.9
44.4
18.5
11.1
29.6
51.9
\
60.9
36.6
14.6
17.1
2.4
1. General results
0
10
20
30
40
50
60
70
80
90
100
URI COUGHS FEVER Acute GE
% Antibiotics
URI
COUGHS
FEVER
Acute GE
STUDY on ANTIBIOTIC USE in
COMMON CONDITION among children (2006)
n = 166; total meds = 715
URI
Prescribing Pattern
(2006)
Prescribing pattern (2008) (n=583)
Jakarta Other cities
Respondent (n)
55 346 237
Median
5 6 6
Max active substances
8 26 14
Types of drugs
Antipyretic
21.8% 40,7% 40,5%
Anticonvulsant
36.4% 24,2% 12,2%
Bronchodilator
50% 57,5% 51,4%
Decongestant
52.7% 48,8% 47,2%
Antihistamine
50.9% 81,5% 75,9%
Mucolitic/expectorant
63% 61,5% 69,1%
Steroid
61.8% 58,3% 56,9%
Antibiotic
54.5% 67,3% 78,4%
Antitussive
10.9% 21,6% 27,4%
Supplement
21.8% 39% 35%
Compounding medicine
77.4% 91,9% 88,6%
Generics
16.9% 28.3% 16.2%
0 100 200 300 400 500 600 700 800
URI
FEVER
Acute GE
Thousands
IMCI
Median
Max
Min
15.000

20.800

56.000


349.000


326.000


747.000

167.000


137.000


117,500

STUDY on COST (rupiah). 406 Rx/
IMCI 3.000 8.500

PENELITIAN 2010: Puskesmas Depok

Means of drugs 3.8 (1 7)
7 drugs: Acute Nasopharyngitis
Non generics
Obat batuk-pilek
Obat diare (kaolin)
Obat mata
Suplemen
Antibiotics: Amoxycillin, Cotrimoxazole, Cephadroxil
Obat non DOEN 36.2%
To: Sehat@yahoogroups.com
From: He.@pm...com
Sent: Thursday, August 24, 2006 10:53 AM
Subject: Mau curhat nih (sharing & asking)
dear all, my daughter fell off and had stitches on her
forehead. What should I do to prevent keloid in the future?
I havent bought the prescription (I did browse; it contains
vitamins and 2 antibiotics). Am I doing the right thing?

1. - amoxsan 500 mg (amoxicilin)
- Riboflavin
- Omeprazole
- amid 100 mg
2. - biothicol 60 ml... (Chloramphenicol)
Please advice, thx
EBM Guidelines
Essential Drug List
Formulary
3. RUM
(Rational Use of Medicine)
THERAPY :

1. advice & information
2. non-drug therapy
3. DRUGS
4. referral, 2
nd
opinion
5. combination
RUM: Patients receive medications APPROPRIATE to their
clinical needs,

in DOSES meet their individual requirements for an
ADEQUATE PERIOD of time,
accurate INFORMATION, and
at the LOWEST COST to them and their community.
WHO conference of experts Nairobi 1985
PROBLEM/S
DIAGNOSIS
GOAL THERAPY
DRUG SELECTION
START THERAPY
MONITOR -
EVALUATE
The process of rational treatment
Efficacy
Safety
Suitability
Cost
Availability
Choosing
a P drug
INFORMATION,
instruction, warnings
1
2
3
4
5
6
P drugs - COMMON COLDS
Goal of treatment: Comforting the child, Not curing the
infection
Inventory effective treatment:
Advice & Information:
Offer plenty of fluids.
Encourage rest.
Moisten the air.
Drug treatment:
Try saline drops. Saline nose drops can loosen thick nasal
mucus and make it easier for your child to breathe.
Soothe a sore throat. For older children, gargling salt water or
sucking on hard candy may soothe a sore throat.
Referral for treatment: Not necessary
P drug & P treatment
Acute GE mild to moderate dehydration
Goal of treatment :
(1) to prevent dehydration or to prevent it from worsening
(2) rehydration;

the goal is not to cure the infection!
Inventory - effective therapy:
Advice & information: continue breastfeeding & other food;
observation
Non-drug treatment: additional fluid
Drug treatment: ORS, oral or NGT
Referral for treatment: Not necessary.
P drug & P treatment
Acute GE mild to moderate dehydration
Metronidazole & antibiotics (cotrimoxazole or ampicillin),
are not listed in the inventory (not effective in treating watery
diarrhoea).
Antibiotics are only indicated for persistent bloody and/or
slimy diarrhoea (less common than watery diarrhoea);
metronidazole is mainly used for proven amoebiasis.
Antidiarrhoeal drugs are not indicated, especially for
children, (mask the continuing loss of body fluids into the
intestines and may give the false impression that something
is being done).
Your P-treatment: advice to continue feeding and to give
extra fluids and to observe the child carefully.
Review of the comments on the Report of the Informal
Expert Meeting on Dosage Forms of Medicines for Children
http://www.who.int/medicines/publications/TRS958June2010.pdf
The Committee also considered extemporaneous preparations
involving polypharmacy. The Committee noted that in 1985 WHO
defined rational use of medicines as requiring that patients receive
medications appropriate to their needs. The custom in some
places is to treat sick children with a mixture of several medi-
cines (puyer) not necessarily all appropriate to their needs.
Commonly, adult solid dosage forms are mixed together ground to a
powder and the powder divided into assumed paediatric doses and
then dispensed for administration to the child. Often, some medicines
in the mixture are not indicated for the condition being treated. These
medicines add to the risk of adverse events without any possi-
bility of conferring additional benefit. The Committee recom-
mended that as this practice is irrational it should not be used.
Prof Rianto Setiabudi
Permasalahan seputar puyer
1. Kemungkinan kesalahan manusia
2. Stabilitas obat tertentu dapat menurun
3. Toksisitas obat dapat meningkat
4. Waktu penyediaan obat lebih lama
5. Efektivitas obat dapat berkurang
6. pencemaran lingkungan
7. tingkat higienis
8. biaya lebih mahal
9. Dokter tidak tahu obat mana
10. Potensial IRUD
GMP
GPP
EBM
RUD
Resep senior??; Resep template??
Prescribing is a complex
and challenging task which
must be based on accurate
and objective information
and not an automated
action, without critical
thinking
or a response to
commercial pressure.
Guidelines, Essential drug list-Formulary
Somehow
PRIMUM NON NO CERE .
RUM, EBM
WHO:
Avoid mixing drugs
As few drugs as possible
Drug = substance + INFORMATION
WHO, Dept. Essential Drugs and Medicines Policy
Irrational use . Health hazards &
wastage
At least, 50% prescription unnecessary,
inappropriate.
Drugs prescribed when actually not needed
Patients are provided with wrong medicines,
ineffective or unsafe .
Effective medicines, the essential drugs -
underused
Age 15 months Fever, coughs, runny nose
Effective treatment:
Close monitoring
Wait & see approach
Lots of fluid
+/- Paracetamol
15 active
substances!
Age 3 ys: Acute GE
R/ Biothicol 200 mg (chloramphenicol)
luminal 12.5 mg (phenobarbitone)
CTM 1.25 mg (antihistamine)
mfpulv dtd No XX 4 dd 1
R/ Nifural syr 3dd cth (antibiotic)
R/ Pedialite (ORS)
R/ Pankreon (pancreatic enzymes)
R/ B complex tab (vit B)
Curcuma tab (appetite stimulant)
Cobazim 1000 mg (CoenzymeB12)
Lysagor tab (appetite stimulant)
Isoniazid 50 mg ..
mfpulv dtd No XV 2 x 1 pulv
Effective treatment?

Close monitoring
ORS
+/- Paracetamol

10 active
substances!
URI
A 2 year old boy
IMCI (MTBS) URI ???
Reasons/Causes for Irrational Drug Use
What will happen if an antibiotic is given for a diarrhoea due to
food poisoning of short duration?
What will happen to a patient with a cold (=coryza) if he is given an
antibiotic?
What will happen to a 5 year old boy given antibiotics for a Upper
Respiratory tract due to a viral infection?

In all 3 situations the patient will eventually get better
What would have been the natural course of the illness?
What is the contribution of the antibiotic?
Can the effects of the 2 (natural course & antibiotics) be
differentiated?
Other examples NSAIDS and antacids/H2 receptor blockers
WHO, Dept. Essential Drugs and Medicines Policy
WHO, Dept. Essential Drugs and Medicines Policy
Reasons/Causes for Irrational Drug Use
Income of the Dispensing Doctor
Separation of Prescribing and Dispensing
National Health Service (UK) very few
dispensing doctors
Study showed this small group had higher
prescription rates
Attitude of Doctor
Active, interventionist do something for the
patient, encourages prescribing
IRRATIONAL POLYPHARMACY for daily
health problems; why?
It takes 2 years to train a doctor about a drug,
3 years to teach him when to use it and
a lifetime to teach him when not to use that drug.
Despite 4 year period of investigation and
continuous discussion . Doctors extremely
reluctant to change their prescribing habits.
WHO, Dept. Essential Drugs and Medicines Policy
WHO, Dept. Essential Drugs and Medicines Policy
Reasons/Causes for Irrational Drug Use
Strong Commercial factor
If the one who decides does not pay
And the one who pays does not decide
And if the one who decides is paid ..

(A very good example of an Imperfect Market)
Doctors = Patients?
4. Patient & IT


A well informed patient is easier to care for
More than 70 000 websites disseminate health
information; in excess of 50 million people seek health
information online.
The Internet offers widespread access to health
information, and the advantages of interactivity,
information tailoring and anonymity.
According to the Pew Research Centers Internet &
American Life Project, 61 percent of U.S. adults go
online for health information. Whats more, nearly all (60
percent) say their findings have influenced a decision
about how to treat an illness and that the advice they
found was helpfula pretty strong indicator that, when
used with requisite caution, the Internet can (and does)
play a positive and vital role in health care.
The Internet is changing not just the way patients get medical
information, but the way they interact with doctors.
Despite the wealth of public information and the good quality
of many Internet resources, Doctors are necessary, Berland
states. "But we are still not doing a great job at talking
with our patients."

HEALTH CARE is a two way process
www.who.int
www.cdc.gov
www.aafp.org
www.drugs.com
www.aap.org
www.rch.org
www.mayoclinic.com
www.drug-interactions.com
www.arizonacert.com
www.epocrates.com
www.penncert.com
www.sph.unc.eduhealthoutcomes/certs/index.htm
www.bmj.co.or.id
www.milissehat.web.id
www.kidshealth.org
www. breastfeeding.com
www.kellymom.com
Ask Doctor 3Qs:
What should
I do?
What is my
problem?
When should
I worry?
Diagnosis
Treatment Plan
Complications
Smart patients & Rx/, Lab
Please ask:
Active ingredient
Indications
Administration, dose
Risk of side effects
Contraindications


Please ask for
generics!
Purpose?
Why? Is it really important?
Consequences if not done?
Other alternative(s)?
Cost?
Accuracy?
Positive, confirmed that I
am sick?
If negative, I am not sick?
Etc etc

5. LESSON LEARNT & ACTION
To be treated you have to
be a very healthy person,
because apart from
disease you have also to
tolerate the medication
Moliere
Related to HARM:
So where is that point, and might we have
reached it already?
Most doctors believe medicine to be a force for good. Why
else would they have become doctors?
Yet while all know medicine's power to harm individual
patients and whole populations, presumably few would
agree with Ivan Illich that The medical establishment has
become a major threat to health.
Many might, however, accept the concept of the health
economist Alain Enthoven that increasing medical inputs will
at some point become counterproductive and produce
more harm than good.
Unsafe
Safe
A long long long long way to go
Phase 1: Awareness
- Denial
- Anger
- Acceptance
Phase 2:
How, what?
Phase 3:
Implementing safe
practices
Paradox
New
drugs
Antibiotic
resistance
SAVE THE PILL
FOR THE VERY ILL
TOO MUCH MEDICINE - CAMPAIGN
BMJ Helping doctors make better decision
Dr Godlee : "Like the evidence based medicine and quality
and safety movements of previous decades, combatting
excess is a contemporary manifestation of a much older
desire to avoid doing harm when we try to help or heal.
"Making such efforts even more necessary are the
growing concerns about escalating healthcare spending
and the threats to health from climate change. Winding
back unnecessary tests and treatments, unhelpful
labels and diagnoses wont only benefit those who
directly avoid harm, it can also help us create a more
sustainable future."

Evidence
Factors influencing
the use of research
evidence
TRANSLATING
LOST IN TRANSLATION !!
Practice
Severe
problem
Healthy,
mild
diseases
What can/should we DO?
OVERUSE, UNDERUSE, MISUSE of
medicine difficult to eliminate
In Relation to Rational Use of Medicine
Power balancing?
Ethical aspect
Respect for autonomy
Benefiscense, non malifiscense
J ustice
Competency
Transparency

J ust as patients depend on their physician,
physicians also depend on their patients
What do we need today?
Ethical Value & Action
Value

Conviction
Commitment
Decision

ACTION
WHO, Dept. Essential Drugs and Medicines Policy
WHY DO WE NEED EBM?
Save LIVES!
We want to do the right thing what is best for our patients

WHY USE EBM?
Daily need for information
Inadequacy of traditional sources of in formation
Disparity between our diagnostic skills & clin judgement vs
up to date knowledge and clinical performance
Develop skills for life long learning
Medicine is a rapidly changing field, dissemination - slow
WHO, Dept. Essential Drugs and Medicines Policy
translate the evidence
Stay up to date
Medical information changes constantly
Unlike bread, our knowledge does not become
visibly moldy or stale we just keep using it
Patient care is driven by the continual generation of
new evidence
We usually fail to get new information in a timely
manner
Up to date knowledge and clinical performance
deteriorate over time
THE SLIPPERY SLOPE
Better therapeutics
Less side effects
Saves money:
Patient,
Hospital,
Country
Ethics and Equity
WHY RUM ?

Protecting patients from :
- Over-treatment
- Under-treatment
- Miss-treatment
RUM ----
1985 to 2013 ..????
Making changes
awkward
Changes take practice
Feel uncomfortable doing
it?
It is OK, DO IT ANYWAY
Each patient represent a story .
Be a great physician. Understand the full story.
Make correct diagnosis.
Consult the patient in designing the treatment plans
that best fit the patient.