No matter how often I see this, it fills me with wonder. How great to be able to slide back the consulting room glass door, step outside, and capture this abundance of buds and early blossoms. These simple pleasures make it great to be alive.
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If you suffered from a heart attack or a stroke you’d probably be interested in trying to reduce your chances of a second one. So here is something which apparently achieves the following results –
35 per cent reduction in risk for cardiovascular death
14 per cent reduction in risk for new heart attacks
28 per cent reduction in risk for congestive heart failure
19 per cent reduction in risk for stroke
Pretty impressive huh?
So what is this wonderful treatment?
“A heart-healthy diet rich in fruits, vegetables and fish” , according to a big study conducted by researchers at McMaster University.
In the report about the study was a little passing comment – “At times, patients don’t think they need to follow a healthy diet since their medications have already lowered their blood pressure and cholesterol — that is wrong,” said Mahshid Dehghan, the study’s lead author and nutritionist at McMaster University’s Population Health Research Institute”
That is actually such an important point. How many people are suckered into the belief that as long as they take drugs they can forget about trying to live a healthier life?
I’ve always taken great pleasure in making a diagnosis. But for me, I go back to the roots of the word. A diagnosis is an understanding. It thrills and delights me to be able to understand people. I think that’s the beginning of the journey to health, because as I concentrate on trying to understand someone, they usually increase their understanding of their condition and even of themselves. That’s powerful and I think, as we are all meaning seeking creatures, it’s a key goal of most consultations – to make sense of our lives (through the creation of our stories) But I reject the reduction of diagnosis to labelling or categorising. For me, that’s just not good enough. I want to know more than the name of a disease. I want to know a person.
Iona Heath writes eloquently about diagnosis in this week’s BMJ
Beyond the technical expertise of those in the craft specialties, the key skill of all doctors is diagnosis. However, diagnosis itself poses profound problems of scope and usefulness. Every experienced clinician is fully aware that no two people ever experience the same diagnosed disease in exactly the same way, and yet the taxonomies of diagnosis and the international classifications that underpin them ignore this underlying truth. The diagnoses tabulated in this way are theoretical abstractions, but we are inclined to give them a level of credence and reality that tends to exceed that granted to the patients so labelled. In this way, our diagnoses begin to condone structural violence and to excuse social injustice
Good diagnosis is an individualising process, not a generalising one.
Ever since I was a little boy I’ve loved to look up at the sky on a clear night and lose myself in the wonder of the fact that the light from every single star has taken years and years to reach the Earth. How incredible that the tiny spots of light landing on the backs of my eyes left those stars millions of years ago!
Its astonishing to think that as you look up at the night sky you are looking at the past, the distant past. And how astonishing to realise now that our latest astronomical instruments let us see back billions of years, almost to the Big Bang itself. But not quite.
I recently came across the phrase “Cosmic Horizon”. The Cosmic Horizon is the furthest visible point in the Universe. In every direction as we scan the skies, we can detect signals from far away stars right up to a point of darkness which is so far away, so far distant in the past, that we can’t see anything any longer. This is the horizon. It’s like the horizon we see where the sky meets the earth or the sea, but much, much further away.
In the book, “The View from The Centre of The Universe”, Joel Primak and Nancy Abrams, building on this idea that the Cosmic Horizon is a limit in the timescale we can know, propose that we, the human race, need to develop our “Responsibility Horizon”.
This is a fascinating idea. Think about it. How far does you current “Responsibility Horizon” extend? One generation, maybe two? When you make decisions, do you consider the impact of those decisions on the lives of your children, or your grandchildren? You might. If you have children or grandchildren you might be concerned about the kind of world we are creating now for them to inhabit in the years ahead. But let’s stretch that beyond two generations. How far ahead do you want your Resonsibility Horizon to reach? And if it’s three or four, or more, generations, how will that influence the choices you make today?
I use a three phase cycle when teaching medical students and doctors.
Phase one is the story.
Phase two, making sense of the story.
Phase three, a therapeutic action.
All doctors have been trained to start with the patient’s story. Sounds simple, and at one level it is, but what makes it complicated is that in every story there is an author and a reader. The patient is the author, and the doctor is a reader. But neither of these roles exist in isolation and the consultation in this phase is a process of co-creation. Both the patient and the doctor bring their stories into the room and, together, they co-author a new story.
Most of these narratives are very, very short stories. Typically less than ten minutes. I remember being very struck by a study which measured how long into a consultation before the doctor first interrupts the patient’s story – 18 seconds. In such short consultations the doctor is seeking to focus and direct the story right from the outset. He or she will decide which story lines to close off, and which to open up. The goal is to quickly move on to phases two and three.
What sense can I make of this patient’s story? Another way to think of this making sense phase is to see that it is about achieving an understanding. The doctor is trying to understand the patient, and the patient is trying to understand their experience. In fact the declared aim of medical undergraduate education is to teach doctors how to make a diagnosis (diagnosis means an understanding). Sadly, the biophysical model and short consultation approach to medicine means that diagnosis is reduced to discovering the presence or absence of a lesion. It’s not about understanding a person in the context of their life, nor about understanding their “illness” in a whole of life context.
The reduction of the understanding phase to the declaration of a clinical label which is then called a diagnosis sets the limits of the third phase – treatment.
The therapeutic interventions are intended to reduce or contain the diagnosed lesions. If no lesions are found, the intention becomes one of reducing the symptoms.
At every stage of this cycle there is a narrowing of vision, which reduces the story to a data set which will be judged as either normal or abnormal. Treatment is then either a surgical procedure or the prescription of drugs to try to alter the data.
What’s the alternative?
Broadening the focus at all stages.
Expand the story from a biophysical one to at least a biopsychosocial one and a story of a person replaces the story of a disorder.
Expand understanding from diagnosis of a lesion to understanding the emergence of an illness in the context of an individual’s life and a person can make sense of their experience.
Expand the interventions on offer beyond surgery and drugs to methods which increase vitality and resilience and a person can experience greater health.
Recommended reading -
Read Arthur Frank’s The Wounded Healer, Kleinman’s Illness Narratives or Cassell’s The Healer’s Art, to better understand the importance of narrative in the shift from biophysical to biopsychosocial.
Read Balint’s The Doctor, the patient and his Illness, Leader and Corfield’s Why do People Get Ill? Or Broom’s Meaning-full Disease to better understand the shift from a disease to an illness agenda.
Read Dan Siegel’s Mindsight, Doc Childre’s The Heartmath Solution or David Servan-Schreiber’s Healing without Freud or Prozac to understand the potential for interventions which don’t involve surgery or drugs.
In Lynne McTaggart’s The Bond she has a chapter entitled “Taking Turns” which describes multiple experiments designed to test the way people use either competitive or collaborative strategies.
One of the most well known of such experiments is “The Prisoners’ Dilemma” (google it if you want the details). Another one, which is also fascinating, is “The Ultimatum Game” where one player receives a sum of money. They offer the other player a share. If the other player accepts the offer, both keep the money. If the player turns down the offer, both leave with nothing.
In both these games a strategy of collaboration wins. In fact using computer modelling researchers were able to devise different game strategies. The one which succeeds over all other strategies is “tit for tat” – start with a generous offer, then follow the other player’s offers. If they make a low offer, punish them with a low offer back in the next round. If they offer a high share, then do likewise next time.
Other experiments include an imagined couple with different interests who are trying to decide where to go on a night out – the strategy which wins when the game is played through several rounds is “taking turns” – partner A’s choice is agreed to this time, and partner B’s choice will then be agreed next time.
What’s interesting about allow these experiments is that collaboration wins out every time – not competitiveness.
The other kind of experiment she describes involves groups which all play by certain rules – everyone plays fair until a player is introduced who has been primed to grab all the biggest shares for himself ignoring the rules. What happens then is that the group totally breaks down with the initial collaboration strategies getting blown away with an every man for himself one.
These latter experiments show that groups naturally prefer collaboration over competition except when there is obvious unfairness at which point social cohesion and collaboration is lost.
That’s such an important lesson for us as we become aware of the grabs made by the 1%, and the widening of the gap between the lowest and the highest paid in society. This socio-economic structure is just not going to last……
We live with a view of ourselves as separate entities, made up of tiny, distinct, independent parts. This idea, this kind of atomism, has been around for centuries.
Now, however, we’re coming to understand that reality isn’t like that.
Lynne McTaggart writes in “The Bond”
The universe contains an indeterminate number of vibrating packets of energy that constantly pass energy back and forth as if in an endless game of basketball with a quantum sea of light. Indeed they aren’t even there all the time, but are constantly popping in and out of existence, making a brief appearance before disappearing back into the underlying energy field.
This is our emerging model of reality, one where there are no “things”, there is no “material” or “substance” distinct from energy. One where everything is constantly changing and nothing is separate.
Thomas Berry writes
We live immersed in a sea of energy beyond all comprehension. But this energy, in an ultimate sense, is ours not by domination but by invocation.
What a lovely phrase. This atomism has led us to believe that we are not only separate from each other but from Nature itself, and that has led to an unhealthy relationship with the Earth – one where we’ve been believing we can dominate and control. But we can’t. There is no separateness.
It seems like there’s one story after another at the moment about vulnerable old people being neglected in hospitals, “care homes” and even in their own homes where home “carers” are failing to provide the “minimum standards of care” – even, according the most recent reports, to the extent that their are breaches of basic human rights.
It makes you wonder about the word “care”.
Within the health service and the “care” industry there’s been an increase in setting standards, developing procedures to record activities and the government’s response to this latest report is to talk of strengthening the inspection systems.
Is this the answer? To set higher “standards”, and to ratchet up the monitoring and inspection processes?
I don’t think so. It doesn’t seem to be enough. The missing link, is, I believe, a prioritisation of people.
What does it mean to be human? If we reduce a human being in any way, we start to lose the very essence of being human. A human being can neither be reduced to an object to be acted on, nor a means of carrying out procedure without losing something. Every human being is unique and lives constantly with a subjective experience of reality. If we forget that we start to act towards each other as if others are objects.
What we need is to reclaim the values – that the most important thing is to care – to feel empathy towards, compassion towards the people – both the people in need of care, and those delivering it. We need to treat people as whole people, not as tasks to be carried out or completed.