I’ve just read Kieran Sweeney’s “Complexity in Primary Care” (ISBN – 1-85775-724-6) and found it both stimulating and agreeable. I am SO glad that books like this are being published. I’ve read both of his previous books – “Complexity in Healthcare” and “The Human Effect in Medicine”. He’s one of those authors who is bringing the fairly new ideas of complexity science to the attention of clinicians, I think with the intention of trying to redress the balance a bit. Medicine has become very reductionist and limited in its approach and whilst this has paid off in dealing with acute diseases it hasn’t helped in dealing with chronic disease OR in the wider desire to maintain health. In addition to this, the modern thinking he scopes out in these books really has a chance of helping us to reclaim a much more human-centred practice of medicine.
Here’s a couple of quotes from the book which really struck me –
The requirements of medical research are limited by insisting that an answer should be numeric, otherwise it is not a real answer.
That reminded me of what I just posted the other day there about the value of patients words over numbers. It also reminded me of this – I once heard a dentist describe his experience of replacing a retired colleague in a specialist facial pain clinic. He didn’t know that his predecessor had devised a scoring system for pain and had trained all his patients to report a figure as a way of telling him how much pain they were experiencing. Apparently, this man would become quite frustrated with patients who tried to talk about themselves and would even say “Stop. Not another word! I want the next thing to come out of your mouth to be a number. Nothing else! On a scale of 0 to 20 how has your pain been?” The dentist who was telling me this story was quite baffled when he took over the clinic and saw one patient after another come in for follow-up consultations and just say “17” or “12” or “9”, then refuse to say another word. They were too frightened! He didn’t find their answers very useful.
It seems that a lot of what I’m reading just now is challenging me to think about non-rational thought, intuition, gut-feelings, whatever you call that way of understanding the world. In particular I’m reading Solomon’s “Joy of Philosophy” and loving it – he argues this point. See what Sweeney has to say about it –
At the theoretical level chaos and complexity can help us to synthesise evidence and intuition. They dignify the notion of intuition, and re-establish the importance of experience and wisdom, seeing them as emergent properties of the thousands of iterative, recursive interactions in consultations.
Oh, I like that! He’s showing that from basic principles of complexity science we can understand intuition is a way of knowing which arises through our interactions with each other. Thank goodness someone is making a call for us to develop a form of medicine which is greater than the sterile world of “Evidence Based Medicine” with its mind-numbing protocols and guidelines.
Heroes Not Zombies 
[…] 7th, 2007 by bobleckridge In Kieran Sweeney’s “Complexity in Primary Care” he quotes from Toon’s “What is Good General Practice?” paper – The […]
Terrific! Thank you for this post. I am becoming quite the fan.
We can recognize intuition. We can tune into it, but we can’t put in on the laboratory bench and measure it. Or, if people are trying to do that, then they are missing the point. Intuition, I believe intuition resists analysis. Louis Armstrong said (of jazz) If you gotta ask, then you’ll never know.
Our intelligence not just in the brain, it’s in the whole body. I love the quote of Sir Ken Robinson’s that we are educated from the neck up and slightly to one side.
My experience with Stanley Keleman’s somatic formative method gives me an embodied experience that is deeply personal. It lets me inhabit my personal world. This too resists the strictures of logical positivism.
We humans are much more, more than we’ll ever know.
This struck me as a rather worrying statement, so I thought I’d ask you to clarify it: are you suggesting there is an greater degree of evidence and empirical research that can be done to make medicine more efficacious, or are you suggesting that Evidence Based Medicine is somehow not up to the task or analysing certain medicines and treatments?
The latter suggestion would be the worrying one for me; if we don’t test medicines with evidence, how else would you suggest we test them??
OK, the short answer would be to recommend you read this book by Sweeney – or at least simply his chapter on EBM – it’s about the most succinct appraisal of the EBM movement I’ve read. However, to say that would probably feel like a cop-out. So let me have a go at some clarification.
Well, EBM, as promoted and practised, is, I think, great for making better prescribing decisions about drugs – for patients with only one disease who have illnesses which have clear diagnoses. My reservations about the EBM are two-fold – first, about what is accepted as “evidence” and second, about how it is promoted as the “only truth” (as if there is no other way to make a decision in good medical practice).
The thing about the “Evidence” is that EBM says there is a hierarchy of evidence which esteems meta-analyses of RCTs at the top, and places patients and clinicians experience at the bottom. Well, RCTs are great for testing pharmacological compounds but not so great for surgery, psychotherapy or other non-drug interventions. So promoting RCT evidence to the highest tends to bias the choice of interventions towards drugs (sometimes that’s a good thing, sometimes, not).
The thing about what I think is the MISUSE of EBM is the latter – when it is promoted as the ONLY way to make a decision about a therapy or a service. If you read Sackett’s original work you’ll see he clearly recommends looking for this “quality” evidence but then considering that in the context of this individual patient, including this individual’s values and choices. When EBM is promoted as “we know best cos we’ve read the trials”, it becomes an arrogance which places the doctor’s knowledge over the subjective experience of the individual patient he or she is trying to help.
There are much bigger issues to consider here too. In Primary Care MOST patients present with a mixture of illnesses which are not amenable today to being captured with a clear diagnostic label and/or with co-morbidity. We are using trial evidence as THE evidence but trial evidence is from patients with CLEAR diagnoses and NO co-morbidity.
What I am arguing for is patient-centredness – THIS patient is the MOST important patient to me today and I have to interpret “evidence” in the light of their context and subjective experience of reality. AND I’m arguing for the importance of considering what CAN’T be measured in patients AS WELL AS what can be.
Oh dear, I could go on!! Does that help?
What do you think? Please let me know. I’m keen to discuss this with others who are struggling with the day to day reality of individuals’ suffering
Hi bobleckridge, you are far better versed in medicine and healthcare than myself, so thanks for listening to my concerns and explaining your position.
I actually agree with most of what you’ve said: I suppose I don’t believe that EBM is the ONLY way to make a medical decision, but I would still maintain that it is the MOST important way. Presentation varies by patient, and obviously subjective experience varies from patient to patient, but we all know that subjective experiences can be biased; even the patient can have distorted experiences. In a toss up between a patient’s experience of reality and what objective evidence indicates, I would prefer the EBM. However, it would be wrong to disregard the patient’s experience as unimportant, which perhaps does happen because many believe that EBM cannot be wrong, or that all other forms of knowledge (if that’s the word) must submit to it.
Perhaps the medical community doesn’t place enough importance on the patient as a personal being with experiences, but rather as another entity to be given product X to treat condition Y. I think you explained yourself very well, and I agree, when you said:
I hope I’ve understood you correctly?
Thankyou for engaging with this so positively. Yes, you’ve understood me exactly correctly.
But see where you say you’d prefer EBM to the patient’s experience of reality? What do you think about pain? As best I can understand it only the person who has the pain can judge whether or not treatment X has made a difference. All the RCTs in the world “proving” the “superiority” of treatment X over Y don’t matter a tuppeny damn in comparison. The EBM method is a statistical method which will, at best, tell me about probabilities. It’s the patient in front of me whose experience of the pain (for example) will (or should) ultimately determine my decision about continuing or discontinuing their treatment.
I chose pain because of its exclusive subjective reality – there is no other way to experience pain! But the same argument applies to depression, anxiety, itch, breathlessness, tiredness……….etc
This is why I place the individual’s NARRATIVE in the highest place when engaged in clinical practice. If you come to me with an illness I want to understand not only what pathology might exist in you that may be the source of your symptoms, I want to know who YOU are – in all that messy, biased, subjective experience of reality. Because the consultation is not about ME, its about YOU.