Archive for September, 2007

A report in the UK has looked at the issue of patient engagement – how involved people are in the decisions about their health care.

The Picker Institute pointed out that in every national poll they looked at, between a third and a half of patients said they were not involved in decisions about their care and treatment as much as they would like.

The studies said patients were particularly keen to have more choice of medication, the hospitals they were treated in and the doctors they were seen by.

Picker Institute chief executive Angela Coulter said: “The rhetoric of patient-centeredness has a hollow core.”

I think the tide is turning. We’re seeing the decline of the “trust me I’m a doctor” approach to medicine. This is a huge challenge to many doctors. How can they retain patients’ trust yet let go of power? Increasingly patients want to be informed about health care options and involved in making the decisions about their own care – choosing (with the doctor’s expert advice and support) the treatments they wish to receive.

But this is only a small part of engagement. As well as sharing power, there needs to be more sharing of responsibility. Too many people feel that they are victims – that disease just happens to them – and that treatments are also something to be done to them. Understanding how to engage with illness, understanding how to be an active player in their own recovery and health, cannot happen without this shift in power.

I look forward to a more engaged practice of health care, which really is patient-centred.

What’s your experience? Are you engaged in your own health care? Does your doctor share power with you?

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Miracle cures?

There is a very common, very sloppy (or deliberate) statement made in medical research articles. Read this –

The landmark randomised trial, the hypertension detection and follow-up programme, showed that a “stepped care” approach incorporating regular review, adherence reminders to patients, and an explicit programme of treatment intensification produces substantial falls in blood pressure and reduces all cause mortality

This is from an otherwise excellent article about how GPs are paid for interventions in Primary Care, published in last week’s BMJ ( if you want the full reference it’s  – BMJ  2007;335:542-544 (15 September), doi:10.1136/bmj.39259.400069.AD)

The phrase I really object to is the last one – the claim that a particular treatment “reduces all cause mortality”. Do the authors really mean that? No. What they mean is that in this particular trial the number of deaths in the treatment group was less than expected over the course of the trial – trials don’t last very long – a few weeks, to at most a few years (exceptionally). What they do NOT mean (surely) is that the drug in question stops people dying – from all causes, forever. The question that is left unasked is what kind of lives, and then, what kind of deaths, do the people have who took this treatment? Because everyone dies from something. No drug “reduces all cause mortality” – not when you take a life-time perspective rather than a short period of a life.

I think it’s time we actually researched this issue – what is the lifetime experience of people who take part in interventionist preventitive treatments? What illnesses do they get? And what do they die from?

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The BMJ carries a weekly column about literary classics and the piece this week by Ross Camidge considers Mary Shelley’s Frankenstein. If you’ve never read the book, you’ve missed something. As Ross Camidge points out the movies over the years have distorted the serious and fascinating consideration of life which Mary Shelley’s book presents. (As well as the original book I highly recommend the biopic about James Whale, who made the original Frankenstein movies – “Gods and Monsters” – a disturbing but very insightful tale)

Frankenstein (the book) is subtitled “The Modern Prometheus”. Don’t know if you remember about Prometheus but he is the one who stole fire from the Gods and took it to Earth to create Life out of the soil. Frankenstein is the creator’s name (it’s not the “monster’s”) and his intention was a good one, but how he handles his creation is one of the morals of the story. Here’s the last paragraph from the BMJ column –

Frankenstein’s outright rejection of his creation, denying it even a name, twisted its basic goodness into hateful barbarity. This is something to think about when treatments go wrong and patients or relatives look to us for answers and support. Or when trainees are heading off the rails and need more intensive mentoring. Frankenstein teaches us that to get the best possible outcome from anything that has involved our creative input requires elements of responsible care, love, and nurturing. And if we do this we will not create monsters.

Oh, that’s so spot on! Let’s bring that back into the agenda when we consider health care and the education and training of health care professionals –  “responsible care, love, and nurturing”

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Dying for drugs

One of the doctors who trained me told me “If you send your patient to a man with a knife he’ll use it”. The advice was about referring to surgeons. He meant if I sent a patient to a surgeon it was highly likely that the patient would end up with some kind of operation, so I should ask myself if I thought that possibility was in the best interests of the patient. All operations carry risks after all.

It was much later when I realised that the same kind of advice applies to specialists who specialise in the prescription of drugs – physicians. Let’s face it, drugs carry risks too.

In the BMJ this week, we are reminded of just how dangerous they are –

The number of reported serious adverse events from drug treatment more than doubled in the United States from 1998 to 2005, rising from 34 966 to 89 842, says a new study.

Almost 90,000 serious bad reactions to drug treatments in the US alone in 2005!

Over the same period the number of deaths relating to drugs nearly tripled, from 5519 to 15 107, show data from the US Food and Drug Administration’s adverse event reporting system, which collects all reports of adverse events submitted voluntarily to the agency either directly or through drug manufacturers (Archives of Internal Medicine 2007;167:1752-9).

15,000 deaths related to prescribed drugs in one country in one year!

I work in Glasgow Homeopathic Hospital and I know that for some people homeopathy is a controversial method but in 250 years do you know how many people have died from the effects of a homeopathic drug? NONE. ZERO. NIL. Nope, not a single one. And yet, all the UK NHS Homeopathic Hospitals have shown that they typically make a difference for two thirds of the patients who attend their clinics – a difference the patients themselves rate as significant (ie changes that make a difference to daily life).

What happened to “first do no harm”? Now don’t get me wrong, there are some highly effective drugs which can, in certain cases, be life-saving. There are many people who live better and longer lives because of the drugs they take. But drugs are dangerous. They should be used with caution. And we should never rely solely on drugs. We need to pay attention to interventions which facilitate recovery from illness and which foster resilience. We need to find ways to reduce the lifetime load of chemicals patients with chronic illnesses end up taking.

Finally, we need to investigate and learn from every single death from medication. To die from a treatment is a tragedy.

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ginza fashion

ginza fashion, originally uploaded by bobsee.

What about clothes? How much do you think you a) express yourself with the clothes you wear and b) assess what other people are like from the clothes they wear?
In Tokyo at the moment there’s a big fashion in young women for wearing short shorts and black socks that stop about an inch or two above the knee. I haven’t seen anyone dressed like that in Scotland so it was very striking at first, but after a day or two there were so many dressed that way that it rapidly became unremarkable.
How much do we manage to express our uniqueness in the way we dress and how much do we express our “badges” of belonging?

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Walking through Ginza in Tokyo the other evening I spotted this building with the most peculiar windows

ginza building

ginza window

Ever seen windows like this?

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When less is more

One of the most interesting points made by Gerd Gigerenzer in his “Gut Feelings” is that in order to understand what has happened it is often useful to consider as much of the information you can collect as possible, but in order to assess something right now, or to make a prediction about the future, you can have too much information and it either confuses you or bogs you down in analyses.

One fascinating example he gives is of a competition to pick stocks and shares. Asked to pick from a given a list of 50 companies in which to invest an imaginary few thousand dollars, the experts and knowledgeable amateurs did a lot of research into the companies then constructed their portfolios in the light of this. Gigerenzer and his colleague went out into the street and asked a random 100 passers-by which companies in the list they recognised. They then made a portfolio of the 10 most frequently recognised companies and this is the portfolio which won hands down, beating ALL the experts.

He gives other examples of this phenomenon. Basically it seems that if we know absolutely nothing about a certain subject then predictions we make will be right no more often than they would by chance. If we know a LOT then our predictions are not great either. However, if we know just a bit, our predictions are very good.

He says this phenomenon is about using intuition rather than a rational analytic consideration of a problem and points out that this intuitive strategy works best in circumstances where uncertainty is high.

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in the sky of grey and pink, originally uploaded by bobsee.

Look at these fabulous clouds – taken from above through the window of the plane from Paris to Edinburgh this morning. Reminded me of that photo I took of Ben Ledi when the sky was grey and pink.

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Dawn over CDG, originally uploaded by bobsee.

Just back this morning from a trip to Tokyo and I took this shot out of the plane window at Charles De Gaulle airport at dawn today

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Gut Feelings

The relationship between intuition and reasoning has been cropping up all over the place for me recently.

I just read Gut Feelings by Gerd Gigerenzer (ISBN 978-0-7139-9751-4) and he gives one of the most cogent models of intuition I’ve ever read. He outlines what he calls “evolved capacities” – these are human qualities or characteristics which have evolved either genetically or culturally. They are language, recognition memory, object tracking, imitation and feelings like love. He makes a good case for the uniqueness of these capacities in human beings (claiming that neither other animals nor computer-based Artificial Intelligence have or ever will have them).

His model of intuition (or “gut feelings”) is that these evolved capacities interact with environmental structures around the individual and are processed through simple rules of thumb to produce what we recognise as gut feelings. I like this model. It fits well with discoveries in evolutionary biology, neuroscience and complexity science. I’m sure others will identify other qualities which fit with his idea of “evolved capacities” and I think the adaptive nature of rules of thumb applied appropriately in different contexts really works.

There’s no doubt that rationalism and logic are only two of the tools we use to understand things and I think Gigerenzer’s model of intuition highlights a major other set of tools which we use (maybe even more frequently than we do reasoning and logic). I also think it’s good to take the mysticism out of intuition and to distinguish it from simple guess work.

In this way of thinking intuition can be both developed and taught and I find that pretty exciting.

One of the key points he makes is that intuitive processes are especially helpful when dealing with situations which are very uncertain – prediction for example. This highlights a role for intuition in everything from health care to investment decisions.

I’ve long been aware that the practice of acute medicine in particular requires rapid intuitive skill – an over-reliance on data collection and analysis in these situations can be fatal. Right off the top of my head I can recall a child with meningococcal meningitis, a young farmer in rural Ayrshire with malaria and man with toothache who turned out to be having a heart attack. In all three of these cases I’m sure it was instant (and I do mean instant!) decision making that saved their lives. In each case the diagnoses were unusual for a general practitioner and none of them would have survived had I waited to do some tests before acting. I’m sure all doctors have had similar experiences – those instants where you “just know” that this is a serious life-threatening situation despite the lack of detailed evidence!

Uncertainty is a fundamental characteristic of  our lives and intuition is one of the key tools we need to deal with it.

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