Heroes Not Zombies

…..same principle I guess. Without considering the individual and unique contexts of a person’s life we can neither understand their illness, nor help them find the best treatment and support. Iona Heath, who writes in the BMJ tackles the dumbing down of medicine in another article this week

We are witnessing a degradation of knowledge, which results from its bureaucratic application to whole populations. Too often, evidence from clinical trials is being shamelessly extrapolated across time, across population subgroup, and across condition. Again and again, efforts are concentrated on crude process measures, while clinical outcomes that are genuinely significant for patients because they reduce or delay suffering or prolong life are ignored. Thirdly, the present state of clinical evidence systematically neglects the reporting of harms

The point she is making is that we are abusing research findings which are conducted on specific groups of people by extrapolating the findings and conclusions and applying them to hugely diverse and significantly different groups of patients. The more we generalise, the poorer our understanding and effectiveness. She argues strongly for not applying the findings of the effects of a treatment on young people, to old people, for example. This is because of two main problems – first the setting of outcomes by the researchers (outcomes which might be important to the group under study, but not the most important to another group) and secondly because of a huge under-reporting of harms of a treatment.

As more and more treatments are directed at an intended long term outcome, the older patient is less likely than the younger one to have a chance of the intended benefit. However, as harms start straight away with treatments, the older patient is more likely to experience harm than benefit than the younger one. In addition, because of other body systems already failing, the elderly patient is more susceptible to harms from drugs than the younger patients.

And that’s just the consideration of age. What about other factors in other contexts which make a substantial difference? Sex, the presence of other diseases (‘co-morbidity’), and economic, social, cultural and psychological factors?

Context is all important in chronic disease especially. Here’s why…..

In acute disease, as we see on the far left, the green circle represents the pattern of symptoms consistent with the disease, and pretty much determines the whole picture. Most patients who are rushed into hospital have obvious patterns of disease. As time passes however we see that the green circle becomes a much smaller subset of the overall symptoms. This is because as the years pass, the individual brings more and more of themselves and their unique contexts into the overall picture. If we only aim at the disease, we miss helping most chronically ill patients.