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Archive for February, 2008

The enigma of health

Posted in books, from the reading room, health, philosophy on February 5, 2008| 8 Comments »

Maybe, like me, you have a collection of “significant” books. By that, I mean books which had a big impact on the way you think, or the way you understand life. I’ve written about some of those books here already, but here’s another one which I read a few years ago. Hans-Georg Gadamer‘s “The Enigma of Health: The Art of Healing in a Scientific Age” is a collection of essays by this professor of hermeneutics (I know, I had to look it up in a dictionary too, but, trust me, this man had a brilliant mind!)

Gadamer died in 2002, and while I was visiting Tokyo, a copy of the Japan Times slid under my hotel room door early one morning, included an obituary about him. I’d never heard of him, but it’s amazing what you’ll read in the wee small hours in a foreign country when your body and your head are still half a day away in your home town! I was completely fascinated with what I read and his thinking about health really captured my imagination so I went online and ordered up “The Enigma of Health” from Amazon. By the time I got back home it was waiting for me. Let me share a few quotes with you. I wrote them down in my Moleskine (as I do!)

Although health is naturally the goal of the doctor’s activity, it is not actually ‘made’ by the doctor.

I make this point with every new patient I see. It’s the big unspoken truth about medical practice. Doctors’ treatments might reduce or remove a pathology, might even redress an inner imbalance, but they don’t cure – only the body does that. He says more about here –

Yet the goal of the art of medicine is to heal the patient and it is clear that healing does not lie within the jurisdiction of the doctor but rather of nature. Doctors know that they are only in a position to provide ancillary help to nature.

Franklin put it another way when he said “God heals and the doctor takes the fees”

I often ask medical students to tell me the answer to this – if a patient with a urinary tract infection gives a urine sample which grows bacteria which the lab shows are sensitive to a particular antibiotic and the patient is prescribed that antibiotic, what will the antibiotic do? The ones who don’t think carefully say the antibiotic will cure the infection. It won’t. It’ll kill the bugs. That’s it. The inflamed bladder wall, which might even be bleeding from the effects of the infection will be restored completely by the body’s repair processes. The healing is natural. The antibiotic only removes the offending bug to let the healing system do its job. This might seem like nit-picking, but it isn’t. It involves a profound change in thinking. Doctors aren’t gods. At best they assist healing and all healing is a natural process.

…the doctor’s power of persuasion as well as the trust and the co-operation of the patient constitute essential therapeutic factors which belong to a wholly different dimension than that of the physico-chemical influences of medications upon the organism or of ‘medical intervention’.

There are some who think that health and illness can be understood in purely physical terms and that treatments can be understood to work, or not work, on the basis of their physico-chemical effects. That’s a limited way of thinking. Healing involves more than that, and may not even involve any physico-chemical intervention at all. Those who think medicine can be reduced to a science (as opposed to a science and an art) rely on measurements of phenomena. Gadamer is brilliant about this –

….modern science has come to regard the results of such measuring procedures as the real facts which it must seek to order and collect. But the data provided in this way only reflect conventionally established criteria brought to the phenomena from without. They are always our own criteria which we impose on the thing we wish to measure.

I believe it was Max Planck who said “facts are what can be measured”. Well, reality cannot be reduced to facts. The tendency to reduce understanding to physical measurements is accompanied by a concept of health as some kind of product – an end point or state which can be known and measured. Gadamer argues instead –

…physicians do not simply create a product when they succeed in healing someone. Rather, health depends on many different factors and the final goal is not so much regaining health itself as enabling patients once again to enjoy the role they had previously fulfilled in their everyday lives.

This clear statement suggests to us that health is an experience and it’s an experience which in its detail will be different for every person depending on the characteristics and environments of their lives. Later in his essays Gadamer considers how far from being a measurable product, health is really what is experienced when illness is not present or goes away. This is the “enigma” of health – that we only know it by its absence. Consider the fingers of your right hand. Right now you’re not really aware of them. Trap them in a car door and then you instantly become aware of them. You get the idea?

This post could go on forever! I’ll stop, but suffice it to say this is a deeply thoughtful consideration of our concepts of health, illness and healing.

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The importance of the person in medicine

Posted in education, from the consulting room, from the reading room, health on February 4, 2008| 8 Comments »

Sometimes these days, with the dominant biomedical model of health and illness it can seem like people don’t actually matter. The individual stories of patients are dismissed as anecdotes and treatments are divided into one of two categories “proven” or “unproven” on the basis of statistical analyses of clinical trials (experiments on pre-selected groups of volunteers). The implication is that what works in health care is the intervention, be that a drug or a surgical procedure. Who the patient is, and who the doctor is, seems to be of secondary, or, sadly frequently, of no importance at all.

Yet, if you are ever unwell, I bet it matters to you who you consult and how they behave. I think we all want to consult a doctor who, frankly, gives a damn! I know I do. How many of us would seek a health care system based on dispensing machines which dole out drugs after you input your symptoms?

Amazingly, this idea of the importance of the person in medicine is having to be fought for. So, it was with great interest that I read a review of a book in the BMJ this week. The book is “When Doctors become Patients” by Robert Klitzman (ISBN 978 0 19 532767 0). The author is a psychiatrist who became depressed and was so shaken by his experience of becoming a patient that he set about interviewing other doctors who had become patients too.

Time and again Klitzman found that becoming a patient transformed the doctors’ views (and of practice) of medicine.

Non-specific complaints, side effects such as weight gain and fatigue, fear, humiliation, and spirituality acquired new significance. Struggling to adhere to burdensome schedules, they became less draconian about poor adherence to treatment. In presenting medical information, they became aware of the importance of framing the information sensitively.

I guess this is not a surprise. You’d expect experience to change your views. However, you’ll probably find it more than a little shocking that the doctors needed the illness experience to figure this stuff out. We’re clearly missing something in medical education.

The phrase that really hit me between the eyes though was this –

In choosing their own doctor, most interviewees preferred bedside manner over technical skill.

It’s what I’ve always felt personally. I’ve always felt that what’s really important is that you find a person who cares, listens and puts your interests at the heart of the consultation. I take the technical skill bit as kind of a given. ALL doctors should have the technical skills they need to do the job and the processes of continuing education, annual appraisal and the coming revalidation procedures of the General Medical Council are all designed to ensure that. But what about the human bit? What about the importance of the person? We need to make this case more clearly. Too often, the technical skills are attended to, and then we stop.

Finally, the BMJ reviewer concludes –

Klitzman, like Gawande and Groopman, is part of a contemporary group of reflective doctors who, through their writings, contribute to the less palpable but nevertheless crucial moral, social, and experiential dimensions of medicine.

We need more of this. Maybe we are building a body of knowledge and opinion but we’re sadly lacking in the areas of research into the “experiential dimensions of medicine” and in providing medical education which considers this as of equal importance to the knowledge of drugs, trials and the technical skills required to do surgical procedures.

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How we learn – teaching and training

Posted in creativity, education, from the reading room on February 2, 2008| 4 Comments »

Pick the Brain has a great post about teaching and learning. It’s called The Movie Director’s Guide to Effective Teaching. In it, Victor Stachura, the author refers to William Glasser’s theories. Well, this is new to me. I’ve never heard of William Glasser. If you have, what do you think about his ideas and his suggestions? There’s a William Glasser Institute and my little browsing there so far has interested me. I want to find out more. Victor Stachura highlights something he read about learning and teaching from studying William Glasser –

“We Learn . . .
10% of what we read
20% of what we hear
30% of what we see
50% of what we see and hear
70% of what we discuss
80% of what we experience
95% of what we teach others.”

I don’t know about you, but that seems intuitively correct to me. I might take issue with the actual figures used and I also think it doesn’t allow for the processing preferences highlighted from the work of things like the NLP approach which helps us to understand that we are different and some process auditory information better than others, some visual information, and yet others kinesthetic information. However, with that in brackets, the overall thrust of this seems right.

If you are involved in teaching this is an important observation and if you want to learn, it’s equally important. It certainly highlights the importance of what is known as active learning. Sitting attempting to learn passively by just listening or just watching something isn’t easy. But when you have something to read, something to see and to hear, and then you discuss it, you will learn so much more. The challenge beyond that I think is to experience and to teach. I don’t know if you can experience much in a classroom, can you? Don’t you need to get out and actually live what you’re learning? I certainly think that’s true of medical training. Can’t see how you become a good doctor without actually doing it! That last step of teaching so works for me! I find that almost every time I teach, not only in the preparation stage, but also in the delivery, I learn something new myself.

I ran a training day based around characters in Lord of the Rings last week and not only did it convince me that I’ve learned more about my subject than ever, but the feedback from the students was about the best I’ve ever had. The day involved film clips from the Lord of the Rings movies and various small and plenary discussion groups. It was active and interactive all day long.

If you teach, how much do you use movie clips? I use them a lot. I find that not only do they combine the auditory and visual stimulation we need, but they are great for getting discussion going and, fundamentally, they provide the group with an experience – usually something involving both thought and emotion.

To return to the blog post which has seeded this one – the main focus of the piece refers to the “primacy-recency” phenomenon – the finding that we remember the first and last things in a sequence better than the things in the middle. Victor Stachura recommends we deal with this in teaching not just by putting important information at the beginning and the end, but by breaking up the lecture every 15 minutes with some audience exercise, or discussion, to keep attention from waning. He points out that good movie directors know this and change the pace of the movie frequently to achieve a similar effect.

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The statins debate

Posted in health on February 1, 2008| 10 Comments »

Des Spence highlighted the rather selective way statistics are used to support promotion of drug treatments to prevent disease. In particular, he has focussed on the heavy promotion of statins to control cholesterol levels in the blood. Several doctors have written in to the BMJ in response to this article.

Malcolm Kendrick, who has written The Great Cholesterol Con, says (in referring to the statistic that to prevent one death a year you have to treat 700 people)

let us assume that you do gain one entire extra year of life for every 700 years of taking a statin. Then, clearly, if you treat for 700 years you will create one added life year.

Using this (overoptimistic) figure means that if you treated someone for 30 years you can expect to provide them with 30/700 added years of life. This is 15.64 days, or, a shade over two weeks.

In short, if a 50 year old man asked you how much longer he could expect to live if he took a statin for 30 years you can inform him “just over two weeks—max.”

(it’s also worth watching his exploration of what DOES cause heart disease – here it is……………it’s for a medical audience so is pretty technical!)

Peter Davies asks for inclusion of statistics of relevance to the patient who will actually be taking the medicine –

Any trial generates four summary numbers: relative risk reduction, absolute risk reduction, number needed to treat, and personal probability of benefit.

Each number is useful and gives some information, but no one number gives us the whole truth about the information. Using one figure on its own, particularly the relative risk reduction above all others, is very risky.

Each figure takes a different viewpoint on the evidence. The relative risk reduction is a public health (area wide) prediction.

The absolute risk reduction puts the starting risk back into the frame.

The number needed to treat measures the workload needed to achieve the relative risk reduction. It’s the beginning of health economics.

The personal probability of benefit answers the patient’s question, “What’s in this for me?”

Peter Davies has written an excellent piece in the studentBMJ about this problem with interpreting the value of “evidence”, with this excellent conclusion –

Acknowledging the various perspectives on data will lead us away from simple statements such as “this works” and “the evidence shows” towards more specific statements of what works for whom and when. It leads us away from guidelines and back to intelligent negotiation, to distinguish treatment of an established disease from treatment for reducing the risk of a disease, whether as primary or secondary prevention. The gradual reclassification of risk factors as diseases, “risk factoritis,” has lead to confusion over applying evidence derived from populations to individual patients who may not need or want our help.

The parties involved all need to admit that they know part of the truth, but never the whole truth—whether about the evidence, the patient, or the disease. The next time anyone tells you that “the evidence shows that this treatment works,” ask, “From what perspective does this seem to work?” If they do not understand your question, then they do not fully understand the evidence.

It’s good to see this discussion in a mainstream medical journal. There are some hard questions about the direction of medicine which need to be asked. The reliance on medication for a “healthier” life is one of them.

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