Archive for June, 2008

Lord Darzi announced his proposals for changes in the NHS in England today. One of the points particularly grabbed my attention – the emphasis on the quality of health care. About time I reckon. We’re still in the midst of a target driven quantities focused health service. Too much emphasis on markers set by managers rather than patients. But hang on, I thought, it’s all very well to talk about quality but what will it actually mean? How do they intend to assess and monitor quality in health care? Couldn’t find the detail in any of the news reports so I went to the Department of Health site and downloaded the full report.

What I found about quality surprised me. I am impressed! They intend to assess three areas of healthcare quality –

1. Patient Safety. I’m glad to see this in the pole position. “First do no harm” is a centuries old piece of medical advice. Too often ignored I feel. They will assess cleanliness of health care environments, errors in prescribing and rates of healthcare associated infections. I’d like to see them add something about ADRs (Adverse Drug Reactions) and rates of surgical complications. Maybe that’ll come some time.

2. Patient Experience. Compassion, dignity and respect are to be assessed by questionnaires. There are other aspects which could be assessed (patient empowerment for example) but this is a good start.

3. Effectiveness of Care. This is the MOST interesting area. Not only will “clinical measures” be considered, but, very importantly, “patient measures”. Here’s the buzz acronym – PROMs – it stands for “Patient Reported Outcome Measures”. This is a great improvement. I know, you might find this amazing. The BIG breakthrough here is to ask patients not only what has been their experience of healthcare but what outcomes really matter to them.

Are there any particular elements of “quality” in health care do you think should be considered?

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There’s a certain professor in England who is conducting a major campaign (with the help of a few friends) against the whole of complementary and alternative medicine in general and homeopathy in particular. His name is Edzard Ernst and it seems the thrust of his campaign is to tell us that he is an expert so we should trust what he has to say and distrust anyone who disagrees with him.

I could give you many examples of the kinds of statements he makes which I disagree with but let me just focus on one he recently made in “Health Service Journal” because I think this is really the key issue of the debate.

People must not confuse the perceived benefits of so-called alternative medicine with the medical facts.

……..consumers trying alternative therapies tend to be well educated and often perceive these treatments to be effective. Perception must, however, not be equated with fact.

What are “perceived benefits”? Well, they are when a patient says they feel better. And what’s a “medical fact”? That’s a bit harder to pin down. Generally a “fact” refers to something objective. In medicine, that tends to mean something which can be measured, something physical. That’s not the only way the term “medical fact” is used however. It’s also used when someone is actually referring to a probability. Experiments in medicine (known as clinical trials) produce results which are frequently presented as “facts”. However, they are actually statistical probabilities. It’s very odd to hear people divide treatments into two categories – proven and unproven (even more odd to describe treatments as either proven or disproven). The world just doesn’t fit into two simple boxes so easily!

When a patient comes to see me complaining of pain, or fatigue, or nausea, or dizziness, or breathlessness, or any of a whole range of symptoms, they are describing their personal, subjective experience. I cannot, no matter how hard I try, know another person’s pain. So, after receiving treatment, when the patient returns to say how he or she is now, then, when they say they have less pain, they have less pain. When they say they are less fatigued, they have less fatigue. When they say they have less nausea, they have less nausea. There is no way I can tell another person I know better than they do, what they are experiencing.

Some of these patients also have objective signs of disease (but not all of them do). Those who have objective signs of disease demonstrate a non-linear relationship between those signs and their symptoms. There is NO direct one-to-one, linear relationship between, say, pain, and the size of a lesion. The amount of pain may vary with the size of the lesion, but it may not. To tell a patient that you know better than they do whether or not they are improving because only you can measurement the difference is absurd. It’s even worse with the many, many patients whose symptoms are NOT related to lesions at all (those whose tests return only “normal” readings). How do you tell them that they are not really getting better when they say that they are? Which “medical facts” are you relying on?

Having dismissed patients’ “perceptions” of improvement, Ernst and others then go on to say that even if the patient really [according to the expert] is getting better, then it is most likely to either have happened anyway (without treatment), or be due to placebo. Actually, that is a problem for every single instance of treatment. It is impossible to distinguish, in an individual, whether or not an improvement would have happened anyway (self-healing), or is due to placebo (self-healing), or is due to specific effects of the treatment (which in the case of most holistic treatments is claimed to be due to stimulation of self-healing).

I disagree with Professor Ernst. I think that for every single patient I treat, their inner, personal, unique, individual, subjective experience should never be dismissed.

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I looked out the window tonight and saw the sun spreading its rays across the sky and the Earth from behind some clouds. It often looks like this here. It’s beautiful. Every time.


Along to the north west a bit, where the rays were not so bright, there were such lovely colours and shades. A real work of art! An inspiration!

textures of land and light

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Oh sometimes somebody just does something simple but original with the internet.

I LOVE this video.

This is one of those videos to watch when you want to smile. It’s heart-warming and just plain JOYOUS

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I don’t think you can understand anything unless you see it in its’ context. The tricky thing about that is that everything exists in multiple contexts, so depending on the context which you choose to consider (the perspective you take), whatever it is you are considering can be understood in different ways. I like that. It means you can never FULLY know ALL there is to know about anyone.

During a consultation with a patient I think it’s important to consider several contexts. I drew myself a simple diagram to illustrate this – I’ve described it in the post about the “Human Spectrometer“.

Today I came across a great flash animation which really makes you think about how scaling up or down totally changes the relevant contexts. Try it out. It’s interactive, informative and fun.

It reminded me of the scale of ten project where a series of images are presented, each one being a magnification ten times greater than the previous one. Here’s one version of that from youtube …….

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Station poem

My post about the blackbird spotted from the delayed train prompted my friend, the poet, Larry Butler, to send me a poem he had written some time back. You can see why it came to his mind on reading that post. I’ve asked him for his permission to publish it here and I’m delighted to say he’s given me the ok – so here it is –

        • Clarkston station missed the 6:30,
        • half an hour to wait on a red bench
        • in the sun with coffee and chocolate,
        • an apple but nothing to do. What
        • more could I want:  less busy traffic
        • on Busby Road, more twitter of blackbirds.
        • A girl with big silver circle earrings
        • turns revealing 3 white stripes on her blue

          track suit trousers.  That’s all I need.

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In “Citadelle” (“Wisdom of the Sands” in English translation), Saint-Exupery (in the chapter I’ve just read), talks about how life, as he says, doesn’t cheat. We get what we focus on. He makes the point that if we focus on discipline to create freedom, what we get is discipline, and if we wage war to create peace, what we get is war. We can tell ourselves we have one particular goal, but what we do in real life is manifest our real goals.

For, when all is said and done, you establish that on which your heart was set; that with which you concerned yourself and nothing else. Even if you made it your concern to fight against it. Thus, when I fight my foe, I establish him, for I shape and harden him on my anvil.

There’s enough in this to feel it touches on an important truth, but something too which disturbs. I don’t hold much with people who blame patients for their suffering. The world, and life, seem much more complex to me, than to be reducible to such a simplistic notion. We always have choices and our choices are enormously important in creating our experiences but we are also affected by the choices of others and the randomness Nature at an individual level (don’t think any of choose earthquakes or twisters for example)

But, as I mull this idea over I find myself thinking (inevitably!) about health and disease. Disease can be quite overwhelming. Pain, exhaustion, stiffness, loss of muscle power…….can be all-consuming, colouring every aspect of life. All of these symptoms draw our attention towards our disease and before we know it, our life, even our sense of self, can become synonymous with our disease. How to find a path to health in there? Well, disease does need to be addressed. But if it becomes the entire, or even the greatest, focus, then disease is what we will experience. To become healthy, we need to do something else. We need to focus in health.

So, what’s health?

I’ve asked this question of a variety of different groups of health care professionals over the last couple of weeks. Here’s my challenge. Describe health, without referring to disease or illness. In other words, describe health as a positive phenomenon in its own right. What does it mean to you to be healthy? (and remember no use of disease, illness or symptom references! No saying it’s when you don’t have “x”!)

Once you know what healthy actually is for you, then it’s likely that focusing on it, paying attention to it, setting your heart on it, will start to bring you the experience of health itself.

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Why do some people get asthma? (In the last 25 years, the number of new asthma cases in the UK has increased six fold among children and three to four fold in adults) Well, as is the case with pretty much every single disease we know about, nobody knows. We are meaning-seeking creatures. We want to make sense of what we experience in life. Who gets any disease without thinking “why me?” And that is a very, very hard question to answer. It would be more convenient if human beings were more like machines. We’d be able to work out exactly why a particular fault had occurred, we’d be able to understand the consequences of that fault and we’d be able to fix it. But human beings are not like machines (even if the way we treat people who are ill seems to assume that they are). Not only do we not know why asthma afflicts more and more people every year, but we cannot explain to any single, individual patient – this is why you have asthma.

One of the main reasons we can’t answer these questions is that we’ve only recently begun to understand that human beings, biologically, are complex adaptive systems. As such, they have particular characteristics which make the answers to these questions hard to find.

Disease is multi-factorial. There are many things which contribute to the development of a disease in an individual. Causation is, therefore, not simple. We can’t say “X’ causes “Y”. However, we can still observe carefully, and experiment and explore to try and understand what the factors are and how they interact.

Here’s an interesting study which tries to uncover some of the factors involved in the causation of asthma. It’s that old factor “stress” again. But this time, they’ve found something interesting and thought-provoking. Not only have they found that life stresses occurring during childhood seem more common in those who develop asthma, but they’ve discovered something interesting about exactly what kind of life stresses can have this impact. In a nutshell, the stress of parents splitting up and the stress of moving home seem associated with an increased risk of developing asthma. Other major events, such as the death of a close relative, or parental unemployment don’t seem to have the same impact. How do they know? The researchers used the finding of increased blood concentrations of the neuropeptide VIP (vasoactive intestinal polypeptide) as the objective manifestion of the stress response. This, and other substances which were also found to be raised, are known to be factors in producing allergic responses, like asthma.

I think this is a useful study. It shows us some of the mechanisms that connect life events to disease and it shows us that we can’t consider all life events to be the same. What matters is what is most stressful for the person experiencing the stress, not how others rate the stressfulness of an event.

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The other day as I was on the way home from work, the train stopped in the middle of the countryside. You never quite know why a train stops somewhere between stations but you can be sure it means the train is delayed. A long time ago I realised that wearing a watch increased my sense of anxiety because I’d sit on a train which was just quietly doing nothing and I’d keep checking my watch to see just how much more delayed we were and figuring how much later I’d arrive than planned. I realised that I had absolutely zero control over the train’s movements and looking at my watch every couple of minutes wasn’t going to get me to my destination any faster. Taking the watch off let me look at other things instead – a book, a paper, a notebook, hey, even the outside world!

So as we sat doing nothing much I looked out the window and something caught my eye.


No, not the buildings in the distance, but that blackbird sitting on the bush. I zoomed in to get a closer look.


Look at him singing away! I couldn’t hear him from inside the train but a song immediately came into my head

I enjoyed the moment.

Here’s my suggestion for today. If you find yourself unexpectedly held up or delayed take a wee look around and see what you can see (or hear, or smell, or feel). What comes to your mind?

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The life force

The concept of a “life force” fascinates me. What is it that enlivens a creature? What changes in that moment between life and death? I vividly remember the first time I had to certify that someone had died. That person was an old man who had died peacefully in a geriatric ward in the middle of the night. As a young doctor this was a diagnosis I absolutely wanted to get right. I took my time and completely convinced myself that this old man had indeed passed away. Perhaps because I spent so long over this, I found myself thinking long and hard about that borderline between living and dying. What changes in a moment? As I sat next to this man’s lifeless body, what had gone? How exactly do we die? Of course, as a doctor I’d learned about the stopping of the heart, about the ceasing of the lungs and about “brain death”, but the closer I looked the harder it seemed to me to discern the exact moment of death. Life and death seem two such absolute states. There isn’t really a transitional zone that is neither life nor death. Even “half-dead” is still life! All these years later I’m no closer to understanding exactly how to pin down the moment of death or to understand what disappears or dissipates at the end of life.

The “life force” (or the “vital force”) is an old concept to try and capture what it is that enlivens us, what it is that is present when we are alive, but gone when we are dead. In fact, for a long time the life force was believed to be an entity, but when the anatomists dissected human bodies and couldn’t find any such entity, the concept lost a lot of ground. Science, it seemed, had shown that no such entity existed and materialistic understandings of the human being became much more accepted than “vitalist” one.

It’s fascinating, therefore, to see the re-emergence of the life force in a totally new guise. Modern systems theory, and complexity science, both show that complex systems have certain characteristics which are remarkably like the old “life force”.

  1. Self-organisation. Complex systems (specifically, complex adaptive systems) have the ability to self-organise. They are made of many, many components, connections and systems, which co-ordinate with each other to maintain overall defence, to adapt and maintain homeostasis of the inner environment, and to be self-repairing.
  2. Autopoiesis. Living systems have the unique characteristic of “self-making capacity”. This is a term coined by Maturana and Varela. Autopoietic organisms can make and maintain themselves.
  3. Emergence. This is a fairly new term which captures that characteristic of being able to produce new, previously unwitnessed, behaviours.
  4. Consciousness. Finally, let me add the phenomenon of consciousness. Not every living creature has consciousness. However, consciousness is a phenomenon which, like the old “life force”, is actually not an entity but a behaviour, or an experience. OK, I know, this is way too simplistic a description of consciousness and clearly it isn’t the same as the life force (think of persistent vegetative states for example). But it strikes me that the life force is a similar kind of phenomenon.

I am repeatedly impressed with the strength of the life force in the patients I see. It seems to me that it’s the basis of their ability to cope, to grow, and to shine. It’s the basis of the fight to overcome disease and to say to Death, “not yet”. Without it, there is, indeed no life at all.

I’m reading Antoine Sainte-Exupery’s “Citadelle” at the moment. Here’s the line I read today which set me off thinking about this post –

The tree is more than first a seed, then a stem, then a living trunk, and then a dead timber. The tree is a slow, enduring force straining to win the sky.

That captures it for me. Aren’t we all the slow, enduring force of life straining to win the sky? The life force flows through us, maintains us, repairs us, and drives our growth. Amazing, isn’t it?

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