Archive for November, 2008

I recently came across this quotation from Martha Graham

“There is a vitality, a life force, a quickening that is translated through you into action, and there is only one of you in all time, this expression is unique, and if you block it, it will never exist through any other medium; and be lost. The world will not have it. It is not your business to determine how good it is, not how it compares with other expression. It is your business to keep it yours clearly and directly, to keep the channel open. You do not even have to believe in yourself or your work. You have to keep open and aware directly to the urges that motivate you. Keep the channel open. No artist is pleased. There is no satisfaction whatever at any time. There is on a queer, divine dissatisfaction, a blessed unrest that keeps us marching and makes us more alive than the others.”

I think this is SO good! From my perspective as a medical doctor, I, too, see that in each of us there is a unique vitality. It’s not an entity but it’s certainly a reality. It energises us; it organises us; protects us and maintains our health. And on top of all that it’s the source of our growth. In times gone by people have considered this phenomenon to be some kind of entity and have named it either the “vital principle”, or the “vital force”. The most modern scientific understanding would be that it’s probably better understood as simply a characteristic of a complex organism. But this quote from Martha Graham is much more poetic than that!

It’s inspirational!

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What’s the point of health care? Does that seem like a question with an obvious answer? It would be reasonable to expect that the answer would be that health care is about caring for people’s health. But that’s an answer which is not really an answer. It raises the question, what is health? Stop and think about this for a moment, because it’s not a straightforward question to answer. My answer is that health is a phenomenon in its own right – it is NOT the mere absence of disease. It has distinct characteristics – adaptability, creativity and engagement. Others will have other answers, other characteristics to add, other qualities. It’s difficult to extricate health from the old concept of “eudaimonia” which tends to be translated as “happiness”, or even “wellbeing”, but I prefer the word “flourishing”. Surely health is about flourishing? The less we flourish, the less we rate ourselves as being healthy, well, or good.

This way of thinking about health is holistic. It demands that we consider the whole of a person’s life, and by that I mean the whole of their present time life (a biopsychosocial approach), and the whole of their life from start to finish. This has at least two consequences. Firstly, it means that all health care must take into consideration, not just objective disease in the form of pathology or lesions, but it must consider the individual patient’s story. No two patients have the same life, and therefore, no two patients share the same experience. With the same disease, two people will experience different symptoms and those symptoms will mean something different to each of them. In addition, each individual will have their own ways of coping, adapting to and dealing with their illness. Health care needs to relevant to the individual who is being cared for.

Secondly, it means that health care interventions will alter the experience and course of a person’s life, but they do not, ultimately, prevent death. The overall mortality for human beings is 100%. We do all die. But much of contemporary health care is predicated on the basis of death avoidance. We are bombarded with claims about “life-saving” medicines and Public Health policies which claim to reduce death rates. Statins, for example, are even promoted for healthy people, to reduce their risk of death from heart attacks and strokes. Whilst nobody would really like to have a heart attack or a stroke, no-one is asking the question, what do people who would have died from a heart attack or a stroke die from instead? The focus is on death avoidance. People are classed as being “at risk” – at risk of dying from disease x. But to make an informed choice about a treatment don’t you need to have an idea of the possible and likely consequences of that treatment? To say a treatment reduces your risk of dying from disease x is all very well, but it doesn’t say much about whether or not you’ll experience a life of greater flourishing. Especially if you develop another more disabling, painful condition instead. The logical extension of this death avoidance thinking is to try to avoid death from all causes. For example, some doctors and scientists have promoted what they call the “polypill” – a combination of drugs all in one pill, which, if taken by the whole population (or in this case the whole population over the age of 50), would significantly reduce the death rate from cardiovascular disease. Well, if you don’t die from cardiovascular disease, what do you die from? Cancer? Nervous system disease? Liver disease? Blood diseases? There’s no way to know of course but isn’t it true that it will be something else? Or do you think healthy people die disease-free?

It’s likely that a person will fight hard for life at all times. (Well, not everyone, as Dylan Thomas wrote, “Do not go gentle into that dark night. Rage, rage against the dying of the light.” exhorting his father to fight for life at the end of his life). Around a third of all health care expenditure is on people in the last year of their lives. (see New England Journal of Medicine 1993:328:1092-6 for example)  You might hope to live three score years and ten, and if you do, you can expect that most health care you receive will be in your last year of life. Think of it this way – assuming 70 years of life (I know, that’s quite an assumption!), one third of your health care will be in one seventieth of your life and two thirds for the other sixty-nine seventieths. Why is that? Because you can expect to flourish for 69 years and suffer for one? I’m not sure that’s most peoples’ experience. If health care is about improving life as opposed to merely trying to avoid death why don’t we direct more of it to life instead of death avoidance?

It seems that our so-called “health care” isn’t focussed on health at all. It’s focussed on death avoidance. That was the goal of the alchemists – the elixir of life which would produce immortality. But that’s a myth isn’t it? Shouldn’t we have health care which is more realistic? After all, if we do address illness holistically, reducing suffering, encouraging healing, resilience and growth, aren’t we likely to also increase the length of life? Might that not be a better way to avoid “premature deaths”?

Maybe we should be concentrating on increasing health, in a eudaimonic sense, instead of concentrating on avoiding death, which, realistically, is ultimately impossible.

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Platform 3 rainy morning

I took this photo while standing on a cold, wet platform waiting for a train to take me to work.
This is not an unusual experience. It’s not a rare experience. It’s very easy to bury your head into your shoulders, stand and shiver, and just wish you were somewhere else.

This year I’ve been reading some contemporary French philosophers, Jean-Philippe Ravoux, Pierre Hadot, and Bertrand Vergely. I’ve not read much, but both in interviews they’ve given and in the few books of theirs which I’ve read, I’ve found that they all three mention two common concepts. The two concepts are captured by these two French words – “quotidien” and “emerveillement”.

Quotidien means daily, but not just in the sense of “daily paper”, or “daily bread”, but in the sense of the “everyday”, of daily life. You’ve probably read a lot about the importance of living in the present. It’s certainly a common theme in Eastern philosophy, but it’s also a very common theme in the work of Western self-help writers and psychologists. Both the concept of the present, and that of the “quotidien”, concentrate us on a period of time – the period of time in which we are most alive. I find the concept of the present a little tricky. It’s very hard to pin down. You only have to breathe out and the present has already become the past. So we tend to stretch the boundaries of the present outwards from a moment to a period of time lasting maybe a few minutes, or hours, or even a day or number of days. The more we stretch the boundaries though, the more what we call the present loses its power. I like the French term, “quotidien”. It’s a period of time I can grasp. It’s today. Every day. It’s the time period in which we are alive, our conscious time, the time when we can act.

The second word, “emerveillement”, is about an attitude towards something. It means a state of wonder, of marvel, even of amazement, or awe. Probably the best way to understand this is to think about the way children engage with the world. Young children find the world a fascinating place. Think of how much fun a child can have even with the packaging in which a present is given. The world really is an amazing place. Ceaselessly fascinating. It’s just that on a day to day basis we slip into autopilot, and as we stumble through our days like zombies, our lives literally pass us by.

So here’s the alternative. Today, this very day, let something catch your attention, and just pause for a moment and wonder. That’s what I did as I stood on that windy, rainy platform. I noticed the lights and the way they reflected on the concrete and the rails. I noticed the row of lamps on the opposite platform, and their reflections stretching into the distance. And I saw the green light glowing at the end of the platform, signalling GO. Green for go. Green, the signal to start. The day was beginning. Another amazing day.

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It kind of annoys me how some illnesses are considered “real” and some not – fibromyalgia is one of those controversial disorders which some doctors dismiss as depression simply because the patient is down (who wouldn’t be with daily pain??) and because none of the tests show anything abnormal. It will probably turn out that this is one of those cases of looking in the wrong place. Because the pain is felt in the muscles, doctors have tended to look at the muscles. And they don’t find anything abnormal. So they look at the joints, or the tendons, ligaments and soft tissues around the joints. Nope, still don’t find anything wrong.
Well, here’s something interesting from France -a team of researchers have found consistent abnormalities in brain function in patients with fibromyalgia. Specifically, they’ve found abnormalities of function in distinct areas of the brain independent of the patient’s depression score. Here’s what they found –

The researchers confirmed that patients with the syndrome exhibited brain perfusion abnormalities in comparison to the healthy subjects. Further, these abnormalities were found to be directly correlated with the severity of the disease. An increase in perfusion (hyperperfusion) was found in that region of the brain known to discriminate pain intensity, and a decrease (hypoperfusion) was found within those areas thought to be involved in emotional responses to pain. In the past, some researchers have thought that the pain reported by fibromyalgia patients was the result of depression rather than symptoms of a disorder. “Interestingly, we found that these functional abnormalities were independent of anxiety and depression status,” Guedj said.

The authors go on to conclude –

“Fibromyalgia may be related to a global dysfunction of cerebral pain-processing,” Guedj added. “This study demonstrates that these patients exhibit modifications of brain perfusion not found in healthy subjects and reinforces the idea that fibromyalgia is a ‘real disease/disorder.'”

I do think this is good news. It means that doctors are beginning to discover something about what kind of disorder fibromyalgia is. But I do despair about this continued categorisation of disease into “real” or not. (with “not” usually being categorised as mental illness) Mental illnesses, such as depression, should be diagnosed in their own right, not as what’s left over after a battery of tests are returned with “normal” stamped on them!

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Barack Obama’s Acceptance Speech

I don’t think I’ve ever been more impressed, moved and inspired by a politician’s speech, than I am by this one.

His beliefs about the possibility of change, the importance of hope and the need for people to join together to act as adults really strike the right chord with me.

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Heading south

Looked up to see what the noise was……..

Heading south

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In an excellent article in the BMJ, Nicholas A Christakis, professor of medical sociology at Harvard, asks the questions all doctors (and their patients) should be asking. He points out that too often these days we misunderstand (or maybe misuse) the results from drug trials.

Doctors say that a drug “works” if, in comparison with the control arm of a clinical trial, significantly more people in the treatment arm respond. Unfortunately, this is a naive oversimplification, and it breeds complacency among patients and physicians alike

He points out that it is frequently the case that a drug which is shown in trials to help more patients than a placebo or other treatment, very often actually only delivers this benefit for the minority of patients who are actually prescribed it. I’ve quoted Dr Roses of GlaxoSKF a few times on that same point!

Countless drugs that have been shown in randomised controlled trials to be effective work in only a minority of patients. Imagine that a drug worked 20% of the time in a trial, compared with 5-10% for a placebo. This is the case for drugs ranging from antihypertensives to minoxidil to cancer chemotherapy. Such a difference in a trial corresponds to an enormous effect size. However, most patients taking such drugs would not benefit—they would hardly think that the drugs “worked.” If you buy a toaster you expect it to be able to toast bread every time it is used. If it does not, you say it does not work and return or discard it. You do not take solace from the claim that, in fact, 30% of the time in the manufacturer’s laboratory the toaster did a better job in browning bread than sunshine alone.

It does amaze me that certain treatments are labelled “proven” in this way. What’s even worse though is when the prescribing doctor then seems to blame the patient for their “failure” to respond to the treatment. This leads me on to the author’s recommendation –

one appropriate reaction is to have a protocol of administration that evaluates a patient’s response. Doctors sometimes already do this in a systematic way (such as when titrating the administration of highly active antiretroviral treatment). But this practice should be more widespread and more formal

Whilst I agree with this recommendation, it still does amaze me. Don’t all doctors routinely check how every individual patient is doing?

Anyway, here’s the take home message, in the last paragraph of the article –

Just because drugs work in trials does not mean they will work in our patients. In fact, we can often expect that they will not work at all.

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