Archive for January, 2009

John Martyn died today, aged 60. I could choose I don’t know how many songs to share to remember him but here is one of his most famous and best. I love this version. It’s from the Transatlantic Crossing series – so many wonderful performances in those programmes. Here he’s joined by Kathy Mattea, Danny Thompson and Jerry Douglas. This made me smile so much first time I saw it, and, damn now its got me smiling and crying at the same time!

Watch it right through to the very end. I just love the closing seconds.

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There have been several studies which have shown that there is evidence of selection bias in the publication of drug trials. In this post here I gave a couple of examples of concerns about both the sheer number of trials conducted vs the number of publication outlets, and the huge percentage of registered trials which never make it as far as even being offered for publication.

Here’s another piece of that jigsaw. Reviewers from the Cochrane Library found that trials which demonstrated a positive effect of the drug studied were much more likely to be published than those which didn’t.

“This publication bias has important implications for healthcare. Unless both positive and negative findings from clinical trials are made available, it is impossible to make a fair assessment of a drug’s safety and efficacy,”

They found that not only were negative trials less likely to be published at all, but those which were tended to be published between and one and four years after the positive trials.

Results from one of the five studies in the review indicated that investigators and not editors might be to blame. The reasons most commonly given for not publishing were that investigators thought their findings were not interesting enough or did not have time. “The registration of all clinical trial protocols before they start should make it easier to identify where we are missing results,” says Kay Dickersin from Johns Hopkins University in Baltimore, USA, another of the researchers on this project.

In other words, those carrying out the research were the ones responsible for deciding not to bother publishing unless the results supported the use of the drug being studied. Sadly, the New England Journal of Medicine study I quoted in the linked post at the beginning of this one, found that 30% of registered trials didn’t make it to publication! So it will take more than a simple registration process to sort out this distortion of the evidence base.

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Maybe you remember the story from last year about the Spanish woman whose trachea (windpipe) had been destroyed by TB, and how a team of doctors in Bristol grew her a new one from her own stem cells? Well, it was a pretty remarkable story, but here’s an interestingly different angle on that story.

Prof Anthony Hollander was responsible for developing the technique of using stem cells in this way and in producing this particular patient’s windpipe.

He recalls this event from his childhood –

One day in 1973 Anthony – a “sickly child” – was off school and at home with his mother, when he found a fatally injured bird in the paved area of their garden in north London. “It was in some distress,” he recalls today. “My mum was too squeamish to deal with it, so I put it out of its misery. For a nine-year-old it was hard to have to do that.” As he remembers it he got to thinking, about death, and about how he might be able to keep people alive. “So I did what all sensible children do when in need of practical help with an idea. I wrote to Blue Peter,” he said. “I can vaguely remember I was thinking about re-routing the blood out of the heart and recirculating it. Then they could fix up the heart and it would be alright again. I just didn’t want that death stuff to happen.”

Blue Peter is a long-running childrens’ programme on the BBC which encouraged interaction with its viewers from the outset. In his letter he described his “strange belief” that he “knew how to make people or animals  alive” and asked for help – including a “model of a heart split in half” and “tools for cutting people open”. Well, the Blue Peter programme editor replied to the letter, as she and her team did to every one of the thousands of letters received every week. She encouraged him to seek information for his idea from the family doctor.

Listen to what he says about receiving the encouraging reply –

“If her letter had shown any hint of ridicule or disbelief I might perhaps never have trained to become a medical scientist or been driven to achieve the impossible dream, and really make a difference to a human being’s life,” …….. ” If you had failed to reply, or had treated my letter as a joke (as perhaps others might have done) it could well have altered the course of my life……..”I remember being thrilled at the time to have been taken seriously. Actually, even nowadays I am thrilled when people take my ideas seriously. I know that might sound strange to you. But my way of doing science is to think up a hundred theories, however mad, and work through them until I find one that fits the data.”

Isn’t that an amazing story? Just to make it all the more amazing, it’s emerged now as a story because Prof Hollander recently wrote to Biddy Baxter, the Blue Peter editor, to tell her how important her letter had been to him and discovered that she was in the process of compiling a book of the childrens’ letters and had already picked his out as one of the letters to include. Coincidence?

I’ll finish this little tale with another quote from Anthony Hollander which, I believe, completely hits the spot –

“As adults we can tend to lose the capacity to dream and think big. Children will dream unselfconsciously. I still do that – I still go around telling people ‘these are the things I want to do’. I don’t have time for any kind of scepticism.”

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I was a little surprised to find this as “news”

Patients and their families want physicians who are gifted in diagnosis and treatment and who are caring individuals with the interpersonal skills needed to communicate complex information in stressful circumstances. A new study in the January 2009 issue of Academic Medicine shows training physicians to be humanistic is feasible and produces measurably better communicators.

It’s kind of sad that this is promoted as newsworthy. But I’m glad it’s being publicised all the same.

“Traditionally medical school curricula have focused on the pathophysiology of disease while neglecting the very real impact of disease on the patient’s social and psychological experience, that is, their illness experience. It is in this intersection that humanism plays a profound role,” said Dr. Frankel, who is a medical sociologist.

This is the heart of the problem I think. It’s this very issue which Havi Carel deals with so clearly in her book.

I did like this quote in the news item however –

In the 1920’s Francis Peabody, M.D., wrote that “the secret of care of the patient is caring for the patient”

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Out walking the other day and I came across this mark on the ground,

the other mark

It’s like a butterfly or a flower or something. What was it? Isn’t it strange and beautiful?

Actually I’ve a pretty good idea what it is. Take a look at the other mark which was nearby,

the mark

One of the interesting things about these marks for me is that I find them compellingly beautiful but they are for sure just accidents, unintentional, the unintended marks left while doing something other than making a mark. They aren’t art. They weren’t even created deliberately but they are definitely the hand of a human being all the same.

Everything we do makes a mark, doesn’t it? Has effects we don’t necessarily intend and leaves the world a little changed.

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Glasgow City Council has made a great images and sound display to celebrate Robert Burns. They project images up onto the City Chambers in George Square and have a PA system playing a soundtrack to accompany them. I went along and filmed it with my Flip Ultra. Take a look. I think you’ll enjoy it. (The programme runs for 15 minutes)

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Nature loves diversity. Healthy ecosystems are filled with a wide range of species. Intensive farming has shown us how single species crops are difficult to maintain in good health which is why they need support from both fertilisers and “-cides” (insecticides, fungicides….). When a particular species becomes a pest we’ve made several attempts to counter them by either directly attempting to cut back their numbers or by introducing some new predator to try and control them. Both experiments can go horribly wrong.

Peter Johnson, at the University of Colorado, has been experimenting with a radically different approach – increasing diversity. He has shown that an effective way to reduce the prevalence of certain parasitical diseases is to increase the biodiversity of the ecosystems in which their hosts live. You can read more about this research here.

This is brilliant work and it shows how serious, common, infective diseases in the world, such as schistosomiasis and Lyme Disease, could be tackled by increasing biodiversity. The logic, of course, is that such diseases are likely to become steadily more problematic as our world loses species.

We really do live in a connected world and there really are better answers to our health problems than just throwing more chemicals around.

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I’ve just read “illness” by Havi Carel (ISBN 978-1-84465-152-8). This is an excellent book and as Raymond Tallis says on the back “should be read and re-read by everyone who is professionally involved with illness, who is ill, or is likely to become ill; which is to say, by all of us”. I couldn’t agree more.

Havi Carel teaches philosophy at the University of the West of England. She has developed a rare but extremely serious disease – LAM – which quickly reduced her lung capacity by 50%. She brings her professional philosophical knowledge and understanding to the personal experience of this illness in a way which both challenges the way we think about illness, (chronic illness especially), and provides a useful framework for a positive engagement with such difficult life-limiting experiences as disabling disease.

I would like to see significant changes in the way health care is delivered based on the lessons revealed in this book. We need a fundamental re-humanisation of our ways of thinking about illness in order to bring about a sea change in the way doctors, nurses and other health professionals work.

Havi Carel writes with great clarity. Don’t be frightened off by the fact she’s a philosopher. Despite the fact that she draws on the work of philosophers from Epicurus to Heidegger and Merleau-Ponty (amongst others), there is nothing difficult to grasp or understand in this book. She skilfully uses the works of great philosophers to both illuminate and clarify our thinking about health and illness. Not only does she use clear, straightforward English, but the personal story woven into book makes it a profoundly moving and completely engaging read.

On a naturalistic view, illness can be exhaustively accounted for by physical facts alone. This description is objective (and objectifying), neutral and third-personal………Phenomenology privileges the first-person experience, thus challenging the medical world’s objective, third person account of disease. The importance phenomenology places on a person’s own experience, on the thoroughly human environment of everyday life, presents a novel view of illness.

Instead of viewing illness as a local disruption of a particular function, phenomenology turns to the lived experience of this dysfunction. It attends to the global disruption of the habits, capacities and actions of the ill person.

This consideration of the relationship between objective and subjective perspectives is I think central to the development of humane and humanly relevant medicine. Eric Cassell nicely explores this conceptually by unpicking the words “disease” and “illness”, and clinically by asking doctors to encourage patients to talk about their “suffering”. The fundamental shift is a change of perspective from the components of the body, to the socially embedded individual human being. Havi Carel’s consideration of the “biological body” and the “lived body” sets a wonderfully clear perspective from which to understand this.

Normally, in the smooth everyday experience of a healthy body, the two bodies are aligned, harmonious. There is agreement between the objective state of the biological body and the subjective experience of it. In other words, the healthy body is transparent, taken for granted……..It is only when something goes wrong with the body that we begin to notice it.

This is exactly the point made by Hans Georg Gadamer in his excellent collection of essays entitled “The Enigma of Health”. For me, reading his essays completely changed the way I thought about health and illness. Havi Carel has given me a new framework for these concepts and values and I find that very exciting.

One of the most useful parts of this book is the exploration of the idea of “health within illness”. We have a tendency to write off the chronically sick expelling them from the land of the healthy to the land of the ill (as Susan Sontag so clearly wrote). But life’s not like that. Having a chronic illness does NOT mean never being able to experience health again. In the last two chapters of the book, “Fearing death”, and “Living in the Present” she tackles this head on, drawing on advice from Epicurus, Heidegger and the contemporary French philosopher, Hadot. The wonder and the joy of the present is something I’ve posted about before – here and here – both times referring to Hadot in particular. I couldn’t agree more.

Let me finish this short review though by focusing on her other really important point –

Empathy. If I had to pick the human emotion in greatest shortage, it would be empathy. And this is nowhere more evident than in illness. The pain, disability and fear are exacerbated by the apathy and disgust with which you are sometimes confronted when you are ill. There are many terrible things about illness; the lack of empathy hurts the most.

Virtually every day I hear terrible stories of heartlessness and carelessness. Of patients who have experienced a total lack of humane care in the hands of health care professionals. Always those stories shock me. In one way I don’t understand them. Why work in a caring profession if you frankly don’t care? But in another way I blame the system. This exclusive emphasis on the biological body reduces human beings to cases of diseases. By ignoring or belittling the patients’ narratives, or by not paying attention to their subjective experiences of their “lived bodies”, we literally de-humanise our practice.

To think of a human being is to think of a perceiving, feeling and thinking animal, rooted within a meaningful context and interacting with things and people within its surrounding.

It’s time to re-humanise Medicine. This book is an important contribution to that project.

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Old and blue

blue wheel
blue wheel

What caught my eye was the blue. This is a good example of how a camera lets you see more than your casual, passing glances do.

I can look at these images for a long time. The more I look at them, the more I see. I love the shapes, the colours, the rusty flakes, the age of the wheel, it’s markings and its worn-ness (is there such a word?).

There’s a word we don’t use very much any more – patina. It’s a lovely word, and a lovely concept……the beauty of the surface of things created by simply having existed in this world for a long time. It provokes thoughts about the connections between human beings and nature, between the manufactured and the weathered, about transience and the ever-changing nature of reality.

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Defining health isn’t as easy as you might think. An article in the BMJ before Christmas raised the issue again and amongst the responses they received this one particularly appealed to me.

The definition of health is important. There is a biomedical component to health, but it exists in a setting that includes biological, personal, relational, social, and political factors. For too long, we as doctors have been timid about defining health, and mostly operated at the level of “absence of disease.” For too long, we as a society have allowed politicians to get away with shunting health off to a “medical domain,” thus avoiding focus on the large scale social and political forces that create health and illness. We need to rediscover the force of Virchow’s statement: “Medicine is a social science and politics is nothing but medicine on a grand scale.” In my essay I propose: “Health is best seen as an ongoing outcome from the continuing processes of living life well. Living life well would be defined in terms of wealth, relationships, coherence, fitness, and adaptability. Disease avoidance would be a minor part of this view of health.” Such a definition is a political statement, informed by my knowledge of medicine and its social context. I believe that achievement of health should be a goal of public policy and that we should want to achieve healthy individuals in a healthy society. I see health as being a moral and practical good in itself, as well as a means towards other ends. If health is to mean anything it has to include ideas of human flourishing and abundance. As a doctor I need an aim, and a context, for my practice of medicine that goes beyond treatment of illness, important though that is.

This was a published as a letter from GP, Dr Peter Davies, in the BMJ. I enjoyed everything he had to say, but I especially agree with the sentiment that health is a process and that “Disease avoidance would be a minor part of this view of health”. Not only disease avoidance but death avoidance, I argue! But what really caught my attention was “If health is to mean anything it has to include ideas of human flourishing and abundance.” Couldn’t agree more!

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