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Archive for May, 2010

I think the original definition of “evidence based medicine” was a good one –

EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)

(from “what is evidence based medicine”?)

But what’s happened to it? Frequently it seems to be reduced to reading summaries of randomised controlled trials then applying those conclusions to everyone. In other words, forget the “clinician’s cumulated experience, education and clinical skills” because it might produce “variance”, and dismiss the patients’ “unique concerns, expectations, and values” as irrelevant. It’s that kind of thinking which led to a young doctor telling me she’d been taught “If a patient takes an evidence based drug and says they aren’t any better, then, either they haven’t taken the drug, or they’re lying.” Clinicians’ cumulated experience will tell you that there isn’t a drug on the planet which will deliver the same outcomes for every single patient who takes it, and as health is a subjective human experience, the patients’ concerns and values can only be dismissed at the cost of failing to deliver effective health care.

So, I was somewhat surprised when I got last week’s BMA Scotland newsletter. Under the heading “Healthcare Quality Strategy for the NHS in Scotland is published”, it said

The Healthcare Quality Strategy has been published by the Scottish government. BMA Scotland believes by focusing on evidence-based policy with proven clinical outcomes for patients, limited resources can be used effectively to deliver improvements to the care and treatment of patients.

I clicked the link to read more

Here’s what it says on the first page –

People in Scotland have told us that they need and
want the following things from the NHS and we have
built this strategy around these priorities:
● Caring and compassionate staff and services;
● Clear communication and explanation about
conditions and treatment;
● Effective collaboration between clinicians, patients
and others;
● A clean and safe care environment;
● Continuity of care; and
● Clinical excellence.

So, how does the BMA manage to get from the document to their summary? Why no mention of the priorities focused on care, compassion, communication, collaboration, cleanliness and continuity of care? Why pick only the last priority and characterise that as a way of rationing medical care according to “proven clinical outcomes”?

Really, it’s high time we put human beings back at the CENTRE of health care…..the patients and the carers……just as it says in the rather excellent “Healthcare Quality Strategy for the NHS in Scotland”. Read it for yourself and see if you agree.

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letting the grass grow

When was the last time you just stopped, sat yourself down in some grass, and listened to the sound of wind swishing through lush, swaying, blades?

Can’t remember?

Do it soon.

(What’s that? It’s only grass? Have you ever really looked? Have you ever really taken the time to listen?)

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mega display of sewing machines
mega display of sewing machines

mega display of sewing machines
mega display of sewing machines

I walked past the old Borders store in Glasgow the other day and had to stop when I saw all the windows lined with hundreds of sewing machines. The shop is being converted into a clothes store. I don’t know if the sewing machines will stay, or if they’re just a screen while they set up the store.

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bird on the wire

bird on the wire

What’s that I hear?
Stop.
Look up.
Zoom in.
Bird song……..little birds, big sounds, instantly……..I hear this…….

Sometimes when the past comes crashing into the present it’s a wholly pleasant experience.

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Do you ever look up for a moment and watch a bird flying?

It’s amazing how fast some of them can fly…..

flight

If you can capture one midflight with your camera you can see the incredible positions of their wings as they beat the air..

flight

Then, look at this one, HOVERING! Just hanging there way above the waves, those tiny eyes keenly spotting the movements of the fish under the water, ready just to plummet instantly like a stone, and capture its prey…

flight

Now, look……..see how they look when they fly together…

formation flying

formation flying

formation flying

Take a look today. You’ll be amazed

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One of the main problems of reductionist thinking in health which considers each disease as complete and separate entities is that the real world is a joined up one. What changes you make in one place ripple through the networks and produce a wide range of unpredictable changes.

Here’s a recent rather unexpected story illustrating this.

Researchers at George Mason University have uncovered a link between smallpox and Aids. People who have been immunised against smallpox have a five-fold reduction in HIV-replication compared to those who have never been immunised. Could this explain the massive increase in HIV in Africa when it appeared? Smallpox was declared eliminated from the world in 1980 and nowadays only researchers working with smallpox are immunised. Could it be that stopping smallpox vaccination, left the population without some kind of protection against HIV?

It’s an interesting and plausible hypothesis.

How often, in Medicine, do we ever consider the potential increases in one disease as another declines. I often wonder what people are going to die from if the great targeted projects against heart disease pay off. After all, human mortality stubbornly remains at 100%, so which causes of death will we see rise, as other ones decline?

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Connected, by Nicholas Christakis and James Fowler, (ISBN 978-0-00-734743-8) is a fascinating study of social networks. In the Preface they write

To know who we are, we must understand how we are connected.

This is what Clay Shirky says in Here Comes Everybody, it’s what Johansson says in The Medici Effect, Andy Clark says in Smart World, and, for me, most powerfully what Barabasi says in Linked. So what does this book add?

The clear focus of Connected is social networks – you’ll be familiar with the idea of “six degrees of separation” where it’s been discovered there are an average of only six steps between any two human beings on the planet. Christakis and Fowler take this finding a step further by highlighting and explaining “three degrees of influence”. In social networks, you influence your friend, who influences their friend, who influences their friend (and the influences flow both ways), but after that, the power of the effect tails off or disappears. The power of the effect seems related to two things – how many connections a person has, and how many of those people to whom they are connected are connected to each other (in other words how many of your friends know each other?)

These simple characteristics create very complex webs and patterns of influence and can explain a wide range of events, from the spread of a viral infection in a community, to the collapse of the financial system, to the spread of obesity, a wide range of disorders, and both cultural and political changes.

It’s a bizarre thought to learn that obesity in a community is distributed the same way as an infection. If your friend’s friend becomes obese, you’re more likely to become obese (and vice versa)! Obesity seems to be contagious.

The book is packed full of interesting and mind-boggling examples. A couple that really struck me were the spread of back pain in Germany – before the wall came down East Germany had a very, very low incidence of back pain, and in the West it was one of the highest rates in the world. After the wall came down, the incidence in the East rose to match that in the West. A study of epidemic control showed that you needed to vaccinate 90% of the population to stop the infection, but if, instead you asked a random selection of individuals who their acquaintances were, then calculated which individuals were most connected, and vaccinated only them, you could control the infection by vaccinating only 30% of the population. I could go on…..but read it yourself, it’s truly mind expanding. Really the idea that we are all separate free-thinking individuals is at best a simplistic delusion. We are who we are because of the way we connect.

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