Archive for September, 2010

James Johnson, Chair of the BMA until 2007, is up in front of the GMC this month. He is….

alleged to have conducted operations that were not justified, shouted at a patient during a procedure and behaved like “a caricature of surgical arrogance”. A General Medical Council (GMC) fitness to practise panel was told that Johnson, who was chairman of the British Medical Association until 2007, also criticised the “incompetence” of colleagues in the operating theatre, did not warn patients about the risks of certain procedures and failed to provide proper care. Johnson is facing a series of serious disciplinary charges, relating to his conduct in regard to 14 patients on whom he operated between June 2006 and January 2008.

In this same week, Dr Geoffrey Hackett, a consultant urologist, says….

More than half the Viagra prescribed to men is not working….

So, that’s an “evidence based”, “proven” medicine, not doing what it says on the tin for more than half the people who take it (same as is the case for most of the drugs doctors prescribe)

Meanwhile, we hear that ghostwriters are writing “research” papers to promote drug companies’ products.

  • Dozens of ghostwritten reviews and commentaries published in medical journals and supplements were used to promote unproven benefits and downplay harms of menopausal hormone therapy (HT), and to cast raloxifene and other competing therapies in a negative light.
  • Specifically, the pharmaceutical company Wyeth used ghostwritten articles to mitigate the perceived risks of breast cancer associated with HT, to defend the unsupported cardiovascular “benefits” of HT, and to promote off-label, unproven uses of HT such as the prevention of dementia, Parkinson’s disease, vision problems, and wrinkles.

Also, Pfizer has been fined $2.3 billion

to settle civil and criminal allegations that it had illegally marketed its painkiller Bextra, which has been withdrawn.

…this, the fourth settlement they’ve reached in such cases since 2002. Does it bother them? Obviously not, after all

the $2.3 billion fine amounts to less than three weeks of Pfizer’s sales

Pfizer isn’t alone in this kind of behaviour, as the NY Times points out….

Almost every major drug maker has been accused in recent years of giving kickbacks to doctors or shortchanging federal programs. Prosecutors said that they had become so alarmed by the growing criminality in the industry that they had begun increasing fines into the billions of dollars and would more vigorously prosecute doctors as well.

So, what do you think? Who’s got the big problems to sort out here?

We’re being conned by the dominant biotechnical model of medical practice which vigorously tries to denigrate and suppress any health care, traditional, alternative or complementary, which falls outwith the bounds of their own domain.

We need a better model of health care, one which focuses on the individual, which prioritises actually caring about patients, and which doesn’t promote a pill for every ill philosophy.

The American Board of Integrative Holistic Medicine principles would be a good starting point.

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Can you see him?


Can you see him now?


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remains of the day

sun setting



As the setting sun was reflected in the skyscraper opposite my Tokyo hotel room, and as day turned, once again, to night, I reflected on how the day had gone, what I’d done, what I’d experienced.

It’s good to reflect at the end of a day…….

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Iona Heath writes in the BMJ recently,  that

we have somehow lost our way in the management of chronic non-communicable diseases. In this arena the largely unexpressed sense of medical impotence seems to have led to the frequent exaggeration of treatment effects and to an excessive emphasis on unproved preventive interventions.

She picks out two issues to highlight

Wishful thinking seems to be encouraged by two serious structural impediments within medicine: firstly, a diagnostic taxonomy that manages to be both rigid and intensely inconsistent; and, secondly, the unjustifiable manipulation of statistical information, with or without intention.
Experience is fluid and continuous, while diagnoses are discrete and dichotomise the normal from the abnormal in a way that has proved useful but that is totally artificial. The insistence that medicine is able to make a clear distinction between these two categories is a major constituent of the pervasive wishful thinking—perhaps particularly in preventive interventions such as mammography, where overdiagnosis of the abnormal can lead to mutilating interventions that have a minimal effect on overall mortality.
In his 2010 Bradford Hill memorial lecture at the London School of Hygiene and Tropical Medicine, Sander Greenland described contemporary statistical practice as perpetuating hopelessly oversimplified biological and mathematical models and of promoting excessive certainty through the promulgation of a two valued logic that allows only complete certainty of truth or falsehood.

She concludes

It is surely time for medicine to reassert a standard of integrity that seeks out and actively curtails wishful thinking and acknowledges the degree of uncertainty at every level of practice, even at the expense of admitting impotence.

As so often seems to be the case, I agree completely with her. Our current fashion for “evidence based” approval labels is built on the merging scientism, which in turn has arisen from logical positivism. It’s continued default to two value thinking (it’s either this or that, right or wrong, good or bad, works or doesn’t) is a ridiculous abstraction that increasingly bears little connection to reality. We live in a highly complex world where human beings are complex adaptive organisms embedded in our unique and multiple environments and relationships.

The claims for “cures” and the claims for “certainty” and rightness of point of view of “experts” is not doing any of us any favours.

Again, I think this illustrates how helpful Ian McGilchrist’s analysis is – there are two world views clashing here and we’ll only make progress if we can integrate both of our cerebral hemispheres and stop believing that only left hemisphere function gets it “right”.

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Which way now?

left or right?

Vegetables, or a campaigning environmental organisation?

green sign

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I believe diagnosis is one of, if not, the most important parts of a doctor’s job. It’s actually the main goal of the entire medical undergraduate curriculum. However, we’ve limited what we mean by diagnosis. A diagnosis is not just the identification of pathology, it’s an understanding of a patient’s illness, a point which is all the more important when you consider patients with “co-morbidities” (more than one thing wrong).
In an interesting personal article in the BMJ Gordon Caldwell, a consultant physician working in acute medicine, says

The time taken to reach the correct diagnosis may be crucial for the patient’s chance of survival. Over my career I have seen many errors in the working diagnosis causing harm to patients and even death.

He also considers the importance of creating the right working environment for doctors to make good diagnoses

I believe that we have not thought about the best places, the physical and psychological environments, in which doctors should do this complex clinical thinking. Often it occurs in small hot rooms subject to constant interruption or even in ward corridors without easy access to laboratory results.

He concludes –

We must design our working spaces and information systems to maximise doctors’ ability to see, understand, and deliberate on the information needed for more precise diagnosis. We must allow clinicians enough time to be careful in diagnosis, treatment planning, and treatment review. We must urgently consider how to provide rooms, time, and information for doctors to do the most difficult part of their job and the part most prone to error: the clinical thinking in making the working diagnosis and treatment plan.

This is absolutely right. The scandal of the NHS is that we expect good health care to be provided without giving doctors adequate time with their patients to really understand them. We also frequently fail to provide good working environments and to share all the relevant information amongst the various members of the team.

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There are some fabulous TED talks but this one from Jill Bolte Taylor describing her experience of having a stroke in the left side of her brain is not only incredibly moving but might change the way you’ll think about your brain, your mind and even the nature of reality.
It is a great confirmation of Ian McGilchrist‘s work on how the left and right side of the brain can be shown to have unique and very different ways of approaching and engaging with the world. She also uses language entirely consistent with the work of Dan Seigel’s Interpersonal Neurobiology approach.

I urge you. Take a few minutes and watch this video. It’s an amazing story.

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I recently discovered the American Board of Integrative Holistic Medicine. They’ve obviously thought very carefully about the practice of medicine and how a doctor should carry out his or her work. I’m particularly impressed with their ten principles and I agree wholeheartedly with all of them.

So, here are their principles. I sign up. These are the colours I want to nail to the mast. Do you agree? If you’re a doctor, would you accept these principles for your practice?

1.    Optimal health is the primary goal of holistic medical practice, deriving from the conscious pursuit of the highest level of functioning and balance of the physical, environmental, mental, emotional, social and spiritual aspects of human experience. The result is a state of being fully alive, a condition of well-being transcending the mere absence or presence of disease.
2.    The Healing Power of Love: Integrative holistic physicians strive to relate to patients with grace, kindness and acceptance, emanating from the attitude of unconditional love as life’s most powerful healer.
3.    Wholeness: Illness is a dysfunction of the whole person – body, mind and spirit – or the environment in which they live, rather than simply a physical disorder or a random isolated event.
4.    Prevention and treatment: Integrative holistic practitioners promote health, prevent illness and manage disease processes. Integrative holistic medical treatment balances relief of symptoms with mitigation of causes.
5.    Innate healing power: All persons have innate powers of healing of body, mind and spirit. Integrative holistic physicians evoke these powers and help patients utilize them to affect the healing process.
6.    Integration of healing systems: Integrative holistic physicians embrace a variety of safe and effective options in diagnosis and treatment, including education for lifestyle changes and self-care, complementary approaches, and conventional drugs and surgery.
7.    Relationship-centered care: The quality of the relationship between physician and patient is a major determinant of healing outcomes which encourages patient autonomy and values the needs and insights of patient and practitioner alike.
8.    Individuality: Integrative holistic physicians expend as much effort in discerning a patient’s uniqueness as they do in establishing what disease may be present.
9.    Teaching by example: Integrative holistic physicians continually work toward the personal incorporation of the principles of holistic health, in turn profoundly influencing patients by their own example and lifestyle choices.
10.    Learning opportunities: All life experiences including birth, illness, suffering, joy, and the dying process are profound learning opportunities for both patients and integrative holistic physicians.

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wakey wakey

I was surprised the other day as I walked over a bridge in Tokyo to see a little boat cruising the canal. I’ve often wondered why there were canals under the roads and between the buildings, and I’d never actually seen anyone sailing on one of them.
river cruise through tokyo

Apparently, in preparation for the Tokyo Olympics in 1964, the city wanted to construct urban expressways, and the land they managed to buy was the network of old canals.
That's why you see this strange web of hidden, and partially revealed canals in the city, and why the high level roads take the routes they do.

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A recent editorial in the BMJ asked a question you don’t often find in medical circles – how long should treatments be continued?
Even in acute disease, the evidence base for treatment duration is weak apparently, but when it comes to chronic disease, the situation becomes so complicated that it seems, it’s pretty much just avoided.
This hides two issues. Despite what drug companies and enthusiastic drug prescribers tell us, there are precious few genuine cures in modern medicine. We’re often presented with simplistic black and white claims about drugs which “work” or are “evidence based” as if acquiring those labels mean they are just a good thing, whereas, in reality most of those drugs don’t actually heal, or even enhance natural healing effects. They just modify symptoms. The second issue is related to the first, if these drugs don’t cure, do they give us better lives? Only you can assess your quality of life, so if you have to take a drug for decades, only you can decide if a drug-taking lifestyle a better one for you, but at least you should be told by whoever initiates your treatment, whether or not they expect you to have to take the drug for the rest of your life.
So next time your doctor is about to prescribe a drug for you, how about asking how long he or she expects you’ll have to take it, and if you really want to be challenging, ask what the evidence is for that expectation.

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