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Archive for February, 2011

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Show your love

Don’t just say it. Show it.

And why not do it every day this month…..it is the month of love

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We shouldn’t reduce health care to a mechanical set of “measurable” processes. Health care is about the human beings – human beings who are suffering, and human beings who are trying to relieve suffering. This paragraph at the end of an article which looks at the difference between psycho-analytic approaches and cognitive behavioural ones captures the idea beautifully

The respected therapist and writer Irvin Yalom, among others, argues that depression and associated forms of sadness stem from an inability to make good contact with others. Relationships are fundamental to happiness. And so a science that has the courage to include the doctor’s relationship with the patient within the treatment itself, and to work with it, is a science already modelling the solution it prescribes. What psychoanalysis loses in scientific stature, it gains in humanity.

 

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This caught my eye

Showing clinical empathy to patients can improve their satisfaction of care, motivate them to stick to their treatment plans and lower malpractice complaints, found a study published in CMAJ (Canadian Medical Association Journal).

What did I think when I read this?

You don’t say!

I mean, seriously, empathy’s a good thing?? But then, I looked again, and there was a little extra word in there which disturbed me…..and several days later, it’s disturbing me still. Can you guess which word is bothering me?

“clinical”

What, oh what, is “clinical empathy”? Maybe I’m a bit odd this way, but you know what? I care about every single patient I see. I just do. I want to help them. I feel for them. Nobody taught me this. I became a doctor because of it. It wasn’t something to include in my curriculum. Surely that’s not odd. It’s certainly not uncommon amongst the doctors I know and work with.

Here’s my question. Why would anyone want to be a doctor if they didn’t care?

OK, you’ll probably come up with a ton of reasons, but if you could choose, next time you need to see a doctor, wouldn’t you rather choose one who connected with you, who understood you (or at least tried to understand you), over one who didn’t?

It’s not my experience I’m unusual. But in my experience, it’s not something which seems to be particularly valued in health care. “Outcomes” are rarely anything to do with caring, empathy, or relationship. I really hope that’s changing. Let’s not modify “empathy” by calling it “clinical empathy”, let’s value and encourage the practice of giving a damn.

(The Scottish government is rolling out through the whole of the NHS in Scotland a measure called “CQI-2”, a measure of the “Consultation Quality”, to capture patient’s experiences of compassion, caring “enablement”. That’s an important step. It’ll be an even more important step if we connect it to funding decisions. )

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Are you well? How’s your energy? If I were to ask you to rate both your well-being and your energy on a ten point scale where 0 is the worst level you could imagine and 10 is the best, what numbers would you give me right now? You’re able to do that. Instantly. But how do you do it? You don’t check your blood pressure, your pulse, your blood sugar etc etc. You assess it holistically. It’s not actually possible to reduce your well-being or your energy to any single element. Yes, of course, individual elements play a part. They are factors, and influences. But your well-being cannot be reduced to component parts. The moment we reduce a human being to a part of a human being we don’t know that human being any more. Maybe we can know how much haemoglobin they have in their red blood cells, but we don’t know them.
There’s a similar thing happens when people say to me when someone gets better, what is it that got them better? Patients regularly say after an admission to our hospital that it was “the whole package”, or “the way everything fitted together”, or they’ll say it was the rest, and the physio and the way they were listened to, and…and….and. It’s not reducible.
What’s our obsession with breaking things down into pieces? According to Ian McGilchrist it’s because our left hemisphere works that way. It abstracts, selects, and then re-presents information to us. Our right hemisphere however processes the world more holistically. Its main focus is the world as it is, without filtering, selecting and re-presenting.
The moment we select only a part of something, we see only what we’ve selected. Some people seem to think if you examine a part of the whole you’ll get closer to the truth. Actually, you get further away.
Maybe it’s time we engaged our right hemispheres more, and quieted down that noisy, rather arrogant left hemisphere.
Health is not reducible to component parts.
Human beings are not reducible to component parts, not even genes.
We should stop treating patients as if they are only the containers of parts, and deluding ourselves into believing we know exactly what produces healing and wellbeing. We don’t.

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Should statins be prescribed for every adult with “raised” cholesterol levels (a recent study estimated this would cover 70% of the adult population of Norway).

A recent Cochrane Collaboration analysis of the accumulated data concludes this –

There is not enough evidence to recommend the widespread use of statins in people with no previous history of heart disease, according to a new Cochrane Systematic Review. Researchers say statins should be prescribed with caution in those at low risk of cardiovascular disease (CVD).

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february love

In my monthly themes, taking the mid-point of February (14th) as my inspiration, I’ve allocated the them of love to the month.

This photo is one I took in France last year and it’s the moment where I caught the light of the sun shining directly down on this couple holding hands.

I know we celebrate Valentine’s Day on the 14th, but why not take this as your opportunity to share acts of loving kindness all month long……?

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John Barry died this week. When you hear just some of the film soundtracks he composed you can’t fail to be impressed. His music is instantly recognisable, not least the Bond film music, Born Free and Out of Africa.

You could argue that through his music, John Barry will live on. Last week, in Scotland (and elsewhere), we celebrated the birthday of Robert Burns. He died in 1796 but in some way, he’s still around. His words, his ideas, the feelings and experiences which were unique to his life, continue to be accessible to us many years on.
I was recently reading about Lacan’s concept of the three realms, or worlds, the Imaginary, the Symbolic and the Real. It occurred to me that there’s something in that model which helps us to understand death (and therefore life) differently. If the Real is all that is, as it is, unfiltered and unprocessed, then it doesn’t take much thought to understand we can never fully know the Real. We process the Real through our sensory organs, our bodies and the activities of our brains, and in so doing, we experience only a small fraction of the totality of all that is at any given moment.

We only experience a small fraction because, first of all our sensory organs are only able to detect portions of reality (bees for example are able to see ultraviolet portions of the electromagnetic spectrum which our eyes are unable to detect, and dogs can hear tones well outwith our detectable range), secondly we only become aware of a portion of what comes through our sensory organs (we can’t pay attention to EVERYTHING at once), and, thirdly, we then use language and other ways of naming and symbolising all of that information to interact with it. From this perspective, each of us experiences a Symbolic world – our abstracted, selective, processed part of the Real.
Enough of that for now…….taking this model though we can see that there are two ways to die. There is the death of the physical body, and there’s the death of the Symbolic self. In the cases of Barry and Burns, the Symbolic self lives on well beyond the death of the physical body.
I recently saw a patient who is clearly experiencing these two deaths the other way around. Due to a progressively degenerative disease, this person has become unable to continue working in a job which gave them a powerful sense of who they were, and with further decline they have become housebound and socially isolated. Bit by bit, they’ve experienced a death of the Symbolic self, whilst the body lives on, albeit in significantly deteriorated form.

A way forward in this situation is to encourage and support reconnection to others, to Nature, to the sense of “emerveillement” which is always possible in the here and now. In so doing, the hope is to re-invigorate the Symbolic self – our personal experience of reality.

We do die twice, but it’s possible to nurture and to develop the Symbolic self, at least to the point of physical death, but with sufficient creativity, to well beyond that particular event.

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