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Archive for October, 2011

In a BMJ article about personal health budgets, the chair of the Royal College of General Practitioners in the UK, Clare Gerada, says

“Should we be spending taxpayers’ money in cash strapped systems on gardening or aromatherapy that may make people feel better, but for which there is no evidence that it actually makes them better?”

This statement is a great example of the power issue at work in the practice of Medicine. The issue of personal health budgets is about the extent to which patients should be given the power to decide about what health care they want to receive. Dr Gerada uses this term “actually makes them better” – what does that mean? If someone who is suffering from a chronic incurable disease (and which chronic diseases are “curable”?) presents with terrible pain, or incapacitating fatigue, or paralysing anxiety, then what exactly is the definition of “better” – is there a “real” better and a “pretend” better? Surely, only the person themselves can tell whether or not their suffering is less, and only the person and their friends and family can tell if that person is now living a “better” life?

This use of “actually” is typical of doctors who reduce illness to lesions. They are thinking about someone who has less pain, but has no change in their underlying pathology – their MS plaques for example. Is that a sensible way to think about illness and health care?

There is a struggle going on, and it’s a power struggle. There are “experts” who think they are the only people who know what is best for patients. I don’t agree with them. If you ignore what the patient is telling you, if you ignore the “evidence” of the person’s life, then you’ve lost the plot!

Patient centred care means putting the patient at the heart of the care – not ignoring them or dismissing their reports of what is helping because “the evidence” doesn’t agree with this patient’s experience.

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One of the main themes of this blog, and probably a core theme of my daily work as a holistic, integrative doctor, is the place of narrative in our lives.

I recently mentioned in another post that working with patients’ narratives was a part of what I and my colleagues do every day at the Centre for Integrative Care in Glasgow. A couple of readers have asked me to say more about that and I thought I’d pull together some thoughts into this post.

One of the first books I read which impressed me about the importance of stories in medical work, was Arthur Frank’s “The Wounded Storyteller”. In this book, which is the product of years of research, Frank claims that there are two very common types of story patients present to clinicians – “restitution” stories, and “chaos” stories. He proposed that we can think of these as two primary “genres” of story. The former is probably the commonest in biomedicine healthcare. It can be captured with the phrase “I’m broke, please fix me”. It’s an approach to illness and health which considers that disease is a dysfunction or lesion somewhere and that if the bit that’s wonky could just be fixed then all would be well. The latter is also very common, especially when there are a multitude of symptoms and the person has  become lost in the illness.

Frank proposes that a clinician’s job is to help patients turn these stories into “quest stories” – based on the principles of Joseph Campbell’s hero narrative.

The integrative journey from stuckness or chaos to flow and coherence emerges out of this creation of a new narrative.

Another reason to work with narratives is the human need for myth creation. We are meaning seeking creatures, and the myths, or universal stories, as Karen Campbell calls them, shape our lives. So it makes sense to understand which myths we’ve incorporated into our stories.

Shifting from the materialistic, reductionist myth to a soulful, heart-focused, holistic one, allows the creation of a much more positive story, one which brings hope, and which opens up the possibilities of a different future path.

A key component of the creation of a future with a more clear set of potentials is choice. William Glasser’s Choice Theory, turns our narratives on their heads, and focuses us on the verbs we use to describe our experience. What emerges is a much more autonomous, more powerful story – a shift from passivity to activity, from victim to autonomous individual, from zombie to hero.

But it’s not just the verbs in our stories which are important. It’s the metaphors too. The amazing work of Lakoff and Johnson demonstrates the embodied nature of metaphor, and in so doing gives us the opportunity to pick up on the metaphors we are using, including the bodily locations of our diseases or disorders, and gain a profound understanding of the meaning of our illness experiences.

I hope for stories of improvement as I work with patients, but the stories which excite me the most, are the ones of transformation. Yet again, this week, I’ve heard several such stories. That makes it a complete thrill and delight to be able to practice Medicine this way.

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Deric Bownds highlights the conclusions of an interesting book about psychological change – “Timothy Wilson’s new book “Redirect: The Surprising New Science of Psychological Change.”

The part which caught my eye was the conclusion –

Wilson uses the thought-provoking metaphor of “story editing” to describe the ingredient common to many of the successful interventions he reviews. They alter the narratives people tell themselves about their world and their place in it: Is it safe or threatening? Do I belong or not? Am I capable or not? During sensitive periods, people’s storytelling can be redirected and the change can build on itself over time. Amend the opening sentence of the story of your transition to college, or to a new job, and the arc of your story may be entirely different from what it would have been otherwise. This helps explain why seemingly simple interventions, such as writing about a traumatic experience, or volunteering for a humanitarian cause, improve health and well-being. They give people an organizing narrative that puts their lives in an optimistic context.

Well that’s certainly my experience. That’s the focus of our everyday work at the Centre for Integrative Care in Glasgow – helping people to write new narratives of their lives (or what I’ve described as helping people to become the heroes of their own stories)

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Autumn

At this time of year, I look out of my consulting room window and the sudden redness of the leaves on this tree catches my eye. It’s one of my personal markers of change.
Change is a certainty in life, but we often resist it.
I think we are all experiencing big changes in the world today. That can be scary, and one response is to cling even harder to how to things are, but clinging doesn’t help.
It’s better to embrace change. After all, not only is it impossible to prevent the leaves turning red, but in fact the change is beautiful. In fact, it puts me in touch with the cyclical phenomena of nature, of the rhythms of season and time.
Take a look again at the byline at the top of this blog – “becoming not being” – there’s a lot to be gained by tuning in to becoming….

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Sometimes I wonder what the big idea is in modern medicine. It seems like its drugs. Drugs for symptoms. Drugs to “manage diseases”. Drugs for healthy people to “prevent diseases”. Drugs to make you happy. Drugs to help you cope. Is it any wonder that health care organisations throughout the world are creaking under the soaring costs of more and more and more drugs. “Evidence based medicine” hasn’t helped – it’s all about prioritising drugs.

So, when I saw this ad on the front page of the free newspaper lying on the train the other day, I thought……well, tell me, what do YOU think?

 

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Pamela Hartzband, MD and Jerome Groopman MD from the Beth Israel Center writing in the New England Journal of Medicine make a strong plea for a return to professionalism and humanity in health care. Here’s the problem, as they see it….

We are in the midst of an economic crisis and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy makers have proposed that patient care should be industrialized and standardized. Hospitals and clinics should be run like modern factories and archaic terms like doctor, nurse and patient must therefore be replaced with terminology that fits this new order

It strikes me this current model of health care is not sustainable. Drug costs are spiralling way out of control and those in power seem to think the answer to health problems is to use a “Fordist” solution, creating health care facilities as factories – treating the mass with pre-ordained treatment plans delivered by people with technical skills.

They highlight the distorted use of “evidence based” approaches as a key problem

the new emphasis on “evidence-based practice” is not really a new phenomenon at all. “Evidence” was routinely presented on daily rounds or clinical conferences where doctors debated numerous research studies. But the exercise of clinical judgment, which permitted the assessment of those data and the application of study results to an individual patient, was seen as the acme of professional practice. Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts.

This “industrial” way of delivering health care diminishes the professionals as much as it does the patients.

Recasting their roles as providers who merely implement prefabricated practices diminishes their professionalism. Reconfiguring medicine in economic and industrial terms is unlikely to attract creative and independent thinkers with not only expertise in science and biology but also an authentic focus on humanism and caring. When we ourselves are ill, we want someone to care about us as people, not paying customers and to individualize our treatment according to our values. Despite the lip service paid to ‘patient-centered care’ by the forces promulgating the new language of medicine, their discourse shifts the focus from the good of the individual to the exigencies of the system and its costs. We believe doctors, nurses and others engaged in care should eschew the use of such terms that demean patients and professionals alike and dangerously neglect the essence of medicine

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Stumbled across this quotation from Mencken yesterday –

“When they speak of the dangers of Americanization… [it] may be described in general, as the decay of spiritual values that has gone on among us during the past two generations. It may be described, in particular, as our growing impatience with the free play of ideas; our increasing tendency to reduce all virtues to the single one of conformity, our relentless and all-pervading standardization. This is what all Europe fears when it contemplates the growing importance and influence of The United States… By Americanization it means Fordization – and not only in industry but also in politics, art and even religion.”

When I read this, a passage from Seth Godin’s “We are all Weird” sprang to mind….

Mass is withering. The only things pushing against this trend are the factory mindset and the cultural bias toward compliance.

The control culture is crumbling. Remember that classic Apple ad?

Think Different

Celebrate your uniqueness. You really are a one off, and nobody, but nobody is a better expert in your personal experience than you are. We should resist being standardised. Be a hero, not a zombie.

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