Archive for May, 2012

Mind the gap

This caught my eye in the lane at the end of my street the other morning.
As I look at it again now, I love the pattern of the leaves, and how the foreground frames the background, and it makes me aware how multi-layered our reality is, and how nice it is to slide your awareness from the leaves, to the light, to the trees in the distance, to the colours and the shadows, and the plants behind the plants, and it just stops me again and I breathe out a long, slow breath and I think “how absolutely amazing it is to be alive”

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I’m always struck by comments from researchers about how many lives may be “saved” if only we would take their recommended drugs. Trouble is, you see, the total number of lives “saved” will always be zero. Drugs might alter your experience of life, but they won’t make you immortal.

As the Onion once famously proclaimed  “WHO announce – Human mortality remains stubbornly at 100%!”

We are creatures. Like other creatures on this planet. But we have evolved something special. Consciousness. With this consciousness comes both self-awareness and imagination, both of which allow us to know that we are mortal. We know we are going to die. We can imagine it. Our problem is…..how do we live with that?

I’ve just finished reading Ernest Becker’s “Denial of Death“. It’s probably one of the most challenging books I’ve ever read. He argues powerfully and convincingly that human beings have both qualities of “creatureliness” (by dint of having a body), and of “godliness” (by dint of our ability to handle symbols and to be able to imagine not just the here and now, but other times, other places and the lives of other people. In essence, we are both biological and symbolic organisms. He lays out the case that the fear of dying is at the heart of what it is to be human, that unlike other creatures which are driven by instinct, we are, instead, driven by this fear. I won’t go into detail in this post, but if you check out the link at the start of the paragraph you can read an excellent wikipedia summary of the book.

Every Saturday it seems there are people in the High Street collecting money for a charity for some disease or other – fight cervical cancer, fight breast cancer, fight diabetes, fight heart disease, fight some other disease. And what if we could for a moment conceive of a world where each, and all, of these diseases were eliminated? Would we still die?

I don’t think a fear of dying is a good basis for a life. I don’t like all the scaremongering of the “Well of Light Brotherhood” types who know with such certainty how the rest of us should be living our lives to reduce our chances of dying.

What do I believe instead?

That we should have a passion for living.

We all die. That’s a fact. It can’t be avoided but it shouldn’t be the one fact which determines how we are to live. Let’s accept our reality and do what we are here to do – live.

How passionate are you about living? What will you do TODAY to live fully and passionately?

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sun sun sun

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Sometimes you find a video which is astonishing in its clarity and impact. Here’s what might be THE best health video I’ve seen so far.
I urge you – take 10 minutes and watch this. I really believe it could change your life.

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Just read Leonora Carrington’s novel, The Hearing Trumpet and was stopped in my tracks by the following passage –

What is the Well of Light Brotherhood? That sounds more terrifying than death itself, a Brotherhood with the grim knowledge of what is better for other people and the iron determination to better them whether they like it or not.

The novel tells the story of an elderly woman put away in a “home” by her son and his wife when her behaviour becomes difficult for them. The home is run by the “Well of Light Brotherhood”.

You know, it seems to me that health care these days is probably run by the same people!!

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Two papers published in the Lancet recently present contrasting views of the future of health care. Researchers in Scotland highlighted the fact that many people with chronic conditions suffer from more than one disease at a time.

The study looked for 40 chronic conditions among the participants’ data. Researchers found that 42% of patients had one or more conditions and 23% had two or more. It also found that only 9% of those with coronary heart disease, had that one disease alone. Similarly, only 23% of those with cancer, had only cancer and no other long-term disease

Why is this such an important point? Well, as the authors of the paper say

“Any country with an ageing population is heading in this direction. All these countries are waking up to the problem. “The status quo isn’t an option because it leads in the wrong direction.” Prof Watt said that rather than more specialists, patients with multiple conditions “need someone who can oversee all the problems of a patient”. “These patients need continuity, and we need ways of measuring how well care is joined-up.”

They highlight the need for more generalist approaches where the patient is seen in the context of their whole life, and that in particular people need continuity of care, co-ordination of care, and individualised care.

Then along comes a different view.  Oxford researchers looked at a single issue – the relationship between cholesterol levels and the chances of suffering from heart disease or a stroke. They conclude
we’ve actually learned is that, whatever your level of cholesterol, reducing it further is beneficial.
and go on to make this remarkable claim
“If we are going to prevent that half of cardiac or stroke deaths, then we’ve got to consider treating healthy people. “It can’t be done any other way.”

Well, that’s a phrase that raises my “aye, that’ll be right!” antennae – anyone who claims “there is no alternative” is pushing their personal view of the correctness of their own opinions too far! We see that with economists, politicians, and scientists. But we live in a complex world and we cannot reduce human life to such simplistic analyses and expect the predictions to work out. The claim of these latter researchers that putting all 50 year olds onto statins for the rest of their lives would “save 2000 lives a year” is pure fantasy.

Which vision appeals to you more? Individualised, holistic care, or mass medicating based on age alone?

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I use a three phase cycle when teaching medical students and doctors.
Phase one is the story.
Phase two, making sense of the story.
Phase three, a therapeutic action.
All doctors have been trained to start with the patient’s story. Sounds simple, and at one level it is, but what makes it complicated is that in every story there is an author and a reader. The patient is the author, and the doctor is a reader. But neither of these roles exist in isolation and the consultation in this phase is a process of co-creation. Both the patient and the doctor bring their stories into the room and, together, they co-author a new story.
Most of these narratives are very, very short stories. Typically less than ten minutes. I remember being very struck by a study which measured how long into a consultation before the doctor first interrupts the patient’s story – 18 seconds. In such short consultations the doctor is seeking to focus and direct the story right from the outset. He or she will decide which story lines to close off, and which to open up. The goal is to quickly move on to phases two and three.
What sense can I make of this patient’s story? Another way to think of this making sense phase is to see that it is about achieving an understanding. The doctor is trying to understand the patient, and the patient is trying to understand their experience. In fact the declared aim of medical undergraduate education is to teach doctors how to make a diagnosis (diagnosis means an understanding). Sadly, the biophysical model and short consultation approach to medicine means that diagnosis is reduced to discovering the presence or absence of a lesion. It’s not about understanding a person in the context of their life, nor about understanding their “illness” in a whole of life context.
The reduction of the understanding phase to the declaration of a clinical label which is then called a diagnosis sets the limits of the third phase – treatment.
The therapeutic interventions are intended to reduce or contain the diagnosed lesions. If no lesions are found, the intention becomes one of reducing the symptoms.
At every stage of this cycle there is a narrowing of vision, which reduces the story to a data set which will be judged as either normal or abnormal. Treatment is then either a surgical procedure or the prescription of drugs to try to alter the data.

What’s the alternative?
Broadening the focus at all stages.
Expand the story from a biophysical one to at least a biopsychosocial one and a story of a person replaces the story of a disorder.
Expand understanding from diagnosis of a lesion to understanding the emergence of an illness in the context of an individual’s life and a person can make sense of their experience.
Expand the interventions on offer beyond surgery and drugs to methods which increase vitality and resilience and a person can experience greater health.

Recommended reading –
Read Arthur Frank’s The Wounded Healer, Kleinman’s Illness Narratives or Cassell’s The Healer’s Art, to better understand the importance of narrative in the shift from biophysical to biopsychosocial.
Read Balint’s The Doctor, the patient and his Illness, Leader and Corfield’s Why do People Get Ill? Or Broom’s Meaning-full Disease to better understand the shift from a disease to an illness agenda.
Read Dan Siegel’s Mindsight, Doc Childre’s The Heartmath Solution or David Servan-Schreiber’s Healing without Freud or Prozac to understand the potential for interventions which don’t involve surgery or drugs.

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Quite a headline, huh? It caught my eye on ScienceDaily.

The article is about a Norwegian research study which has estimated the amount of morbidity caused by prescribed drugs. By morbidity they mean things like –

new medical problems (adverse drug reactions, drug dependence and intoxication by overdose) and therapeutic failure (insufficient effect of medicines and untreated indications).

Of course if you have a look at the fine print on the little bits of paper included in packets of prescribed drugs you’ll be aware that the potential “new medical problems” they can cause is often a pretty extensive list. It’s interesting to see them considered as three separate categories however. All drugs have the potential to cause direct harm in the form of “adverse drug reactions”. We call these “side effects” and some are pretty minor, but some can end a person up in hospital, or even cause death (10,000 deaths a year in England was one estimate ). Most people are pretty aware of the potential that drugs can cause side effects. I think most people are probably also aware that too much of any drug will likely cause harm, and that’s the category “drug overdose”. Most frequently this is not a deliberate act of self-harm, but the taking of too high a dose to try and achieve the claimed effect of the drug – more painkillers, more sleeping tablets, more tranquilisers. The third category is “drug dependence” and I think a lot of people associate that with illegal drugs – heroin, cocaine etc. But in fact, drug dependence has both physical/chemical aspects related to the way a drug changes our inner environment, and psychological ones where people begin to believe they couldn’t stop or reduce their prescribed drugs.

This study goes beyond these three categories however, and includes “therapeutic failure”, again subdivided, this time into two categories – “insufficient effect” and “untreated indications”. In other words, where people take a prescribed drug and it doesn’t do what the doctor intended it to do. This occurs much more frequently than people think (despite the young doctor who told me she’d been trained – “if a patient takes an evidence based drug and doesn’t get better, either they haven’t taken the drug, or they are lying”). Dr Roses of Smith Kline Glaxo said

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

The estimate of this drug-related morbidity in this study is just over a half of all the people who take a prescribed medicine. Is that a shocking figure? I think so.

When I trained as a GP, I was taught to take a holistic approach to patients, and to be cautious about prescribing. I was taught values which included not prescribing a “pill for every ill”. It seems that prescribing is on the up. (“Prescriptions for antidepressants have risen by 43% in the past four years to nearly 23 million a year, NHS figures reveal.” and “The total number of prescription items dispensed increased by nearly two thirds between 1998 and 2008,” )

Not only is there a pill for every ill now, but even people with no symptoms of illness are being prescribed life long medication in an attempt to prevent them becoming ill. Sadly, over half of those people, who aren’t actually sick, will suffer from this preventive strategy.

What happened to the medical value of “first do no harm”? Shouldn’t we developing ways of improving and sustaining human health which don’t involve using drugs which have such a potential to cause harm? And saving the drugs for the situations where their potential harms are outweighed by their potential benefits? That’s the strategy we employ at the NHS Centre for Integrative Care in Glasgow. It’s a strategy I’d like to see more of.

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cloud and hill

I swear the view from my window amazes me anew every single day. I mean, just look at THIS!
Goodness, what an amazing dance of water on the earth. I’ve never seen the clouds and mist caress the folds of the mountain like this.
Just beautiful

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Tokyo Station by night.

I’m amazed to watch the constant snaking in and out of the station of the long, long trains they have here in Japan. From the 32nd floor here it looks like a giant train set (if only I had a bank of remote controls!)
But as I gaze down on all this activity I wonder, not just at the mind boggling complexity of making it all run so smoothly, but I wonder where everyone is going?
We’re a busy species, aren’t we?
Weird, therefore, to sit in the hermetic almost-silence of a high rise hotel room, watching, but not hearing anything other than the raindrops hitting the glass, and the muffled murmurings of the trains like waves breaking on the shore, or a distant creature breathing…..

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