Archive for February, 2013

The GMC has recently revised its guidance on prescribing. Here’s the relevant paragraphs related to what a doctor is expected to do before they issue a prescription –

3. For a relationship between doctor and patient to be effective, it should be a partnership based on openness, trust and good communication.  Each person has a role to play in making decisions about treatment or care.
4. No single approach to discussions about treatment or care will suit every patient, or apply in all circumstances. Individual patients may want more or less information or involvement in making decisions depending on their circumstances or wishes. And some patients may need additional support to understand information and express their views and preferences
5. If patients have capacity to make decisions for themselves, a basic model applies:
a. The doctor and patient make an assessment of the patient’s condition, taking into account the patient’s medical history, views, experience and knowledge.
b. The doctor uses specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which investigations or treatments are likely to result in overall benefit for the patient. The doctor explains the options to the patient, setting out the potential benefits, risks, burdens and side effects of each option, including the option to have no treatment. The doctor may recommend a particular option which they believe to be best for the patient, but they must not put pressure on the patient to accept their advice.
c. The patient weighs up the potential benefits, risks and burdens of the various options as well as any non-clinical issues that are relevant to them. The patient decides whether to accept any of the options and, if so, which one. They also have the right to accept or refuse an option for a reason that may seem irrational to the doctor, or for no reason at all.
d. If the patient asks for a treatment that the doctor considers would not be of overall benefit to them, the doctor should discuss the issues with the patient and explore the reasons for their request. If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient, they do not have to provide the treatment. But they should explain their reasons to the patient, and explain any other options that are available, including the option to seek a second opinion.
What interests me most about this is that the GMC is absolutely clear that health care is a partnership. We often seem to deliver health care as if the expert knows everything and the patient knows nothing. But, in fact, the GMC expects that doctors will act more as expert advisors to enable patients to make their own choices, and that whilst the doctor does not need to defer to the patient’s choice, neither does the patient have to defer to this particular doctor’s choice.

Read Full Post »

There is a big difference between what is complicated and what is complex.
A machine can be very complicated. As cars have become ever more sophisticated they have become more complicated. It’s not easy to see what’s wrong when your car breaks down, unless you have learned how it works.
Machines are made up of different parts, and there may be hundreds or thousands of parts in a machine but we can still learn exactly how it works and how to fix it by learning bit by bit just how each part works and how it affects any other part.
People on the other hand are complex. We also are made up of many many parts, billions and billions of cells, each of which is an agent acting on many other cells, and each of which, in turn is acted upon by many other cells. In fact, through the multiplicity of interactive connections which exist, it becomes impossible to deal with any single part in isolation, or, indeed, to be able to accurately predict the over all effects of any single change. It’s parts don’t necessarily function the same way in isolation as they do when under the influence of their multiple connections.
This structure makes the organism a complex one, not a complicated one.
Here is the key difference –
A complicated structure can be understood by understanding its individual parts.
A complex one can only be understood as a whole.

Read Full Post »

This week I sat next to a student on the train. She was revising her notes on “clinical research”. I was struck by her list of keypoints under the heading “the scientific method”

  • Observation
  • Description
  • Explanation
  • Prediction
  • Control

I have a life long interest in science, but for me, science is just one form of enquiry. I’m actually an insatiably curious person. I love learning. I’m constantly reading. I read on the train, I read in cafes, at home, at work, everywhere. Having a kindle reader on my iphone and my ipad has made it even easier to weave reading into my day. I have thousands of books in my own library. I have google searches set up, rss feeds delivered to my MrReader app, Flipboard and Zite apps on my ipad…..I’m a reader!

But I’m also a photographer and a writer, as you can see if you browse through this blog. And I’m a thinker. I love to learn, to reflect, to understand. I love that every work day I get to spend time with people and try to understand them.

I observe, I describe and I explain.

But predict? I’m not so keen on that one. I find life so complex and every human being so unique, that I find it impossible to predict the future. In broad brush terms, or in generalisations, or statistical probabilities I can have a bash, but I know that for this person, right here, right now, I can’t predict how things will go.

And control?


No thank you. Way too much compliance and control going on in our society for my liking and it doesn’t seem to be improving much. I’m a lot more keen on values than I am on control.

Is science about control? I thought it was about discovery and wonder. I thought it was about learning with every new insight that we have more to learn.

I was very impressed the first time I read Deleuze and Guattari who described three ways of thinking

Art – which is thinking about percepts and affects

Philosophy – thinking about concepts

Science – thinking about function

I like that. Science for me is about discovering patterns, and getting some insights into how something works. That’s what I loved about my undergraduate medical degree – discovering the anatomy, physiology, biology of how the body works. It’s been years and years of daily medical practice, of reading, of reflecting and of thinking, which has brought me to my present place of understanding how a person works. And I sure haven’t got all THAT figured out!

There’s something that jars with me about science directed towards control. But maybe that’s because I don’t like to be controlled!


Read Full Post »

Health is not a THING.

Health is not an entity or a product.

Health is more than the sum of the set of “normal” measurements.

Health is a lived experience.

As an experience, health is a characteristic described by the experiencing person, by the subject. Without a person to experience health, there is no health.

So, why do we deliver health care by treating diseases and people as objects, or by processing people to reach pre-determined targets, which might have precious little to do with the experience of health?

The shocking report on Stafford Hospital, suggesting between 400 and 1200 patients might have died due to the way they were treated in the hospital concludes that

“There was a lack of care, compassion, humanity and leadership,” he said. “The most basic standards of care were not observed and fundamental rights to dignity were not respected.”

Chris Ham of the Kings fund says

The priority must be to shift from a culture in which the behaviour of staff is driven by compliance with targets to one in which there is a real commitment to patient-centred care in every hospital and surgery

But so far the government’s response seems to be to drive towards greater compliance with tougher regulation and inspections.

The problem isn’t one of control, it’s one of “care, compassion and humanity”. How did the Health Service come to this?

Increasingly we treat health care delivery in the same way we treat a business or a factory, by measuring, standardising, and enforcing compliance. None of that seems to be improving the experience of health care because none of that is based on the fact that health is a lived experience, not a product.

Every single human being is unique.

Every life is unpredictable.

A truly patient-centred care will consider the uniqueness of the individual at all stages in the health care journey, and will require imagination – the imagination needed to enable health care workers and managers to imagine what it would be like to experience what the patients are experiencing.It will also take a lot of non-judgemental listening. Without really hearing a person’s story, we fail to know their uniqueness, fail to comprehend or consider their beliefs, values or wishes.

The Stafford story is not the end of the story. It’s probably the tip of an iceberg. Maybe now is a wake up call for all of health care. Maybe now is the time to reconsider the commodified, reductionist, materialistic basis of the current model which pushes more and more drugs into more and more people every single year, and processes more and more people through hospital beds ever more quickly.

After all, if health is an experience, we should design health care around making personal experiences better.

Check out the manifesto for slow medicine.

Read Full Post »

Ocean steps

I so admire the way John O’Donohue expressed himself. Here’s a phrase he used in his interview with Krista Tippett.

The ancient conversation between the ocean and the stone

He mentioned this in discussing the relationship between the visible and the invisible. I especially liked the way he describes

the visible world is the first shoreline of the invisible world

and how he said that human beings are THE PLACE WHERE THE INVISIBLE BECOMES VISIBLE.

In another interview, I heard David Sloan Wilson say that

Evolution only sees action. Whatever goes on in the head is invisible to evolution unless it is manifested in what people do.

But see, if John is right, and I think he is, then the human being is the place where the invisible becomes visible. Yes, that is partly through our actions, or our choices which lead to our actions, but it is also through our very bodies. Everything that occurs in that inner invisible world, and most of what occurs is not accessible to the conscious mind, changes the way our bodies and our brains function. Those changes continuously interact with the world in which we exist. Even our rate of breathing changes the gases in the air around us. As bodies warm up, so does a room, and as a room warms up, so the body responds. In countless, continuous ways, what happens inside us changes the world outside us, which in turn, changes the world inside us.

We are in continuous ancient conversation – between our invisible reality and our visible reality.

It strikes me that it is pointless to think of a human being as if the invisible is irrelevant, unimportant, or in any way of lesser significance to visible, “objective” reality.

Read Full Post »