Archive for May, 2013

Raindrops on petals

Ok, so it was a really rainy day in Glasgow, but raindrops on petals are SO beautiful

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How can a doctor practice holistically? Intention and attention are certainly fundamentals but there are concepts and mental frameworks which set up holistic care. Here are three key ways to make holistic care happen.

1. Looking for connections

If a human being is considered as a complex adaptive system, then symptoms and physical changes in individual are understood to be connected. Every part of a complex adaptive system can act on, and, in turn, be acted upon, by other parts. So what’s the connection between this symptom and another one? How are all the symptoms connected up? Looking to see what connections there are develops the focus from parts towards the whole.

Within a human being we can become aware of whole systems of interconnection. The fields of psychoneuroimmunology (the interaction between the mind, the nervous system and the immune system), psychoneuroendocrinology (the mind, the nervous system and the endocrine system), and in more recent times, interpersonal neurobiology (the links between the mind, the brain, and others), have all advanced our understanding of the interconnectedness within a human being, and between an individual and their environment.

2. Looking for context

Every living being is in constant active relationship with multiple environments, physical, social, cultural, temporal. A holistic approach entails seeing the individual within their particular environments and understanding how they are related. In other words, exploring the contexts of the person, their health and their illness.

A reductionist approach de-contextualises phenomena. Randomised, controlled trials, for example, claim to “control for” contextual factors and study individual phenomena without those influences and relationships. I have serious doubts if such approaches are ever really achievable, but even if they were, the findings would need to be re-contextualised to make sense of an individual life.

In a holistic approach, context is always important.

3. Stories and metaphors.

I’m particularly fascinated by individual stories. Every person I see tells me a new story, and its always a fascinating one. We make sense of our lives through story. We understand the present in the light of both the past, and of future hopes and fears. We gain a sense of Self through story. We understand each other through the shaking of our stories.

For me, narrative is the core of a holistic approach.

There is also one very intriguing element of an individual story which, when it manifests itself is like a nugget of gold, the embodied metaphor. For example, the person who presents with an eye problem whose core issue is that “my family don’t see things the way I see them”. The whole area of embodied metaphors is a fascinating one and if it appears in someone’s story, it can be the key to resolving the problem.

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I think of myself as a holistic doctor. But what does that mean, and how can I practice holistically?

One way to understand the holistic approach is to consider what we attend to, and what we intend.

By attend to, I mean what do we pay attention to, or focus on. In training I was taught to focus on parts and pathologies and that’s the core focus for most medical care. We create our health care systems around parts and pathologies. That’s why hospitals have a Dermatology Department, a Chest Clinic, a Gynaecology Department, a Gastrointestinal Clinic etc. All of these services focus on body parts (which are members of certain body systems or regions) and on trying to treat the pathologies discovered in those parts. General Practice, in the time of Balint and the creation of GP Training Schemes in the UK, was built around a focus on the person and the relationship between the doctor and the patient. The core of good General Practice was seeing this patient not as another case of disease x, but as John Smith, the 52 year old farmer, whose wife died last year in a car accident, and whose dairy farm is barely paying its way, whose father died of a heart attack aged 52, and who has phoned you to say he has been getting pains in his chest for the last three days. However General Practice has been reconstructed in recent years around pathologies and diseases. Now the average GP Practice has an Asthma Nurse, a Diabetic Clinic, a target to check blood pressure readings and smoking activities and an appointment system created to facilitate fast, problem-orientated consultations.

Holistic care involves a focus on the person, not the part. Any problems or pathologies are considered within the context of the person, not the other way around. Who is this person who I am speaking to? How do they live? And what are experiencing that is disturbing or distressing them? How is this disease experienced by them, and when and how did it appear in their life?

I attend to the person, and the person’s individual experience (revealed through the telling of their story, through their non-verbal communications and through the changes in their bodies)

What do I intend? The therapeutics taught in medical training is intended to manage disease. Doctors might talk of cures (rarely, in my experience) but particularly in the area of non-communicable chronic illness the intention is to control symptoms or limit further progress of pathology. There are no cures for asthma, diabetes, high blood pressure….. or any chronic disease. Diseases are managed by the prescription of drugs, and those drugs are for life, because they are not intended to produce healing.

Healing – there’s another word you don’t hear doctors use much. But surely all health care should be about healing (if healing means moving in the direction of greater health). Health, if it improves in patients receiving these treatments, is a kind of side effect. It appears, hopefully, as the disease or pathology reduces.

In my daily work, I, and my colleagues, intend to heal. Does that mean we try to cure? Well, to answer that would open a debate about what is cure, and I’ll leave that for another day. Let’s say we intend to maximise health. I don’t know any cures for MS, or asthma, or diabetes, but I do know that patients with those illnesses can experience different degrees, or levels of health.

My intention is to maximise health through stimulation and support of self-regulation and self-repair, and in so doing the patient will experience the care as healing. The way we try to mobilise self-healing is through care which is integrative. Integrative care is any intervention or therapy which increases the amount of integration, or coherence, in the person.

I do not believe that holistic = good, and disease management = bad. We need good disease management. Good disease management in acute care will save a life today. Good disease management will improve the quality of someone’s life by controlling symptoms and inhibiting the progress of pathology. But it takes holism to maximise healing and bring the best possible health experience to a person.

If we are providing health care, surely somewhere in the system, there needs to be the intention to heal, and is there ever a case for not attending to the person, but only attending to the pathology?

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One of the characteristics of health is resilience. But what is resilience?

One definition is –

Resilience is the capacity of a system to absorb disturbance and reorganise while undergoing change so as to still retain essentially the same function, structure, identity, and feedbacks.

I like this definition. It captures the essential elements of reorganisation and change whilst retaining integrity and coherence. In other words, when something disturbing happens (and in health terms that can be anything which is a biological stressor – infectious organisms, chemicals, drugs, injuries or operations, or psycho-social stresses ie significant life events) then the system, or the organism, makes an adaptive response. The response has two aspects – defence, which tries to maintain the internal status quo, and reorganisation, which produces change within. Both are necessary, and whilst they can seem like opposites, both functions are required.

When someone is resilient they are less likely to be infected when a bug is doing the rounds, less likely to be overwhelmed or blown off track by major life events, AND they are more likely to recover and repair when damaged, but, more than that, are more likely to change, develop and grow.

As Prigogine demonstrated with his concept of “dissipative structures”, living forms develop and grow by falling apart. Reorganisation involves elements of breaking down, or dis-organising what is already there, and of putting things back together but in a new way.

How do we maximise resilience?

I read a paper recently which considered the phenomenon of resilience in relation to “fragile states” and the author highlighted two ways to maximise resilience.

Firstly, to develop “resilience-sensitive” policies (or actions), and, secondly, to create the conditions which support resilience. I think both of these ideas are useful in thinking about resilience in health care.

Our treatments should be “resilience-sensitive” ie if a drug, or an operation, or whatever other treatment is used impairs resilience it is less likely to be effective than one which at worst is neutral, but at best, is stimulative or supportive of resilience. How often do we think of this aspect in health care?

Secondly, how do we create the conditions to foster resilience? That’s a question that crosses the boundaries from the personal to the social and political. There are environmental, societal and economic aspects to that question. Is a polluted environment going to be conducive of resilience? What about an unsafe community? And what about the increasing inequality in income distribution? At a personal level, what about emotional intelligence? What about food? What about exercise? What about Nature?

What do you think?

What could you do to foster and maximise your resilience?

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No matter how often I see this, it fills me with wonder. How great to be able to slide back the consulting room glass door, step outside, and capture this abundance of buds and early blossoms. These simple pleasures make it great to be alive.

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