Heroes Not Zombies

Henning Mankell, who you might have heard of as the author of the “Wallander” books, has been diagnosed with cancer and has written a series of articles about his experience of the diagnosis and the treatment.

That same evening my wife, Eva, told me about something she had heard on the radio. A doctor had been talking about the art of medical treatment. “Nobody talks about ‘the art of medical treatment’ nowadays,” she said. “But that’s what it all boils down to, even so.” She is right, of course. When you have lived for almost 70 years, as I have, you have quite a wide experience of doctors met over the years. Doctors in different situations, in different countries. I don’t think I’ve ever come across an absolute dud, somebody I’ve run a mile to get away from. Obviously, some have been more capable than others; some have been impatient or preoccupied; others have seemed to have unlimited time available. But the doctors I remember most clearly are those who have displayed what can be described, certainly by me, as the innermost subtleties of the art of medical treatment. Alleviation, consolation, perhaps even cure, always involves a dialogue in which the patient and doctor learn how to talk to one another, and if possible create a continuity. Medication and other treatments are never enough in themselves. If the patient doesn’t understand what the doctor is saying, or if the doctor is unwilling or unable to interpret the questions and worries of the patient, the dialogue that is at the very heart of medical treatment will never materialise.

So, what is this? This art of medical treatment? There are some clues in Henning’s words – a dialogue; continuity; the creation of a relationship; the need to understand each other; opening a space to allow the patient’s questions and worries to be expressed and the ability to interpret them.

Why use the term “art”? Well, it’s partly to differentiate this aspect of medical practice from the science which is also required, and partly to refer to the craft, or skill, of the therapeutic relationship. These are people skills, communication skills which require non-judgemental, empathic listening. But I think the “art of medical treatment” is even more than that. It invokes a consideration of what medical treatment is.

What is the purpose of medical treatment? What is a doctor seeking to do with each and every consultation? Surely, it’s an attempt to assist a person to a better life. It’s not just about prescribing, or surgical interventions…..as Henning says “Medication and other treatments are never enough in themselves” – not that treatments are unnecessary – they just aren’t enough.

I feel the same way about diagnosis. It’s one thing to diagnose a disease, but it’s quite another thing to understand a person and their illness. We need our scientific knowledge to diagnose diseases, but we need our art of medical treatment to understand a person and their illness.

I’m struck by the relevance of Henning Mankell’s reflections for me at this point, as I reflect on my medical career, and am blessed to have patients share with me just what it is that they valued about their care over the years – you can read about that here. To summarise, it seems to me, they are telling me what they valued was my “art of medical treatment”.

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I think there are many problems with what is known as “Evidence Based Medicine” (not least being the influence of vested interests such as Pharmaceutical companies on the production of “evidence”), and there is an interesting consideration of some of the issues in the BMJ. The paragraph on patients with multi-morbidity ie patients who are suffering from more than one chronic ailment at the same time caught my attention.

as the population ages and the prevalence of chronic degenerative diseases increases, the patient with a single condition that maps unproblematically to a single evidence based guideline is becoming a rarity. Even when primary studies were designed to include participants with multiple conditions, applying their findings to patients with particular comorbidities remains problematic. Multimorbidity (a single condition only in name) affects every person differently and seems to defy efforts to produce or apply objective scores, metrics, interventions, or guidelines.

Both the first and the last sentences of that paragraph really strike me.

“the patient with a single condition that maps unproblematically to a single evidence based guideline is becoming a rarity” – really? Who actually “maps unproblematically” to a guideline? No wonder they say it is becoming a rarity. Was it ever not so? Every single human being is unique. Each one of us has a unique genetic code, is born in a particular place at a particular time and lives a unique life, full of specific life events, challenges, difficulties, opportunities. Each of us tells an utterly unique life story when we sit with a doctor. That story is influenced by the past which is still active within us, and by our values, beliefs, preferences, our sensitivities, our coping strategies and our personal priorities. Biologically each of us is an open, dynamic system. We are continuously being influenced by, and are influencing, the environments in which we live. We never stay the same. At each stage of life we have different bodies and different minds from what we had before and we live in a world which previously never existed. If you’ve ever sat in a consulting room day after day, with patient after patient, you’d know that mapping individuals unproblematically onto guidelines is a fantasy.

“Multimorbidity (a single condition only in name) affects every person differently and seems to defy efforts to produce or apply objective scores, metrics, interventions, or guidelines” Even the most diehard statistics fans know this one. The more conditions a person has, the more difficult it is to predict how things are going to go, which treatments are going to work well for them, and which are going to do them harm. It’s worth remembering that there is no evidence for polypharmacy. Anywhere. The truth is individuals are so unique that even those with a single diagnosis will not experience the same course of the disease, will not get the same results from the same treatments, and will not experience the same particular side-effects or harms. The problems which are highlighted in the situation of multimorbidity still exist in situations where a single disease has been diagnosed. The problems multiply for sure, but there isn’t a situation where they don’t exist.

Sometimes I think there is only one “best” evidence base when treating a person, and that is the ongoing, careful, humble, consideration and understanding of what this person is experiencing. Whatever treatment is given, only this patient’s unique experience is the final arbiter of its usefulness. Not some statistics-oriented guideline produced by a non-clinician who will never have any interaction with this patient.

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Does this bother you?

It obviously bothers the investors who wiped $1 billion off the share value of GSK after this story appeared.

Dr Peter Gøtzsche, the founder of the Nordic Cochrane Centre, recently described drug companies of behaviours which we would normally attribute to organised crime. He strikingly said

The main reason we take so many drugs is that drug companies don’t sell drugs, they sell lies about drugs.

A post I wrote a couple of years back about GSK being fined $3 billion mentioned that between 2009 and 2012 drug companies had paid $11 billion in fines. ProPublica summaries some of the biggest fines from 2009 to 2014 here.

An analysis by Dr Syndey Wolfe at the end of 2013 showed Big Pharma had paid $30 billion in fines from 1991 to 2012. He concluded

“There is a pathological lack of corporate integrity in many drug companies.”

Well fines like these, large as they seem to be, aren’t stopping these behaviours and why is that?

Over the past decade, the 11 largest global drug companies reaped about $711 billion in profits, according to a new analysis from the Health Care for America Now (HCAN) advocacy group. In 2012 alone, the drug companies’ annual profits totaled nearly $84 billion.

No wonder there are profits like this. A recent report titled “Health, United States, 2013” — found

the percentage of Americans taking prescription drugs has increased dramatically. During the most recent period, from 2007 to 2010, about 48 percent of people said they were taking a prescription medication, compared with 39 percent in 1988-1994.

and

One in 10 Americans said he or she had taken five or more prescription drugs in the previous month.

and, shockingly,

About one in four children took one or more prescription drugs in the past month, compared to nine in 10 adults 65 and older, according to the study.

Don’t you think we have a problem here?

Are prescription drugs the best way to increase the health of human beings? And if it is, why are more and more people needing more and more drugs? Or are more and more drugs being prescribed because of the way drug companies behave?

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