Heroes Not Zombies

Steven Charlap tells the story of the failure of his MDPrevent business which he had to close down last month. It’s an honest and thought provoking reflective piece. His idea was to have a medical practice which focused on health instead of disease, which advised patients and supported them in making lifestyle changes instead of prescribing for them. It didn’t work out. For a number of reasons……he didn’t get enough referrals from other health care providers, had many problems with health insurance companies, and, he says, the patients weren’t really up for it.

Based on our review of the credible research, our model mostly excluded dietary supplements and multivitamins because the science mostly did not support their use. When it came to pharmaceuticals, we didn’t rush to prescribe if there were a non-drug alternative. This approach was a turn-off to many patients who expected a prescription or emphatically clung to beliefs in supplements. And the no-cost, no-deductible, no co-payment provisions in Medicare’s preventive benefits may have had an adverse effect on people’s sense of its value. How much would you appreciate something that has no cost to you? For many patients, it seemed easier to take supplements than to be more attentive to food labels and exercise habits.

I have a lot of sympathy for this doctor. I think the present system of health care is not about health, and is not sustainable. I’m not so sure about the emphasis on prevention however…..let me explain – to prevent something has a negative tone for me, and I think health is a positive attribute. I prefer a focus on positively creating health, rather than negatively trying to prevent, or avoid disease.

His conclusion is particularly striking –

Patients loved my practice because I was willing to spend up to two full hours with them, most of it not reimbursed by insurance. The extra time often meant successfully making a diagnosis that had eluded other doctors for many years. It takes a very long time to get a thorough history and do a good exam and almost no time to prescribe a medication for a presumed illness. I chose the former. Insurance pays for the latter. Unfortunately, we still have a healthcare system that makes money by treating disease, rather than by preventing it.

and that last sentence is the real indictment in this story “we still have a healthcare system that makes money by treating disease, rather than by preventing it.”

What do you think? Do you think we need health care which helps people to create health? Would you like a service like that?

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(Part 1)

I was taught that bad medical practice was to prescribe a pill for every ill.

I especially remember sessions where we had to reflect on our use of the prescribing pad, asking ourselves exactly why we were choosing to prescribe at all, not just why we chose a particular drug.

That teaching may be long since gone. Prescribing rates grow exponentially. I read the other day about the number of prescription drugs found in waste water in cities, and how around 70% of adult Americans now take at least one prescription drug every day.

I wonder why that is. Why are more and more people being prescribed more and more drugs? Are we, as a species, becoming sicker and sicker? Is it because the drug companies “don’t sell drugs. They sell lies about drugs“? Is it because of the distortion of “evidence” by drug companies?

I think it is at least in part due to the fact that modern medicine is practised on the basis of a delusion that human beings are complicated machines. They are not. They are complex organisms.There is a huge difference. When you see a person as a machine with a part which doesn’t work, the idea that you can sort that part with a drug makes some kind of sense. What’s lost in this way of thinking is a very, very important truth.

The only healing which occurs is natural healing. It is the person’s own healing system which gets the results. Drugs, if they do anything useful, act as adjuncts to steady things up whilst the body gets on with sorting itself out. There is not a drug on the market which directly cures anything. Benjamin Franklin said “God heals and the doctor takes the fee” – same observation, framed in a particular way.

So, given that the truth is we don’t have any drugs which cure, and its only the natural self-healing capacities of the human being which actually repair tissue, and restore health, then why don’t we FIRST of all seek to stimulate and support self-healing, self-care and self-repair, and ONLY when necessary, support the process with a carefully prescribed drug?

The problem with the data, algorithm, drug model of medical practice is that all roads lead to drugs.

We need new maps. We need to be able to understand how to set the conditions for recovery, for resilience and for health. We need to understand how to live differently to have sustainable health, and to maximise health when we have a chronic condition.

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The NHS in England is trying out an approach to Primary Care where the patient accesses the GP Practice website, completes an online questionnaire about their symptoms, has their identity checked by a member of staff on the phone, then receives a prescription for a drug.
This is pretty much what happened during the great swine flu epidemic, except I think they skipped the ID check – answer 4 questions online correctly and win a box of Tamiflu. Honestly, I thought Medicine had reached a new low at that point.

Here’s what I was taught at Edinburgh University then subsequently in GP training –
Start with the patient’s history. By the time you’ve taken the history you should have a diagnosis, or a differential diagnosis (a list of possibilities).
Next do a physical exam as needed to confirm the diagnosis
If you still haven’t confirmed the diagnosis, then ask for any investigation which potentially will confirm the diagnosis.
The next stage is treatment options (I’ll come to that later)

I was taught the history is not a data set. It is a narrative. Patients come and tell a story. They don’t come to share data.
Data can be collected on examination and investigation which can help inform the doctor and the patient but data is NOT “the truth, the whole truth, and nothing but the truth”
Human beings cannot be reduced to data sets. Mary Midgely, the philosopher, said

One cannot claim to know somebody merely because one has collected a pile of printed information about them

As a GP I learned that some people present with “minor” ailments as a “ticket” to access the doctor. There is actually a bigger issue they want to address (often emotional, psychological or related to a more chronic symptom) and the “minor” ailment is what precipitates the appointment request – it is neither the sole reason, nor even the main reason for the consultation.

As a GP I learned that noticing the patient’s body language, their speech pattern, their hesitancies and word choices opened up the potential to explore what they were really experiencing and concerned about – and so allowed a fuller, “better” diagnosis – and so a more appropriate treatment.

As a GP I learned that eye contact, my body language, the way I formed a question all either opened up, or closed down, possible other avenues to explore with a patient.

How often has a patient told me something important only to add they had never before told that to anyone?

What about patient centred care and compassion? Human beings don’t fit algorithms. Human beings, as complex adaptive systems (CAS), are open, emergent, dynamic, changing, contextually embedded creatures. What algorithms have been invented which can cope with the complexity of individuality? The complexity of everyday living?

We can squeeze people into algorithms, but we can’t make algorithms which fit the breadth and depth of natural variety.

And this is the heart of my concern.

Is the practice of Human Medicine about the health of human beings? If it is, we have to work with the reality of what a human being is. A complex, conscious living being who communicates and makes sense of the world through narrative, and who is embedded in a web of interconnections which inform their values and their choices. If it is, we have to work with the reality of diversity and uniqueness.

Please, please, let’s emphasise the need for a scientific approach to human health – one which is based on the science of living creatures, not one based on a delusional reductionist, materialistic science of complicated machines.

We are heroes, not zombies.

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