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Archive for the ‘from the consulting room’ Category

so that’s what I do

Posted in from the consulting room, from the reading room, life, perception, personal growth on November 1, 2013| 2 Comments »

When I was reflecting (for my annual appraisal) the other day, I got to wondering again about just how we understand what a doctor does.

Then I stumbled upon the Greek origin of the word therapy – therapeuein……which means to pay attention or to listen to.

That’s it!

That’s what I do – I pay attention.

That’s what I hear is most appreciated – patients tell me they appreciate having the chance to express themselves, to tell their story, and for that story to be listened to, attentively and without judgement. But paying attention isn’t just about listening, it’s looking out for patterns, seeking out connections, creating meaning and sense by weaving it all together.

Paying attention is therapeutic.

And that got me thinking…..isn’t that how I try to go through life…..paying attention? So is that therapeutic? For Life? For Nature? For the world? For me?

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Patterns and habits

Posted in from the consulting room, from the dark room, from the living room, health, life, personal growth, photography on October 25, 2013| Leave a Comment »

worn stone

 

Jung said “The world will ask you who you are, and if you do not know, the world will tell you.”

Do we make ourselves, or does the world make us?

Actually, that’s one of those questions which poses a false duality. The truth is it’s a two way process, an interaction, a conversation, relationship, a dance.

I’m fascinated by the patterns we see everywhere. As I listen to someone’s story, I’m listening for patterns. What kinds of patterns?

Well, I suppose you could call them habits.

  • Habits of the body
  • Habits of the head
  • Habits of the heart

The habits of the body are our physical actions, the ways in which we use our bodies to move and to interact with the world. Think of your eating habits, your exercise habits, your physical preferences, how you experience the world and how you engage with it.

The habits of the head are our thoughts, our beliefs and our world view. Think especially of whether or not your thinking habit focuses on the past, the present or the future? What are you sensitive to? What do you notice? How do you interpret the world? It’s especially helpful to think of how we approach the world, and Iain McGilchrist’s brilliant understanding of the clearly different ways in which the left and right hemisphere’s of the brain approach the world is really exciting.

The habits of the heart are revealed in the patterns of our emotions, our longings, and our passions. What moves you? What touches in you in your heart? In your soul?

This is the examined life – where you become aware of your inherited and acquired patterns which create the habits of your existence. And if you want life to be different, you’re going to have to create some new habits, or change some old ones.

zen sand

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The healing isle

Posted in from the consulting room, health on September 26, 2013| 2 Comments »

healingisle

 

So you’re sailing along, getting on with your life, when suddenly a storm hits, and you are blown onto the “Acute Beach”. Now you are ill, or injured. If you’re lucky you’ll find your way to the “DMC” (Disease Management Centre – that’s probably a hospital, clinic or doctor’s office) where the broken bit will get fixed and you’re back down on the beach, into your own canoe, and paddling off into the rest of your life again.

Except, often, that’s not what happens. It turns out there isn’t a simple part to be replaced or fixed, and before you know it you’re mired in the “Chronic Bog”, only to spend the next few weeks, months, or years trudging back and forward between the DMC and the Bog. Doesn’t feel so good, and it doesn’t get you back into the flow of life again either.

So, what next?

Maybe you meet an “integrative medicine” specialist and they take you on a journey, up the “Hill of Understanding” where you get a good overview, check out the lay of the land, and see more clearly just how you got here in the first place. That feels better. It’s good to be understood. It’s good to be able to put all the pieces together, see the connections, and work out just what needs to happen to get healthy again.

Maybe some time down at the “ITS” is going to be needed (“Integrative Therapy Spa”) – where health-making therapies stimulate and support your recovery, and give you a helping hand to start to heal.

After that, your health coach can help get you some time down at “Education Lake” where you can learn about health and healing, find out what the connections are between the mind and the body and learn what you need to know to get well.

You might also benefit from some time on the “Practice River” learning some new skills, like “mindfulness meditation”, stretching and moving exercises, ways of dealing with stress and so on.

Luckily for you that “integrative medicine specialist” is with you all the way, and you follow the path back down to the sea, and onto your boat to sail off and live the rest of your life.

Wouldn’t that be a good idea?

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Health making – weaving the web to catch health

Posted in from the consulting room, from the dark room, health, life, photography on August 4, 2013| 4 Comments »

 

web

 

When I was little, my grandfather read me Walter Scott’s Tales of a Grandfather. One of the stories was about Robert Bruce who had lost a number of battles with the English, and was sitting in a cave, feeling defeated and in despair. He noticed a spider trying to make a web. Time and again, it tried to spin its thread, and time and again, it failed. But it didn’t give up. As he watched, attempt after attempt, finally he saw it successfully create its web. He was inspired. “If this little spider never gives up and so succeeds, then so might I”. He went on to his famous victory in the Battle of Bannockburn in 1314.

This old story came to mind as I walked along the lane on my way to work this week when I noticed how the early morning sunlight was illuminating this web.

A few days on (my mind never stops, and seems to continue to make connections even when I’m not aware it’s doing so!), I was thinking about how this strategy of the spider can help us understand how to achieve those less tangible goals in life – you know the ones like happiness, love, and health.

I go to work every day to be involved in health making. For much of my working life as a doctor my focus was on disease management, but in this latter half of my career, it’s been squarely on health making.

So how do we make health?

I explore that pretty much all the time. But this web brought a different verb to mind – “catch”.

How do we catch health?

We talk about catching diseases after all, so why don’t we think about how to catch health?

The spider isn’t like a hawk, or a lion, or some other predator. It doesn’t spy on it’s prey, then jump on it. (OK, some spiders do, and you could argue that the rest do once the fly is caught in the web, but bear with me here)

What spiders do is create the conditions for success.

They don’t say “there’s a fly over there, if I run fast enough I can catch it”. They spin a web.

The web hangs there and the spider waits to see what gets caught in it. This requires first of all a lot of effort and creativity on the part of the spider. Look at the web in my photo. It’s both beautiful and quite stunningly amazing when you stop to consider that the spider there spun all of the raw material, the thread, out of its own body, then created this distinct pattern of the web. The spider can’t just sit about and wait till a fly hops into its mouth. I has to create the conditions. It has to put in the effort and it has to choose where to apply its effort.

This choice of where to put the web is probably both instinctive and learned. (Is it? I don’t know. Maybe a spider expert out there can enlighten me) But there is also an element of luck. It’s affected by weather conditions, other creatures, and the amount of passing fly traffic!

I think health making is a bit like this you know.

We can catch better health by creating the conditions for it.

We need to apply ourselves, we need to draw upon our instincts and our learning, and there’s an element of chance.

But I’ll tell you one thing for sure, and it’s the same old lesson Robert Bruce learned. You have to persevere. It’s a way of life, not an event.

 

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Writing your wounds

Posted in from the consulting room, health, writing on July 21, 2013| 1 Comment »

Well, here’s a very interesting study from New Zealand. Researchers took a group of 49 adults from 64 to 97 years old and got them all to write for 20 minutes each day for three consecutive days. One group had to “write about the most traumatic/upsetting experience in their life, delving into their deepest thoughts, feelings, and emotions about the event, ideally not previously shared with others”, and the other, “write about their daily activities for tomorrow, without mentioning emotions, opinions or beliefs.”

Two weeks later, all participants received a standard 4mm skin biopsy on their inner arm. The resultant wounds were photographed regularly over the following days to determine the rate at which they healed. On the 11th day after the biopsy, the wounds were completely healed on 76.2 percent of those who had done the expressive writing. That was true of only 42.1 percent of those who had written about everyday activities.

Measures of stress levels and depression were the same in both groups, so just how this faster healing resulted from the expressive writing isn’t clear. Fascinating though!

 

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If only….

Posted in from the consulting room, health on June 26, 2013| Leave a Comment »

Don Berwick, recently appointed to head up the post-Mid-Staffs Review, was the person who introduced me in 2001 to the concept of “complex adaptive systems” in Appendix B of “Crossing the Quality Chasm“.

I happened to be diving into the writings of the French philosopher, GIles Deleuze, at the time, and somehow this “CAS” concept fell right into place with Deleuze’s philosophy of rhizomes and of becoming…..so much so that in 2007, when I started this blog, I chose the subtitle “becoming not being….”

I know the American Republicans really don’t like him, but I’ve enjoyed a lot of what he has had to say, and when he praised the NHS at its 60th anniversary he said (amongst other things) this –

First, put the patient at the center – at the absolute center of your system of care. Put the patient at the center for everything that you do.  In its most helpful and authentic form, this rule is bold; it is subversive.  It feels very risky to both professionals and managers, especially at first.  It is not focus groups or surveys or token representation.  It is the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself.  It means customizing care literally to the level of the individual.  It means asking, “How would you like this done?” It means equipping every patient for self-care as much as each wants.  It means total transparency – broad daylight.  It means that patients have their own medical records, and that restricted visiting hours are eliminated.  It means, “Nothing about me without me.”  It means that we who offer health care stop acting like hosts to patients and families, and start acting like guests in their lives.  For professionals made anxious by this extreme image, let me simply remind you how you probably begin every encounter when you are following your best instincts; you ask, “How can I help you?” and then you fall silent and you listen.

People throw around the words “patient centred” and “consultation” like mantras these days, but sadly, its often lip service. It’s NOT difficult to practice the way Don Berwick recommends. Check out his questions in that paragraph –

How would you like this done?

and

How can I help you?

When did a health care professional last ask you those questions? Do you feel treated as an individual? With your values, your beliefs and your wishes being held as CENTRAL? Do you feel treated as a guest in the lives of NHS staff? OR do you feel YOU are the host, and they are the guests in YOUR life?

Let me say again – this is NOT difficult. The doctor, the nurse, the physio, are there to help you. They are there to listen and there to help you find a better way to cope with these symptoms, or address this disease, or whatever has led you to seek them out (a desire for better health I expect)

Don Berwick is revisiting this ethic in his new post and saying that he can be confident that the NHS can be more made safe because

“One of the most important guarantors of continuing excellence in the NHS is the ability to include and invite and listen to the wisdom of patients, families, carers and communities”

There’s still way too much of the attitude that “we” (the “experts”) know best, and “you” the patients, families, carers and communities should just get on with swallowing the “evidence based” tablets we prescribe.

“nothing about me without me”

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7 out of 10….is this working for you?

Posted in from the consulting room, health on June 24, 2013| 1 Comment »

The Mayo Clinic claims that 70% of Americans are taking at least one prescription drug.

More than half of these are taking at least two different drugs.

20% are taking five or more prescription drugs.

Here are the top five, in order of frequency –

  1. Antibiotics
  2. Antidepressants
  3. Opiate painkillers
  4. Antihypertensives
  5. Vaccines

Prescription drug use has increased steadily in the U.S. for the past decade. The percentage of people who took at least one prescription drug in the past month increased from 44 percent in 1999-2000 to 48 percent in 2007-08. Spending on prescription drugs reached $250 billion in 2009 the year studied, and accounted for 12 percent of total personal health care expenditures. Drug-related spending is expected to continue to grow in the coming years, the researchers say.

So, here’s what I’m wondering. What is our working model for health care? What are we trying to achieve? Health? And if that’s our goal, how are we doing? Does this study indicate we are on the right road? Is this a sustainable direction? How do we pay for every more expensive health care of this type every year?

Oh, and isn’t it interesting that three of the top five are called “anti-” something? This suggests that our only hope is that health will emerge as a side-effect of these treatments…..they certainly aren’t designed to improve health directly.

And just in case you think antibiotics create health, have a look here.

If 7 out of 10 people in a population are taking drugs, are those drugs bringing them what they hope for?

 

 

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Health and disease, the intimate, unpredictable links

Posted in from the consulting room, health on June 19, 2013| 2 Comments »

Less disease = more health

More health = less disease

Which of those two statements do you agree with?

Of course, neither equation is that simple. Sometimes bringing a disease under control, or removing a pathological lesion, results in a person’s health increasing. It’s true in most acute diseases. But it’s a bit more complex in chronic illness. Better managed diabetes allows the patient a better health experience, and controlled asthma does too, but those chronic diseases don’t go away and a person with any chronic disease isn’t likely to experience health as fully as someone who doesn’t have any such disease. Sometimes increasing health, resilience and wellbeing not only reduces limiting symptoms, but allows the innate self-healing capacity of human beings to work so well that the disease is removed completely. Other times, again in chronic situations, it results in greater wellbeing but not erradication of the disease.

The lack of simplicity reflects the fact we can’t put parts of life into unconnected boxes. There aren’t two, separate, complete states – disease and health. But they influence each other. They influence each other in unpredictable ways because human beings are complex adaptive systems, and such systems have distinct types of relationships between their parts – non-linear links. Non-linear links are typical of human feedback loops. And that’s a good description of the relationship between health and disease – they are bound together in non-linear negative feedback loops.

Most health care focuses on the first statement. We have a disease-focused, disease-management service, not a health service. Health, if it increases, does so as a kind of side-effect of the treatment. Yet, health is still the goal. Taking a health-making focus creates or enhances the conditions for reduction, or control, of disease. But that too may not be enough. The human ability to self-heal is not perfect, and not omnipotent. Management of a disease really can contribute to better health.

Why don’t we do that more?

Are we doing our best to help people to experience as much health as possible?

Not if we only focus on disease. Not if we only focus on health.

We need an integrated health service – where disease management AND health making are available to all patients.

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It works! It doesn’t work! Can both these statements be true?

Posted in from the consulting room, from the reading room, health on June 17, 2013| 1 Comment »

An article in the BMJ recently repeated the statement made several years ago by a researcher who works in the area of pharmacogenomics for GlaxoSKF, the drug company. He 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.”

Whilst that observation caused a stir at the time, and is causing a stir again, now it’s been repeated, at the time it didn’t really surprise me. You don’t have to work as a GP for long to discover that there are no drugs which do what the manufacturers and researchers say they do for every single patient who you prescribe for. How many different BP pills does the doctor have to try sometimes to get hypertension under control? How many different painkillers? Different antidepressants, anticonvulsants, treatments for constipation, diarrhoea…..you name it. I really don’t know of any drug on the market which does what it claims to do for EVERY single patient who takes it. What did surprise me were the figures quoted – 90% of the drugs only work in 30 – 50% of the people!

And yet, there are still those who claim there are only two kinds of treatments available – those which work, and those which don’t.

Life just isn’t like that.

But here’s another comment in that BMJ article which really grabbed me, and I don’t know why I didn’t see this so clearly before!

Pain relief is not normally distributed but usually bimodal,being either very good (above 50%) or poor (below 15%). Using averages is unhelpful and misleading, because “average” pain relief is actually experienced by few(if any)patients, and it tells us nothing about how many patients will experience clinically useful pain relief [BMJ 2013;346:f2690 doi: 10.1136/bmj.f2690]

What does this mean? “Bimodal”? Well, here’s another article, referred to in this BMJ article, pointing out the same problem –

Systematic reviews of regulatory trials often pool average data. In acute and chronic pain, however, underlying distributions are commonly not normal, tending to be U-shaped rather than bell-shaped, where the average describes few individuals [PAIN 149 (2010) 173–176]

When you look at the effect of a drug on a research population you don’t get drugs which work, and those which don’t. What you get is two distinct groups of patients – those who get a “good” result, and those who don’t.

By averaging out the results of the entire group, this reality is obscured.

Whilst these articles refer to painkillers, I believe this finding is likely to be found with pretty much any therapy you can think of. There will be a group who really get no benefit, AND a group which get significant benefit.

This is a common problem in health care – there are no average people. Every single person needs to be considered and treated as an individual. After all even the results from the group trials have been obscured by this averaging out.

 

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Montaigne’s criticism of doctors

Posted in from the consulting room, from the reading room, health, philosophy on June 6, 2013| 3 Comments »

Montaigne was pretty critical of doctors and the practice of Medicine. You probably think that’s hardly surprising given he lived in the 16th century and wasn’t Medicine a pretty dangerous practice in those days, with harms frequently outweighing benefits. Maybe that’s all changed since those days? With the technological advances of the 20th century doctors have a range of interventions they can use now where the benefits outweigh the harms (for some of the people, some of the time). And at least we don’t bleed and purge patients to death any more, do we?

OK, let me reflect on the current benefits outweighing the harms argument. Let’s deal with harms first of all, because in some ways they are more straightforward. Here’s a couple of interesting facts. Medical interventions are the third most common cause of death in the US. Numbers of deaths decreased when Israeli doctors went on strike. So, there is still plenty of potential for doctors to harm you.

What about benefits? Many infections which previously could overwhelm and even kill patients can now be successfully treated with antibiotics (although we are never far away from predictions that our fifty or so years of success in that area are coming to an end as bacteria adapt, develop resistance to the drugs, and spread that newly acquired ability far and wide). In Surgery there have been enormous improvements. I’ve talked to two patients this week who recently underwent cholecystectomy (removal of the gall bladder) using four small cuts in their abdomens, an extremely short hospital stay and very rapid, complete recovery. Cholecystectomies weren’t like that when I was a young doctor. People having a heart attack who have a clot in a major artery can have it quickly dissolved, or a stent inserted to break through the blockage within hours now. Montaigne’s last two years of life were spent bed ridden, in pain, from kidney stones. You wouldn’t believe how easily that can be dealt with nowadays. I could go on. I’m sure you can add your own examples from your own experience.

But.

There’s a problem. And I don’t mean the harms problem. The problem is that interventions, especially drugs, but surgical ones too, don’t result in the same benefits for everyone who receives them. Roses, of GlaxoSmithKleine, famously gave the game away when pushing the case for pharmacogenomics. He said – We all know that most drugs (90%) don’t work for most patients most of the time (less than 30 – 50%). Why did that statement seem so shocking? Don’t we all know that? Why have all pharmacies got shelves full of drugs which all claim to do the same thing? Whether they are pain relievers, treatments for cold symptoms, allergies, or tummy upsets? Every prescribing doctor will tell you they are glad they have a number of drugs to choose from because no single drug gets the results every time it is prescribed (this is true of EVERY drug, from painkillers, to blood pressure pills, to treatments for asthma, heart failure, epilepsy…..you name it). And here’s where the next aspect of the problem arises. It’s a version of if you give a man a hammer everything will look like a nail. There are drugs and surgical procedures which effectively alter diseases, directly changing the characteristics or behaviours of dysfunctional tissues or organs. (These interventions are often claimed as cures, but I think doctors should retain a little humility here – there are no cures other than through the human being’s capacity to self-heal and self-repair. Treating diseases can increase the chances that self-healing will work, but no drugs or operations directly stimulate or support self-healing.) But what happens when all the drugs tried don’t work? Often one or a number of them are continued, in reality because the doctor doesn’t have anything else to offer. But continuing a drug which is not working tips the balance between benefits and harms enormously. The longer most drugs are taken, the greater the risk of harm. Almost worse than this is that this form of Medicine is used completely inappropriately. Many, many drugs are not prescribed to cure, to heal, or even to control a disease. Instead they are prescribed to reduce symptoms. Reducing symptoms can reduce suffering and whilst we can be supportive of that, it can inhibit dealing with the causes of the symptoms.  However, Palliative care in terminal illness can seriously reduce suffering completely appropriately. But when the cause of the suffering is not addressed, and is ongoing, then a symptom reduction strategy leads to the same problem as the ineffective drug one – the balance tips from benefit to harm.

So Montaigne’s experience and views are still relevant over four hundred years on. Dealing with doctors can be a dangerous experience, and giving them power over you is still not a great idea. I’m of the opinion that the less you have to deal with doctors, the better your life!

When I read some of Montaigne’s comments about doctors, one thing he said which particularly struck me was why don’t doctors have much better health than other people, given they claim specialised knowledge and skills in health?

So, I did some research to see if it was still true that doctors’ health and illness knowledge brings no advantages over others. It’s not entirely true. The famous phenomenon of doctors as an occupational group giving up smoking on reading of Richard Doll’s epidemiological work has resulted in doctors having less smoking-induced illnesses than others. However I can find no evidence that doctors live significantly longer than other people (of similar wealth, race and sex). Nor can I find any evidence that doctors are less likely to suffer from diseases over all.

Looks like Montaigne is right again – if doctors are the experts in health, how come they don’t have healthier, longer lives?

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