Heroes Not Zombies

Did you catch this news story about community nursing in the Netherlands recently? Click through to the BBC site to read the details.

There’s been a revolution in community nursing in the Netherlands in recent years. The company, Buurtzorg, set up six years ago, began with 100 nurses, and now has 6500 of them working in teams of 10, each team covering a neighbourhood of 10,000 people. That means that 60% of the community nurses in the Netherlands are now working for this company.

What’s so radical about what they do?

The completely human-centred, humane practice of nursing delivered with a high degree of personal autonomy by the nurses (there are no managers managing their case loads), emphasising continuity of care (reducing both the number of home visits required AND the number of different people visiting individual patients), and the focus on enabling both personal and community empowerment (they involve relatives, volunteers and friends in supporting the vulnerable elderly at home).

The company also runs a local radio show in Amsterdam (Radio Steunkous – which translates as radio “support-stocking”) which  “offers health advice, provides information on local services, and puts people in touch with each other.”

Instead of breaking down a patient’s life into “needs” which are then addressed by separate “tasks” delivered by a large number of different people, the nurse-patient relationship becomes the holistic centre of the care.

I love that this delivers quality care, more continuous care, and fosters independence and community, but I was also really taken by the comments of the nurses themselves –

“What we want to show is that if you have the autonomy, if you develop your skills and craftsmanship, then it’s the most beautiful job you can find.”

Read Full Post »

Our blood vessels are a hugely important part of our bodies. I suspect most of us think of our blood vessels (arteries, veins, capillaries) as a kind of complex tubing. To the naked eye, blood vessels certainly look like tubes, or pipes, and their key function seems to be to provide channels to move the blood around our bodies.
But let’s look a little closer. Lining these vessels, on the inside, is a very, very thin layer called the endothelium. It is only a few nanometers thick (I know. It’s not actually easy to visualise something that thin). This is a fascinating, living, constantly changing tissue.
To fight infections, the body has to get specialised cells, leukocytes, to the right place. The endothelium co-operates with these cells by allowing them to pierce holes in it so they can pass through to the target area. However, a lining with holes in it would be a disaster for health, so the endothelium has to repair itself immediately. Researchers continue to learn just how it does this.
It’s now been discovered that the healing response involves an interplay of quite astounding behaviours and abilities. The whole process can be observed using electron microscopes which show how a leukocyte can pierce the endothelium, and over a ten minute period up to seven leukocytes can pass through the opening before it is completely sealed up.
The healing of the holes involves a change in the cells which make up the endothelium. In response to a loss of tension in the wall, the cells grow tiny little foot-like structures, lamellipodia, and actually move towards the hole to seal it up. The whole process requires the production of proteins which produce “reactive oxygen species” (ROS), such as hydrogen peroxide.
ROS chemicals have a bad name. High levels of ROS seriously damage cells, and are implicated in a wide range of problems, from heart disease to cancer and even aging. However, in much smaller amounts, they are the key to body defences and healing. This phenomenon is an example of hormesis where a small amount of something has an opposite effect to a large amount of the same thing. The large amount is damaging, whilst the small amount is healing.
I don’t know about you, but I find it exciting and astonishing to think of all this activity going on inside me body! All these incredible, responsive, detailed healing systems involving tissues which are made of individual cells which can grow feet and move, to amazingly complex feedback systems controlling the production and removal of an enormous range of chemicals, getting just what’s needed to the right place at the right time.
I don’t really understand why the model of a human body as a machine is so popular – it’s so wrong! We are a complex living community of cells who are in constant communication with each other to mutually support and enhance their existence.
This is what integration looks like.
This is what a complex adaptive system looks like.
A living community.

Read Full Post »

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.

Read Full Post »

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?

Read Full Post »

OK, so I’m getting older and I guess I’ve reached that age where I think some things aren’t as good as they were. In particular I’m concerned that the practice of Medicine has become more technical and less human. So, it wasn’t really a surprise to read the details of a study which measured how much time doctors were spending on different activities through their day. The details however are, frankly, shocking.

The study of first year internists at two of Baltimore’s largest academic medical centers, showed that the doctors spent 12% of their time examining and talking to patients, and 40% at a computer.

Now, I reckon only just a tenth of your working time as a doctor spent in direct face-to-face work with patients is surprisingly low, but to be spending almost four times as much time at the computer as you spend with patients?!

Here’s what the researchers thought about their study –

“One of the most important learning opportunities in residency is direct interaction with patients,” says Lauren Block, M.D., M.P.H., a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of General Internal Medicine. “Spending an average of eight minutes a day with each patient just doesn’t seem like enough time to me.” “Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training,” says Leonard Feldman, M.D., the study’s senior author and a hospitalist at The Johns Hopkins Hospital (JHH).

The researchers are concerned that the trainee doctors aren’t getting enough time in direct patient care to learn their trade. But worse than that, what are they learning about the way to work as doctors?

Although this isn’t a perspective expressed by the authors, I do wonder if the whole drive towards a mechanistic, reductionist approach to health, coupled with a shift in emphasis from patient experience to group-based statistics, isn’t partly to blame for this finding.

Isn’t it time to organise the practice of Medicine in way which would allow doctors to spend most of their time talking to, examining or directly caring for, or treating, their patients?

Read Full Post »