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Archive for the ‘from the consulting room’ Category

Fancy a dose of Vitamin N?

Posted in from the consulting room, from the reading room, health, life, science on June 7, 2012| 8 Comments »

Vitamin N?

It’s what Richard Louv, author of “Last Child in the Woods”, and “The Nature Principle” , refers to as the therapeutic agent we call Nature. It’s a clever idea, as is his diagnosis of “Nature-deficit Disorder” which he claims is widespread in our urbanised societies.

He writes about how exposure to nature is healing and mentions that in Japan “Forest Medicine” and “Forest Bathing” are becoming recognised medical treatments.

He even has his own definition of nature – ” human beings exist in nature anywhere they experience meaningful kinship with other species”

A 2008 study published in American Journal of Preventive Medicine found that the greener the neighborhood, the lower the body mass index of children. “Our new study of over 3,800 inner-city children revealed that living in areas with green space has a long-term positive impact on children’s weight and thus health,” according to senior author Gilbert C. Liu, MD

And….

A study of 260 people in twenty-four sites across Japan found that among people who gazed on forest scenery for twenty minutes, the average concentration of salivary cortisol, a stress hormone, was 13.4 percent lower than that of people in urban settings.6 “Humans . . . lived in nature for 5 million years. We were made to fit a natural environment. . . . When we are exposed to nature, our bodies go back to how they should be,” explained Yoshifumi Miyazaki, who conducted the study that reported the salivary cortisol connection. Miyazaki is director of the Center for Environment Health and Field Sciences at Chiba University and Japan’s leading scholar on “forest medicine,” an accepted health care concept in Japan, where it is sometimes called “forest bathing.” In other research, Li Qing, a senior assistant professor of forest medicine at Nippon Medical School in Tokyo, found green exercise—physical movement in a natural setting—can increase the activity of natural killer (NK) cells. This effect can be maintained for as long as thirty days.7 “When NK activity increases, immune strength is enhanced, which boosts resistance against stress,”

I like these ideas – a lot! You can read more here and here.

Our hospital, the NHS Centre for Integrative Care at Glasgow Homeopathic Hospital, is built around a beautiful garden, and patients frequently comment about the increase in well-being they feel gazing out into, or wandering around in, the garden.

My recent trip up to Crarae Gardens gave me a similar experience. Don’t you feel better after spending some time in natural environments? Which ones are especially good for you?

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What kind of world do you live in?

Posted in from the consulting room, health, philosophy, science on June 7, 2012| 1 Comment »

Here are two questions which are in my mind during every consultation I have with a patient.

What kind of world does this person live in? and What coping strategies does this person use?

Of course like every doctor I will have a number of questions in mind during a consultation. The primary goal of undergraduate Medicine is to teach diagnosis (as best I conceive it, “diagnosis” is an “understanding” – an explanation for what the patient is experiencing). So that is likely to be one of the main goals of all consultations – what’s the diagnosis? Having achieved an understanding/explanation/diagnosis, the doctor then wants to answer the question “what am I going to do about this?” What the doctor does might be to further examine, investigate, or seek the opinion of a specialist. Or what the doctor does might be a therapeutic act – the most common being either the prescription of a drug, or the carrying out of a surgical procedure.

In other words, the same two questions are important for the doctor too. What kind of world does the doctor live in? And what are his or her coping strategies?  The world view frames the diagnosis, and the coping strategies determine the actions.

The current dominant practice of Medicine has emerged from a particular world view, and this world view is the basis of the actions chosen. So what is that world view? (I’m not going to try and nail down a label for the current Medical orthodoxy, but others have termed it “biomedicine”, “Western Medicine”, or even “scientific Medicine”. Whatever the label, I’m referring to the type of Medicine most commonly practised in the UK, and, yes, of course, you’ll see that is very similar to the commonest practices in many other countries too)

The world view from which the current orthodoxy emerges is based on certain postulates –

  1. There is only one reality.
  2. Reality can be “partialised”. It can be divided into parts which can be studied separately in order to know the whole.
  3. Knowledge can be acquired by an observer who is separate from, and stands apart from, reality.
  4. Observing has no influence on what is observed. (or the influence can be isolated or “controlled”)
  5. The observer’s values and meanings can be isolated and suspended.
  6. Two events related in time can be assumed to be causative – “A is the outcome of B”.
  7. Specifics can be generalised i.e. an explanation from one time and place can be applied to other times and places.
  8. Reality can be described in terms of “laws” and “norms”.

I don’t find these postulates either helpful or convincing. What are the postulates behind my world view as a doctor?

  1. There are multiple realities. No two individuals experience identical realities.
  2. The multiple realities are inextricably interconnected to create the whole. As such no single part can explain the whole.
  3. No-one is outside of reality.
  4. Every act of observation influences (creates even) what is observed.
  5. The observer’s values and meanings create their reality. They can’t be suspended. (Points 3 and 4 are connected to there being no object which can be known without the active involvement of a subject)
  6. Complexity and chaos theories show us that reality is non-linear. Causation can never actually be proven.
  7. Specifics always occur embedded in multiple contexts and as such are always unique. Generalisation involves ignoring the contexts.
  8. Laws and norms are cultural constructions to describe common patterns. Nature is diverse and natural phenomena are emergent (continually evolving and developing into different patterns)

How do you think these different world views affect firstly the diagnosis, and secondly the actions taken?

 

 

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Making the healthy sick

Posted in from the consulting room, health on June 2, 2012| 1 Comment »

There’s an excellent article published in the BMJ this week highlighting the increasing problem of “over diagnosis” (defined as “when people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death”)

Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy. A burgeoning scientific literature is fuelling public concerns that too many people are being overdosed, overtreated, and overdiagnosed. Screening programmes are detecting early cancers that will never cause symptoms or death, sensitive diagnostic technologies identify “abnormalities” so tiny they will remain benign, while widening disease definitions mean people at ever lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them. With estimates that more than $200bn (£128bn; €160bn) may be wasted on unnecessary treatment every year in the United States, the cumulative burden from overdiagnosis poses a significant threat to human health.

Where’s the problem coming from? The authors discuss a number of the factors, but they pretty much boil down to an overly reductionist view of illness, commercial and vested interests in technologies and drugs, and fears of under diagnosis.

Drivers of overdiagnosis

  • Technological changes detecting ever smaller “abnormalities”

  • Commercial and professional vested interests

  • Conflicted panels producing expanded disease definitions and writing guidelines

  • Legal incentives that punish underdiagnosis but not overdiagnosis

  • Health system incentives favouring more tests and treatments

  • Cultural beliefs that more is better; faith in early detection unmodified by its risks

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Mmmm…chocolate!

Posted in from the consulting room, health on June 2, 2012| Leave a Comment »

You probably eat chocolate because you like it. I know I do! But here’s a study suggesting significant health benefits from eating 100g of dark chocolate (greater than 60% cocoa) every day for 10 years.

Results Daily consumption of dark chocolate (polyphenol content equivalent to 100 g of dark chocolate) can reduce cardiovascular events by 85 (95% confidence interval 60 to 105) per 10 000 population treated over 10 years. $A40 (£25; €31; $42) could be cost effectively spent per person per year on prevention strategies using dark chocolate. These results assume 100% compliance and represent a best case scenario.

Conclusions The blood pressure and cholesterol lowering effects of dark chocolate consumption are beneficial in the prevention of cardiovascular events in a population with metabolic syndrome. Daily dark chocolate consumption could be an effective cardiovascular preventive strategy in this population.

If you’re worried about the weight gain potential of 100g of chocolate a day, the researchers suggest “substituting chocolate for other snacks”! (what they mean is balance it out with other changes in your diet)

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Fear of dying or passion for living?

Posted in books, from the consulting room, from the living room, health, life on May 27, 2012| 1 Comment »

I’m always struck by comments from researchers about how many lives may be “saved” if only we would take their recommended drugs. Trouble is, you see, the total number of lives “saved” will always be zero. Drugs might alter your experience of life, but they won’t make you immortal.

As the Onion once famously proclaimed  “WHO announce – Human mortality remains stubbornly at 100%!”

We are creatures. Like other creatures on this planet. But we have evolved something special. Consciousness. With this consciousness comes both self-awareness and imagination, both of which allow us to know that we are mortal. We know we are going to die. We can imagine it. Our problem is…..how do we live with that?

I’ve just finished reading Ernest Becker’s “Denial of Death“. It’s probably one of the most challenging books I’ve ever read. He argues powerfully and convincingly that human beings have both qualities of “creatureliness” (by dint of having a body), and of “godliness” (by dint of our ability to handle symbols and to be able to imagine not just the here and now, but other times, other places and the lives of other people. In essence, we are both biological and symbolic organisms. He lays out the case that the fear of dying is at the heart of what it is to be human, that unlike other creatures which are driven by instinct, we are, instead, driven by this fear. I won’t go into detail in this post, but if you check out the link at the start of the paragraph you can read an excellent wikipedia summary of the book.

Every Saturday it seems there are people in the High Street collecting money for a charity for some disease or other – fight cervical cancer, fight breast cancer, fight diabetes, fight heart disease, fight some other disease. And what if we could for a moment conceive of a world where each, and all, of these diseases were eliminated? Would we still die?

I don’t think a fear of dying is a good basis for a life. I don’t like all the scaremongering of the “Well of Light Brotherhood” types who know with such certainty how the rest of us should be living our lives to reduce our chances of dying.

What do I believe instead?

That we should have a passion for living.

We all die. That’s a fact. It can’t be avoided but it shouldn’t be the one fact which determines how we are to live. Let’s accept our reality and do what we are here to do – live.

How passionate are you about living? What will you do TODAY to live fully and passionately?

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This is better than drugs

Posted in from the consulting room, from the viewing room, health, video on May 23, 2012| 3 Comments »

Sometimes you find a video which is astonishing in its clarity and impact. Here’s what might be THE best health video I’ve seen so far.
I urge you – take 10 minutes and watch this. I really believe it could change your life.

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Who decides what’s best for you?

Posted in books, from the consulting room, from the reading room, health on May 21, 2012| 2 Comments »

Just read Leonora Carrington’s novel, The Hearing Trumpet and was stopped in my tracks by the following passage –

What is the Well of Light Brotherhood? That sounds more terrifying than death itself, a Brotherhood with the grim knowledge of what is better for other people and the iron determination to better them whether they like it or not.

The novel tells the story of an elderly woman put away in a “home” by her son and his wife when her behaviour becomes difficult for them. The home is run by the “Well of Light Brotherhood”.

You know, it seems to me that health care these days is probably run by the same people!!

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Reality medicine vs fantasy medicine

Posted in from the consulting room, health on May 18, 2012| 4 Comments »

Two papers published in the Lancet recently present contrasting views of the future of health care. Researchers in Scotland highlighted the fact that many people with chronic conditions suffer from more than one disease at a time.

The study looked for 40 chronic conditions among the participants’ data. Researchers found that 42% of patients had one or more conditions and 23% had two or more. It also found that only 9% of those with coronary heart disease, had that one disease alone. Similarly, only 23% of those with cancer, had only cancer and no other long-term disease

Why is this such an important point? Well, as the authors of the paper say

“Any country with an ageing population is heading in this direction. All these countries are waking up to the problem. “The status quo isn’t an option because it leads in the wrong direction.” Prof Watt said that rather than more specialists, patients with multiple conditions “need someone who can oversee all the problems of a patient”. “These patients need continuity, and we need ways of measuring how well care is joined-up.”

They highlight the need for more generalist approaches where the patient is seen in the context of their whole life, and that in particular people need continuity of care, co-ordination of care, and individualised care.

Then along comes a different view.  Oxford researchers looked at a single issue – the relationship between cholesterol levels and the chances of suffering from heart disease or a stroke. They conclude
we’ve actually learned is that, whatever your level of cholesterol, reducing it further is beneficial.
and go on to make this remarkable claim
“If we are going to prevent that half of cardiac or stroke deaths, then we’ve got to consider treating healthy people. “It can’t be done any other way.”

Well, that’s a phrase that raises my “aye, that’ll be right!” antennae – anyone who claims “there is no alternative” is pushing their personal view of the correctness of their own opinions too far! We see that with economists, politicians, and scientists. But we live in a complex world and we cannot reduce human life to such simplistic analyses and expect the predictions to work out. The claim of these latter researchers that putting all 50 year olds onto statins for the rest of their lives would “save 2000 lives a year” is pure fantasy.

Which vision appeals to you more? Individualised, holistic care, or mass medicating based on age alone?

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Half of patients affected by drug-related morbidity

Posted in from the consulting room, health on May 10, 2012| 5 Comments »

Quite a headline, huh? It caught my eye on ScienceDaily.

The article is about a Norwegian research study which has estimated the amount of morbidity caused by prescribed drugs. By morbidity they mean things like –

new medical problems (adverse drug reactions, drug dependence and intoxication by overdose) and therapeutic failure (insufficient effect of medicines and untreated indications).

Of course if you have a look at the fine print on the little bits of paper included in packets of prescribed drugs you’ll be aware that the potential “new medical problems” they can cause is often a pretty extensive list. It’s interesting to see them considered as three separate categories however. All drugs have the potential to cause direct harm in the form of “adverse drug reactions”. We call these “side effects” and some are pretty minor, but some can end a person up in hospital, or even cause death (10,000 deaths a year in England was one estimate ). Most people are pretty aware of the potential that drugs can cause side effects. I think most people are probably also aware that too much of any drug will likely cause harm, and that’s the category “drug overdose”. Most frequently this is not a deliberate act of self-harm, but the taking of too high a dose to try and achieve the claimed effect of the drug – more painkillers, more sleeping tablets, more tranquilisers. The third category is “drug dependence” and I think a lot of people associate that with illegal drugs – heroin, cocaine etc. But in fact, drug dependence has both physical/chemical aspects related to the way a drug changes our inner environment, and psychological ones where people begin to believe they couldn’t stop or reduce their prescribed drugs.

This study goes beyond these three categories however, and includes “therapeutic failure”, again subdivided, this time into two categories – “insufficient effect” and “untreated indications”. In other words, where people take a prescribed drug and it doesn’t do what the doctor intended it to do. This occurs much more frequently than people think (despite the young doctor who told me she’d been trained – “if a patient takes an evidence based drug and doesn’t get better, either they haven’t taken the drug, or they are lying”). Dr Roses of Smith Kline Glaxo 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.”

The estimate of this drug-related morbidity in this study is just over a half of all the people who take a prescribed medicine. Is that a shocking figure? I think so.

When I trained as a GP, I was taught to take a holistic approach to patients, and to be cautious about prescribing. I was taught values which included not prescribing a “pill for every ill”. It seems that prescribing is on the up. (“Prescriptions for antidepressants have risen by 43% in the past four years to nearly 23 million a year, NHS figures reveal.” and “The total number of prescription items dispensed increased by nearly two thirds between 1998 and 2008,” )

Not only is there a pill for every ill now, but even people with no symptoms of illness are being prescribed life long medication in an attempt to prevent them becoming ill. Sadly, over half of those people, who aren’t actually sick, will suffer from this preventive strategy.

What happened to the medical value of “first do no harm”? Shouldn’t we developing ways of improving and sustaining human health which don’t involve using drugs which have such a potential to cause harm? And saving the drugs for the situations where their potential harms are outweighed by their potential benefits? That’s the strategy we employ at the NHS Centre for Integrative Care in Glasgow. It’s a strategy I’d like to see more of.

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How kind were you today?

Posted in from the consulting room, health on April 26, 2012| 7 Comments »

Here’s a question I asked myself as I headed home today, and I think you might like to ask yourself the same question…..

How kind was I today?

I often hear stories of unkindness. Patients tell me about their experiences of not being heard, of being judged or dismissed, of, frankly, being treated unkindly, by health care professionals. But today one of our inpatients really made me think more deeply about it as she itemised for me the acts of kindness which she had experienced from individual after individual during her stay in our hospital this week. She said she didn’t know such a place existed. I was delighted to hear such encouraging feedback, and, yet, surely the “norm” in healthcare should be kindness?

That got me wondering…..what if every doctor, every nurse, every day asked themselves “How kind was I today?”

(And don’t give me the “cruel to be kind” thing – being cruel is cruel, you have to be kind to be kind!)

Maybe talking about the need for empathy and compassion is too hard for some professionals to hear, but surely everyone can relate to kindness.

Let’s increase the kindness quotient!

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