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Archive for the ‘from the consulting room’ Category

Love from the beginning

Posted in from the consulting room, from the reading room, health, neuroscience, psychology on December 19, 2011| 3 Comments »

Last year I studies Interpersonal Neurobiology with Dan Siegel, whose book, Mindsight, I highly recommend. He teaches around the essential triad of brain, mind and relationships and understanding the links between these three turns out to be tremendously illuminating. On the relationship front, Dan draws on his training in attachment theory and demonstrates the links between early nurturing and personality later in life – particularly in connection with how we form relationships.

Sir Harry Burns, the Chief Medical Officer of Scotland, highlighted in a brilliant presentation earlier this year the key importance of early years in determining future health and health behaviours.

On top of this comes this research from the University of Minnesota demonstrating –

“Your interpersonal experiences with your mother during the first 12 to 18 months of life predict your behavior in romantic relationships 20 years later,” says psychologist Jeffry A. Simpson, the author, with University of Minnesota colleagues W. Andrew Collins and Jessica E. Salvatore. “Before you can remember, before you have language to describe it, and in ways you aren’t aware of, implicit attitudes get encoded into the mind,” about how you’ll be treated or how worthy you are of love and affection.

Wow! during the first 12 to 18 months! How important is love? You can’t over emphasise it.

You might be thinking yikes, if it’s set in the first 18 months, what hope is there? Well, it turns out we can have lots –

The good news: “If you can figure out what those old models are and verbalize them,” and if you get involved with a committed, trustworthy partner, says Simpson, “you may be able to revise your models and calibrate your behavior differently.” Old patterns can be overcome. A betrayed baby can become loyal. An unloved infant can learn to love.

 

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Hug more – it’s good for you!

Posted in from the consulting room, health, neuroscience, video on November 25, 2011| 1 Comment »

Nice little article on the School of Life site about the relationship between compassion and circulating levels of oxytocin.

It references Paul Zak’s talk on TED.COM.

It appears that there’s a relationship between our oxytocin levels and how much compassion we experience. Of course, as with so much neuroscience, this can’t be described as simply cause and effect but the correlation is still an interesting one.
I particularly like the concluding recommendation about how to increase your oxytocin levels –

To make a decision to raise the level of oxytocin in our bodies – Zak’s prescription is “eight hugs a day” – and reduce, say, levels of the stress hormone cortisol, seems as conscious a moral choice as giving to charity or embracing a religious creed. And if the outcome is the same, then let’s get hugging now

 

Never mind your 5 a day veggie and fruit portions – have you had your 8 hugs today yet??

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The power of vulnerability

Posted in from the consulting room, from the viewing room, health, video on November 1, 2011| 2 Comments »

This is one of the most inspiring, funny and moving TED talks I’ve seen so far.
Brene Brown’s qualitative research has led her to conclude that one of the most important issues for human beings is connections – we need to be connected, to belong, to love and be loved. This need for connections is the basis of our feelings of vulnerability, and that vulnerability can be the basis of feelings of shame, of feeling not good enough, not deserving of love or connections.
She found that well, “whole hearted” people, feel just as vulnerable as those who feel anxious or depressed by their vulnerability. The difference is in how they handle it. Many people choose to numb out these painful feelings, but in so doing, they numb out ALL their feelings. The whole hearted recognise vulnerability and painful feelings as part of reality. They acknowledge and accept them, but focus on personal authenticity…..anyway, check out this fabulous talk, enjoy it, and make up your own mind.

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Whose health is it anyway?

Posted in from the consulting room, health on October 25, 2011| 3 Comments »

In a BMJ article about personal health budgets, the chair of the Royal College of General Practitioners in the UK, Clare Gerada, says

“Should we be spending taxpayers’ money in cash strapped systems on gardening or aromatherapy that may make people feel better, but for which there is no evidence that it actually makes them better?”

This statement is a great example of the power issue at work in the practice of Medicine. The issue of personal health budgets is about the extent to which patients should be given the power to decide about what health care they want to receive. Dr Gerada uses this term “actually makes them better” – what does that mean? If someone who is suffering from a chronic incurable disease (and which chronic diseases are “curable”?) presents with terrible pain, or incapacitating fatigue, or paralysing anxiety, then what exactly is the definition of “better” – is there a “real” better and a “pretend” better? Surely, only the person themselves can tell whether or not their suffering is less, and only the person and their friends and family can tell if that person is now living a “better” life?

This use of “actually” is typical of doctors who reduce illness to lesions. They are thinking about someone who has less pain, but has no change in their underlying pathology – their MS plaques for example. Is that a sensible way to think about illness and health care?

There is a struggle going on, and it’s a power struggle. There are “experts” who think they are the only people who know what is best for patients. I don’t agree with them. If you ignore what the patient is telling you, if you ignore the “evidence” of the person’s life, then you’ve lost the plot!

Patient centred care means putting the patient at the heart of the care – not ignoring them or dismissing their reports of what is helping because “the evidence” doesn’t agree with this patient’s experience.

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Healing narratives

Posted in from the consulting room, from the reading room, health, life, narrative on October 21, 2011| 10 Comments »

One of the main themes of this blog, and probably a core theme of my daily work as a holistic, integrative doctor, is the place of narrative in our lives.

I recently mentioned in another post that working with patients’ narratives was a part of what I and my colleagues do every day at the Centre for Integrative Care in Glasgow. A couple of readers have asked me to say more about that and I thought I’d pull together some thoughts into this post.

One of the first books I read which impressed me about the importance of stories in medical work, was Arthur Frank’s “The Wounded Storyteller”. In this book, which is the product of years of research, Frank claims that there are two very common types of story patients present to clinicians – “restitution” stories, and “chaos” stories. He proposed that we can think of these as two primary “genres” of story. The former is probably the commonest in biomedicine healthcare. It can be captured with the phrase “I’m broke, please fix me”. It’s an approach to illness and health which considers that disease is a dysfunction or lesion somewhere and that if the bit that’s wonky could just be fixed then all would be well. The latter is also very common, especially when there are a multitude of symptoms and the person has  become lost in the illness.

Frank proposes that a clinician’s job is to help patients turn these stories into “quest stories” – based on the principles of Joseph Campbell’s hero narrative.

The integrative journey from stuckness or chaos to flow and coherence emerges out of this creation of a new narrative.

Another reason to work with narratives is the human need for myth creation. We are meaning seeking creatures, and the myths, or universal stories, as Karen Campbell calls them, shape our lives. So it makes sense to understand which myths we’ve incorporated into our stories.

Shifting from the materialistic, reductionist myth to a soulful, heart-focused, holistic one, allows the creation of a much more positive story, one which brings hope, and which opens up the possibilities of a different future path.

A key component of the creation of a future with a more clear set of potentials is choice. William Glasser’s Choice Theory, turns our narratives on their heads, and focuses us on the verbs we use to describe our experience. What emerges is a much more autonomous, more powerful story – a shift from passivity to activity, from victim to autonomous individual, from zombie to hero.

But it’s not just the verbs in our stories which are important. It’s the metaphors too. The amazing work of Lakoff and Johnson demonstrates the embodied nature of metaphor, and in so doing gives us the opportunity to pick up on the metaphors we are using, including the bodily locations of our diseases or disorders, and gain a profound understanding of the meaning of our illness experiences.

I hope for stories of improvement as I work with patients, but the stories which excite me the most, are the ones of transformation. Yet again, this week, I’ve heard several such stories. That makes it a complete thrill and delight to be able to practice Medicine this way.

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Telling a new story

Posted in from the consulting room, health, psychology on October 18, 2011| 4 Comments »

Deric Bownds highlights the conclusions of an interesting book about psychological change – “Timothy Wilson’s new book “Redirect: The Surprising New Science of Psychological Change.”

The part which caught my eye was the conclusion –

Wilson uses the thought-provoking metaphor of “story editing” to describe the ingredient common to many of the successful interventions he reviews. They alter the narratives people tell themselves about their world and their place in it: Is it safe or threatening? Do I belong or not? Am I capable or not? During sensitive periods, people’s storytelling can be redirected and the change can build on itself over time. Amend the opening sentence of the story of your transition to college, or to a new job, and the arc of your story may be entirely different from what it would have been otherwise. This helps explain why seemingly simple interventions, such as writing about a traumatic experience, or volunteering for a humanitarian cause, improve health and well-being. They give people an organizing narrative that puts their lives in an optimistic context.

Well that’s certainly my experience. That’s the focus of our everyday work at the Centre for Integrative Care in Glasgow – helping people to write new narratives of their lives (or what I’ve described as helping people to become the heroes of their own stories)

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Is this a good lifestyle?

Posted in from the consulting room, from the dark room, health, photography on October 14, 2011| 2 Comments »

Sometimes I wonder what the big idea is in modern medicine. It seems like its drugs. Drugs for symptoms. Drugs to “manage diseases”. Drugs for healthy people to “prevent diseases”. Drugs to make you happy. Drugs to help you cope. Is it any wonder that health care organisations throughout the world are creaking under the soaring costs of more and more and more drugs. “Evidence based medicine” hasn’t helped – it’s all about prioritising drugs.

So, when I saw this ad on the front page of the free newspaper lying on the train the other day, I thought……well, tell me, what do YOU think?

 

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Against the industrialisation of health care

Posted in from the consulting room, from the reading room, health on October 13, 2011| 1 Comment »

Pamela Hartzband, MD and Jerome Groopman MD from the Beth Israel Center writing in the New England Journal of Medicine make a strong plea for a return to professionalism and humanity in health care. Here’s the problem, as they see it….

We are in the midst of an economic crisis and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy makers have proposed that patient care should be industrialized and standardized. Hospitals and clinics should be run like modern factories and archaic terms like doctor, nurse and patient must therefore be replaced with terminology that fits this new order

It strikes me this current model of health care is not sustainable. Drug costs are spiralling way out of control and those in power seem to think the answer to health problems is to use a “Fordist” solution, creating health care facilities as factories – treating the mass with pre-ordained treatment plans delivered by people with technical skills.

They highlight the distorted use of “evidence based” approaches as a key problem

the new emphasis on “evidence-based practice” is not really a new phenomenon at all. “Evidence” was routinely presented on daily rounds or clinical conferences where doctors debated numerous research studies. But the exercise of clinical judgment, which permitted the assessment of those data and the application of study results to an individual patient, was seen as the acme of professional practice. Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts.

This “industrial” way of delivering health care diminishes the professionals as much as it does the patients.

Recasting their roles as providers who merely implement prefabricated practices diminishes their professionalism. Reconfiguring medicine in economic and industrial terms is unlikely to attract creative and independent thinkers with not only expertise in science and biology but also an authentic focus on humanism and caring. When we ourselves are ill, we want someone to care about us as people, not paying customers and to individualize our treatment according to our values. Despite the lip service paid to ‘patient-centered care’ by the forces promulgating the new language of medicine, their discourse shifts the focus from the good of the individual to the exigencies of the system and its costs. We believe doctors, nurses and others engaged in care should eschew the use of such terms that demean patients and professionals alike and dangerously neglect the essence of medicine

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Uniqueness – seen best at the one to one level

Posted in from the consulting room, health on October 5, 2011| 4 Comments »

I heard on the news last night that 70 people had been killed by a bomb in Somalia. What do you think about that? What do you think about those 70 people? What did the terrorist think about those 70 people? Did he, or she, know any of them? Could the bomber name any of them?

Reduction of individuals to a mass, by terrorists, by journalists, by governments, businesses, scientists, blinds everyone to the absolute uniqueness of every person.

It’s not possible to see the uniqueness of an individual when we absorb them into a mass.

But there’s another way to lose the uniqueness of individuals. Go in too close. In Medicine we focus on a part of a person – their blood pressure reading, their cholesterol level, their “lesion” – but when we do that we lose sight of the individual, the person whose body we are peering into, and in so doing their uniqueness is lost in their becoming a “case of hypertension”, or “a cancer patient”.

Zoom out to the mass, and we lose the individuals and everything which makes them unique, makes them uniquely human. Zoom in to the lesions or the biological parameters, and we lose the individuals and everything that makes them unique (even looking at an individual’s DNA doesn’t reveal anything like their full uniqueness)

There’s only one level at which we can see a person’s uniqueness – the level of the person – one to one, me to you, you to me. That’s what I’ll be doing again today. Sitting listening to individual, unique stories of men, women and children. I think that’s what being a doctor is about – fully focusing on the uniqueness of each and every person I see for the time I spend with them. The knowledge of the mass might enter the exchange, the knowledge of the parts might enter the exchange, but the consultation has to begin and end with a clear focus on this whole, unique person.

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Patient centered outcomes

Posted in from the consulting room, health on October 4, 2011| Leave a Comment »

In the US, they’ve set up a research institute, The Patient Centered Outcomes Research Institute, with a funding of $600 million a year!

It’s good to see a resourced emphasis on patients. The current dominant model in decision making in health care policy often seems to put the average, or the group, over that of the person. The evidence based medicine model originally recommended taking the statistical results from group experiments, then working out with individual patients what is best for them. I’ve heard a doctor say she was taught that if a patient takes an evidence based drug and says she is no better, then either she hasn’t taken the drug, or she is lying. That strikes me as bonkers. One way to get a more relevant decision for individual patients is to use “patient centred outcomes”.

The new US research institute will focus on the following four questions –

1. “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”

2. “What are my options and what are the benefits and harms of those options?”

3. “What can I do to improve the outcomes that are most important to me?”

4. “How can the health care system improve my chances of achieving the outcomes I prefer?”

Shouldn’t these ALWAYS be the questions a doctor and a patient should consider together? I think so.

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