Heroes Not Zombies

As far as possible I’m keen on finding ways to help people without using drugs or technologies. I know that both drugs and technologies (I’m including surgical treatments in there) have their place (mostly in acute, not chronic, situations in my opinion), but I really think that the people involved in health care are undervalued. So I was interested to see this piece about leg ulcer treatments.

A five-year study led from the University of Leeds has shown that ultrasound therapy does nothing to speed up the healing process of leg ulceration — contrary to what had been expected. Traditional methods of nursing care, which are cheaper and easier to deliver, work just as well, the authors conclude…..”The key to care with this group of patients is to stimulate blood flow back up the legs to the heart. The best way to do that is with compression bandages and support stockings — not ‘magic wands’ — coupled with advice on diet and exercise. Believe it or not, having a really hearty chuckle can help too. This is because laughing gets the diaphragm moving and this plays a vital part in moving blood around the body.”

So, good nursing care and laughter are effective treatments…..not just in a “feeling better” way (which is often strangely disdained by materialists), but in actually getting chronic leg ulcers to heal up. Interesting, huh?

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I stumbled across this piece in the NY Times. It starts like this

Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

At this point I stopped and checked two things – firstly, had I been redirected to “The Onion” without realising, and, secondly, was the article written on April 1st? Turns out the answer was “no” to both of these potential explanations. I read on.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional. Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”

This can’t be true. Tell me it isn’t true! Has there been a major shift in psychiatry in the US to deliberately NOT listen to patients, but to focus only on drugs? Apparently. Dr Levin misses the old style but finds he’s pretty good at the new one….

“I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.” “I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

At least in the article they interview one psychiatrist who has opted out of this shift and she hits the nail on the head

“Medication is important,” she said, “but it’s the relationship that gets people better.”

You know, I think this is the key issue here. When did we reduce “relationship” to “talk therapy”? As if a relationship between a patient and a doctor can be reduced a treatment intervention, and that drugs, of course, can be prescribed more quickly and “efficiently” than a relationship so drugs win!

If this really is true, I think it’s profoundly sad. In my opinion it’s a greater valuing of human relationships and a greater emphasis on people – patients and practitioners – that’s needed in medicine today.

Less drugs, more relating! That’s what I say!

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There are many interesting studies of the placebo effect which show the potential of a “chemically inert” substance to produce biochemical and physiological changes in a human being, ranging from the release of endorphins to the loss of hair in chemotherapy trials in volunteers given a placebo which they believe might be a chemotherapy drug. One of the most startling I remember reading was where medical students were given either a barbiturate or amphetamine. The former of these drugs is a sedative, and the latter a stimulant. The researchers switched the labels basically – they told the students who were given a barbiturate that it was an amphetamine and those who received the amphetamine were told it was a barbiturate. Amazingly the students experienced the effects of the drug they thought they were receiving even though they were swallowing the drug which should have done the opposite.

Here’s a more recent study which is just as startling. This shows that people taking part in a trial of painkillers experienced pain severity dependent on their expectation.

The volunteers were placed in an MRI scanner and heat applied to the leg at a level where it begins to hurt — set so that each individual rated the pain at 70 on a scale of 1 to 100. An intravenous line for administration of a potent opioid drug for pain relief was also introduced. After an initial control run, unknown to the participants, the team started giving the drug to see what effects there would be in the absence of any knowledge or expectation of treatment. The average initial pain rating of 66 went down to 55. The volunteers were then told that the drug would start being administered, although no change was actually made and they continued receiving the opioid at the same dose. The average pain ratings dropped further to 39. Finally, the volunteers were led to believe the drug had been stopped and cautioned that there may be a possible increase in pain. Again, the drug was still being administered in the same way with no change. Their pain intensity increased to 64. That is, the pain was as great as in the absence of any pain relief at the beginning of the experiment.

The MRI showed brain changes consistent with their reported experience of pain. In other words, despite receiving a powerful painkilling drug, when they were told the active drug wasn’t there, their pain increased – counteracting the “effects” of the drug.

This is yet one more study which shows that the placebo effect is a real effect – it’s not pretend, it’s not about just believing you feel better, it’s not the same as taking nothing. However, what really stimulated my interest in this study was this final quote in the report –

‘We should control for the effect of people’s expectations on the results of any clinical trial. At the very least we should make sure we minimize any negative expectations to make sure we’re not masking true efficacy in a trial drug.’

The “true efficacy”? What’s that then? The effect of the drug with the human taken out? The effect of the drug disregarding the subjective reality of the patient? What world is that? Is that the world you live in? Are there any humans who have no subjective reality? No values or beliefs? No inner experience? And isn’t pain, and pain relief, in fact, a subjective, inner experience? The “true efficacy” of a drug includes the placebo effect. The “true efficacy” of a drug is, in part, dependent on what the prescriber says and does. The “true efficacy” of a drug is the real experience of real human beings.

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Have you read the book, “The Butterfly and the The Diving Bell”? Or seen the movie? If so, you’ll have an idea of what “locked in syndrome” is. It’s where someone is completely paralysed and unable to communicate apart from maybe being able to blink an eye. Can you imagine? Can you imagine what that must feel like? Well, read this study of people who have this condition and prepare to be amazed. 91 people took part in this study.

Over half the respondents acknowledged severe restrictions on their ability to reintegrate back into the community and lead a normal life. Only one in five were able to partake in everyday activities they considered important. Nevertheless, most (72%) said they were happy.

Said they were happy! Isn’t that amazing? And here’s what amazes me, perhaps even more.

But a shorter period in the syndrome — under a year — feeling anxious, and not recovering speech were also associated with unhappiness. A greater focus on rehabilitation and more aggressive treatment of anxiety could therefore make a big difference, say the authors, who emphasise that it can take these patients a year or more to adapt to this huge change in their circumstances.

In other words, they adapted. Doesn’t this speak volumes about the human capacity to adapt? And doesn’t it make you wonder just what happiness is?

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Having just written a post about the importance of caring in health care, last night, I opened a novel to start reading it, and here’s what I read first….

….for the secret of the care of the patient is in caring for the patient. Francis W Peabody, October 21, 1925

Couldn’t say it better myself. Funny it pops up so close to that post. I love the amazing surprises of life.

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We shouldn’t reduce health care to a mechanical set of “measurable” processes. Health care is about the human beings – human beings who are suffering, and human beings who are trying to relieve suffering. This paragraph at the end of an article which looks at the difference between psycho-analytic approaches and cognitive behavioural ones captures the idea beautifully

The respected therapist and writer Irvin Yalom, among others, argues that depression and associated forms of sadness stem from an inability to make good contact with others. Relationships are fundamental to happiness. And so a science that has the courage to include the doctor’s relationship with the patient within the treatment itself, and to work with it, is a science already modelling the solution it prescribes. What psychoanalysis loses in scientific stature, it gains in humanity.

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