Heroes Not Zombies

This caught my eye

Showing clinical empathy to patients can improve their satisfaction of care, motivate them to stick to their treatment plans and lower malpractice complaints, found a study published in CMAJ (Canadian Medical Association Journal).

What did I think when I read this?

You don’t say!

I mean, seriously, empathy’s a good thing?? But then, I looked again, and there was a little extra word in there which disturbed me…..and several days later, it’s disturbing me still. Can you guess which word is bothering me?

“clinical”

What, oh what, is “clinical empathy”? Maybe I’m a bit odd this way, but you know what? I care about every single patient I see. I just do. I want to help them. I feel for them. Nobody taught me this. I became a doctor because of it. It wasn’t something to include in my curriculum. Surely that’s not odd. It’s certainly not uncommon amongst the doctors I know and work with.

Here’s my question. Why would anyone want to be a doctor if they didn’t care?

OK, you’ll probably come up with a ton of reasons, but if you could choose, next time you need to see a doctor, wouldn’t you rather choose one who connected with you, who understood you (or at least tried to understand you), over one who didn’t?

It’s not my experience I’m unusual. But in my experience, it’s not something which seems to be particularly valued in health care. “Outcomes” are rarely anything to do with caring, empathy, or relationship. I really hope that’s changing. Let’s not modify “empathy” by calling it “clinical empathy”, let’s value and encourage the practice of giving a damn.

(The Scottish government is rolling out through the whole of the NHS in Scotland a measure called “CQI-2”, a measure of the “Consultation Quality”, to capture patient’s experiences of compassion, caring “enablement”. That’s an important step. It’ll be an even more important step if we connect it to funding decisions. )

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Should statins be prescribed for every adult with “raised” cholesterol levels (a recent study estimated this would cover 70% of the adult population of Norway).

A recent Cochrane Collaboration analysis of the accumulated data concludes this –

There is not enough evidence to recommend the widespread use of statins in people with no previous history of heart disease, according to a new Cochrane Systematic Review. Researchers say statins should be prescribed with caution in those at low risk of cardiovascular disease (CVD).

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Iona Heath writing in the Public Library of Health Medicine journal nails the issue of disease mongering.

There are a number of issues to consider in relation to the problem of disease mongering. She particularly focuses on the use of pharmaceuticals for preventitive medicine reasons.

The first step has to be a genuine disentanglement of the medical profession from the pharmaceutical industry—there really is no such thing as a free lunch

Sadly, there is an enormous, unhealthy, amount of pharmaceutical industry influence on not only individual doctors, but on regulatory bodies, governments and the publication of so-called evidence on which policies and protocols are based. Until we tackle this influence, disease mongering will continue to grow apace.

Beyond this, there is a need for better science that has the integrity to demand more explicit acknowledgment of the limits of medical knowledge, less extrapolation beyond research findings, and much more responsible use of statistics, so that the true extent of the benefits and harms of proposed treatments can be properly understood.

There’s a terrible tendency these days for people to claim knowledge which enables them to make predictions about treatments with certainty. Human life is not certain, and, as human beings can be considered as complex adaptive systems, it is impossible to predict outcomes in detail in any individual case. Research trials and statistics are not the whole truth, and they never will be.

Most variables are distributed across a continuum, but despite this, the medical tradition has been to dichotomise the continuum into normal and abnormal

It is irrational to divide human phenomena into two discreet categories – normal and abnormal. It isn’t scientific to do that, and it certainly isn’t realistic. There is no such thing as some drugs which work and others which don’t. No drug has the same effects on everyone who takes it.

When doctors treat patients with diseases, progress can be assessed and the outcome is measurable. This means that if the patient responds to treatment, it can be continued; if not, the treatment can be stopped. When doctors treat people who are merely at risk of disease, the outcome is probabilistic, so whether disease is prevented or was never going to develop, the treatment continues indefinitely

I’m not sure it’s always so clear that a patient has responded to treatment, or at least, responded sufficiently to treatment. After all, who is to judge the “sufficiently”. However, I do agree with Dr Heath’s point that if you prescribe drugs to reduce risks you can never stop prescribing them. You are condemning those “at risk” to a lifetime of treatment as if they had a disease.

Part of the rationale for expenditure on the treatment of health risks is that it will reduce health costs in the long run, but such arguments do not stand up to close scrutiny. The costs of health care are highest during the year before death, regardless of the age at which death occurs. Everyone must die and be cared for while dying, and no amount of preventive pharmaceuticals can reduce the cost of providing this crucial end-of-life care

You don’t make people healthier by prescribing drugs, and you never achieve immortality. We all die, and the last year of life is the year we receive most health care.

Dr Heath’s final sentence is this –

Ultimately, the only way of combating disease mongering is to value the manner of our living above the timing of our dying.

Couldn’t put it better. We need to focus on health more than disease, and on living, more than dying.

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There are a depressingly large number of stories around about the inappropriate levels of influence drug companies have over government authorities who are responsible for developing, delivering and regulating health care. Most of the ones we read relate to the US and UK, but here’s one from France.
This is the story of a drug called Mediator which is supposed to be prescribed for diabetics to help them lose weight, but seems to have been prescribed to a lot of French people over the years whether they’re diabetic or not. As far back as the 1990s reports of deaths occurring in patients taking this drug began to emerge and the problem seemed so serious that the US, Switzerland and Spain all banned it. More recent studies have suggested between 500 and 2,000 French people may have died taking this drug. The question being asked is why did it take until November 2009 for the French authorities to act on the evidence?
The company which makes Mediator is Servier which is an old French family business with longstanding connections in the French establishment.

“Servier has shown an extraordinary capacity for escaping criticism,” said Socialist deputy Gerard Bapt, a cardiologist who has taken a close interest in the scandal. “The main reason is because it has been able to infiltrate all the relevant scientific committees working on this drug.” For Irene Frachon, “the conflicts of interest are palpable… Among the medical establishment, in the pharmaceutical and cardiological communities, there are people close [to the Servier laboratories].”

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Larry Dossey has written an article about harmony and chaos. As he rightly points out the concepts of harmony, order and “coherence” are so universally accepted as characteristics of a healthy system or organism that nobody really ever considers that this way of thinking might not completely capture the reality of health.
I suppose one area where I began to realise that health isn’t all about order and coherence was when I discovered that epileptic fits arise, not when the brain dissolves into the chaos of an “electrical storm” as was previously thought, but, rather when consistent waves of co-ordinated electrical activity wipe out the normal brain function. In other words, a seizure emerges out of rigidity, not chaos.
Healthy brain activity is probably more accurately represented as edge of chaos which can tip, on the one hand, into total chaos, or, on the other, into rigidity – neither of which is healthy.
It seems that studies on aging are beginning to highlight a similar issue. Both at the level of individual organs, like the heart, and at the level of the whole organism, it seems that as we age we lose a capacity to exist in some healthy zone of near chaos. In fact as we age we stiffen, we lose flexibility and, hence both resilience and adaptability.

“Chaos in bodily functioning signals health. Periodic [regular, rhythmic, coherent] behavior can foreshadow disease. Transitions to strongly periodic dynamics are observed in many pathologies, including Parkinson’s disease (tremor), obstructive sleep apnea, sudden cardiac death, epilepsy, and fetal distress syndromes, to name but a few.”

This makes a lot of sense when you consider the characteristics of complex systems. It’s true that you need a healthy level of “integration” ie of harmonious linkage between differentiated parts. However, for a system to be adaptable it must be flexible and for it to grow it needs to develop new patterns (a biological phenomenon known as “emergence”). Emergence only occurs when a system moves towards a “far from equilibrium” point, or some kind of tipping point. There are characteristics of complex systems known as “bifurcation points” where a system may go one way or another, and of “phase transitions”, where the whole behaviour of a system might suddenly change (for example, where liquid water turns to gaseous steam).
We are complex adaptive systems. We do need an incredibly intricate complex set of checks and balances, of feedback loops, of harmony and coherence. But we also need a bit of chaos, too much regularity can mean insufficient flexibility.

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Jonah Lehrer’s written a good piece in Wired about the importance of therapy
By therapy, he’s specifically referring to talking therapy as opposed to drug therapy. We’ve got a very drug-centric approach to health care, but the research evidence into anti-depressants clearly shows they are no more effective than placebo for all but the most severe depressions. So why do we persist in using drugs as first line treatments for depression? In fact, we often dismiss the value of the “talking therapies” (psychoanalysis has found it very hard to present an “evidence based” case, the way Cognitive Behavioural Therapy has done, and, as a result, often loses out in decisions about resource allocation)
Lehrer refers to some work comparing a mindfulness approach to depression to drug treatment and the conclusion on long term effectiveness was –

The results were stark. Not surprisingly, patients who escaped depression with the help of anti-depressants, and then stopped taking the drugs, relapsed about 70 percent of the time. The chemical boost was temporary. However, during the 18 month follow-up period, only 28 percent of patients in mindfulness therapy slipped back into the mental illness.

As he helpfully concludes –

What we often forget is that therapy alters the chemical brain, just like a pill. It’s easy to dismiss words as airy nothings and talk therapy as mere talk. Sitting on a couch can seem like such an antiquated form of treatment. But the right kind of talk can fix our broken mind, helping us escape from the recursive loop of stress and negative emotion that’s making us depressed. Changing our thoughts is never easy and, in severe cases, might seem virtually impossible. We live busy lives and therapy requires hours of work and constant practice; our cortex can be so damn stubborn. But the data is clear: If we are seeking a long-lasting cure for depression, then it’s typically our most effective treatment.

And this is the nub of the issue, isn’t it? Life is complex and resolving difficulties takes time, effort and practice. It’s foolish to consider human beings as chemical/mechanical beings which can be “fixed” with chemical and mechanical “solutions”. Human interaction, awareness, consciousness, communication, all bring about changes in the internal “chemical” environment. My preference would be that we address people as people not as examples of some “chemical imbalance”.

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In another piece of research looking at the psychoneurological mechanisms involved in placebo responses, we can clearly see that the placebo response is neither “nothing”, nor something artificial. In fact, it seems to be an integral part of every single therapeutic intervention.

By falsely dividing drugs into “verum” and “placebo”, or “proven” and “ineffective” we fail to understand these intrinsic biological healing capacities.

This is an interesting paper because it explores this phenomenon in detail, but the part which really struck me was the reference to the work of Benedetti et al on patients with Alzheimers. They show that damage to the prefrontal cortex specifically reduces the placebo response in these patients. Not only does it reduce the response to a prescribed placebo, but it results in the reduction of effectiveness of drugs such as analgesics, presumably because part of EVERY drug action is a placebo action and as this component is inhibited, the drug dose needs to be increased to continue the desired effect.

I’m sure a lot more work needs to be done to understand these mechanisms but it is encouraging to find research which at least begins with the hypothesis that the placebo effect is neither a trick nor is it equivalent to doing nothing.

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There are a couple of common views about new drugs amongst doctors. Both are based on the same phenomenon.

The first is “use new drugs quickly……..before their benefits wear off”

The second is “don’t use new drugs quickly……wait till you find out what there real effects are”

The phenomenon these views are based on is that when a drug first becomes available as a new “proven” or “evidence based” drug, it often seems spectacularly wonderful. Remember barbiturates? Benzodiazepines? Steroids? Betablockers? SSRIs? and so on and so on. When they first come to market they are described as breakthroughs (I don’t mean all the me-too drugs which just copycat the new ones). The early studies show wonderful outcomes and precious few side effects. However, it seems that frequently not only do the side effects become more predominant and problematic but the early promises turn out to be not quite so spectacular as originally believed.

It’s interesting to see this phenomenon now being more formally described.

But now all sorts of well-established, multiply confirmed findings have started to look increasingly uncertain. It’s as if our facts were losing their truth: claims that have been enshrined in textbooks are suddenly unprovable. This phenomenon doesn’t yet have an official name, but it’s occurring across a wide range of fields, from psychology to ecology. In the field of medicine, the phenomenon seems extremely widespread, affecting not only antipsychotics but also therapies ranging from cardiac stents to Vitamin E and antidepressants: Davis has a forthcoming analysis demonstrating that the efficacy of antidepressants has gone down as much as threefold in recent decades. For many scientists, the effect is especially troubling because of what it exposes about the scientific process. If replication is what separates the rigor of science from the squishiness of pseudoscience, where do we put all these rigorously validated findings that can no longer be proved? Which results should we believe?

I’ve said it before……this binary thought process of dividing treatments into “those which work” and “those which don’t” is nonsense. The world is not so simple. And “facts” are a lot more slippery and context bound (in time as well as circumstances) than a lot of “scientists”, and certainly drug companies,  would like us to believe.

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