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Archive for the ‘from the consulting room’ Category

Evidence based medicine….with the human beings stripped out

Posted in from the consulting room, from the reading room, health on May 28, 2010| 5 Comments »

I think the original definition of “evidence based medicine” was a good one –

EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)

(from “what is evidence based medicine”?)

But what’s happened to it? Frequently it seems to be reduced to reading summaries of randomised controlled trials then applying those conclusions to everyone. In other words, forget the “clinician’s cumulated experience, education and clinical skills” because it might produce “variance”, and dismiss the patients’ “unique concerns, expectations, and values” as irrelevant. It’s that kind of thinking which led to a young doctor telling me she’d been taught “If a patient takes an evidence based drug and says they aren’t any better, then, either they haven’t taken the drug, or they’re lying.” Clinicians’ cumulated experience will tell you that there isn’t a drug on the planet which will deliver the same outcomes for every single patient who takes it, and as health is a subjective human experience, the patients’ concerns and values can only be dismissed at the cost of failing to deliver effective health care.

So, I was somewhat surprised when I got last week’s BMA Scotland newsletter. Under the heading “Healthcare Quality Strategy for the NHS in Scotland is published”, it said

The Healthcare Quality Strategy has been published by the Scottish government. BMA Scotland believes by focusing on evidence-based policy with proven clinical outcomes for patients, limited resources can be used effectively to deliver improvements to the care and treatment of patients.

I clicked the link to read more

Here’s what it says on the first page –

People in Scotland have told us that they need and
want the following things from the NHS and we have
built this strategy around these priorities:
● Caring and compassionate staff and services;
● Clear communication and explanation about
conditions and treatment;
● Effective collaboration between clinicians, patients
and others;
● A clean and safe care environment;
● Continuity of care; and
● Clinical excellence.

So, how does the BMA manage to get from the document to their summary? Why no mention of the priorities focused on care, compassion, communication, collaboration, cleanliness and continuity of care? Why pick only the last priority and characterise that as a way of rationing medical care according to “proven clinical outcomes”?

Really, it’s high time we put human beings back at the CENTRE of health care…..the patients and the carers……just as it says in the rather excellent “Healthcare Quality Strategy for the NHS in Scotland”. Read it for yourself and see if you agree.

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Joined up thinking

Posted in from the consulting room, from the reading room on May 21, 2010| Leave a Comment »

One of the main problems of reductionist thinking in health which considers each disease as complete and separate entities is that the real world is a joined up one. What changes you make in one place ripple through the networks and produce a wide range of unpredictable changes.

Here’s a recent rather unexpected story illustrating this.

Researchers at George Mason University have uncovered a link between smallpox and Aids. People who have been immunised against smallpox have a five-fold reduction in HIV-replication compared to those who have never been immunised. Could this explain the massive increase in HIV in Africa when it appeared? Smallpox was declared eliminated from the world in 1980 and nowadays only researchers working with smallpox are immunised. Could it be that stopping smallpox vaccination, left the population without some kind of protection against HIV?

It’s an interesting and plausible hypothesis.

How often, in Medicine, do we ever consider the potential increases in one disease as another declines. I often wonder what people are going to die from if the great targeted projects against heart disease pay off. After all, human mortality stubbornly remains at 100%, so which causes of death will we see rise, as other ones decline?

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Diversity and uniqueness

Posted in from the consulting room, health, Uncategorized on May 11, 2010| Leave a Comment »

Once again Iona Heath gets it right. In last week’s BMJ she wrote about the clash between organisational models and clinical models of health care. In short, she was pointing out that the moral imperative of a doctor was to provide the best care for the individual patient, and that the political perspective was focused at a population level.

I thought this paragraph was particularly pertinent.

Politicians tend to emphasise the uniformity of people. Despite the contemporary emphasis on choice, they cling to a normative view of patient aspiration, which is then reflected in the increasingly rigid guidelines that dictate clinical care. Clinicians, on the other hand, emphasise the diversity of patients and the challenge that this represents in providing the space needed to allow each individual patient to retain his or her moral stature—an aspiration that goes way beyond the meagre rhetoric of choice.

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The Renewal of Generosity

Posted in books, from the consulting room, from the reading room, health, narrative, philosophy on April 25, 2010| 2 Comments »

I recently stumbled over Arthur Frank’s “The Renewal of Generosity” (ISBN 978-0226260174). Many years ago I read and was hugely impressed by his “The Wounded Storyteller”. It’s a great small book which is an important contribution to the struggle to create a better way of practising medicine in the 21st century. Doctors and patients are increasingly demoralised by the reduction of health care to technical procedures and the delivery of products (what Dan Siegel describes as “diagnose and drug” in his analysis of contemporary psychiatry). The everyday, subjective experiences of both patients and doctors are dismissed as irrelevant in the pursuit of measurement, targets and throughputs. Isn’t it some kind of indictment of our current health care that he can say this on page one –

My conviction is that at the start of the 21st century the foremost task of responding to illness and disability is not devising new treatments, though I’m grateful this work will proceed. Our challenge is to increase the generosity with which we offer the medical skill that has been attained.

That’s the word which really struck me – generosity. I think a lot about compassion and its central place in good health care, but I’ve not really considered the work generosity. It’s such a good word. Somehow it not only encompasses compassion but it contains within it a sense of enlarging life – my own life, and the lives of others to whom I am generous. It’s a welcoming, loving, life growing word. It’s a good word to bear in mind when considering “how to live”, how to find happiness and how to create well-being.

His key theme in this book is to weave together the teachings of ancient Stoicism (a much misrepresented classical philosophy I believe), with the case for dialogue. He primarily draws on the writings of the Stoics, of Levinas and Bakhtin.

The practice of medicine is a relationship between two people. What are we to call these two people? As a doctor, I’m fairly comfortable with the term, “patient”, but it bothers me that it seems to imply something passive, expecting the ill person to just be treated, and that contains the seeds of objectification – treating people not as people, seeing them as instances of disease, instead of persons who suffer. I hate the word “client”. It’s laden with commercialism and contractualism for me. However, Frank pulls a different set of words out of the bag and they hit me between the eyes –

The renewal of generosity will be hastened if participants in medical relationships think of themselves not (at least not only) as patients and professionals, much less as consumers and providers, but as guests and hosts.

Guests and hosts! He elaborates and explains, but I won’t share that here. Just think about this idea for a moment. I’ve never encountered it anywhere else. Wonderful.

I love so much of what he has to say about the importance of dialogue –

Dialogue suggests that the world is co-experienced by two of more people. Each one’s perspective is necessarily partial, and each needs to gain a more adequate sense of the world by sharing perspectives.

I wrote about that from a neuroscience perspective recently here.

The enlarging of perspective, or, in the other words, the attempt to see a more full picture demands dialogue. It prevents us from dismissing others through judgement and classification.

…no final, finalising discourse that defines anything once and forever. No last word can be said about this you, whose horizons of possibility remain open.

“whose horizons of possibility remain open”……how often do we forget that? How often do we squash hope with the illusion of certainty? How often do we practice as if we know exactly what a treatment will bring about for the person undergoing it? Having open horizons of possibility is a characteristic of healthy living.

We have other good reasons for dialogue apart from sharing our perspectives to gain a fuller picture. We use dialogue to value the other.

…the moral demand of dialogue is that each grant equal authority to the other’s voice……it’s being willing to allow their voice to count as much as yours

[doctors] are taught monological medicine: the doctor is the one cognitive subject in the consulting room, and the patient is an object for that cognition.

Identification with others requires giving up monologue.

The other element which we have to consider when we focus on dialogue is the other part of the doctor-patient (or host-guest) relationship – the carer. I think our system of medicine dismisses this almost entirely. The focus on “randomised controlled trials” is a focus on the statistics of groups. Once a drug or treatment is “proven” it seems to be irrelevant who delivers it, or how. Yet that’s not our experience when we are ill. Who the doctors and nurses are is important to us. How they talk, how they listen, how they treat and care for us. The idea that its the treatment which is important and the not the person administering it seems inhuman to me.

We can keep the question before us: what do they think about how I am imagining them? and we can believe that what they think matters.

We should honour patients’ stories, not dismiss them as “subjective” or “anecdotes”. They matter.

Finally,

…the person who we see ourselves revealed to be is seen most fully in others’ responses to us

Isn’t that so true? What have you seen of yourself in others responses to you today?

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The Wounded Storyteller

Posted in from the consulting room, health, narrative, Uncategorized on April 25, 2010| 5 Comments »

In “The Wounded Storyteller” (ISBN 0-226-25993-5) Arthur Frank describes his study of how patients talk about their illnesses, where he identified three major “genre” of narrative which we use to talk about illness – the “restitution story”, the “chaos story” and the “quest story”. I thought that was such an interesting insight and such a wonderful ideal to aim for.

Most patients tell the restitution type of story. It goes along the lines of “I’m broken, please fix me”. Our whole health care system seems created around this idea. Patients present their broken bits for fixing, the fixing is the outcome or target to be delivered cost-effectively, doctors are seen as the fixers and the process of health care is experienced as a passive one by the patient.

The chaos story is also very common. Frequently we become overwhelmed by not only the illness, but also the diagnosis and the treatments. In a chaos story a patient is lost in an ocean of suffering, confusion and distress. As they tell their story it comes tumbling out in all its complexity and it can be very hard to see the person who is suffering from the vast intense collection of symptoms and problems. Indeed, even the storytellers can’t find themselves any more in the middle of this terrible experience.

Frank proposes a beautiful alternative genre of story to tell – the “quest story”. A quest story has certain clear elements and they are the ones you find in “hero stories” in all cultures around the world. The “hero”, he proposes, is the patient. Their quest is health. The adventure is the illness. As the patient encounters various investigations, diagnoses, symptoms and treatments, they are experienced as challenges which need to be met in order to gain “boons”. It’s the gaining of these boons which grows the hero into the person who can attain the goal of the quest. (Think of the traditional tale of the prince who wants to marry the princess but first is told he needs to slay the dragon, overcome the wicked witch, and so on, before he can become the man worthy of the princess’ hand in marriage).

One of the best examples of this is Lance Armstrong‘s autobiographical “It’s not about the Bike” (ISBN 978-0224060875). Lance is a professional cyclist who was a great sprinter but when he tried the Tour de France he found he didn’t have the stamina for it. He developed testicular cancer with widespread metastases and was given only a slim chance of survival. He underwent surgery and chemotherapy successfully, became depressed by the whole experience, then got back on his bike. A year later he entered the Tour de France and won it. He went on to win it eight times in a row – more than any man has ever done before. In his book he says if he’d had to choose between cancer and winning the Tour, he’d choose cancer every time. That shocked me when I read it. He went on to explain, cancer and dealing with it made him the man who could win the Tour de France. That’s a quest story! (let me be clear – he’s not advocating cancer as a good thing, something to be welcomed, or worse, sought – he’s telling the story of how dealing with a serious illness can actually grow us, ultimately changing our lives for the better)

The challenge, I think, is to find a way to live, which is a quest story in it’s own right……to become heroes, not zombies.

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Life’s best when it’s flowing

Posted in from the consulting room, from the dark room, from the living room, health, life, photography, tagged , , on April 7, 2010| 2 Comments »

I’ve long held that a way of thinking about health is to use the concept of flow. When the various different aspects of our selves and our lives integrate in a coherent way we experience flow – good energy, good vitality, strength, the feeling of being alive (there are many ways to describe it)

waterfall

I recently came across an interesting expansion of this idea when I read “Mindsight” by Dan Siegel (ISBN 978-0553804706).
He describes health as being like a flowing river and he says the river has two banks, either of which we tend to drift towards as we become unwell.
One bank is rigidity, and the other is chaos.

It’s true. We can see that in some illnesses we are stuck, caught in loops, trapped in ever decreasing circles which shrink our world. What should be flowing has become solidified, sluggish, frozen, or blocked.
In complexity terms, this kind of pattern exists around “point attractors”. You’ll be familiar with point attractors in the universe; they are the black holes which suck everything into them. Nothing escapes.
In other illnesses everything seems to fall to pieces, life itself falls apart and we find ourselves lost, or overwhelmed with confusion. We don’t know who we are, or where we are, and we don’t know how to find a way out.
In complexity terms, this kind of patterns exists as a “chaos attractor”, a zone of chaos where there are no clear patterns but which somehow maintains itself.

Which of the patterns are most familiar to you?

Rigidity?

icicles

or Chaos?

sea path

Healing involves a release from these states – from rigidity, or chaos, to flow.

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What’s most important in health care?

Posted in from the consulting room, health on March 2, 2010| 11 Comments »

What’s most important in providing good health care?

My answer – people.

Every doctor I know has personal stories of experiencing a dehumanisation of patients in health care. From the well known “liver problem in bed 3” way of referring to someone, to stories like the ones Dan Siegel tells in his “Mindsight” book of being clearly and specifically instructed not to ask about patients’ lives and feelings, but, instead to concentrate on “diseases”.

Here’s two conversations I’ve had with junior doctors in the last few months. One told me that she had been instructed by her clinical teacher “Don’t believe patients. They lie all the time. You can only trust the results” By “results”, they meant the results of investigations – blood tests, X-Rays etc. The second told me she’d been taught “If a patient takes an evidence based drug and says that it didn’t help, they’re either lying or they didn’t take the drug.”

Frankly, both these conversations shocked me. It seems like dehumanisation has been take to a new level. What kind of doctor has these attitudes and beliefs? Are these caring doctors? What, or who, do they care about? Are they scientific doctors? Is it scientific to dismiss patients’  narratives and patients’ subjective experiences? It’s not. Dr Robert Smith, in his book, “Patient-centered Interviewing. An Evidence Based Approach” describes clearly and eloquently why it’s not. Without considering all the “data” available, he says, then the assessment will be invalid. He makes the point that the “data” includes the patient’s reported subjective symptoms.

These attitudes were very evident in the recent Science and Technology Committee’s attack on homeopathy. They made it very clear that they considered irrelevant the fact that repeated research has shown 70% of patients who received homeopathic treatment on the NHS stated that it helped them.

There’s another consequence of the failure to make people the most important priority in health care – that’s they way the health carers are treated. There’s wholesale destruction of professionalism underway with nurses’ and doctors’ work being broken down into hundreds of individual tasks which can be measured and monitored. Procedures become more important than people, and the nurses and doctors feel undervalued.

It’s sad. And it’s not good.

Do we need to create a campaign to redress the balance? To insist that people are more important than statistics? To teach doctors to believe what their patients tell them and to show that there are no “evidence based drugs” which work in every person who takes them? To create the conditions for more care and more respect?

I think we do. What do you think?

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Where’s pain?

Posted in from the consulting room, health on February 26, 2010| 5 Comments »

I do find the splitting of human beings in two apparently separate parts, body and mind, very odd. As I’ve said to patients, I’ve never met a mind without a body, and I’ve only met a body without a mind in the mortuary. Sure, it’s common for people think using a two-value system – right or wrong; good or bad; black or white – but it’s always a highly inaccurate way of describing reality. I’ve heard people wrangle over whether someone’s pain is in their body or their mind, and that seems a particularly peculiar question to me. In fact, I once I heard a health service worker describe a patient as “one of those people whose pain is all in their mind”. What did that mean? They were pretending to have pain? They were making it up? How do you experience pain without using your mind? Can we put the mind aside when considering pain?

I guess what people mean when they talk this way is where is the source of the person’s pain? Is it a physical lesion? Or is it a mental one?

I still don’t find that helpful. Surely we need to consider a person as a person, and a person with pain as a person with pain. Subdividing them isn’t helpful.

But, here it is again, in today’s Independent newspaper, that extremely odd tendency to consider human beings in two separate parts. In an article by Jeremy Laurence about research showing Cognitive Behavioural Therapy can be effective in people with back pain…..

Cognitive behaviour therapy is established as the most effective of the talking treatments and has revolutionised the way doctors approach psychological conditions such as depression and anxiety. But it is not usually associated with physical ailments such as back pain. The technique involves helping patients to break habitual ways of seeing things and to think positively instead of negatively. Zara Hansen, a member the research team from the University of Warwick said: “We are not saying back pain is all in the mind. It is very much a physical problem but the way you understand it affects the way you manage it.”

Physical ailments such as back pain? What does that mean? Does everyone with back pain have a physical lesion in their back? No, they don’t. Can cognitive behavioural therapy only help “problems of the mind”? How odd to consider patients in such divided ways. The researcher, Zara Hansen, promulgates the same peculiar thinking with her “We are not saying back pain is all in the mind. It is very much a physical problem but the way you understand it affects the way you manage it.”

Seriously, finding lesions which can be modified, repaired, or removed is one thing, but to consider a subjective phenomenon like pain as being divisible into physical or “in the mind”…….let’s move on. Far too many people with pain have had surgical operations to remove the claimed physical cause of their pain, only to find themselves with just as much pain as before.

People with pain deserve to be understood as whole people, and to have care which is suitably holistic. Otherwise, the pain remains…..

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The Decision Tree – Health 2.0

Posted in from the consulting room, health on February 23, 2010| Leave a Comment »

Thomas Goetz’ new book, “The Decision Tree” looks interesting. His theory, based on research evidence, is that two behaviours significantly improve health outcomes – being personally involved in taking the decisions about your own health care, and sharing with others.

A decision tree, essentially, is a flow chart – it’s a kind of algorithm, a way to factor in various strands of information and probabilities to move towards an optimal outcome. So it’s a way of thinking about our healthcare as a series of deliberate choices, where we are the primary decision-makers. When we take on that role, we tend to have better health.

I like what he says about DNA – that it’s an indicator, not an inevitability. However, I wonder how people will cope with the knowledge of their DNA disease markers? Will they feel like they’ve got some ticking time bombs on board? And, he’s very balanced about screening programs, recognising that they are problematic, not least because of the false positives they throw up.

He points out that giving people personal feedback on their behaviour changes and involving them in communities are two tried and tested techniques which can be delivered much more easily now with smartphones and online communities.

In an interview with him on the freakonomics site, he says this –

One of the amazing things I learned in writing the book is that many popular drugs don’t really work all that well. Anti-depressants work at best around half the time; chemotherapies for cancer work at best 20% of the time. This is the hit and miss of modern pharmacology – there are no sure things.

It’s amazing how that well-established fact is still ignored. As he’s an editor of Wired magazine, it’s no surprise that his hope lies in pharmacogenomics coming up with the ways to produce more targeted drugs.

I’m pretty excited about the Health 2.0 ideas. Social networks and wikis are two potentially useful tools for patients, and I think Goetz’ book adds others – the decision tree itself and the emphasis on personalised feedback.

Potentially, this is all about a shift in power, away from doctors and towards patients. In my opinion that’s a trend to be encouraged.

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The health benefits of enthusiasm and contentment

Posted in from the consulting room, health on February 19, 2010| 7 Comments »

In a new study just published in the European Heart Journal researchers have looked at the impact of a “positive affect” on the chances of getting heart disease. What’s “positive affect”?

Positive affect is defined as the experience of pleasurable emotions such as joy, happiness, excitement, enthusiasm and contentment. These feelings can be transient, but they are usually stable and trait-like, particularly in adulthood. Positive affect is largely independent of negative affect, so that someone who is generally a happy, contented person can also be occasionally anxious, angry or depressed.

Here’s what they found

After taking account of age, sex, cardiovascular risk factors and negative emotions, the researchers found that, over the ten-year period, increased positive affect predicted less risk of heart disease by 22% per point on a five-point scale measuring levels of positive affect expression (ranging from “none” to “extreme”).

As always, the researchers strongly plead for more research, both to clarify if their findings are revealing something true, and to begin to develop methods for helping people to develop a more positive affect. Is it possible to increase your positive affect? Well, think about what makes you happy, excited, brings you joy. Think about how you experience moments of contentment. What are you enthusiastic about? How could you spend more time than you currently do following your passion?

I wonder how this study connects to the well proven benefits of TM in reducing heart disease?

I practice TM 20 minutes twice daily. That’s 40 minutes of contentment. I often think of myself as a “peripatetic enthuser” – I am passionate about life. The daily world excites me, fills me with wonder and amazement. I laugh a lot. Will this way of living reduce my chances of heart disease? I don’t know. Maybe it will, if this research is correct. But I don’t live this way to try and avoid diseases. I don’t live this way to try to avoid dying. I live this way because this is how I want to live.

Here’s my personal view on avoiding heart disease. I hope I’ll never get it, but whether I do or not, I’d rather live enthusiastically, passionately and joyfully. If this way of living reduces my chances of heart disease, that’s a bonus.

But what does this mean for health care? Our current focus on reducing premature deaths from heart disease, has got two strands – “lifestyle” changes eg not smoking, eating less and exercising more, and taking drugs – statins, or even, as some advocate, a whole mix of drugs in one pill. That whole thrust seems to be towards death avoidance, and it’s not a strategy I personally prefer. I’ve a real penchant for focusing on, and building up, the positive.

Make better dents.

A life well lived today, is a life well lived, irrespective of how long that life turns out to be.

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