Heroes Not Zombies

Defining health isn’t as easy as you might think. An article in the BMJ before Christmas raised the issue again and amongst the responses they received this one particularly appealed to me.

The definition of health is important. There is a biomedical component to health, but it exists in a setting that includes biological, personal, relational, social, and political factors. For too long, we as doctors have been timid about defining health, and mostly operated at the level of “absence of disease.” For too long, we as a society have allowed politicians to get away with shunting health off to a “medical domain,” thus avoiding focus on the large scale social and political forces that create health and illness. We need to rediscover the force of Virchow’s statement: “Medicine is a social science and politics is nothing but medicine on a grand scale.” In my essay I propose: “Health is best seen as an ongoing outcome from the continuing processes of living life well. Living life well would be defined in terms of wealth, relationships, coherence, fitness, and adaptability. Disease avoidance would be a minor part of this view of health.” Such a definition is a political statement, informed by my knowledge of medicine and its social context. I believe that achievement of health should be a goal of public policy and that we should want to achieve healthy individuals in a healthy society. I see health as being a moral and practical good in itself, as well as a means towards other ends. If health is to mean anything it has to include ideas of human flourishing and abundance. As a doctor I need an aim, and a context, for my practice of medicine that goes beyond treatment of illness, important though that is.

This was a published as a letter from GP, Dr Peter Davies, in the BMJ. I enjoyed everything he had to say, but I especially agree with the sentiment that health is a process and that “Disease avoidance would be a minor part of this view of health”. Not only disease avoidance but death avoidance, I argue! But what really caught my attention was “If health is to mean anything it has to include ideas of human flourishing and abundance.” Couldn’t agree more!

Read Full Post »

A study of medical students in Brazil found that 38% of them had at least 10 of a list of 63 depressive symptoms during their internship years –

Affective symptoms represent the core symptoms of a depressive mood, based on students’ reported levels of sadness, dissatisfaction, episodes of crying, irritability and social withdrawal. The cognitive cluster assessed pessimism, sense of failure or guilt, expectation of punishment, dislike of self, suicidal ideation, indecisiveness and change in body image. Finally, the somatic cluster assessed the presence of slowness, insomnia, fatigue, loss of weight and loss of sexual interest

Such study results are both shocking and no surprise. A junior doctor’s job is highly stressful for a host of reasons. Pretty much every doctor I know would identify with the symptoms highlighted by the Brazilian researchers. When I read this I wondered these two things –

Does such a training make for better doctors? I doubt it. Such an experience is something to be survived and whilst I’m well aware that difficulties and even illnesses can teach us a lot about ourselves and even contribute to our growth, I wouldn’t recommend dysfunction and disease as the best teaching methods!

These experiences are more likely because we pay insufficient attention to the humanity of the real people who are health carers (the parallel to paying insufficient attention to the humanity of the real people who are patients). We practice a system of medicine which is focused on tools and techniques, not least on drugs, because our clinical focus is disease (lesions, pathology), not health. The rise of something called “Evidence Based Medicine” has made this worse. “EBM” is based on the statistical analyses of experimental “controlled” trials. The design of these trials is intended to “control for” the human factors in order to reveal the specific treatment factors ie the effects of the prescription, not the prescriber. It is virtually impossible to read in any significant clinical trial who the actual carers were. It’s as if they don’t count. They are irrelevant. But they aren’t. And until we change our values in health care and give a higher priority to the fact that health care is delivered by real people to real people then we aren’t going to change the outcomes.

Is it impossible to imagine a medical training which doesn’t cause depression in a third of the people who embark upon it?

Read Full Post »

The focus of medical practice is the lesion. It’s the lesion, the abnormal cells, tissue, organ or body system which IS the disease. This is the pathological approach to health. It gives pre-eminence to physical, “organic” abnormalities, names them (diagnosis) and then seeks to directly address those abnormalities with treatments. The treatments are primarily surgery to physically remove the lesions, and chemicals (drugs) to act against the lesions (or, in the case of infections, to act against the infecting organisms).

This approach works well for most acute disease and for clearly identifiable lesional problems. In fact, the more localised the problem, the greater the success of this way of working. However, there are at least two major difficulties. Firstly, the more complex a disorder, the harder it is to identify a “lesion” which is the sole cause of the patient’s illness. Secondly, there’s the difference between objective findings and subjective experience. Studies of symptoms have shown clearly that there is no direct linear relationship between lesions and symptoms. Not everyone with the “same” lesion (same diagnosis at same stage of disease) has the same symptoms or the same symptom severity. And, a person can have debilitating or incapacitating symptoms without lesions.

Here’s a study which highlights the other side of this coin – people can have lesions without symptoms. In this study, people with abnormalities in their MRI scans typical of Multiple Sclerosis but without any symptoms of MS – in other words where the findings were by chance while investigating some other problem – were followed up. 30% of them had developed symptoms of MS within about 5 years, but another 30% showed more lesions on the scan within 5 years but still no symptoms of MS. The researchers ask the question – does someone have MS if they have MRI-revealed lesions but no symptoms whatsoever? They argue a definite NO.

“Diagnosing a patient with MS has serious psychosocial and treatment implications, and physicians have an obligation to follow appropriate criteria in making the diagnosis,” Bourdette said. “Patients must have symptoms to receive a diagnosis. This study sets the stage for establishing a process for evaluating these patients and following them to help determine the risk of developing MS. Until then, we should not tell them that they have MS or treat them with disease-modifying therapies. For now, it’s best to remember the wise advice that we ‘treat the patient, not the MRI scan.'”

Read that conclusion carefully. They are arguing that we should address people not lesions. If we fully take that on board, there are significant consequences for the way we provide health care.

Read Full Post »

The placebo effect is much misunderstood, seriously under-researched and full of peculiarities. I must admit I’ve assumed that the placebo effect is the body’s self-healing effect. I’ve always thought that’s an important point to make because otherwise people tend to think of the placebo effect as some kind of trick. Whatever it is, it’s real. Symptoms can be modified or even removed, and the “nocebo” effect (that’s the one where harm is caused) can cause real illness. It’s not a pretend effect, even if the intervention is deliberately a pretend one!

However, I’ve just read a short article on the Edge, where a psychologist muses about the placebo effect and raises an issue I hadn’t considered. If the placebo effect is the self-healing effect, why doesn’t the body just get on and do it without the placebo? That’s a good point. Where’s the advantage in waiting for a push? In the article, Nick Humphrey considers the phenomenon from an evolutionary biology perspective and there’s something in what he says, but I’m left with the nagging doubt that whatever the placebo effect is, it IS NOT the self-healing effect. It might be related to the self-healing effect. It might even have its impact by provoking the same, or similar pathways to the self-healing effect. But maybe it’s distinct and different from the placebo effect, not least in it kicking in and getting to work without the need for an external push.

We tend to use such concepts in un-thinking ways. One of the tricks we use to stop our thought processes is to name something and in so doing convince ourselves that we now KNOW it. It’s not true though. Sadly, often when we name something, that naming stops us from thinking – especially if the naming is judgemental. (I think it was Wendell Johnston, the General Semanticist, who said “Judgement stops thought”) After all, what exactlly IS the placebo effect? Spontaneous healing? The natural capacity to recover? A statistical trick? And what IS the self-healing response? How DO people get well? We know some of the components and pathways eg inflammatory responses, the immune system, various hormones and so on, but can all these components be considered together to constitute something called the “self-healing response”?

The answer is…….we don’t know. But don’t you think it would be a good thing if we did? (fields of research such as psychoneuroimmunology and psychoneuroendocrinology are exploring these questions – google them and see what comes up!) If we understood the self-healing system then we could develop the healthcare interventions which were not only designed to promote healing but which actually did stimulate and support it. Why do we concentrate on “disease management” and “symptom control” instead?

Read Full Post »

One of the things that frustrates me about clinical epidemiology (which goes by the name “evidence based medicine”) is how often it seems detached from the real world. Whilst researchers and statisticians pore over reviews of randomised clinical trials, real people with real problems turn up each day in the doctors’ consulting rooms. In the British Medical Journal there’s a regular column entitled “From the Frontline” and it’s written by a Glasgow GP called Des Spence. I always read his column because so often it reflects the daily reality I used to experience as a GP and which I still experience as a Glasgow hospital doctor. This week his column was particulary good – a healthy, realistic alternative view of the government’s “Quality Outcomes Framework” within which all UK GPs now practice.

It is not just the huge financial opportunity cost, nor the well made unwell, but the wanton consumption of our medical energies that I take issue with. Our energy has been spent bean counting the measurable while dismissing the most valuable aspect of medical care, the immeasurable. Perhaps I am wrong. But I will stand my ground of absolute scepticism until some redcoat finds real evidence to run through my Jacobean heart.

Well said, Des!

I especially appreciate your succinct “Our energy has been spent bean counting the measurable while dismissing the most valuable aspect of medical care, the immeasurable.” It’s a daily sadness to me that we increasingly pay attention to the measurable while dismissing the immeasurable in health care.

Read Full Post »

Researchers at Ohio State University have just published a randomised clinical trial of pyschological interventions in women with breast cancer. Here’s the summary conclusion –

breast cancer patients who participate in intervention sessions focusing on improving mood, coping effectively, and altering health behaviors live longer than patients who do not receive such psychological support. The study indicates that reducing the stress that can accompany cancer diagnosis and treatment can have a significant impact on patients’ survival.

This was a study of 227 women who had been treated for breast cancer for an average of 11 years. Half of them were given an intervention designed to address stress and help them cope better psychologically (I can’t find the actual detail of the intervention yet!). The intervention group experienced about half the recurrence rate of the others and that group also had about half the risk of death from breast cancer.

Two things interest me about this trial. Firstly, it shows that non-drug, non-surgical interventions in serious conditions like cancer can both positively influence the course of the disease and even reduce the chance of dying from the cancer. Secondly, by reporting improved mood, and healthy behavioural changes, the researchers highlight the value of interventions which make living better. I recently wrote about death avoidance and made a plea for health care which is focused on living. This little trial is a piece of that jigsaw. It not only shows the potential for such interventions but it begins to make the case for such approaches to become routine.

Read Full Post »

A few years ago I stumbled across the works of the “General Semanticists“. I won’t go into detail about this school of thought here, but it originated with a man called Alfred Korzybski in the early years of the 20th century. He wrote and taught about the way in which human beings reacted as whole organisms to their environment. One of the most interesting features of this way of thinking is the emphasis it gives to not only environment, but to what Korzybski called the “meaning environment” – in other words both symbols and the symbolic power of the environment itself. This focus raises all kinds of issues including change, transience, and context. The book which made this whole way of thinking clear to me was Samuel Bois’ Art of Awareness (ISBN 978-0965103701).

One of the ways of thinking they highlighted for me was “two value thinking” – we do this a lot. It’s the process by which we classify experience into one of two categories – us and them; black or white; and so on. Although generalisation and categorisation can be useful tools they are dangerous and frequently stop us seeing reality. You’ll come across this a lot in medicine. I’m sure you’ll have heard people talk about treatments as either “proven” or “unproven”; “evidence-based” or “not evidence-based”; “drugs which work” and “drugs which don’t”. But this is a silly and unhelpful way to think about treatments because all treatments need to be considered within the inescapable context of the individual. And you can’t even say a treatment “works” or “doesn’t work” for an individual – the same treatment can work at some point for a person, but then not work at another.

Think about painkillers as a simple example. Is there a “proven” painkiller which will kill pain for all individuals on all occasions? No. And, actually, it’s the same with all medical treatments. The only person who can tell you whether or not a treatment is beneficial for them, is that person – doctors have to listen to their patients and hear what their experience is. It’s very frustrating for patients to be told by a doctor that their lack of benefit they’ve received from a particular treatment is their own failure – because the treatment is “proven”. Similarly, it’s very frustrating for a patient to be denied a treatment which brought them benefit because somebody has ruled, on the basis of clinical epidemiology, that that particular treatment is “not evidence-based” or “does not work”.

The world is more complex than that. See if you can spot any two-value thinking today, and consider different contexts to see the weakness of this type of thought.

Read Full Post »

What’s the point of health care? Does that seem like a question with an obvious answer? It would be reasonable to expect that the answer would be that health care is about caring for people’s health. But that’s an answer which is not really an answer. It raises the question, what is health? Stop and think about this for a moment, because it’s not a straightforward question to answer. My answer is that health is a phenomenon in its own right – it is NOT the mere absence of disease. It has distinct characteristics – adaptability, creativity and engagement. Others will have other answers, other characteristics to add, other qualities. It’s difficult to extricate health from the old concept of “eudaimonia” which tends to be translated as “happiness”, or even “wellbeing”, but I prefer the word “flourishing”. Surely health is about flourishing? The less we flourish, the less we rate ourselves as being healthy, well, or good.

This way of thinking about health is holistic. It demands that we consider the whole of a person’s life, and by that I mean the whole of their present time life (a biopsychosocial approach), and the whole of their life from start to finish. This has at least two consequences. Firstly, it means that all health care must take into consideration, not just objective disease in the form of pathology or lesions, but it must consider the individual patient’s story. No two patients have the same life, and therefore, no two patients share the same experience. With the same disease, two people will experience different symptoms and those symptoms will mean something different to each of them. In addition, each individual will have their own ways of coping, adapting to and dealing with their illness. Health care needs to relevant to the individual who is being cared for.

Secondly, it means that health care interventions will alter the experience and course of a person’s life, but they do not, ultimately, prevent death. The overall mortality for human beings is 100%. We do all die. But much of contemporary health care is predicated on the basis of death avoidance. We are bombarded with claims about “life-saving” medicines and Public Health policies which claim to reduce death rates. Statins, for example, are even promoted for healthy people, to reduce their risk of death from heart attacks and strokes. Whilst nobody would really like to have a heart attack or a stroke, no-one is asking the question, what do people who would have died from a heart attack or a stroke die from instead? The focus is on death avoidance. People are classed as being “at risk” – at risk of dying from disease x. But to make an informed choice about a treatment don’t you need to have an idea of the possible and likely consequences of that treatment? To say a treatment reduces your risk of dying from disease x is all very well, but it doesn’t say much about whether or not you’ll experience a life of greater flourishing. Especially if you develop another more disabling, painful condition instead. The logical extension of this death avoidance thinking is to try to avoid death from all causes. For example, some doctors and scientists have promoted what they call the “polypill” – a combination of drugs all in one pill, which, if taken by the whole population (or in this case the whole population over the age of 50), would significantly reduce the death rate from cardiovascular disease. Well, if you don’t die from cardiovascular disease, what do you die from? Cancer? Nervous system disease? Liver disease? Blood diseases? There’s no way to know of course but isn’t it true that it will be something else? Or do you think healthy people die disease-free?

It’s likely that a person will fight hard for life at all times. (Well, not everyone, as Dylan Thomas wrote, “Do not go gentle into that dark night. Rage, rage against the dying of the light.” exhorting his father to fight for life at the end of his life). Around a third of all health care expenditure is on people in the last year of their lives. (see New England Journal of Medicine 1993:328:1092-6 for example)  You might hope to live three score years and ten, and if you do, you can expect that most health care you receive will be in your last year of life. Think of it this way – assuming 70 years of life (I know, that’s quite an assumption!), one third of your health care will be in one seventieth of your life and two thirds for the other sixty-nine seventieths. Why is that? Because you can expect to flourish for 69 years and suffer for one? I’m not sure that’s most peoples’ experience. If health care is about improving life as opposed to merely trying to avoid death why don’t we direct more of it to life instead of death avoidance?

It seems that our so-called “health care” isn’t focussed on health at all. It’s focussed on death avoidance. That was the goal of the alchemists – the elixir of life which would produce immortality. But that’s a myth isn’t it? Shouldn’t we have health care which is more realistic? After all, if we do address illness holistically, reducing suffering, encouraging healing, resilience and growth, aren’t we likely to also increase the length of life? Might that not be a better way to avoid “premature deaths”?

Maybe we should be concentrating on increasing health, in a eudaimonic sense, instead of concentrating on avoiding death, which, realistically, is ultimately impossible.

Read Full Post »