Heroes Not Zombies

Can’t remember the last time I disagreed with Iona Heath and in this week’s BMJ she’s written an article which, yet again, I fully agree with. She’s writing about the connection between respect and health.

The evidence that poverty undermines health is now overwhelming, and the task for every member of any society worthy of the name is to transform that knowledge into some form of redress. Each of the dimensions of poverty—low income, inadequate education, unemployment, poor housing, social isolation, and even the carrying of knives—have a common core, which is the attrition of hope, opportunity, dignity, and respect. All four are intimately related, and the erosion of one damages each of the others.

If we are serious about trying to improve the health of the population we need to shift our focus from a disease-driven agenda to a health-driven one and that will require us to tackle inequalities. As Dr Heath says, the link between poverty and ill health is well proven and it is totally unreasonable to expect doctors to improve the health of the population by trying to ameliorate the effects of the diseases caused by inequality.

She’s also right when she concludes –

Respect means facing the reality and the effects of inequality and injustice, both within society as a whole and within the health service, rather than believing that they can simply be managed away.

The problems of ill health cannot be managed away. The solutions don’t lie in more drugs, faster operations or “health service reform”. They lie in rediscovering that health is an individual human experience and by a focus on “hope, opportunity, dignity and respect”.

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Lord Darzi announced his proposals for changes in the NHS in England today. One of the points particularly grabbed my attention – the emphasis on the quality of health care. About time I reckon. We’re still in the midst of a target driven quantities focused health service. Too much emphasis on markers set by managers rather than patients. But hang on, I thought, it’s all very well to talk about quality but what will it actually mean? How do they intend to assess and monitor quality in health care? Couldn’t find the detail in any of the news reports so I went to the Department of Health site and downloaded the full report.

What I found about quality surprised me. I am impressed! They intend to assess three areas of healthcare quality –

1. Patient Safety. I’m glad to see this in the pole position. “First do no harm” is a centuries old piece of medical advice. Too often ignored I feel. They will assess cleanliness of health care environments, errors in prescribing and rates of healthcare associated infections. I’d like to see them add something about ADRs (Adverse Drug Reactions) and rates of surgical complications. Maybe that’ll come some time.

2. Patient Experience. Compassion, dignity and respect are to be assessed by questionnaires. There are other aspects which could be assessed (patient empowerment for example) but this is a good start.

3. Effectiveness of Care. This is the MOST interesting area. Not only will “clinical measures” be considered, but, very importantly, “patient measures”. Here’s the buzz acronym – PROMs – it stands for “Patient Reported Outcome Measures”. This is a great improvement. I know, you might find this amazing. The BIG breakthrough here is to ask patients not only what has been their experience of healthcare but what outcomes really matter to them.

Are there any particular elements of “quality” in health care do you think should be considered?

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There’s a certain professor in England who is conducting a major campaign (with the help of a few friends) against the whole of complementary and alternative medicine in general and homeopathy in particular. His name is Edzard Ernst and it seems the thrust of his campaign is to tell us that he is an expert so we should trust what he has to say and distrust anyone who disagrees with him.

I could give you many examples of the kinds of statements he makes which I disagree with but let me just focus on one he recently made in “Health Service Journal” because I think this is really the key issue of the debate.

People must not confuse the perceived benefits of so-called alternative medicine with the medical facts.

……..consumers trying alternative therapies tend to be well educated and often perceive these treatments to be effective. Perception must, however, not be equated with fact.

What are “perceived benefits”? Well, they are when a patient says they feel better. And what’s a “medical fact”? That’s a bit harder to pin down. Generally a “fact” refers to something objective. In medicine, that tends to mean something which can be measured, something physical. That’s not the only way the term “medical fact” is used however. It’s also used when someone is actually referring to a probability. Experiments in medicine (known as clinical trials) produce results which are frequently presented as “facts”. However, they are actually statistical probabilities. It’s very odd to hear people divide treatments into two categories – proven and unproven (even more odd to describe treatments as either proven or disproven). The world just doesn’t fit into two simple boxes so easily!

When a patient comes to see me complaining of pain, or fatigue, or nausea, or dizziness, or breathlessness, or any of a whole range of symptoms, they are describing their personal, subjective experience. I cannot, no matter how hard I try, know another person’s pain. So, after receiving treatment, when the patient returns to say how he or she is now, then, when they say they have less pain, they have less pain. When they say they are less fatigued, they have less fatigue. When they say they have less nausea, they have less nausea. There is no way I can tell another person I know better than they do, what they are experiencing.

Some of these patients also have objective signs of disease (but not all of them do). Those who have objective signs of disease demonstrate a non-linear relationship between those signs and their symptoms. There is NO direct one-to-one, linear relationship between, say, pain, and the size of a lesion. The amount of pain may vary with the size of the lesion, but it may not. To tell a patient that you know better than they do whether or not they are improving because only you can measurement the difference is absurd. It’s even worse with the many, many patients whose symptoms are NOT related to lesions at all (those whose tests return only “normal” readings). How do you tell them that they are not really getting better when they say that they are? Which “medical facts” are you relying on?

Having dismissed patients’ “perceptions” of improvement, Ernst and others then go on to say that even if the patient really [according to the expert] is getting better, then it is most likely to either have happened anyway (without treatment), or be due to placebo. Actually, that is a problem for every single instance of treatment. It is impossible to distinguish, in an individual, whether or not an improvement would have happened anyway (self-healing), or is due to placebo (self-healing), or is due to specific effects of the treatment (which in the case of most holistic treatments is claimed to be due to stimulation of self-healing).

I disagree with Professor Ernst. I think that for every single patient I treat, their inner, personal, unique, individual, subjective experience should never be dismissed.

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Why do some people get asthma? (In the last 25 years, the number of new asthma cases in the UK has increased six fold among children and three to four fold in adults) Well, as is the case with pretty much every single disease we know about, nobody knows. We are meaning-seeking creatures. We want to make sense of what we experience in life. Who gets any disease without thinking “why me?” And that is a very, very hard question to answer. It would be more convenient if human beings were more like machines. We’d be able to work out exactly why a particular fault had occurred, we’d be able to understand the consequences of that fault and we’d be able to fix it. But human beings are not like machines (even if the way we treat people who are ill seems to assume that they are). Not only do we not know why asthma afflicts more and more people every year, but we cannot explain to any single, individual patient – this is why you have asthma.

One of the main reasons we can’t answer these questions is that we’ve only recently begun to understand that human beings, biologically, are complex adaptive systems. As such, they have particular characteristics which make the answers to these questions hard to find.

Disease is multi-factorial. There are many things which contribute to the development of a disease in an individual. Causation is, therefore, not simple. We can’t say “X’ causes “Y”. However, we can still observe carefully, and experiment and explore to try and understand what the factors are and how they interact.

Here’s an interesting study which tries to uncover some of the factors involved in the causation of asthma. It’s that old factor “stress” again. But this time, they’ve found something interesting and thought-provoking. Not only have they found that life stresses occurring during childhood seem more common in those who develop asthma, but they’ve discovered something interesting about exactly what kind of life stresses can have this impact. In a nutshell, the stress of parents splitting up and the stress of moving home seem associated with an increased risk of developing asthma. Other major events, such as the death of a close relative, or parental unemployment don’t seem to have the same impact. How do they know? The researchers used the finding of increased blood concentrations of the neuropeptide VIP (vasoactive intestinal polypeptide) as the objective manifestion of the stress response. This, and other substances which were also found to be raised, are known to be factors in producing allergic responses, like asthma.

I think this is a useful study. It shows us some of the mechanisms that connect life events to disease and it shows us that we can’t consider all life events to be the same. What matters is what is most stressful for the person experiencing the stress, not how others rate the stressfulness of an event.

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I had a letter published in the BMJ today. Here’s the text –

What exactly does it mean to say that a treatment produces a decline in “all cause mortality by 21%” in a group of patients aged 80 and over? How long did the treatment postpone deaths from “all causes?” A month? A year? Forever? Use of all cause mortality without a time frame stops researchers and readers asking what the treated group end up dying from. By focusing too narrowly we fail to clarify the true consequences of taking a particular treatment.

I wrote this in response to an Editorial about the treatment of elderly patients with high blood pressure. Somewhat astonishingly the article claimed a study had shown that treating over 80 year olds with antihypertensives not only reduced their chances of having a heart attack or a stroke but produced a reduction in mortality “from all causes” by 21%.

That just cannot be true……..not without qualification. And the qualification is the time period under study. The author of the editorial made no mention of the time period. Mortality remains 100%. Everybody, but everybody, dies. If we effectively reduce the chances of dying from one particular kind of disease, then before we make an informed choice to do what will achieve that, don’t we need to know what we’re MORE likely to die from instead? In fact, it’s not just a matter of death, it’s a matter of life. With an increasing emphasis from biomedical medicine to take drugs for life for a healthier life we desperately need some good whole of life research to show what the impact these interventions have on not just the kinds of deaths such people experience, but the kinds of lives they experience too.

There is a terrible tendency still in Medicine to think in too small pieces. We need the bigger picture.

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Well, well, well. I bet you thought incense might smell good, it might contribute to a feeling of well-being partly through its symbolic ritual use, and partly through some kind of behavioural training, where the smell triggers previously experienced relaxation.

It transpires, however, that frankincense contains some psychoactive chemicals. The resin from the Boswellia plant “activates poorly understood ion channels in the brain to alleviate anxiety or depression”. OK, so this is one of those strange pieces of research conducted on mice, but the researchers claim they may have identified a whole new class of antidepressant and anxiolytic drugs.

I always find myself a bit torn over these kinds of findings. First of all, it’s certainly interesting to read about new discoveries which may help ameliorate human suffering, and it’s also interesting to hear scientists describe potential mechanisms which explain known phenomena, but there’s something a little disturbing too. It’s that reduction of something to its component parts that always makes me uneasy. Even if the incense contains chemicals which can be shown to act on specific parts of the brain, to extract that component not just from the incense but from the whole experience of which incense burning is just a part, and turn it into a marketable product, feels somewhat diminishing.

Oh well, I suppose there’s no need to do an either/or with this one. If ritual and meditative practice involving the burning of incense increases well-being and a new drug or two can be developed to treat patients who are suffering from anxiety and depression, then who says someone can’t avail themselves of both solutions together?

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I’ve just read Patient-centered Interviewing. An Evidence-based Method, by Dr Robert C Smith (ISBN-13 978-0-7817-3279-6). This is one of the best medical textbooks I’ve ever read. I really hope that even in medical schools where the teachers haven’t even heard of this approach, that they will be teaching something very, very similar.

The premise of this book is very simple, and it is that the doctor-patient interview is at the heart of all medical practice. Unlike sick plants or animals, human beings are able to reflect on their own inner experience and to convey that experience using language. These latter qualities make medical practice different from other sciences and crafts. One of the first doctors to make this so very clear was the great George Engel, who proposed, back in the late 1970s, that we move from a biomedical model of human health, to a biopsychosocial one. It is this understanding which underpins “patient-centered interviewing”.

The subtitle of the book is also striking, however, “An evidence-based method”. Much is made of “evidence” these days, and it is arguable that the great ideals of Sackett and his colleagues for “Evidence Based Medicine” has become distorted at the hands of both managers who want to control finances and the practice of doctors, and those who have a narrowly materialistic view of the world, who only value what can be objectively measured. This book, however, takes meets that issue head on by presenting a truly evidence-based approach to the commonest medical procedure on the planet, the one which the average American physician carries out between 140,000 and 160,000 times in his or her working life – the interview.

The patient-physician relationship is the center of medicine. Relationships are central to medical practice…..At the core of any therapeutic relationship is the feeling that an individual can safely expose his or her vulnerability and that he or she is genuinely cared for. These qualities are not merely a matter of having a good bedside manner or of being nice. They have actually been associated with outcomes of care…….The core skill of relationship-building is empathy, which is an accurate recognition and acceptance of another’s emotional state.

Scientific methods usually involve the concept of data. As Smith says,

Although uniquely private and subjective, symptoms and concerns are the primary data – the hard data of the science of medicine – and clinicians and students can enhance their scientific value by good interviewing. These human data lead to most diagnoses and determine most treatments. By “human data”, I mean information that the patient communicates either in words of by nonverbal, but uniquely human, ways, such as a frown. These data are found in no other domain.

He makes what he terms the “humanistic argument” which is that we should “hear and understand our patients in a way that validates them as human beings rather than as objects of study” He points out that this leads to increased patient autonomy which in turn helps them to communicate more clearly what they are actually experiencing and, when it comes to treatment, are much more likely to follow through in their own interests. The biomedical model has produced a doctor-centered approach to interviews – the aim is for the doctor to establish the physical diagnosis – so, the doctor asks lots of questions and the patient is expected to give short, focussed answers. Studies of this method have shown that in over two thirds of interviews, the patient does not manage to complete their opening statement of concerns, being interrupted, on average, 18 seconds into their account. Smith is not derogatory about the doctor-centered approach and recognises its value in establishing urgency, clear physical diagnoses, and treatment plans. However, he argues, it often goes wrong because it fails to allow the doctor to comprehend the patient’s personal concerns and, in particular, the psychosocial contexts of their symptoms. This book lays out a method for a medical interview which begins with a patient-centered approach then moves to a doctor-centered one, concluding with a comprehensive, balanced summary of what has been understood through both approaches together. Crucially, he argues that a solely doctor-centered approach is unscientific because it produces biased data about the patient which is not so reliable and not so valid.

The patient-centered interview has five steps

1. Welcoming the patient, introducing yourself, making them comfortable.

2. Capturing both the patient’s and the doctor’s agendae.

3. Facilitating the narrative by using open-ended questions to explore the presenting complaint

4. Developing the personal story and the emotional story through relationship-building skills of emotion-seeking and emotion-handling.

5. Summary and transition to doctor-centered part of interview

I particularly like his little mnemonic of NURS for emotion-handling skills –

N = Naming – saying what the emotion is – “sad”, or “frustrated”, or whatever

U = Understanding – accepting and validating the emotion

R = Respecting – emphasising the positive elements of the patient’s coping

S = Supporting – offering support and partnership to work to bring about improvement

In Appendix B, Smith has included George Engel’s Foreword to the First Edition – which is a short essay worth buying the book for! In it, Engel explains how he developed the concept of the biopsychosocial approach. He quotes Heisenberg – “What we observe is not nature itself but nature exposed to our method of questioning”

Physicist Heisenberg’s dictum exemplifies a fundamental distinction between 17th- and 20th-centure scientific thinking, the latter of which is derived from such conceptual developments as evolution, relativity, quantum mechanics, general systems theory, far-from-equilibrium thermodynamics, and, more recently, chaos and complexity theory. Loosely speaking, we are applying biomedical and biopsychosocial as labels to contrast the two positions. Actually, what Heisenberg enunciates is what clinicians have known from time immemorial – namely, that the answers you get from a patient depend on the questions you pose and how you do. More broadly, it exposes the fallacy of the 17th-century natural science position that what scientists discover exists entirely external to and independent of themselves. In fact, rather than simply examing or observing something “out there”, scientists devise mental constructs of their experiences with the observed as a means of characterising their understanding of its properties and behaviour. This change in perspective began in physics with relativity theory, which required acknowledgement that the location of the observer cannot be ignored relative to what is being observed. The rediscovery of the obvious occurred in that transformation – namely, that science itself is a human activity. The lesson is that humanness and human phenomena cannot be excluded from science.

I find this book very timely. It might be over 30 years since Engel showed how the practice of medicine should change, and in that time both systems approaches, chaos and complexity theories and discoveries should have transformed our understanding of both health and disease. But we are only at a beginning, and the dominant viewpoint is still the 17th-century mechanistic one. Medicine needs to catch up with some of the new findings from science. Evidence, it turns out, is produced within the complex web which stretches from the subjective to the cosmological.

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