Heroes Not Zombies

I recently posted about the claimed health benefits of tomatoes, and continuing in that vein………something else I really enjoy is my daily coffee.

Apart from enjoying it, can I add a little health-benefit smugness to my mug? Turns out I can! Recent research has shown that caffeine protects the “blood brain barrier” from the damaging effects of cholesterol. One of the many ill-effects of cholesterol is damage to the tissues which protect the brain from toxic substances circulating in the blood. The researchers believe this may explain the potential for a coffee a day to reduce the chances of getting Alzheimer’s Disease.

Like with the tomatoes, I don’t really need other reasons to enjoy coffee, but it’s good to know I can consider it part of my healthy lifestyle!

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We do live in a “pill for every ill” society. Arthur Frank, in his “Wounded Storyteller” describes the commonest type of story told by patients in contemporary society as being the “Restitution Story”. By this he means “I’m broke, Doc, please fix me”. He says it’s the fast food approach to health, the quick oil change while-you-wait approach. It’s technological and it’s based on a conception of illness as being about a bit of the body that’s not working and on a conception of Medicine as being about applying the right technology for the quick fix.

Whilst this approach has delivered dramatic results in acute situations, it’s done really nothing in the long term for chronic ones. Even in societies where the burden of death and disability from infectious disease has been reduced we are seeing steadily growing rates of chronic illness. The quick fix approach doesn’t deliver long term health and it doesn’t deliver a very effective fix!

Here’s a paper from the “Harvard Health Letter“, headed “Managing Seven Common Conditions without Medication”.

In summary, they say Arthritis – lose weight, gain mobility and less pain; Cholesterol – drop your LDLs (bad blood fats) 5% by keeping saturated fats off your diet; Cognitive decline – brain exercise and physical exercise slows this up; Depression – regular physical activity lifts mood; Diabetes – regular physical activity drops sugar levels; High Blood Pressure – lose weight, regular exercise; reduce salt and drop your BP; Osteoporosis – lose weight and eat more vit D and calcium for stronger bones.

OK, so not exactly rocket science – basically lose weight and exercise more – but at least it’s a start. It’s the mentality behind this report that appeals to me though. When our first concern with an illness is what drug to take or operation to have, we’ve missed the boat. Our first concern should be “what do I need to do differently?” because if you keep doing the same you’ll just get more of the same! But I think we need to push this agenda a lot further and into areas so far pretty unexplored. Sure, things like smoking, alcohol, drugs, diet and exercise are all modifiable factors in our lives which can influence which diseases we get and how those diseases progress, but we need to think of whole people, and not solely in this kind of mechanical or reductionist way. Mental states are significant factors in maintaining health and in determining recovery – positive attitudes, empowerment, hope, loving and being loved aren’t talked about so much by doctors or health care providers but they should be. In fact, if we treat people as only physical bodies we don’t treat them as human beings at all. We are much more than our physical selves.

So let’s all agree that diet, exercise and drugs are important considerations in health and illness, but what other factors would YOU consider? What about writing for example? Or music?

What factors are important in YOUR life to keep you healthy, or that you’ve found were important parts of your recovery from illnesses?

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Every time I see a patient for a first consultation I draw the following diagrams to explain what I’m trying to do and how it might fit with whatever other treatments they are receiving.

First I draw two simple shapes –

I say, “The circle on the left represents health and the disordered looking circle on the right represents ‘not health’. In acute diseases, it’s usually pretty easy to understand what’s caused the problem (represented by the red arrow). For example, along comes the flu virus and gives you flu, or along comes the number 6 bus and knocks you down and breaks your leg”. “The whole purpose of undergraduate training in medicine is to teach doctors how to recognise the disordered circles. It’s called ‘making a diagnosis’. This training focuses on the disease or the lesion. The doctor says ‘I know what this is. It’s the flu.’ or ‘You’ve got a broken leg’ or whatever. Whatever the problem, the body sets about its normal activity of trying to repair damage and restore health. This process is represented by the sweeping purple arrow –

“Interestingly, because doctors are trained to diagnose the problem in terms of the disease, all the treatments you are offered are intended to fight, suppress, or remove the disease. What the treatments are not designed to do is enhance the process represented by the purple arrow. Benjamin Frankin understood this. He said ‘God heals and the doctor takes the fee’. It seems strange to me that at medical school we only learn about pathology, about diseases and how to fight them, when, in reality, nobody, but nobody, gets better from any illness without the healing process working. It’s the body’s own capacity to self-repair, self-heal and self-restore which returns, or attempts to return you to health. Treatments directed against diseases might give the body a better chance to do that. In fact, with many diseases, the problem may be too serious for the body to manage to self-heal without the support of fighting the disease. Fighting the disease isn’t a bad thing. It’s just not enough. We need to see what we can do to support and promote your self-healing.”

I then add the following elements to the diagram –

What this shows is the addition of arrows, representing treatments, on the top right directed against the disease. The horizontal lines represent the kind of wall these treatments attempt to put between the disease and the outside world. Many, many treatments are called “anti-something” – anti-biotics, anti-inflammatories, anti-depressants, anti-hypertensives – that’s because most treatment is intended to act against the disease. I point out that, that may be important to do, but that what is missing are the treatments represented by the arrows added on top of the big purple arrow. These represent any treatments intended to support and stimulate the processes of self-repair and self-recovery. (I might then have a discussion with the patient about what factors influence these processes). The final element of this little diagram is the addition of the arrows around and within the circle which represents health.  What I say about them is “In acute disease, as we already discussed, the cause is often obvious and single. In chronic diseases, however, the factors which have produced the problem are typically multiple. The aetiology, or origin, of chronic disease in a person is multifactorial. Some of these factors may be internal – genetic factors, hormonal and nutritional factors for example. Some of them will be external – impacts from the environment, viruses, bacteriae, physical trauma, emotional and psychological traumas and so on. Really anything which impacts on you as a person can impact on your health, and may be a factor involved in causing the illness.’

I find this introduction opens up a holistic, mind-body approach to any illness, empowers the patient, allows for their to be hope, and takes away any “either/or” thinking about dealing with illness from a biomedical perspective of fighting the disease or a biopsychosocial perspective of helping a person with an illness to recover better health.

What do you think? Tell me if this is clear and whether or not you think it is helpful. It’s easy for me to adjust the conversation with the patient at the time, but in a little post like this it might not be so clear?

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It’s an old adage in medicine – “First do no harm”. I really think this must be our first consideration when thinking of all therapeutic interventions. The first question I have is what harm might it do? The next question is what good might it do? Then it’s a matter of weighing the one against the other. Is the potential pay-off worth running the risk of the possible harm?

When I started as a General Practitioner it was common for us to do serial injections of tiny amounts of allergens to reduce somebody’s allergic disease symptoms. Hay fever and allergies to house dust mite were probably the commonest allergies treated. A series of injections would sometimes bring some relief from sneezing, runny noses, itchy eyes and so on. The trouble was, that the potential harm turned out to be sudden death. Not that it ever happened to any of my patients, but the authorities rightly decided that the risk of death was too high a price to pay for possible relief from itchy eyes and runny noses, so they withdrew the treatment from GPs.

Well today there was a report about GlaxoSmithKline having evidence that one of their drugs (seroxat) increased the suicide risk in under-18s but they didn’t tell the authorities about this concern for a long time. This created the false belief that it was a safe drug when it wasn’t. Prescribers were likely to fall at the first hurdle – the first do no harm hurdle. What makes this case worse is that they also had evidence that their seroxat wasn’t even effective in treating depression in the under-18s so prescribers then fell at the second hurdle too.

It’s not good enough.

In this time of pushing drug solutions for all health problems through claiming that published trial evidence (usually paid for by the drug manufacturers) will reliably guide doctors, this type of bad behaviour by the drug companies undermines trust and shakes the very foundations of Evidence Based Medicine.

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Can I just take a minute to clear something up?

This is an issue that comes up for me with patients probably every week if not most days. It’s about pain. Many patients present to the doctor with a main problem which is about pain. The way doctors are trained is to focus on making a diagnosis. Now, that’s a good idea. I always tell people we can’t figure out what might help until we understand what’s wrong. But the problem arises with the dominant medical paradigm, which is known as the “biomedical model”. This model has been around for three or four hundred years now and it focuses on the concept of disease as a lesion. By lesion I mean something objective which can be observed, or measured.

Two problems arise from this rather mechanical model. First is that if a lesion can’t be found the patient’s symptoms tend to be dismissed as psychological (or worse – pretended!) Anyone who understands health and illness will know that this is nonsense. You don’t need to find a lesion to accept, understand and attempt to alleviate a human being’s suffering. Second is that symptoms and lesions do not exist within a linear relationship.

Pardon?

Well, let me take the example of pain. Let’s imagine someone has a disease where we can see and measure the lesion – cancer would be a good example. There is no simple relationship between the cancer and the amount of pain a person experiences. Two people with the same cancer of the same size in the same part of the body can have utterly different experiences of pain. And any one person can have a cancer that changes size (getting bigger or smaller) without any significant change in their experience of pain.

There is no direct, linear relationship between a pain and a lesion.

Strangely, a lot of people don’t understand that (and I include a lot of doctors there) but it should never be forgotten. Pain needs to be addressed, understood, and managed as pain. It cannot be understood, and managed effectively as a manifestation of a lesion.

This is the value of a holistic, patient-centred approach to illness. The focus is on the person and their experience, not exclusively on their lesions. Pain is real. It doesn’t become unreal in the absence of a lesion.

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A study by Professor Kirsch and colleagues of Hull University has set a bit of a cat amongst the Pharma pigeons. It’s a pretty technical study but in summary what they did was got access to all the trial data submitted to the FDA by drug companies applying for licences for the big four new generation antidepressants – fluoxetine, venlafaxine, nefazodone, and paroxetine. This data, by the way, included trials which were not published but which they obtained access to through a Freedom of Information application.

What they found was that there was no evidence the drugs were more effective than placebo in patients with moderate or severe depression. They did show that the worse the depression at the outset of the trial, the greater the effect of the drug over placebo, but they did a fascinating analysis which showed that the explanation for this was likely to be the decreased placebo response in more severely depressed patients.

Given these are drugs with well known side effects and dangers, and that some 16.2 million prescriptions for these drugs were made in England in 2006, this study comes as something of a shock.

The responses to this study are even more interesting. Most experts and authorities quoted on the news items today have made the point that we all know that talking therapies work for depressed patients but that drugs are prescribed because there are insufficient numbers of therapists available. This is a shocking explanation. Drugs as a substitute for people. What’s the problem? Insufficient funds for the provision of enough therapists? Seems so. So why do we prefer to spend literally millions on drugs which probably don’t work instead? The answer lies partly in the way medicine is currently delivered. The priority is given to drugs. You can’t placebo control human care or loving attention. Maybe it’s time we began to change our priorities and save the drugs for when therapeutic relationships are not enough.

Does this study mean that people taking antidepressants should stop them because they are useless? NO. The problem with all this so-called “evidence” which comes from highly artificial clinical trials which seek to remove the human factors and average out the results to the point of dismissing the range of difference within the study group is that it fails to show us who might benefit most from a particular treatment. Within these studies are individuals who are substantially improved by the drug, and others for whom taking the drug was of no benefit at all. However, it is reasonable to assume that drugs alone are not enough. Depressed people need more care than mere pharmaceutical care.

Does it mean that we should invest in trying to treat depression with alternatives to drugs? YES. It’s about time we gave clinical priority to people in medicine, investing in sufficient numbers of well-trained doctors, nurses and therapists to give ill people the time and attention they need to become well – if possible, without the risks of prescribed medicines.

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