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Archive for the ‘from the consulting room’ Category

Randomised Controlled Trial of Parachute Use

Posted in from the consulting room, from the reading room, health, humour, life on December 20, 2007| 5 Comments »

Every Christmas issue of the British Medical Journal, now known simply as the BMJ, has some really fun articles. I haven’t opened this year’s issue yet but when I picked it up from behind my door just now a study from old BMJ Christmas issue came to mind. It was a systematic review of the evidence base for the use of parachutes. In the introduction they say –

The perception that parachutes are a successful intervention is based largely on anecdotal evidence. Observational data have shown that their use is associated with morbidity and mortality, due to both failure of the intervention1 2 and iatrogenic complications.3 In addition, “natural history” studies of free fall indicate that failure to take or deploy a parachute does not inevitably result in an adverse outcome.4 We therefore undertook a systematic review of randomised controlled trials of parachutes.

The authors completely failed to find a single randomised controlled trial of parachute use! This article is typical of the BMJ Christmas editions. It’s funny, tongue in cheek, but thought-provoking and makes serious points through the use of humour. I love their conclusion –

Only two options exist. The first is that we accept that, under exceptional circumstances, common sense might be applied when considering the potential risks and benefits of interventions. The second is that we continue our quest for the holy grail of exclusively evidence based interventions and preclude parachute use outside the context of a properly conducted trial. The dependency we have created in our population may make recruitment of the unenlightened masses to such a trial difficult. If so, we feel assured that those who advocate evidence based medicine and criticise use of interventions that lack an evidence base will not hesitate to demonstrate their commitment by volunteering for a double blind, randomised, placebo controlled, crossover trial.

Any volunteers? (and, no, you’re not allowed to volunteer anybody else!)

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Life not going well? Here’s the answer….

Posted in from the consulting room, health on December 13, 2007| 1 Comment »

There’s an ad running on TV here in the UK at the moment. It’s for a drug called Anadin Extra – a painkiller basically.

This really struck me. Here we have a woman with too many responsibilities, trying to literally juggle her tasks and her relationships. She’s not coping. She’s getting headaches. How is she going to get a better life? How is she going to tackle that old life-work balance thing? How can she be happier, healthier?

The drug companies answer?

Take drugs

I think that’s sad – especially when the drug companies themselves even know that most drugs don’t help most people.

What kind of a vision is this for a healthy society?

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Are we born empathic?

Posted in from the consulting room, from the reading room, neuroscience on December 10, 2007| Leave a Comment »

A colleague at work read my post on mirroring.

She said, if it’s true that different people have different scan findings in the areas of the brain associated with mirroring neurones (which, it is hypothesised, are responsible for empathic ability), then does that mean that some people are born with greater empathic potential than others? And can the potential be developed?

This is a common question in neuroscience – when we identify either physical structures within the brain responsible for certain behaviours and qualities, or differences in function in those areas as highlighted by functional scans, then are we saying that people are born with these brain differences which then determine their characteristics? Some people might make that claim but from my reading I’d say almost every scientist thinks that the physical characteristics of the brain, originating in genetic makeup and embryonic development, are important, and may even set the limits of possibility. However, the nervous system is more “plastic” (the specific meaning of this is nothing artificial, it means it can change), than a simple one-off scan will ever show. Neuronal pathways develop, grow or shrink, depending on demand. What this means is that while we are probably born with different potentials, everyone’s potential can be developed or suppressed by experience.

She asked the question because she was wondering why some doctors are more empathic than others. Specifically, she wondered if empathy could be learned. I’m pretty sure empathy can be learned. I’ve seen medical students and qualified doctors become more empathic as they train in homeopathy which emphasises the patient’s narrative and a clear understanding of the patients’ experience.

But the question got me thinking about the place of empathy in the consultation. How much is it a quality developed from “mirroring”? Difficult to answer, but I think there’s an even more important element – being interested.

If a doctor is not truly interested in what a patient has to say, then they won’t listen, won’t understand and won’t be empathic. Can being interested be faked? No, I don’t think so. You’re either genuinely interested in somebody or something, or you’re not. Pretending to be doesn’t work. I’ve often said, when discussing the art of medicine, that if I ever need to see a doctor because I’m not well, then I’ll want one who frankly gives a damn! I want a doctor who, at least for the duration of the consultation, is genuinely interested in me. In fact, I’d recommend that anyone who doesn’t find people totally, compellingly interesting, shouldn’t study medicine in the first place!

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In houses it’s location, location, location. In health, it’s context, context, context……

Posted in from the consulting room, health on December 9, 2007| Leave a Comment »

…..same principle I guess. Without considering the individual and unique contexts of a person’s life we can neither understand their illness, nor help them find the best treatment and support. Iona Heath, who writes in the BMJ tackles the dumbing down of medicine in another article this week

We are witnessing a degradation of knowledge, which results from its bureaucratic application to whole populations. Too often, evidence from clinical trials is being shamelessly extrapolated across time, across population subgroup, and across condition. Again and again, efforts are concentrated on crude process measures, while clinical outcomes that are genuinely significant for patients because they reduce or delay suffering or prolong life are ignored. Thirdly, the present state of clinical evidence systematically neglects the reporting of harms

The point she is making is that we are abusing research findings which are conducted on specific groups of people by extrapolating the findings and conclusions and applying them to hugely diverse and significantly different groups of patients. The more we generalise, the poorer our understanding and effectiveness. She argues strongly for not applying the findings of the effects of a treatment on young people, to old people, for example. This is because of two main problems – first the setting of outcomes by the researchers (outcomes which might be important to the group under study, but not the most important to another group) and secondly because of a huge under-reporting of harms of a treatment.

As more and more treatments are directed at an intended long term outcome, the older patient is less likely than the younger one to have a chance of the intended benefit. However, as harms start straight away with treatments, the older patient is more likely to experience harm than benefit than the younger one. In addition, because of other body systems already failing, the elderly patient is more susceptible to harms from drugs than the younger patients.

And that’s just the consideration of age. What about other factors in other contexts which make a substantial difference? Sex, the presence of other diseases (‘co-morbidity’), and economic, social, cultural and psychological factors?

Context is all important in chronic disease especially. Here’s why…..

acute/chronic

In acute disease, as we see on the far left, the green circle represents the pattern of symptoms consistent with the disease, and pretty much determines the whole picture. Most patients who are rushed into hospital have obvious patterns of disease. As time passes however we see that the green circle becomes a much smaller subset of the overall symptoms. This is because as the years pass, the individual brings more and more of themselves and their unique contexts into the overall picture. If we only aim at the disease, we miss helping most chronically ill patients.

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Flow

Posted in from the consulting room, health, life on December 9, 2007| 2 Comments »

Flow

There’s something about the idea of flow which really seems to work when thinking about health. In Chinese medicine there is a concept of “chi” or “Qi”– a kind of energy. We don’t use such a concept in our Western model but maybe we should. Why? Well a couple of reasons –

First of all – measuring energy – I’m not talking about weird and wonderful machines that claim to measure energies in a human being – I don’t think we’ve understood what energy is in a biological sense. I don’t mean calories and basal metabolic rates and so on. I mean that sense of vitality, of well-being, of having a certain amount of energy, that’s hard to pin down but so, so easy to know. Think of the 1 – 10 scale and asking people to self-rate their energy level with 1 representing the worst possible energy they can imagine and 10 the best. They can do it in a flash. People have no trouble quickly assigning a number on scale to their current energy state. You can even break it down into different energies – mental, physical, emotional for example, assessing each using the 1 – 10 scale. People can do it easily. What are they doing? How do they assess their energy level? What are they measuring and how? It’s not at all clear but it still seems both possible and useful.

Secondly, there is the idea of energy as flow. In the Chinese system chi isn’t just energy that sits there humming away at a certain level. It’s something more dynamic than that. They have descriptions of this energy as flowing or becoming sluggish or even stopped. So for us, we can not only measure our energy levels but we can sense the flow – is my vitality flowing? Is my physical, mental, emotional energy flowing? Or have I become sluggish, or even blocked? Maybe we can just adopt the Chinese concept without looking for a thing called chi, and without taking on board all the detailed dogma of TCM chi?

Csikszentmihalyi uses the concept in relation to psychological processes in his studies of happiness. I like his work and I think he’s described something very real by using the concept of flow, but I’m meaning something more holistic than he does. I mean flow in the sense of the whole organism, not just a psychological state or a function of mind, but also the function of all the body’s systems and processes.

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The art of medicine and the value of experience

Posted in from the consulting room, health, philosophy on December 8, 2007| 3 Comments »

There’s a doctor and bluegrass musician called Dr Tom Bibey left a comment on one of my posts and you know how it is with the net…..you can’t resist following the trails, so I popped across and browsed his blog. What a treat! Here’s a quote from one of his posts –

Folks who believe they know a patient by the paper they keep are so naive.  The impact of sitting at someone’s kitchen table and sifting through the array of pills from different Docs the patient ”thinks” they might be taking is powerful.  Everyone trying so mightily to pass rules to govern human behavior needs to make a few house calls before they get so dadburn high and mighty as to their perceived importance.

See, to me, that’s wisdom. Yes, we need our statistics and our research, and our science, but there really is something called the art of medicine, and people who have no experience of it, probably don’t understand it. To be a good doctor though I think involves making use of the whole self – the brain and the heart – understanding how things work, how to interpret science, but also learning how to relate, how to be compassionate and caring every single day, with every single patient. Without that, you never really get to know anyone and without knowing them, you’ve no way of understanding them, and without understanding you’re working in delusion not reality.

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MacNamara’s Fallacy

Posted in from the consulting room, health on December 7, 2007| 5 Comments »

I just came across something called the MacNamara Fallacy – as best I can see it was first described by Charles Handy in his book, The Empty Raincoat (haven’t read it yet but just ordered a second hand copy through Amazon marketplace for a penny!) – Robert MacNamara was US Secretary of Defence during the Vietnam War.

One of the worst characteristics of the current approach to health (an approach shared in other spheres like education, management and so on) is the tendency to measure what can be easily measured and then base every decision on that, disregarding as unimportant whatever cannot be easily measured.

Here’s the quote (this time referred to by Dr David Haslam in the RCGP journal –

Haslam D (2007). British Journal of General Practice 57:545, 987-993.)

  • The first step is to measure whatever can be easily measured. This is OK as far as it goes.

  • The second step is to disregard that which can’t be easily measured, or to give it an arbitrary quantitative value. This is artificial and misleading.

  • The third step is to presume that what can’t be measured easily isn’t important. This is blindness.

  • The fourth step is to say that what can’t be easily measured doesn’t exist. This is suicide.

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Hospitals can be dangerous places

Posted in from the consulting room, health on December 7, 2007| 2 Comments »

I guess most people would agree with my attitude that if you can manage to avoid hospitals you should. Yes, they are necessary, but, yes, they are dangerous too. How dangerous? Well, a study from the University of York has taken the approach of reading through the records of a thousand patients admitted to one hospital and found almost one in ten of those admitted suffered from an adverse event. They reckon about 30 to 50% of these could have been avoided.

“Our research does confirm though that hospitals are not completely safe places, and that people should try to steer clear of them unless absolutely necessary.”

A Department of Health spokesperson said

“As the study suggests, many adverse events could be avoided if lessons were properly learned and fed back into practice.”

That’s the challenge and that’s part of the answer. Medicine is a person-intensive activity. We should be investing in the training and practice of everyone who works in hospitals. Not just the clinicians. The people who work in hospitals all have important jobs to do and if they don’t do them to the best of their ability all the time, patients suffer. We need to foster a culture of reflection and learning, of continual improvement, not of blame. It’s not about targets. It’s about people.

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Drug companies and the threat to Evidence Based Medicine

Posted in from the consulting room, health on November 27, 2007| Leave a Comment »

Evidence Based Medicine has three principles – consider the evidence for an intervention; consider the relevance of this evidence for this particular patient based on clinical experience and; thirdly, in consultation with the patient respecting their values and perspectives – to draw up a therapeutic plan. That first part about the evidence base is weakened if the evidence itself is distorted. There are a number of ways to distort it.

One is to spin the findings, as was highlighted in this research –

Previous studies have shown that randomised controlled trials with financial ties to single drug companies are more likely to have results and conclusions that favour the sponsor’s products, and a recent study suggests that the same holds true for meta-analyses.

So researchers in the US set out to determine whether financial ties with single drug companies are associated with favourable results or conclusions in meta-analyses on blood pressure lowering (antihypertensive) therapies.

A total of 124 meta-analyses were included in the study, 49 (40%) of which had single drug company financial ties. Differences in study design and quality were measured.

Meta-analyses with single drug company financial ties were not associated with favourable results but were significantly more likely to have favourable conclusions, even when differences in study quality were taken into account.

In fact, the data show that studies funded by a single drug company have a 55% rate of favourable results that is transformed into a 92% rate for favourable conclusions, representing a 37% gap. The gap shrinks to 21% (57% to 79%) when two or more drug companies provide support. Yet the gap vanishes entirely for studies done by non-profit institutions alone or even in conjunction with drug companies.

These findings suggest a disconnect between the data that underlie the results and the interpretation or “spin” of these data that constitutes the conclusions, say the authors.

Another method is not to publish negative trial findings. Bayer, has just suspended one of its drugs because a trial showed it carried a higher risk of death.

The BART study was the latest in a series of worries about Trasylol’s safety in past years. In 2006 a study published in the New England Journal of Medicine showed increased risks of kidney failure, heart attack, and stroke (2006;354:353-65).

As a result, safety warnings for Trasylol were strengthened in 2006, and approval for use was limited to patients who were having heart bypass graft surgery and were at increased risk of blood loss and blood transfusion during the operation.

In October 2006 international drug regulators’ worries heightened when it became known that Bayer had failed to disclose to the agencies or their advisory panels the results of an unpublished study that had been sponsored by Bayer. Indeed, Bayer scientists had defended Trasylol at an FDA panel hearing but had not mentioned their own study.

Bayer announced that it regretted the mistake and that according to an internal investigation the findings of the trial had been withheld by two Bayer employees and not been passed on as necessary.

Evidence Based Medicine only works well for patients if it is applied in full, and the issue of pharmaceutical company influence on what becomes known and how it is presented required constant vigilance. The more we can have non-drug company funded experts involved in careful peer review the better.

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Meditation and good outcomes in psychotherapy

Posted in from the consulting room, health, psychology on November 21, 2007| 1 Comment »

Here’s an interesting study which looks at the influence of meditation on patient care. It wasn’t the patients who did the meditating however. It was the therapists. The researchers took a group of trainee psychotherapists and split them into two groups. One group practiced mindfulness meditation and the other didn’t. The patients they were treating showed improvements as follows –

the [patients treated by the meditation] group showed greater symptom reduction than the [no meditation] group on the Global Severity Index and 8 SCL-90-R scales, including Somatization, Insecurity in Social Contact, Obsessiveness, Anxiety, Anger/Hostility, Phobic Anxiety, Paranoid Thinking and Psychoticism.

So, who therapist is, and how they learn to focus their attention seems to matter. I’ve never learned meditation but I do think that care is a human activity and the current drive to homogenise medicine as if human individuality is not important is misguided. It is important who your therapist is and it is important that the therapist learns and practices focussed attention and active listening whatever the actual therapy being used.

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