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Archive for the ‘from the consulting room’ Category

Set a beacon and spread some light

Posted in from the consulting room, health, life on November 3, 2007| 7 Comments »

I’m a Lord of the Rings fan – both the book and the movies. One of my favourite scenes is this one –

I find this inspiring. I think this is what we can do. If you have passion for life, you light a beacon. That beacon spreads light that changes lives. If I had to write down one tip for a better life it would be this – be passionate. Passion is flow. The Chinese have a concept of Chi – a kind of energy. Csikszentmihalyi espoused the concept of “flow“. In modern, Western terms, we are able to be very aware of energy. I often ask medical students to take a score from 1 to 10 where 1 is the worst possible energy they can imagine and 10 is the best possible and to tell me what figure they’d apply right now to describe their own energy state. They can all easily state a number. Then I ask them to do the same thing for their mental energy and they find that equally easy. Then I ask them how they came up with the numbers they picked. What did they assess, and how did they do that? What criteria did they use? Which parameters did they pick? They don’t know. We assess our own energy levels holistically and intuitively. We don’t have to break it down into components, and the strange thing is that the energy we are measuring is not measurable by either instruments or others. Only we are capable of assessing and experiencing our own energy levels.

I think this “energy” idea is related to flow. Flow can be thought of as the Western equivalent of Chi. When the flow is strong, and we are “in the flow” then we feel well, our energy feels good and we alive and healthy. When our flow is weak, we’re unwell. Passion is both a product and a cause of this flow. When we are passionate about life, our energies flow, our creative abilities surge, our resilience is strong and we touch, and are touched by, others. Passion is contagious.

Pass it on.

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Too much competition is bad for you

Posted in from the consulting room, health, life on November 3, 2007| 2 Comments »

Research by Danny Dorling at Sheffield University has shown clear links between inequality and death rates.

Sure, there’s a kind of intuitive logic to the fact that poorer people suffer poorer health, but a slightly less intuitive finding is that the amount of social inequality (as indicated by the differences in income between the poorest and the richest) impacts on death rates in all countries, rich or poor. So, within any one country, when social inequality gets greater, mortality rates rise. Danny Dorling’s research has shown that this is an age dependent factor – he’s shown that the larger the inequalities in a society, the greater the mortality in people from 15 – 65 ie. people of working age.

there is an age related mechanism that results in higher mortality being experienced in societies where there is greater social competition, all else being equal. Higher rates of income inequality tend to reflect more competitive rather than more cooperative societies. Whatever the mechanism that results in harm from competition (or protection from cooperation), it has its strongest effects in early to middle adulthood.

One of his conclusions particularly struck me –

social inequalities as reflected through unequal incomes are damaging to health for those living in both rich and poor nations, and the direct mechanisms for such damage are likely to vary by area. Psychosocial stress is unlikely to be the only route by which income inequality damages health. However, the underlying mechanism may be similar—that, because humans are social animals, human health is best protected when people cooperate.

It’s that last phrase that really interests me. “…..because humans are social animals, human health is best protected when people cooperate”

It’s always been the case that the big impacts on the health of populations doesn’t come from the skills of doctors, or the power of drugs, but from the changes in the contexts of peoples’ lives. Education, housing, sanitation, food and water, and income are still the most powerful levers of power in the creation of health.

Yes, of course, there’s lots we can do as individuals. We can make choices about our own lives. And when we are sick individual treatments can make a difference, but if we want more people to have more health, if we want to reduce suffering from cancer, heart disease, mental illness and a host of other diseases, the big gains come from changes in these areas. How we behave towards others, whether or not we value competition or cooperation more highly, impacts on the prevalence of disease and on death rates in people under the age of 65.

One of the things I love about the net, is how it gives us a chance to build our links, to share ideas and thoughts, to encourage and inform each other. In short, to cooperate. And, well, who would have thought it, turns out that’s good for you!

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Money as a motivator in healthcare?

Posted in from the consulting room, health, life on November 3, 2007| Leave a Comment »

I’ve a lot of respect for a London GP, Iona Heath, who frequently writes in the BMJ, . Last week she wrote an opinion piece about what she sees as the corrupting influence of money on healthcare. I know that healthcare is a big debate in the US, what with Rudy Giuliani throwing around mis-information about cancer treatment to bash what he calls “socialised medicine”. Well, I guess if he reads Iona Heath’s views he’ll confirm his current view that the UK has it all wrong. The system of payment for GPs in the UK has changed with the government paying them for carrying out certain procedures (actually mainly paying them for recording certain pieces of information, like whether or not a patient smokes, BP readings and so on). This has resulted in massive income rises for GPs and the advocates of the system say this shows that money motivates doctors to work according to best practice. Here’s what Dr Heath says –

But if money is thought to be the only motivation, hugely important human aspirations are systematically marginalised and our conception of what it is to be human and a member of society is diminished.

And, this –

In The Burial at Thebes, his translation of the story of Sophocles’ Antigone, Seamus Heaney gives King Creon these words: “Money has a long and sinister reach. It slips into the system, changes hands and starts to eat away at the foundations of everything we stand for. Money brings down leaders, warps minds, and generally corrupts people and institutions.” It seems an extraordinarily accurate description of the state of the NHS. Money is everywhere the driver of change but it is warping minds and corrupting both individuals and institutions. There seems no place left for the altruism of public service to flourish and this is taking a huge toll of the morale of those working in the frontline of health care, whose motivation has always gone beyond the simple question of money. The neglect of altruism seems likely to prove both destructive of social solidarity and ultimately extremely costly for individual citizens.

Let me put my cards on the table. I completely agree.

From the age of three I wanted to be a doctor. Don’t know where that idea came from because there were no family connections with doctors but I pursued that dream and became a doctor back in 1978. Graduation Day was one of the most thrilling days of my life. But it’s only after graduation that doctoring starts and my training jobs were tough, demanding and challenging. In 1982 I became a GP. From the start I’ve always loved working with patients and I always brought my constant curiosity and desire to improve and change things with me. I always made what others would consider stupid decisions about money, not least deciding to leave one practice and join another in 1986 resulting in a drop in income of 70% overnight. Money didn’t motivate my medical decisions. But the government always thinks otherwise and the trend to motivate doctors to carry out government-determined tasks by paying more for what the authorities wanted the doctors to do started to take off in the early 1990s. It drove me out of general practice. It just didn’t sit right with me that I might get paid more if I persuaded a patient to choose one particular course of action over another. I wanted to help every single patient to choose the action they preferred, not to choose the one that paid me more. And I realised that when patients became aware of the payment system they started to question whether I was recommending a treatment because it was good for them or good for me. That was it. I couldn’t do that.

So I stopped.

In fact that was my crisis point. I resigned as a GP and didn’t have another job to go to. For the next 8 months, I got by on one day of clinics at Glasgow Homeopathic Hospital, a weekly radio show (Phone Dr Bob!) and I wrote a textbook of homeopathy for GPs. Financially, it wasn’t clever! Then I got the job I still do – a full-time job at Glasgow Homeopathic Hospital with half the week seeing patients and half the week focussing on teaching. It’s a great job. I love every day of it. There is no greater thrill and sense of reward than I get from the privilege of meeting new patients, getting to know people over time and helping them to find relief from suffering and to experience better health. Financially, I’d be way, way, better off if I’d stayed as a GP (or if went back into general practice now) but in terms of satisfaction and fulfilling a life’s purpose? Well, this current job ticks those boxes for me.

That’s my personal story, but I don’t think my motivations are unusual. I don’t think most doctors become doctors for the money and I totally agree with Iona Heath that creating the health care system around money as a motivator is destroying the environment in which altruism and the desire to care can thrive.

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Nutrition and mental health

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

(by special request of damewiggy….) What are the links between food and mental health? The short answer is definite but complex. There is growing evidence of links between food and mental health and the Mental Health Foundation in the UK launched a campaign with Sustain last year to raise awareness of this. Their website is a great place to start and they have a lot of really useful studies and information there. MIND also has a very balanced summary of the issue. What these reports and articles are saying is that there seems to be growing evidence of the part played by food in mental health. From first principles this makes a lot of sense – after all the brain is an organ of the body and it’s function is dependent on it’s nutritional supplies amongst other things. Also, we are increasingly getting a clearer picture about the mind and understanding it’s not all about the brain. Both the concepts of the embodied mind and the extended mind force us to consider that the mind is a more complex phenomenon than just the product of brain function. This has enormous implications for us in terms of considering the health of the body, and of the contexts within which the individual lives. Part of this is about nutrition – and here I’m thinking of nutrition as not only about the biology and chemistry of food but of the effects of eating patterns, the social impacts of what’s eaten when and with whom, the memories, associations and expectations that we tie to particular foods, the connections between eating and the health of relationships, and so on.

It’s a complex issue.

But it doesn’t stop there, in my opinion. Because everybody is different. And not only do we not have individual and different food preferences but the same food will have different effects on different people. It’s a good idea to become more self-aware about this – what effects do different foods have on you?  Are there some things which seem to drain your energy, make you irritable, to make you happy and give you an energy burst? Are there certain foods you crave? Others which disgust you, and yet others which upset you in some way? Your answers to those questions won’t be the same as other people’s answers but they are the important answers for you. Self-observation, raising your awareness around your own relationship to food is way more useful than any expensive, and probably dubious tests.

Let me finish with a personal story. I’m an optimistic, energetic and pretty cheerful character. I went on the Atkins Diet once. I did it for four weeks. I felt exhausted. My legs were so heavy I could hardly climb the four flights of stairs to my flat. And worst of all I felt depressed. Utterly. It was if someone had put a pleasure filter between me and the world and is was sucking all the joy out of life before life got to me. Within hours of stopping the diet I was my good old cheery energetic self again. Now, I know a lot of people who have an utterly different experience on the exact same diet. But that was my experience and it taught me what kind of diet is definitely not good for me.

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Too much optimism is bad for you

Posted in from the consulting room, health, psychology on October 30, 2007| 14 Comments »

There’s an enormous literature these days on happiness, and pretty much all of it pushes some variety of positive thinking. The Happiness Hypothesis is one of the most thoughtful of these books, and Stumbling on Happiness is a fairly good read too, and Professor Layard’s Happiness is worth reading if you want to understand why the English NHS is about to spend millions on CBT.

But I’ve never been a fan of either bandwagons or one-size-fits-all treatments so I read this study about optimism with interest.  Two professors at Duke University’s Business School have come up with an interesting way of measuring optimism – they asked people how long they expected to live and then compared these estimates with actuarial tables of life expectancy. Optimists were classed as those whose self assessment of longevity was beyond that of the statistical predictions and 5% of them were classed as super-optimists – people who reckoned they’d live a good 20 years longer than the statistics would predict! Interesting method, huh?

What they then did was interview people about their behaviours (being a business school they were most interested in financial behaviours). They found the following –

Puri and Robinson find that optimists:

  • Work longer hours;
  • Invest in individual stocks;
  • Save more money;
  • Are more likely to pay their credit card balances on time;
  • Believe their income will grow over the next five years;
  • Plan to retire later (or not at all);
  • Are more likely to remarry (if divorced).

In comparison, extreme optimists:

  • Work significantly fewer hours;
  • Hold a higher proportion of individual stocks in their portfolios, and are more likely to be day traders;
  • Save less money;
  • Are less likely to pay off their credit card balances on a regular basis;
  • Are more likely to smoke.

In other words, while a dose of optimism might be good for you, too much optimism was associated with riskier and less healthy behaviours. I guess it’s this kind of thing that makes it very difficult to do health education with teenagers – trying to tell them smoking will shorten their lives means nothing to most of them – they think those problems are highly unlikely to happen to them.

I think that all coping strategies in life are good if they work for you, but that any coping strategy which is pushed to an extreme will start to harm you. So a little optimism is no doubt a good thing but optimism which is way beyond the probable can disengage a person from reality.

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Squeezing the world into pigeon-holes

Posted in from the consulting room, from the living room, health, life on October 30, 2007| 6 Comments »

Don’t you hate it when people judge you? And don’t you hate it when people assume they know all about you because they’ve stuck you in some pigeon hole? You know the kind of thing. I mentioned in another post sitting on the train recently next to two men who spent the whole journey dismissing huge swathes of humanity – doctors they said were only interested in one thing – money; Iraq was always a hell-hole, now it was just a hell-hole with less buildings; everyone who lives below the Mason-Dixon line is an in-breeder……and on and on and on. These are not uncommon conversations.

One way we function as human beings is to focus on part of reality, classify it and judge it. We do that to try and get a sense that we understand the world and we also do it to try and control our experience of reality. The thing is this strategy brings loads of bad side-effects. For a start, generalised judgement stops thought. Once you judge a whole class of something, you stop thinking about it. By that I mean you stop seeing, stop hearing, stop experiencing the context-sensitive reality of the individual member of that “class”.

I find this way of thinking very, very disturbing. I understand why it’s there, and I know that human beings are incapable of experiencing the totality of experience as it is. We can only perceive and experience aspects of reality at any given moment. But when we are not aware of the enormous down-side of this human function then we are no longer living in the real world. Instead we limit our experience of reality to our pigeon-hole set. We see everything through the thick discoloured lenses we’ve made for ourselves.

This happens in all areas of life. In Medicine, it happens with diagnoses. How sad it is to see people classified as a “case of X” and how much more sad it is to meet a person who can only see themselves as a “case of X”. When we squeeze every patient into a tightly defined diagnostic box we stop seeing them as who they are. People with mental illnesses experiences this a lot. Once they’ve been given a “diagnosis” they often find that all of their experience is interpreted by the doctors as part of that diagnosis. This is what leads to bad and dangerous prescribing. I recently saw a patient who had suffered from a variety of symptoms for the last couple of years. He was investigated at the outset of the illness and given a particular diagnosis. The diagnosis was wrong. But despite the fact that every time he saw his doctors he told them that certain treatments weren’t working they wouldn’t listen. The doctors said they were prescribing the right medicine for his problem. But they weren’t! Luckily, he got sicker and ended up with other doctors and a different investigation which revealed the true diagnosis. Since getting the appropriate treatment for that condition he’s not in a wheelchair any more.

We also stop experiencing the reality of the rich uniqueness of every human being when we classify them according to race, religion, accent, or life-style. It’s sad and it’s such a stupid way to live. Next time you catch yourself, or somebody else, saying that “all X are Y”, challenge them. All X are never all Y! And if you think they are, you’ve lost touch with reality.

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Better medicines, or money-making medicines?

Posted in from the consulting room, health, Uncategorized on October 26, 2007| 3 Comments »

The BMJ has published a report criticising the way drugs are regulated in Europe

Silvio Garattini and Vittorio Bertele of the Mario Negri Institute for Pharmacological Research in Milan are critical of the dominance of pharmaceutical industry priorities in bringing drugs to market. They appeal for a more patient and doctor led priorities.

There are two common issues which doctors and patients have about prescription drugs – firstly, the drugs which are available often don’t work for individual patients, so there is always a desire for drugs which work better than the ones currently available; and secondly, drug company priorities are more market driven – they are more likely to fund research into drugs for developed countries problems than developing countries problems, even though many more people die from common diseases in those latter countries. The reason why the first problem is not addressed by the current system is summed up in the article –

New drugs have only to show they are of good quality, effective, and safe, independently of any reference or comparison to drugs already on the market. This results in overuse of trials against placebo. Even when new drugs are compared with existing treatments, the trials often seek to show equivalence or non-inferiority rather than superiority to those already available. Such trials could allow drugs into the market that are less active or safe than those in current clinical use. This is because the non-inferiority limit includes a higher incidence of adverse events. The wider the limits the smaller the sample needed and consequently the higher the chance of missing a difference and concluding for non-inferiority. Sometimes limits are so wide that what is considered non-inferior statistically may be worse clinically

They conclude

It is unethical to experiment on patients with the sole aim of obtaining a marketing authorisation. New drugs should be required to have some added value (greater efficacy or less toxicity) to current treatments or be cheaper

So true. This is a European perspective but exactly the same problems are present in the US. And what about the majority of people in the world? How could the system be improved to meet the most pressing health needs in the world, rather than just in developed countries?

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Drug company money paying for medical education. No problem. Nothing to see. Move along there.

Posted in from the consulting room, from the reading room, health on October 24, 2007| 3 Comments »

JAMA (The Journal of the American Medical Association) has published a survey of the links between Medical Schools and the pharmaceutical industry in the US.

They found that 60% of departmental heads had a financial relationship with a drug company as a consultant, member of a scientific advisory board, a paid speaker, an officer, a founder, or a member of the board of directors.

Two thirds of departments at medical schools and large teaching hospitals had relationships with industry that involved research equipment, unrestricted funds, support for research seminars, residency and fellowship training, continuing medical education programmes, discretionary funds to buy food and drink, support for professional meetings, subscriptions to professional journals, and intellectual property licensing.

Overall, they say, 80% of clinical departments and 43% of non-clinical departments had at least one tie with industry.

Now, I don’t know about you, but that concerns me. That’s an awful lot of influence. What do you think the teachers think about it?

Despite these ties “more than two thirds of all chairs with a personal relationship with industry reported that their personal relationships had no effect on the various types of departmental functions. A similar percentage claimed that there was no effect on their personal financial status,” the authors say.

No problem. Nothing to see. Move along there………..

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Poetry and health

Posted in creativity, from the consulting room, from the reading room, health, writing on October 22, 2007| 2 Comments »

When I was recently on holiday on the Isle of Skye I popped in to An Tuireann for a look around, a bite of lunch (had fabulous home-made, thick chunky oatcakes and crab pate), and to log on to the net via their free wifi connection. While uploading photos to flickr, and writing a post or two for this blog, I got chatting to Mark Goodwin, the Literature Development Officer. A delightful and gentle man. He gave me a few postcards from the Poetry Box and I read the poems on them. They were so good! Here are some extracts I noted –

from At The Shrink, by Angela McSeveny –

I can hear the whisper of his pencil

Against the paper

As he jots down notes.

The point jerks like a seismograph

Measuring the impact of my answers.

I blurt out some startling truth

And watch, baffled,

When his right hand doesn’t move.

Well, I can tell you, that little segment got me re-thinking how I take notes! Amazingly, it had never occurred to me, until I read this, that the movement of my pen on the paper of the patient’s case record might be having an impact on the patient. But more than that, these lines also highlight for me how we all discriminate, categorise and judge what we see, hear, experience. A patient tells their story. I listen, hearing some parts more clearly than others, interrupting, or leading this way or that, according to my interest, and in the process create my version of their story…….which turns out, hopefully, to be similar, but, for sure, will be new, unique and different, co-authored by the pair of us.

from…Night Sister, by Elizabeth Jennings

How is it possible not to grow hard,

to build a shell around yourself when you

have to watch so much pain, and hear it too?

………..

You have a memory for everyone

None is anonymous and so you cure

what few with such compassion could endure

I never met a calling quite so pure.

Reading this again just now, made me think again about that study which measured doctors’ responses to others’ pain. But the last line is the one which really struck me – ‘I never met a calling quite so pure’. You don’t hear much about ‘calling’ any more. Sadly, the current ethos is one of reducing every health carer’s job to a list of tasks and competencies, then assuming that any person who can tick all the correct boxes will be able to carry out exactly the same job. It’s not like that. People matter. The personality, the values and the motivation of a health care worker will shine through, for good or for bad! The new way of selecting young doctors for training posts in the UK uses a computer-based questionnaire system and does not accept the submission of a cv for example, and the candidates for GP training are referred to only by their numbers (to prevent prejudice on the part of the selectors from the candidates’ surnames). How many have a ‘calling’, and would any selector rate such a claim?

And finally, from Elma Mitchell’s, ‘This Poem” –

……even the simplest poem

may destroy your immunity to human emotions

All poems must carry a government warning

Words can seriously affect your heart.

Oh, so true! How a word can sting, burn, wound, comfort, move, excite, quicken or slow the heart! One of my favourite writers is Raymond Carver. He can write both poetry and prose in a way that you can be moved to tears by a tiny handful of his words.

So, what do you think about the relationship between poetry and health? Have you any experiences you’d like to share?

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Deaths from prescribed medication up 155% in 10 years

Posted in from the consulting room, health on October 21, 2007| 11 Comments »

The Independent on Sunday today carried a special report on adverse drug reactions to prescribed medication in England.

Between 1996 and 2006 in England the number of prescriptions issued by doctors has risen 51%, from 498 million to 752 million. Over the same period the number of reported deaths from adverse reactions to these drugs has shot up 155%, from 382 to 973 (actually they estimate the number of deaths reported is only 10% of the real number – this would give 10,000 deaths a year!) Also over this period the number of serious reactions to drugs has increased 214%, from 5,022 to 15,760, resulting in the occupation of 5,600 beds by patients with these serious problems. This has an estimated cost to the NHS in England of £466 million a year. This is an astonishing sum of money. I can’t help but think about the arguments used against Tunbridge Wells Homeopathic Hospital claiming the cancellation of a contract with them would save about a quarter of a million pounds a year. They could save a lot more than that if drugs were prescribed less frequently and more carefully.

A British Medical Association spokesperson said –

The British Medical Association said last night that the figures amounted to a “wake-up call” and is calling for better training in the medical profession. Dr Peter Maguire, deputy chairman of the BMA Board of Science, said: “This big rise in fatal and serious adverse drug reactions should be a wake-up call to all doctors. We have a large number of new medications, but there are also fake drugs coming into the market, and more and more people are using herbal and over-the-counter drugs, as well as all the existing prescription drugs. On top of that, people are living longer and we have the situation of polypharmacy, where we treat people with several medications.

These figures are quite shocking aren’t they? The contemporary paradigm of medicine is to focus on the disease and try to treat either the pathology or the symptoms with drugs in the first instance. Despite the rise of Evidence Based Medicine, drug trials do not typically identify the adverse reactions to drugs. We have to wait until people in the real world start to experience them before we see the problems. We should be cautious about prescribing, and we need to put more effort into understanding and developing non-drug solutions to health problems (after all, four out of ten of the top reported drugs are prescribed for mental health problems). However, drugs can make a huge difference to peoples’ lives. They are often necessary. So we have to train doctors to be better prescribers. One of the main problems identified in this report is that patients often complained that a drug was causing them problems but the doctors didn’t pay heed to what the patient said. This is fundamental. Doctors should listen to their patients. Carefully. And should trust what they tell them.

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