Heroes Not Zombies

The easiest way to offend a patient is to fail to engage with their reality by projecting our assumptions, theories and realities upon them. – Brian Bloom. Meaningful Disease.

There’s an awful lot of arrogance around these days. So many people seem to assume they are the sole possessors of The Truth. In my own sphere of work, I frequently read pontifications from non-clinical “scientists” berating doctors and patients. The arrogance usually takes the form of a fairly abusive attack on anybody who claims a benefit from a therapy which the “scientist” doesn’t support. It’s a “Trust me I’m an expert” at best, and it’s “Just be quiet, I know better than you” at worst. Arrogance is never appealing.

My view is that a good scientist is a humble scientist and never claims to possess The Truth, never claims to know all that needs to be known about any subject.

A good doctor puts the patient first. As Brian Bloom says in the quotation at the beginning of this post, projecting their own assumptions or theories onto the patient is a failure to engage. A failure to engage is a failure to practice good medicine.

The balance of power has started to shift in the doctor-patient relationship. I’m glad. It’s time doctors cared about every patient they meet, put the patients’ agendas to the fore, and it’s time for us to reject one-size-fits-all treatments which actually never ever have fitted everyone.

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I’m big on empathy. I think it’s such an important quality for doctors. Cold, distant, doctors don’t appeal to me. But I also understand the importance of trying to keep the emotions which empathy stirs in check. If I sat in tears and distress with my patients all day, not only would I soon become lost in depression and despair, but I wouldn’t be able to meet any of my patients’ needs. There’s a balance to be struck, and the balance point changes constantly throughout the doctor-patient interaction. I can’t be a useful therapist unless I understand the patient. So, I have to begin, at least, with empathy. I need to do my best to put myself in their shoes, to try to understand their experience of the world and to try to figure out what’s going on in their lives. But then I need to call upon my knowledge and skills and access my previous experience and carry out whatever therapy seems appropriate. Actually this might not be a therapy stage yet, it might be a physical examination, or working out which investigations to suggest.

When I worked as a junior hospital doctor, one of my responsibilities was to be in charge of the cardiac arrest team. This was high pressure, dramatic work. Basically the shrieking pager was screaming that someone had just died and I had to run as fast as I could to their bedside to take charge of the other half dozen or so folk who had also run there to try and save this person’s life – to get their heart restarted, to get them breathing again. You can imagine how my heart was banging and how “wired” I’d be feeling. This was high energy, high stress. BUT everyone would say “I felt really anxious until Bob turned up, then you could see everyone became calm” Wow! I never understood that. How could people pick up “calm” from me when inside I was feeling anything but calm!

Well, here’s a fascinating paper where researchers decided to study empathy in doctors from a neuroscientific perspective. Actually, Clive Thompson’s most excellent blog, “collision detection” was where I read about this and he not only gives a superb summary but his reflections on it are also worth reading.

The researchers used a technique called functionalMRI scans which measures and displays brain activity as it happens. They got a group of doctors and a group of non-doctors to watch video clips of people having acupuncture needles inserted or of being touched with Q-tips. And they asked them to rate how much pain they thought the subjects were experiencing.

Among the control group, the scan showed that the pain circuit, which comprises somatosensory cortex, anterior insula, periaqueducal gray and anterior cigulate cortex, was activated when members of that group saw someone touch with a needle but not activated when the person was touched with a Q-tip.Physicians registered no increase in activity in the portion of the brain related to pain, whether they saw an image of someone stuck with a needle or touched with a Q-tip. However, the physicians, unlike the control group, did register an increase in activity in the frontal areas of the brain–the medial and superior prefrontal cortices and the right tempororparietal junction. That is the neural circuit that is related to emotion regulation and cognitive control.

They also asked the two groups to rate the level of pain they felt people were experiencing while being pricked with needles. The control group rated the pain at about 7 points on a 10-point scale, while the physicians said the pain was probably at 3 points on that scale.

So, it seems that doctors learn how to shut down the empathy functions of the brain. Now, you can argue that’s a good thing, or you can argue that’s a bad thing. I come back to my hero not zombie perspective. If a doctor goes on automatic pilot, he or she is likely to lose the ability to empathise and not even realise it’s happened. It’s important for doctors to be reflective and aware, so they can increase and decrease the empathy functions as is appropriate.

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In the field of medicine there’s an interesting split between experience-based approaches and theory-based ones. I suppose it’s always been like that but in recent years Professor Sackett and colleagues’ approach to research has created something called “Evidence Based Medicine” (EBM) which, in it’s initial conception seems a very sensible idea, but which has, I feel, been distorted somewhat in recent years. Some people have taken Sackett’s method and applied the results to produce one-size-fits-all interventions and this was never the good Professor’s original plan. (He is in fact quite specific about the importance of the individual patient’s values and preferences in making treatment decisions). The one-size-fits-all approach is used to exert financial controls on health care and is promulgated by the “trust me, I’m an expert” brigade.

When it comes down to an individual patient, only this person can tell us about their pain or their other troublesome symptoms. Only this person can tell us what impact a treatment has made on their symptoms. In fact, we have all had the experience that a medicine which somebody else found helpful turns out to be hopeless for us (you can apply this to every form of medicine).

This was famously alluded to by Dr Roses of Glaxo who said –

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

My daily work is as a practising doctor. My priority therefore is to try my best to help each individual patient I meet. Yes, if there is a theoretical benefit available from a particular drug, then I should consider it, but, it wouldn’t help the patient if I didn’t bow to their experience. There’s no point banging on with the same treatment which a patient is telling me is not working for them. I really dislike the arrogance of those who claim to know what is best for each and every patient on the basis of “research” or “evidence”. It turns out that many patients don’t actually get the benefits in experience which the “evidence” theoretically offers.

Let me be clear – research is a good idea. It helps us to see what potentials treatments hold. What it doesn’t do is tell us what this individual patient will experience as a result of this individual treatment. We need to retain our humility as practitioners and never assume we know for certain what a patient needs in the way of treatment.

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