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How we cope – learning from the movies. Part 2

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

This is Part 2 in a series. You’ll find Part 1 here.

One of the major ways of creating a sense of self is through group identity. We see this especially strongly in small towns and villages where there are very real, very active communities. What I mean by that is not just people who live in the same street or same town but people who work together, play together, live together. Communities of people who share values and traditions which bond them together. I gave an example of such a community in the Part 1 of this series where I showed a clip about Hobbits. Well, hobbits are, of course, imaginary creatures, and some people find it hard to identify with fantasy so here are two clips from a movie entitled “Brassed Off”. This is an at times funny, at times tragic tale of a mining community in the north of England. It’s set in the Thatcher years when the coal mines were being closed down and these communities were being destroyed. A characteristic of these northern towns was the brass band. It was just one of the ways the community bonded. Mining towns would regularly have brass band contests – like this –

You can feel the spirit of these people and how the music, the beer and the comraderie created a cohesive, group identity.

The band leader is called Danny and in one scene he has a heart attack and as he lies, seemingly dying, in his hospital bed his band gather outside and pay their respects, by playing “Danny Boy”

Oops! I should’ve warned you to have your tissues ready! Moving, isn’t it? It’s probably the only time a brass band has moved me to tears!

Think back to the character we saw at the start of About a Boy. Can you imagine that he would have the same needs, the same desires and the same experience as these characters in this tale?

We are all different in so many ways and, in health care, to find the best treatment for someone, we have to discover who this person is who has this particular disease. Otherwise we’re probably going to fail to help them to recover.

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How we cope – learning from the movies. Part 1

Posted in education, from the consulting room, from the viewing room, health, life, movies on October 2, 2007| 6 Comments »

I was recently asked to give a talk at a Palliative Care Conference in Dundee. One of the organisers had seen me use movies as a educational tool when teaching doctors and wanted me to demonstrate that. It was well received and I thought I’d put up a series of posts based on the talk. I hope you like them.

TWO QUESTIONS FOR ALL DOCTORS

I think the core of a doctor’s job is to try and understand people. One thing I find helpful in that regard is to have two questions at the back of my head during every consultation –

  1. What kind of world does this person live in?
  2. How does this person cope?

With the first question, I’m trying to understand what’s important to the person and how they create a sense of self. I won’t go into this in much more detail just now but one well-known way of viewing the world is through the triad of body, mind and spirit. I find that quite helpful. We can consider each of these as a focus and for every one of us we can place ourselves on the this map – the body, mind, spirit map.

For the purposes of understanding where someone lives on this map, I think that the body represents the physical. These are people to whom physical security and physical reality are paramount. They prioritise material issues and they tend to prefer to have a rational, logical approach to problems – you’ve probably heard someone say “Don’t give me your touchy-feely nonsense!” when asked to discuss how they are feeling. Utility and practicality are their key values. For others, emotional security is more important. They are very aware of feelings and of relationships. They see themselves in relation to others. The third focus is spiritual and by this I mean the need to make sense of the world and the idea that there is something greater than each of us as individuals. This might be religious but it might not. What is important to that person is that they need to have a sense of purpose.

This map, by the way, is not a set of boxes into which people should be placed. The map is more like a map of three areas or neighbouring countries with flexible, moving, overlapping borders. Some people spend all their lives in only one of the countries but most move around!

This, for me, is a fundamental way of creating a sense of self – a way of answering the “who am I?” question. But related to this there is another way, which is how we see ourselves in relation to others. For all of us we live with a tension of two opposites – the need to be separate, unique, individual AND the need to belong, to love and be loved, to identify with others. I say this is related because I find that often the physically-focussed person is more towards the pole of individuality and separateness and the emotionally-focussed towards the pole of identification with others.

So take a look at this movie clip and listen the main character’s monologue. Here is a man who has a sense of being self-contained and who is materially-focussed.

“I am Ibiza!”

To see the opposite pole, have a look at this clip. Here are people whose sense of identity comes from the community –

“It is no bad thing to celebrate a simple life”

These are two good examples of very different ways of experiencing the world, different sets of priorities and different ways of creating a sense of self.

OK, so some of you will be saying hobbits?? They’re not real! But, trust me, the Hugh Grant character in About a Boy isn’t real either! But let me address that in Part 2 where I’ll show a couple of clips from one of my favourite movies, Brassed Off, which is set in a Northern English mining community. You can compare that to the lifestyle of the hobbits in the Shire.

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Drug companies, informed consent, and Africa

Posted in from the consulting room, from the viewing room, health, movies on October 2, 2007| 1 Comment »

I stumbled upon this news item. It’s the story of Pfizer, an $8.5 billion law-suit and the Nigerian government. It’s one of those sad tales of a drug company testing out a new drug developed in Africa. The drug concerned is Trovan and the case relates back to 1996 when an epidemic of meningitis was raging in Kano, Nigeria. Pfizer gave Trovan to 100 children and another “proven” treatment for meningitis to another 100. Nigeria alleges that the deaths of 11 children and permanent health problems of many others were the result of Pfizer’s trial. Whatever the truth of the matter, and however the trial turns out, it raises an issue which is highly contentious which is the use of poor African’s in drug trials conducted by multi-nationals. The original story was broken by the Washington Post.

Did you ever see “The Constant Gardner“?

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Why homeopathy and what is it anyway?

Posted in from the consulting room, health, tagged on September 26, 2007| 18 Comments »

I work at Glasgow Homeopathic Hospital. I’m a medical doctor, used to be a GP (Family Physician), but I became gradually disenchanted with prescribing only antis (anti-biotics, anti-depressants, anti-inflammatories, anti-histamines, anti-hypertensives……..you get the picture) and only having the time to focus on little bits of people instead of the people themselves (we call those little bits diseases by the way). I had perhaps strangely had a notion that being a doctor would be about being involved in healing (ever tried looking up “health” or “healing” in a medical textbook? Don’t bother. No such index items!) so just suppressing bits of people didn’t feel like what a proper doctor should be doing. On top of that there were situations every day where I just didn’t have anything good to offer (everything from infant colic, to night cramps, restless legs, sports injuries, PMT…….blah, blah, blah – believe me, there are LOTS of problems your doctor doesn’t have answers for!)

I happened upon a course in “Homeopathy” at Glasgow Homeopathic Hospital back in 1983 – didn’t know there was such a hospital and had no idea what “homeopathy” was anyway, but something about the ad caught my attention – wish I could remember what it was! – I think it was something that mentioned “healing”! Well, I signed up. I learned there about homeopathic medicines, how safe they were, and what their indications were and they gave us a wee box of 10 remedies to go and try out in our practices. Well, from the first try I was amazed at how good these treatments were. They could deliver improvements in conditions I hadn’t other answers for and that was VERY useful. Patients would stop me in the street and thank me for the prescription because it had helped so much – that NEVER happened when I prescribed an anti-something!

To cut a long story short, the patient demand for homeopathic treatment drove my learning and after I passed the Membership exam of the Faculty of Homeopathy I started working at the Glasgow Homeopathic Hospital in the Outpatient Dept every wednesday. Well, my wednesdays soon got an awful lot more satisfying than the mondays, tuesdays, thursdays and fridays, so I had a crisis. All my life I’d wanted to be a doctor, no, not just a doctor, but a GP, and here I was thinking I don’t want to be a GP anymore. So I stopped being a GP and for a few months did a weekly radio show on ScotFM, wrote a textbook of homeopathy for GPs, and did my wednesday clinics. After a few months my friend and colleague, David Reilly at the Homeopathic Hospital suggested we make a bid for the creation of full-time position for me at the hospital. I started there full-time in 1995 and I’m still there. I love it! Every single day, every single clinic, every single patient. I look forward to every day of work. How many people can say that?

So what do I do there? What’s this homeopathy?

Everyone I see there has been referred by another doctor or nurse. Everyone I see has a chronic problem – everything from chronic pain, to allergies, skin problems, cancer, multiple sclerosis, psychiatric problems like depression, bipolar disorders, you name it. I see a lot of kids. Almost half my practice is treating children. The thing most of these people have in common is that they’ve already tried the drugs, surgery and so on recommended by other doctors but they’re still not well, still suffering. Amazingly, our in-house audits consistently show that across the board, after receiving homeopathic treatment, around two-thirds of these patients claim a benefit which makes a difference to their daily lives.

So, no wonder it’s such a treat to work there. Most of the patients get benefits from the treatments which they didn’t find elsewhere. That’s hugely satisfying if your goal in life as a doctor is to try and relieve suffering.

Ok, enough, you’re probably thinking, what on earth is this homeopathy thing anyway?

Dr Samuel Hanhemann, was a German doctor who lived from 1755 – 1843 As a young doctor he soon grew disenchanted with the practice of medicine of his day – he thought that blood-letting, cupping, leeching, purging and poisoning patients was pretty brutal and didn’t seem to actually heal anyone. So he stopped being a doctor and to earn some money he translated textbooks into German. One day he was translating Cullen’s Pharmacopoeia from English into German and he read about the treatment of swamp fever with Peruvian Tree Bark. Cullen said this drug worked by being an “astringent” ie it dried the body up. Hahnemann, wondered if that was right, so to test it out, he took some. Much to his surprise, he found that he got all the symptoms of swamp fever. How interesting! The drug which can cure the disease can produce the same disease when given to a healthy patient (that’s not exactly true but it’s how he saw it). He then tested a bunch of other common drugs of the time and found the same phenomenon. He called this “the treatment of like cures like” – “homeopathy”.

Does this make sense? Well, yes it does. There’s a phenomenon we know called “hormesis” – where a drug which has one effect at a high dose, has an opposite effect at a low dose. Think of aspirin. In high doses it makes the body temperature rise, yet in low doses it can lower a fever. Professor Bond, pharmacologist in Houston coined the term “paradoxical pharmacology” to describe this phenomenon and even created a receptor theory model to explain it. Nothing really controversial here. Let’s move on.

Hahnemann thought that doctors shouldn’t be poisoning their patients so he decided to find out what was the smallest possible dose of a medicine which would bring about a healing effect (when prescribed on the basis of this like treats like idea). There weren’t any drug companies in those days so doctors had to prepare their own medicines. Hahnemann used a method of serial dilutions and succussions to make his medicines (that’s a stepwise series of dilution of the original substance with vigorous shaking of the test tube between each dilution). He got another surprise. Not only did the smaller doses cause less harm, they actually seemed to cure quicker! The more dilute preparations had a more powerful effect! OK, I hear you say, enough’s enough. This is crazy thinking! Well, it gets worse. Cos he pushed this dilution theory way up to 1 in 10 to the power 30 and beyond – trust me, I’m a doctor – that means there are NONE of the original molecules left! Now THAT is controversial! In fact, its at this point where some people start to say homeopathy is sheer nonsense and can’t possibly work!

Would it surprise you to know I disagree with that view?

You might want to go check out the scientific research in homeopathy. I recommend you start here. In short, there are many clinical trials of homeopathy and many have shown effects of homeopathic treatments that cannot be dismissed as placebo. Something seems to be happening and its probably not placebo. In fact the clinical trial evidence in homeopathy is not very strong and doesn’t really answer any of the questions about this treatment so we need to look elsewhere. Elsewhere includes what are known as outcome studies. These are studies of what actually happens to patients who have homeopathic treatment (not comparing this to placebo medicines). Consistently such studies show around two out of every three patients get benefits from homeopathic treatments. So, however you explain it, for most people it does exactly what it says on the tin – it helps. What about the idea that such ultra-high dilutions can have a consistent biological effect? Is that nonsense? Well, interestingly, there have been a number of laboratory studies in recent years which show that water does indeed have the capacity to communicate specific effects of substances which have been diluted in it many times. This is early work but it shouldn’t be dismissed.

But what IS homeopathy?

Homeopathic medicines are prepared from natural substances – plants, minerals, substances of animal origin – all of which are serially diluted and succussed many, many times to prepare the actual medicines. Every single medicine has its own unique picture of symptoms as described in homeopathic materia medicae – these are reference books based on clinical trials (called “provings”), clinical experience and toxicological information about the substances. The idea is that the picture of the remedy should match, as closely as possible, the picture of the patient’s illness (actually I prefer the concept of the “narrative” as opposed to the “picture”).

The narrative of the patient’s illness reveals their unique experience (no two people with the same diagnosis have the same narrative) and it reveals their patterns of coping (and failing to cope) – this is what we are looking for in selecting a specific homeopathic medicine – the narrative of the experience and the patterns of coping. When the patient takes the homeopathic medicine the intention is to stimulate their processes of self-repair, self-recovery and self-healing. The intention is NOT to suppress but to heal. The medicines themselves are non-toxic – they have no significant side-effects, a record over 200 years of absolutely NO fatalities, and can be safely taken in conjunction with other prescribed medication.

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A decade of getting fat

Posted in from the consulting room, health on September 25, 2007| 3 Comments »

I read two reports about obesity today – one from the USA – which highlights the issue of the increasing prevalence of both advertising for high fat high calorie foods and the number of sales points for “junk” food (especially in the environments of teenagers. The other from Scotland showing we have the highest rates of obesity in developed countries second only to the USA. These figures are not new. But I was just wondering about the massive amount of obesity around as I walked through Queen St Station in Glasgow yesterday. Here’s my question –

What has changed in the last ten years to produce this obesity epidemic?

There are a lot of theories out there but the common themes seem to be increased consumption of “fast foods” – people prepare many less meals from scratch now, and eat many more meals outside of the family home. A close ally to this is the increased consumption of sugar-laden fizzy drinks. By the way, have you ever seen a skinny person drinking a “Diet” fizzy drink? There’s a message there!

The other major theme is a reduction in physical activity with children spending more time sitting watching TV and playing computer games, and schools offering less sports and exercise time, and in adults, a huge shift, through globalisation, in jobs, away from physically demanding jobs towards sedentary jobs (and in addition a reduction in the amount of exercise, including walking, taken by the average adult)

Well, whatever the causes, the changes are way more obvious than the more talked about global warming, and in our lifetimes, it’s looking like the obesity epidemic will kill many more of us than global warming does.

The point is, the obesity epidemic is a typical complex phenomenon. There are no single causes and no quick fixes. This is just the kind of issue we need to get to grips with. We need the science to help us understand what’s happening and what interventions might make a significant difference. We need ingenuity and creativity to tackle it. And we need to care. Today’s children aren’t going to have very healthy long lives unless we do.

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Your involvement in YOUR health care is so important

Posted in from the consulting room, health on September 24, 2007| 8 Comments »

A report in the UK has looked at the issue of patient engagement – how involved people are in the decisions about their health care.

The Picker Institute pointed out that in every national poll they looked at, between a third and a half of patients said they were not involved in decisions about their care and treatment as much as they would like.

The studies said patients were particularly keen to have more choice of medication, the hospitals they were treated in and the doctors they were seen by.

Picker Institute chief executive Angela Coulter said: “The rhetoric of patient-centeredness has a hollow core.”

I think the tide is turning. We’re seeing the decline of the “trust me I’m a doctor” approach to medicine. This is a huge challenge to many doctors. How can they retain patients’ trust yet let go of power? Increasingly patients want to be informed about health care options and involved in making the decisions about their own care – choosing (with the doctor’s expert advice and support) the treatments they wish to receive.

But this is only a small part of engagement. As well as sharing power, there needs to be more sharing of responsibility. Too many people feel that they are victims – that disease just happens to them – and that treatments are also something to be done to them. Understanding how to engage with illness, understanding how to be an active player in their own recovery and health, cannot happen without this shift in power.

I look forward to a more engaged practice of health care, which really is patient-centred.

What’s your experience? Are you engaged in your own health care? Does your doctor share power with you?

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Miracle cures?

Posted in from the consulting room, health on September 23, 2007| 1 Comment »

There is a very common, very sloppy (or deliberate) statement made in medical research articles. Read this –

The landmark randomised trial, the hypertension detection and follow-up programme, showed that a “stepped care” approach incorporating regular review, adherence reminders to patients, and an explicit programme of treatment intensification produces substantial falls in blood pressure and reduces all cause mortality

This is from an otherwise excellent article about how GPs are paid for interventions in Primary Care, published in last week’s BMJ ( if you want the full reference it’s  – BMJ  2007;335:542-544 (15 September), doi:10.1136/bmj.39259.400069.AD)

The phrase I really object to is the last one – the claim that a particular treatment “reduces all cause mortality”. Do the authors really mean that? No. What they mean is that in this particular trial the number of deaths in the treatment group was less than expected over the course of the trial – trials don’t last very long – a few weeks, to at most a few years (exceptionally). What they do NOT mean (surely) is that the drug in question stops people dying – from all causes, forever. The question that is left unasked is what kind of lives, and then, what kind of deaths, do the people have who took this treatment? Because everyone dies from something. No drug “reduces all cause mortality” – not when you take a life-time perspective rather than a short period of a life.

I think it’s time we actually researched this issue – what is the lifetime experience of people who take part in interventionist preventitive treatments? What illnesses do they get? And what do they die from?

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Frankenstein

Posted in from the consulting room, health on September 23, 2007| 1 Comment »

The BMJ carries a weekly column about literary classics and the piece this week by Ross Camidge considers Mary Shelley’s Frankenstein. If you’ve never read the book, you’ve missed something. As Ross Camidge points out the movies over the years have distorted the serious and fascinating consideration of life which Mary Shelley’s book presents. (As well as the original book I highly recommend the biopic about James Whale, who made the original Frankenstein movies – “Gods and Monsters” – a disturbing but very insightful tale)

Frankenstein (the book) is subtitled “The Modern Prometheus”. Don’t know if you remember about Prometheus but he is the one who stole fire from the Gods and took it to Earth to create Life out of the soil. Frankenstein is the creator’s name (it’s not the “monster’s”) and his intention was a good one, but how he handles his creation is one of the morals of the story. Here’s the last paragraph from the BMJ column –

Frankenstein’s outright rejection of his creation, denying it even a name, twisted its basic goodness into hateful barbarity. This is something to think about when treatments go wrong and patients or relatives look to us for answers and support. Or when trainees are heading off the rails and need more intensive mentoring. Frankenstein teaches us that to get the best possible outcome from anything that has involved our creative input requires elements of responsible care, love, and nurturing. And if we do this we will not create monsters.

Oh, that’s so spot on! Let’s bring that back into the agenda when we consider health care and the education and training of health care professionals –  “responsible care, love, and nurturing”

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Dying for drugs

Posted in from the consulting room, humour on September 23, 2007| 2 Comments »

One of the doctors who trained me told me “If you send your patient to a man with a knife he’ll use it”. The advice was about referring to surgeons. He meant if I sent a patient to a surgeon it was highly likely that the patient would end up with some kind of operation, so I should ask myself if I thought that possibility was in the best interests of the patient. All operations carry risks after all.

It was much later when I realised that the same kind of advice applies to specialists who specialise in the prescription of drugs – physicians. Let’s face it, drugs carry risks too.

In the BMJ this week, we are reminded of just how dangerous they are –

The number of reported serious adverse events from drug treatment more than doubled in the United States from 1998 to 2005, rising from 34 966 to 89 842, says a new study.

Almost 90,000 serious bad reactions to drug treatments in the US alone in 2005!

Over the same period the number of deaths relating to drugs nearly tripled, from 5519 to 15 107, show data from the US Food and Drug Administration’s adverse event reporting system, which collects all reports of adverse events submitted voluntarily to the agency either directly or through drug manufacturers (Archives of Internal Medicine 2007;167:1752-9).

15,000 deaths related to prescribed drugs in one country in one year!

I work in Glasgow Homeopathic Hospital and I know that for some people homeopathy is a controversial method but in 250 years do you know how many people have died from the effects of a homeopathic drug? NONE. ZERO. NIL. Nope, not a single one. And yet, all the UK NHS Homeopathic Hospitals have shown that they typically make a difference for two thirds of the patients who attend their clinics – a difference the patients themselves rate as significant (ie changes that make a difference to daily life).

What happened to “first do no harm”? Now don’t get me wrong, there are some highly effective drugs which can, in certain cases, be life-saving. There are many people who live better and longer lives because of the drugs they take. But drugs are dangerous. They should be used with caution. And we should never rely solely on drugs. We need to pay attention to interventions which facilitate recovery from illness and which foster resilience. We need to find ways to reduce the lifetime load of chemicals patients with chronic illnesses end up taking.

Finally, we need to investigate and learn from every single death from medication. To die from a treatment is a tragedy.

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More options than drugs and surgery

Posted in from the consulting room, health on September 10, 2007| Leave a Comment »

You’d be forgiven for believing that medicine was all about drugs and surgery. But its not. As we begin to understand human beings as complex adaptive beings we are beginning to explore holistic approaches to health care. I’m not talking about New Age therapies of any kind. I mean ways of addressing suffering which consider the whole person within the contexts of their life.

Pain Clinics are amongst the most radical in this regard. Chronic pain can ruin lives and despite the best efforts of specialists using the best “evidence based” drugs, many patients still don’t get relief. Those who research pain these days tend to have both holistic and pragmatic views  – they know that pain is not about lesions, is not directly proportional to the pathology in the patient’s body and is modified by emotional, psychological and social factors.

A new study of “mind-body” interventions of pain rates these methods as especially suitable for the elderly (because of the dangers inherent in many powerful drugs which are not suitable for patients who are more frail).

But if a therapy for pain is effective at reducing pain why limit it to a specific age group? And why try it last? At the Glasgow Homeopathic Hospital where I work we see a lot of patients with chronic pain. We have a notice in the pharmacy – “TEETH” – its stands for “Tried Everything Else? Try Homeopathy!” – because the vast majority of patients we treat have already failed to find relief from all the other more orthodox treatments (drugs and surgery!) I think that it’s a shame people go through the harmful and side-effect laden treatments first – wouldn’t it make more sense to try the safer treatments first and reserve the more dangerous ones for those who don’t get relief from these gentle approaches?

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