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Archive for the ‘from the consulting room’ Category

What a consultation with your doctor should be like

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

In Kieran Sweeney’s “Complexity in Primary Care” he quotes from Toon’s “What is Good General Practice?” paper –

The consultation is the patient’s forum for coming to understand her illness, not merely a rational understanding, but an understanding which involves the emotions and which contributes to the growth of the individual.

Oh, how, very, very true.

Print that out. Take it with you next time you have to consult a doctor. That’s what the consultation should be about – it’s YOUR forum, for YOU to gain an understanding of what’s happening in a way that will “contribute to the growth of the individual”.

There’s your standard. Measure your doctor visits against it!

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Complexity, evidence and intuition

Posted in from the consulting room, from the reading room, health, science on September 7, 2007| 6 Comments »

I’ve just read Kieran Sweeney’s “Complexity in Primary Care” (ISBN – 1-85775-724-6) and found it both stimulating and agreeable. I am SO glad that books like this are being published. I’ve read both of his previous books – “Complexity in Healthcare” and “The Human Effect in Medicine”. He’s one of those authors who is bringing the fairly new ideas of complexity science to the attention of clinicians, I think with the intention of trying to redress the balance a bit. Medicine has become very reductionist and limited in its approach and whilst this has paid off in dealing with acute diseases it hasn’t helped in dealing with chronic disease OR in the wider desire to maintain health. In addition to this, the modern thinking he scopes out in these books really has a chance of helping us to reclaim a much more human-centred practice of medicine.

Here’s a couple of quotes from the book which really struck me –

The requirements of medical research are limited by insisting that an answer should be numeric, otherwise it is not a real answer.

That reminded me of what I just posted the other day there about the value of patients words over numbers. It also reminded me of this – I once heard a dentist describe his experience of replacing a retired colleague in a specialist facial pain clinic. He didn’t know that his predecessor had devised a scoring system for pain and had trained all his patients to report a figure as a way of telling him how much pain they were experiencing. Apparently, this man would become quite frustrated with patients who tried to talk about themselves and would even say “Stop. Not another word! I want the next thing to come out of your mouth to be a number. Nothing else! On a scale of 0 to 20 how has your pain been?” The dentist who was telling me this story was quite baffled when he took over the clinic and saw one patient after another come in for follow-up consultations and just say “17” or “12” or “9”, then refuse to say another word. They were too frightened! He didn’t find their answers very useful.

It seems that a lot of what I’m reading just now is challenging me to think about non-rational thought, intuition, gut-feelings, whatever you call that way of understanding the world. In particular I’m reading Solomon’s “Joy of Philosophy” and loving it – he argues this point. See what Sweeney has to say about it –

At the theoretical level chaos and complexity can help us to synthesise evidence and intuition. They dignify the notion of intuition, and re-establish the importance of experience and wisdom, seeing them as emergent properties of the thousands of iterative, recursive interactions in consultations.

Oh, I like that! He’s showing that from basic principles of complexity science we can understand intuition is a way of knowing which arises through our interactions with each other. Thank goodness someone is making a call for us to develop a form of medicine which is greater than the sterile world of “Evidence Based Medicine” with its mind-numbing protocols and guidelines.

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The richness of stories

Posted in from the consulting room, from the reading room, health, narrative on September 5, 2007| 4 Comments »

When patients consult me I begin the first consultation (after having made my introductions) with some variation along the lines of “Your doctor has sent me a referral letter which gives me some of the background information about your illness but it’s best you tell me your story yourself”. This allows the patient to set the agenda and to tell me whatever they want to tell me in their own preferred order. When they come back to see me for a follow-up appointment I tend to begin with a question like “How’s things?” – deliberately vague and open, again to let the patient tell their story their own way.

I try to write down their exact first words. How they are doing is often captured richly in those opening sentences. For example, something along the lines of “Doing well. Got back to work and really enjoying it now” or “Managed to have our first family holiday in years”, tells me that there has been a significant shift. The details follow but the essence and magnitude of the change is often right there in the first few words.

We use an “outcome scale” with our patients in Glasgow Homeopathic Hospital. “0” means no change; “1” means some improvement, but not enough to be of value in daily living; “2” means improvement of value in daily living; “3” is significant change which has brought a significant improvement in daily living; and “4” is hallelujah, I’m cured!

Whilst it’s satisfying to see that two-thirds of our patients score a 2 or more, these bare numbers really lack the richness of the actual words the patients use. What is more important really is to capture the “story” of the change. The story needn’t be a long one; the first few minutes are usually time enough the hear it because the essence of the story is conveyed literally in the first three of four sentences the patient utters.

Interesting that this issue was on my mind today as I was musing about to capture these changes more systematically, when I came across a post on Lifehack about stories. (This post, by the way is Part 6 in a series about Chip Heath and Dan Heath’s book Made to Stick: Why Some Ideas Survive and Others Die)

This phrase really struck me –

Stories, then, allow us to impart not just our conclusion, but the actual experiences by which we came to that conclusion.

That’s it! I thought. That’s it in a nutshell. Figures are so uninteresting because they present a conclusion. They are thin information. How much richer is the information conveyed in a story!

I can tell you that in all my years of practice I’ve never heard the exact same story twice. It’s by telling their stories, with their own preferred vocabulary, in their own preferred way, that patients convey the experiences of their illnesses to me. And healing is in no small measure a matter of enabling somebody to tell a different story, to start a new chapter with new vocabulary and to develop new themes – positive themes, health themes as opposed to illness ones. It’s such a treat!

Surely we must resist the current trend to do medicine by numbers where individual stories don’t matter, where individual people don’t matter!

Here’s to the richness of stories!

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How do you know how engaged your are?

Posted in from the consulting room, health, life on September 3, 2007| 5 Comments »

Wesley Fryer’s excellent Moving at the speed of creativity blog has an interesting post today on “Measuring Engagement“. Engagement is, I think, a key quality of a healthy life. But what does it mean exactly?

I think of it as being in active exchange with your environment – both consciously and unconsciously; physically, emotionally and spiritually. There are three elements to this –

  1. the environment
    We are embedded in multiple environments. By that I mean you can’t see who you are in isolation. Nobody exists out of all context. Our environments are multiple – the physical environment of air, light, heat, noise and so on; the relationship environment of our place in our own personal networks of people (family, friends, colleagues, society etc); the semantic environment of meaning – the sense we make of the signals and symbols around us; and so on…multiple life contexts.
  2. being in exchange
    Within our environments we are continually receiving and responding to signals – detecting changes and adapting to them.
  3. active
    By active I especially mean conscious – the greater our awareness, the greater our ability to choose between possible responses to the changes in our environments. In addition, by active, I mean creatively active, because when well we don’t just respond to changes in our environments, we initiate changes too.

Wesley Fryer’s area of interest is education. I’m primarily a physician but a significant part of my job is education so that perspective interests me too. I share his interest in web technologies and it’s a Facebook development that seems to have stimulated this particular post. Facebook has measured applications on the basis of numbers of users but is now changing that to measure “engagement” instead – by this they really mean they are measuring a number of ways users interact with an application. Jeremiah Owyang argues that this is not really “engagement” but just “interaction”. Whatever you think about the Facebook model, Wesley goes on to consider how teachers measure engagement in the classroom (as opposed to just participation).

So, all this got me thinking. If I believe that engagement is a key quality in health, how do I know how well that is functioning in a particular patient’s life? Let me explain a little further…….

When someone has chronic suffering, be it pain, breathlessness, depression, whatever, their lives can become much smaller. They can retreat from work, from social interaction, and even from the basics of life – not noticing the world around them, collapsing further and further into a deep, black, hole. As they start to become well again they begin to notice more and respond to more around them, become more active socially and their lives gradually expand. This expansion is one of greater engagement (in illness, the contraction of life is a loss of engagement).

So, here’s my query – how do you know you are more or less engaged in life? Are you aware, when your world is either shrinking or expanding, of what it is that’s changing? What does “engagement” mean to you?

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Noise kills

Posted in from the consulting room, from the dark room, health, photography on August 23, 2007| Leave a Comment »

I made up a wee mindmap of virtues for myself which I pasted into the front page of my moleskine. I survey it every morning so I can have one of the virtues, or areas of virtues, in my mind as I go through the day. This morning I settled on the “Calm” area – slow, silence and tranquillity are my three virtues there, so imagine my surprise when I see this article in the Guardian as I travel through to Glasgow on the train.

Coronary heart disease caused 101,000 deaths in the UK in 2006, and the study suggests that 3,030 of these are caused by chronic noise exposure, including to daytime traffic.

This is quite astonishing. I know that noise can be really irritating but I hadn’t thought through the idea that chronic noise levels induce chronic inflammatory (“stress”) responses in the body that might actually lead to death from heart disease!

So, tranquillity and silence turn out to be even more important than I had realised.

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Drug-based preventitive treatments

Posted in from the consulting room, from the reading room, health on August 14, 2007| 2 Comments »

The BMJ published a study today which has been reported across at ScienceDaily. This is an incredibly thoughtful article which questions the prescribing of lipid-lowering drugs (statins) to the elderly. Whilst there is good evidence that lowering lipid levels in younger patients reduces their risk of suffering from cardiovascular diseases, there is not good evidence that the same benefits can be achieved with the elderly. However, doctors are being encouraged to treat the elderly with the same assumptions as they make when treating younger patients. Worryingly, one of the studies conducted in the over-70s who take statins shows that while there did seem to be a reduction in death from cardiovascular diseases, the overall mortality remained the same. In other words they died from something else. In this particular study there was an increase in deaths from cancer. The authors of this paper ask a question which I’m astonished has not been asked before.

Is it possible, they ask, that by introducing preventive treatments in the elderly aimed at reducing the risk of a particular cause of death, we are simply changing the cause of death without the patient’s informed consent?

Too often drugs are presented to the public and the medical profession in terms of “saving lives”. Drugs don’t save lives. However, they do alter the experience of dying, and, of course, therefore, the experience of living. But when coerced into taking medication to “prevent” future diseases, patients are not being told exactly what not dying from this particular disease might mean for them. What are they more likely to die from if they don’t die from heart disease for example? This is not a question that should only be asked when treating the elderly. It’s time we had some decent research on how medication changes the experience of living and dying, not just research which only focusses on single diseases. Only then can doctors and their patients make truly informed decisions.

However, the issue of treating the elderly as if you can expect they will receive the same benefit from a treatment as a younger person is also something we need to think about. It doesn’t make sense. People are different and “evidence” from drug trials conducted on younger people may well not be at all useful “evidence” when making a prescribing decision for an elderly person. To be useful, evidence has to be relevant to the individual patient who is being persuaded to take medication.

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Seligman’s Virtues and Strengths

Posted in from the consulting room, life, personal growth, psychology on August 8, 2007| 8 Comments »

When I read Authentic Happiness by Martin Seligman I was very taken by the notion of identifying your strengths and building on them (as opposed to the more traditional New Year’s Resolution method of picking out your greatest weaknesses and hopelessly wrestling with them!). At the time, somehow, I missed his reference to “virtues”. Then when I read The Happiness Hypothesis recently, Jonathon Haidt’s description of virtues and his reinforcement of the idea of a link between ancient virtues and the findings of positive psychology sent me back to read Seligman’s book again. And there it is, clearly, in black and white – he lists what he says are the SIX main virtues (dropping seven of Franklin’s?) and the 24 “strengths” which lead to the development of those virtues.

Here are his SIX virtues –

  1. Wisdom
  2. Courage
  3. Humanity
  4. Justice
  5. Temperance
  6. Transcendence

Quite different from Franklin’s, at least, at first sight.

Let me summarise his “signature strengths” for you. These lead up to the virtues.

Wisdom

  • Curiosity
  • Love of learning
  • Judgement
  • Ingenuity
  • Emotional intelligence
  • Perspective

Courage

  • Valor
  • Perseverance
  • Integrity

Humanity

  • Kindness
  • Loving

Justice

  • Citizenship
  • Fairness
  • Leadership

Temperance

  • Self-control
  • Prudence
  • Humility

Transcendence

  • Appreciation of beauty and excellence
  • Gratitude
  • Hope
  • Spirituality
  • Forgiveness
  • Humor
  • Zest

Now, I’m sure you’ll see when we come down to the level of what Seligman calls strengths there is considerably more overlap with Franklin’s virtues. However, there are significant differences.

If you’d like to read more about Seligman’s Signature Strengths and Virtues I suggest you go have a look at his website (it’s free) and read the book Authentic Happiness.

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Human Traces

Posted in books, from the consulting room, from the reading room, health, life, neuroscience on July 21, 2007| 6 Comments »

Human Traces by Sebastian Faulks (ISBN 978-0-099-45826-5) is a novel of ideas. Set in the late 19th, early 20th century it tells the story of two young men who become idealistic doctors, determined to work together to understand mental illnesses so that they can cure them. In addition, they hope that in understanding the interface between the body and the mind they will understand what it is to be human.

I found it really absorbing. Much of the discussion was around subjects which are very familiar to me – consciousness, the relationship between the body and the mind, the debate about whether mental illnesses have neurological bases or not, and the still young area of evolutionary biology. However, as a doctor, the book has additional relevance. After all, my experience is also one of idealism and hope; the belief that doctoring will be about curing, and the gradual erosion of that to aim at managing diseases instead of curing them (that last is a painful loss – for sure, doctors have cures for many acute diseases now, but the burden of illness is chronic disease and, sadly, we seem a long way off from finding genuine cures for those)

Sebastian Faulks floats an incredibly interesting hypothesis about the hearing of voices, having one of the characters, Thomas, propose that this was a facility that all human beings possessed but which has since been lost by most of us. He cites the literary evidence of Man’s relationship to God/gods where the earlier stories show people hearing voices which they obeyed – they experienced the daily reality of their gods; and later stories showing that people no longer reliably heard those voices and had to throw lots, examine entrails, find unusual characters (prophets) who could still hear the voices, in order to know what the gods wanted. He links this idea to the emerging concept of evolution and natural selection by proposing that the hearing of voices was linked to the development of consciousness and the loss of the voices was related to the development of self-awareness through the acquistion of language. If you are not familiar with any of these ideas this novel is a great place to introduce yourself to this area of thought.

However, this 609 page novel did not engage me emotionally……..until page 595. From page 595 to the very last word of the novel, it hit me like a sledgehammer. I didn’t just cry. I sobbed. I was totally unprepared for it. This is quite honestly one of the most powerful pieces of writing I’ve read. Maybe it hit me so hard because it touched so many issues which lie in the core of my being – what is it to be a doctor? what use am I to others? how do we get a sense of self and how does it feel to lose that to an illness like dementia? what does it mean to become invisible? and, ultimately, what trace do I leave on this Earth?

There are a number of phrases and passages which have stimulated a whole lot of things for me, and I’ll return to post about some of them separately.

Thought provoking, educational, well-written, and, ultimately, powerfully emotional.

Highly recommended.

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Becoming a hero…..slowly

Posted in from the consulting room, from the reading room, health, life on July 19, 2007| 6 Comments »

I read a great post on the SlowDownNow.org blog. In it Christopher Richards describes his experience of being looked after by a doctor who took his time, then his experience of trying to find a new doctor after this first one had retired.

I’m pretty sure we’re losing something really important with our current round of NHS reform. And its something related to speed. Sure you need fast, effective treatment when you are acutely unwell, but the surgeon or physician who is tending you still needs to take his or her time and not rush things or the job just won’t get done properly. However, the big demand in health care these days is chronic disease and here we really have been looking for quick fixes at the expense of taking our time to listen, to understand and to enable patients to adapt, to grow and to enlarge their lives in the presence of their diseases.

An American sociology professor, Arthur Frank, wrote “The Wounded Storyteller” (ISBN 0-226-25993-5) to describe his study of how patients talk about their illnesses. He identified three major “genre” of narrative – the “restitution” one – which is the quick fix approach to health care (“A bit of me’s broken. If you could just fix it or replace then I’ll be on my way”). This is appropriate in much urgent and acute medicine but is really of no use in chronic illness or in enabling patients to become genuinely healthy. He proposes that doctors should help their patients to create new narratives – “quest narratives” based on the principles of Joseph Campbell’s work on the structure of myths and legends (otherwise known as Hero stories).

That very process entails a shift from the quick, the immediate, the partial to the slow, the lasting and the whole.

I wrote here about countering Getting Things Done with Dolce Far Niente, and here about finding the spaces where you can relax, and here about becoming aware of the gaps in our experience.

What ways do you slow down?

Does slowing down improve your quality of life? Give you time to reflect, re-charge, and to grow?

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Choose hope

Posted in from the consulting room, from the dark room, health, photography on July 6, 2007| 2 Comments »

rainbow over castle, originally uploaded by bobsee.

What’s the significance of a rainbow? Is there a pot of gold at the end of it? In this case it looks like the pot of gold must be in Stirling Castle!
The rainbow is a hopeful symbol isn’t it? This beautiful one which I saw on wednesday made me think of the two states I often see as a doctor – hopelessness and hopefulness.
Some doctors tell people how long they’ve got to live. Usually these are people with cancer. But these prognoses are just based on statistics. For this individual who sits with me today I have no way of telling how they’re life will progress let alone of telling when they’re going to die. More than once I’ve told patients that having a disease doesn’t give you knowledge of when you’re going to die.
Pretty much in every condition a doctor will see someone who gets worse, someone who doesn’t get better and someone who does. The proportions of people in each of these categories changes with different diseases. But there are ALWAYS people who defy expectations. Look at Stephen Hawking. He has Motor Neurone Disease and most people with this disease die within a couple of years of diagnosis. Stephen Hawking has had this disease over 40 years now.
Patients with any disease have a choice about how to live their lives. They can choose to give up in despair, or they can choose to hope. A doctor’s job includes helping patients to choose hope – realistic hope, not crazy hope!

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