Feeds:
Posts
Comments

Archive for the ‘from the consulting room’ Category

Humans beat the machines!

Posted in from the consulting room, health on May 24, 2007| Leave a Comment »

I was taught at medical school that the way to make a diagnosis (that is to understand what’s wrong with a patient) was to listen carefully to them (take a history) and examine them thoroughly. Only if the diagnosis remained obscure at this point would we subject the patient to any investigations. Sadly, there has been an increasing reliance on technology to the point where many doctors seem to be losing the ability to diagnose on the basis of listening and looking. A study from the University of Winsconin has shown another problem with this.

The researchers studied patients with acute appendicitis. They compared what happened to those who went straight to surgery after the diagnosis had been made clinically, and those who first went via a scanner room to have a CT investigation to make the diagnosis. Those who went via the scanner (two thirds of all the patients!) took longer to have their operation done than those who went direct to theatre (only a third of them). The scanner group had twice the rate of burst appendix (perforation) and twice the number of post-op complications.

Moral of the story? Don’t rely on machines as a routine way to make a diagnosis.

We need to make sure medical students and doctors know how to look and listen and make good diagnoses without relying on technology.

Read Full Post »

Meaning-full Disease

Posted in books, from the consulting room, from the reading room, health on May 14, 2007| 6 Comments »

Meaning-full Disease. Brian Broom
ISBN 978-1-85575-463-8

I read a reference to Brian Broom’s work in “Why Do People Get Ill?“, and like that book, his “Meaning-full Disease” should go on every doctor and would-be doctor’s reading list – not just on their shelves, but in their active reading list. Professor Broom leads the post-graduate programme in MindBody Healthcare at Auckland University of Technology and works as a physician specialising in allergies and clinical immunology, a psychotherapist and a mindbody specialist in Christchurch. That tells you something about what you might expect from this book. His main area of interest is psychosomatic disease. This is a term which has fallen out of favour and come to mean illnesses without any associated physical disease. However, it is making a comeback thanks to work like this and Leader and Corfield‘s work amongst others. It is particularly making a comeback because of its focus on the links between the body and the mind in illnesses where there are significant pathological changes to be found.
Broom explores the truly fascinating observations that patients’ physical diseases are often best understood by uncovering the meanings that their illnesses have for them. He pleas for a more holistic, more humane practice of medicine by placing the scientific world view in its rightful place – not as the bearer of all truth, but as a subset of experience.

“the lifeworld is a rich, multidimensional, experienced reality of which the scientific world is a part-representation, a reduction, or an abstraction.”

He sets out a powerful argument for seeing both subjective and objective experience as different manifestations of an underlying unified phenomenon, referring to both phenomenologists such as Merleau-Ponty and Husserl, and Japanese writers, Yasua and Ichikowa (the latter he quotes as saying “my ‘object-body’ and my ‘subject-body’ are inseparably united in their deeper layer, and cannot be separated clearly and decisively, except through intellectual abstraction”. I particularly enjoyed his reflections on this so-called divide between objective and subjective where he says to touch your left hand with your right – as you do this you experience you left hand objectively and in the same moment subjectively your left hand feels touched. He goes on to muse about the position of hands pressed together in prayer which similarly dissolves the barriers between subjective and objective. A lovely image and a nice way to get us thinking about these two ways of experiencing the world.
There is much more to illness than the biomedical model elucidates for us. This in no way devalues the model which is still a powerful way to not only conceptualise disease but to treat it, but trying to understand a person’s whole experience by seeking what lies behind the pathology requires quite other skills which doctors are sadly not so strongly encouraged to acquire. One of the best passages in Professor Broom’s book is where he describes the process of his work moving back and forth in a consultation between the “thing of the illness and it’s meaning”. Sounds like how a consultation should be.

Read Full Post »

What’s Wrong with Doctors?

Posted in from the consulting room, from the reading room, health on May 13, 2007| Leave a Comment »

Richard Horton has written an excellent review of “How Doctors Think” by Jerome Groopman here.

The main point he makes is that doctors make mistakes primarily because of failures in the ways they think.

Good doctoring is about listening and observing,
establishing a trusting environment for the patient, displaying
authentic empathy, and using one’s skills and knowledge to deliver
superb care. But a neglected aspect of this professionalism is getting
doctors to think about their own thinking. Only by doing so are doctors
likely to reduce the number of errors they make. What should they do?

Here’s a summary of his recommendations in answer to that question –

  • Encourage patients to tell and retell their stories. “a critical element of any mutually respectful therapeutic partnership
    that the doctor acknowledges the patient’s version of the truth of his
    or her story.”
  • Slow down. “The more time a doctor takes, the fewer cognitive errors he will make”
  • Once a decision is made, always retain an element of doubt.

None of these recommendations is in tune with current medical thinking. Doctors are encouraged to make diagnoses on the basis of the results of investigations. The art of listening to a patient’s story to make a good diagnosis even before a physical examination and any tests are run has receded as doctors are increasingly encouraged to treat patients according to protocols and guidelines created on the basis of statistical analyses of what’s measurable (stories are dismissed as anecdotes and unreliable subjectivity). Rather than slow down, health authorities around the world push doctors to see more and more patients more and more quickly. And doubt? Still, young doctors are encouraged to be certain and to believe in the rightness of their decisions. Retaining a healthy amount of doubt would make doctors more humble and more able to recognise when they are not getting it right after all.

Read Full Post »

3 Ways to know if you are healthy

Posted in from the consulting room, health on May 13, 2007| Leave a Comment »

A healthy being has certain qualities or characteristics. Health is much more than the absence of disease. Health is a positive phenomenon in its own right. How can you know if you are healthy? And how can you increase your health?

Adaptation. How are you coping with change? Nothing stays the same. No two days are the same. Sometimes we feel stuck but always our bodies, our minds and the environments in which we live are changing. Change is the reality of life. When we are healthy we cope with change. We adapt. I was once invited to teach in Santa Fe, and flew to Albuquerue from Edinburgh arriving late at night. My host, a doctor colleague, picked me up and took me to his house about 10pm. I went to bed and fell asleep only to wake about 4 hours later gasping for breath. Alarmed I wakened my host saying “I think I’ve developed asthma!”. “Don’t be silly,” he said, “We’re 7,000 feet up here. You’ve come from sea level. It’s the altitude.” By the next afternoon I was breathing completely normally. I had adapted. A healthy organsim adapts. Whether the changes in your life are physical, emotional or social, coping is a fundamental part of health.
Creativity. Human beings don’t just cope by maintaining some kind of status quo however. We continuously grow and develop. Physically and psychologically. Creativity is the ability to both express yourself and to make something new. In biological terms we use the word “emergence”. This is the word coined to capture the idea that things change in a growing system so that new behaviours and new phenomena appear (usually unexpectedly). The abilities to solve problems with new solutions, to express ourselves and to continuously make our lives new is also a fundamental part of health. An organism that is not growing and developing is dying. Think of your house plants for example!
Engagement. “No man is an island.” We all exist within multiple environments – geographical, social, cultural and so on. It is actually impossible to consider someone fully without situating them in the world. In fact, there is a kind of paradox at the heart of all our lives. We need to be separate, unique (we even have a whole immune system dedicated to recognising what is not us and keeping it out!), but we also need to be connected, to love and be loved, to share. Depression is a real black hole. It sucks everything of life inwards and cuts us off from others and from the world. A healthy person is engaged with the world, interacting, loving and being loved.

So, there’s my three criteria. If you want to know how healthy you are check yourself out against them. How are you coping? How are you growing? and How are you connecting?

Read Full Post »

4 Questions every doctor should ask

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

When you feel ill, you want to try and figure out what’s going on. If it’s not something simple and obvious then you might need to go and consult a doctor. It’s likely the doctor will ask some questions. These questions are not random. The doctor has been trained to ask them. In fact, the doctor will have a lot more questions in his or her head than the ones you are actually asked. It’s these “back questions” that interest me. The ones running continuously through the doctor’s mind which form the basis of the whole consultation.
Doctors are trained to think about illness in a particular way. The thinking model is known as the “biomedical model”. The biomedical “back question” is this –

“What is the diagnosis?”

By diagnosis, we mean, what is this disease? Of course, there are other “back questions” which become more important once the diagnosis is made – “What action do I need to take?” and “What’s the prognosis?” for example. However, those questions are completely dependent on the answer to “what is the diagnosis?”. In the biomedical model, the diagnosis is the identification and naming of the disease. Once that’s done, the treatments are applied with expectations wholly informed by the doctor’s understanding of disease.
But disease is only part of the problem. You don’t feel diseased, you feel ill. Illness involves both the disease and the person who has the disease. Illness is the whole experience of your suffering. We are not machines and no two of us are identical. If a doctor wants to more effectively treat a patient they should use a different model from the “biomedical” one. They need a model which helps them understand the person who has the disease. This other model has been given many names but let’s use the one “holistic”. To understand the whole of a person’s illness the doctor needs to have different “back questions”.
I think to do this a doctor needs to use these four key “back questions”

  1. “What’s this person’s experience?” – the doctor needs to hear your story including a good clear description of what you are feeling, what sensations you have been experiencing, when you’ve had these sensations and in what circumstances. Your experience of illness is subjective. Nobody else can experience the pain, or nausea, or breathlessness, or distress, or whatever it is that you are experiencing. The doctor can only try to understand what your subjective experience is by enabling you to tell your story.
  2. “What kind of world does this person live in?” – we all experience the world differently. We pay attention to different aspects of life and we are affected differently by them. To understand who the person is who has this illness, the doctor needs to know what you are affected by, what’s important to you and how you experience the world.
  3. “How does this person cope?” – we all have different coping strategies. Some cope by retreating, hiding away, shutting down, whilst others cope by crying for help, needing company and support. There are many other patterns but if the doctor is going to figure out how best to help you he or she needs to find the treatments that will work best with your particular coping strategies.
  4. “What sense does this person make of this?” – we are meaning-seeking creatures. We always want to make sense of our lives. Why has this happened to me? Have I done something wrong? Is it because of my diet, or a bug that’s infected me, or my genes, or is it God punishing me? The sense we make of our illness may not only influence our chances of recovery but can actually determine the prognosis.

If these four “back questions” continuously run through the doctor’s mind, the question “what is the diagnosis?” will fall into place, not as THE important question, but as AN important question. The disease can still be named, but it will now be understood within the context of the person who has the disease. Only then will this individual, will YOU, get the most appropriate help to restore your health.

Read Full Post »

How objective is objective?

Posted in from the consulting room, health, narrative on April 22, 2007| 4 Comments »

Patients’ stories are often dismissed by doctors as being too subjective to be of value. Objective information is rated more highly. In fact the dominant paradigm of the biomedical model is “evidence-based medicine” where a hierarchy of value has been created which emphasises the findings from research trials conducted on groups of patients over the individual stories of doctors and patients. Let’s understand and maybe challenge this hierarchy.
By subjective we usually mean a person’s unique experience. No two people can have identical experiences because no two people are identical. The dismissal of a patient’s story is the dismissal of personal experience.
We tend to think of objectivity as being outside ourselves, as being a phenomenon which is free from individual prejudice, as if it is unfiltered or pure. However, objectivity is actually just a consensus of personal, subjective views.
Take a look around your room now. What do you see? A computer probably! Maybe you can see a chair. Let’s just focus on the chair for a moment. This experience you are having right now of seeing that chair is subjective. It is YOU who is seeing the chair. But if everyone who comes into your room can also see that chair then seeing that chair becomes objective. The observation becomes more reliable in the sense that you could say to a perfect stranger “Come into my room and tell me what you can see” and, amongst other things, the stranger will report seeing that chair.
But subjectivity and objectivity are not mutually exclusive, either/or, categories. There’s a range or degrees of objectivity. For example, what colour is that chair in your room? The answer to that question will vary. Not everyone will agree about the colour of an object because colour sensation is a highly subjective phenomenon. Let’s push this one step further. Is it a comfortable chair? Well, now the consensus will become seriously shaky. You cannot be sure that a stranger coming into your room will describe that chair as comfortable.
The greater the consensus of experience, the more we are likely to call it objective, because we know that there will be a high probability that almost everyone will concur.
However, what matters to me if I have a pain is my experience of the pain. Nobody else can experience my pain. The concept of objectivity becomes irrelevant. If I take a painkiller, only I can tell you if it is working for me. No doctor or scientist knows better than you do about your pain. So claims that only treatments which are “evidence based” ie which work for many other people should be offered to patients are not supportable. Clinical trials (group experiments) reveal useful information about possibilities and even probabilities but they should never be treated as the last word on something. “Evidence” is never complete. However, although a majority of people may claim relief of their symptoms from a particular treatment, we can never guarantee that that treatment will work for this particular patient. Some people will only respond to a totally different treatment, possibly one which has never been shown to help the majority of patients. We should never prevent patients from having the treatment that works for them just because that treatment hasn’t helped most other patients.
How many patients should get relief from a drug before we can claim this drug is “evidence based”? Well,
However, as Dr Roses of Glaxo SmithKline, specialist in pharmacogenomics at Glaxo SmithKline famously 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.”

That’s a minority then. This falls far short of objectivity as consensus. Why is that? Because what matters is not just what most people experience but, when it comes to your health, your illness, it’s your story that matters. A doctor can, and should, tell you that a particular treatment has been shown to help a certain percentage of patients but you will decide which treatment to continue with solely on the basis of your unique personal experience. It’s your story, your feelings, your sensations that matter most when it comes to your health.

Read Full Post »

Black swans

Posted in from the consulting room, from the living room, from the reading room, narrative on April 19, 2007| 5 Comments »

There’s a website called Change This. They publish articles which they call “manifestos”. I just came across this one. Nassim Nicholas Taleb argues that unpredictable events are like “Black swans” – until one is seen we lack the imagination to even think such a creature is possible basing our expectations entirely on our previous experience. Taleb says a Black Swan is rare, its occurrence has a large impact, and it is predictable only retrospectively (we explain it with a narrative we make up after the event).

It’s an interesting idea. There’s a phenomenon described in complexity science which is similar to this. It’s called “emergence” and it means the kinds of events and behaviours that occur which are brand new and have never been seen before. For example, when a particular hurricane suddenly starts to behave differently from all previous hurricanes. I see this all the time in patients. There is a terrible tendency in Medicine to focus on diseases rather than the people who have the diseases. Once a diagnosis has been made (the disease has been named) a prognosis is made on the basis of how other cases progressed. But the thing is that again and again patients just don’t comply with statistics. Take Stephen Hawking as an example. He has a disease called Motor Neurone Disease. Usually people die within two years of a diagnosis of this disease. Stephen Hawking was diagnosed over 40 years ago.

People are different. It is impossible to accurately predict an outcome for any single individual with a particular diagnosis. The future is, and always will be, uncertain. That’s not a bad thing, though we crave certainty. I once had a patient who told me her husband had been diagnosed with cancer and had been told he had six months left to live. I asked her how she felt about this and her answer took me completely by surprise (you could say it was a Black Swan!). She said “I’m angry. Very angry. It’s not fair. How come he gets to know how long he’s got and I don’t get to know how long I’ve got?!” I had to explain that actually he might not die in six months time!

But Taleb’s idea about Black Swans makes another interesting point which is about the human use of narrative to make sense of things. Even though an event might be totally unlike any event we’ve ever seen before we’ll do our best to explain it as if it had been predictable all along. This further feeds our tendency to believe in certainty and predictability.

The contemporary practice of Medicine as strongly based on encouraging decision making on the basis of what’s already known (this is called Evidence Based Medicine), but as I once heard Dr Harry Burns (Chief Medical Officer of Scotland) say “If we base all our treatments on what we already know how can we come up with new, better treatments?”

We need imagination. Without imagination we cannot see what might be. Even with imagination however we’ll still have masses of experiences which we didn’t expect. That’s how life is… I don’t want a wholly predictable life. Do you? Understand me here, I’m not saying I want nothing to be predictable. I do want to know that when I catch the 0735 Glasgow train it’s got a good chance of getting me to Glasgow at 0820 (OK, maybe one day!!). I like routines and rhythms. But I like surprises too and the fact that every single patient I see tells me something I’ve never heard before makes my day. Every day.

Read Full Post »

The Human Spectrometer

Posted in from the consulting room on April 9, 2007| 2 Comments »

Doctors are trained to diagnose. In effect this means understanding a patient’s illness, interpreting their suffering, making sense of it. However, in practice, undergraduate medical training makes disease, not illness, the focus. Eric Cassell nicely distnguishes between “disease” and “illness” in his “The Healer’s Art” (ISBN-10: 0262530627). Illness, he says, is the patient’s whole experience of suffering, whilst disease is the pathology.

In fact, the developments in Medicine over the last few hundred years have mainly been driven by technologies which allow us to look deeper and deeper, considering smaller and smaller elements of a human being. At first, we started to look at the organs inside a body to see where disease lay, then with the invention of the microscope, we looked into the organs to see the cells, and so on, right up to the present day where we look at the DNA. This has helped us to greatly improve our understanding of how the human body functions and what is happening when a part of the body becomes disordered. However, a person is more than a material body made up of DNA, cells and organs. Every person is different but what makes them unique is not just their DNA but their connections. We all exist as organisms embedded in multiple environments. This concept of embeddedness is an important one in biology. If I want to understand a patient who presents with a particular illness I need to explore who they are in the contexts of their families, their relationships, their physical and cultural environments.

I’ve thought about this a lot and I’ve made this little device to help me to more consciously practice holistically. This is a simple strip of photos I’ve taken. You can think of it as a kind of slide rule. When a patient presents to the doctor they tell their story. They say, this is what I am experiencing, this is where it started and this is what I’m concerned about. (OK, they might say a lot more than that, but most people will tell a story that includes those elements). As the doctor tries to understand what is happening, tries to make sense of the patient’s story, in order to make a diagnosis, he or she will shift the focus of consideration.

Start with the person in the middle of the strip (that’s me, reading) – the person. As you move your focus to the left you can look deeper and deeper in. Where does the problem lie? What is not functioning? Where is the disease? Is it at the level of a system? Say, the nervous system? Or at the level of an organ? Do I need to do an XRay or a scan? What is happening at cellular level? Do I need to biopsy something? And what about at a molecular level? What lab tests would elucidate what’s going on here?
Human spectrometer

Pretty much that’s how most consultations with doctors go – listening to the story, examining the body, running some tests. This can all be extremely helpful but let’s now go back to the person who might have the disease. How do we understand their illness? How do we understand the contexts of their illness? Move the focus to the right. What about this person’s relationships, and family? Have their been any major changes or issues there recently which may have had an impact? How do we understand this person’s illness in the particular society to which they belong? And finally, what about thinking more globally? Understanding this person and their illness in the larger world.

Why is this important?

Well, everything to the left of the person in this “spectrometer” is a consideration of the disease they have, but in order to become healthy, to recover, to cope or to heal, we have to support that individual’s unique systems and strategies of defence and repair. We can only do that by understanding who this person is who has this disease. So, only to consider what lies within the person is not enough, we also need to consider who this person is and how they experience life.

Read Full Post »

Why Do People Get Ill?

Posted in from the consulting room, from the reading room on April 2, 2007| 11 Comments »

Why Do People Get Ill. Darian Leader and David Corfield. ISBN 978-0-241-14316-2. This is a book written by a psychoanalyst and a philosopher. Amy spotted a review of it in The Observer. It gripped me from the outset – always a sign of a good book I reckon. In the first few pages these statements caught my eye –

3.5% of the decline in mortality due to infectious disease since 1900 can be attributed to pharmacological intervention

5 – 10% of healthy adults and 20 – 40% healthy children carry it [streptococcus pneumoniae]

Typhus and dysentery will flourish with greater success in defeated armies rather than victorious ones.

The first of those quotes is really interesting because there is now a huge emphasis on drugs as being, if not the only, then certainly the best, treatments (and cures) for most illnesses. Antiobiotics in particular have achieved almost mythological status as saviours of suffering humans. Yet they are only responsible for a tiny percentage of the lives saved from death from infection. What are the big saviours then? Well, clean water, effective sewerage systems, better housing and reductions in poverty are amongst the main ones. This is not news. I learned this in “Sociology in relation to Medicine” (a course in my undergrad medical course at the University of Edinburgh) in 1972 (and it wasn’t new then!)

The second quote tells us that loads of people have “nasty” bugs (we have a terrible tendency to describe some bacteria as nasty and some as nice, entirely on the basis of the potential harm they can cause us – nothing to do with the personality characteristics of bugs!) which apparently don’t seem to be causing them any harm. How come?

The third quote claims that mortality from a serious infection like typhus is affected by the mental state of the individuals who catch the bug. This is one of the key points of this book. These observations are not new to me and they probably are not new to you but when you stop for a moment to think about them they are startling and they tell us loud and clear that illness is not a mechanical process. Illness is always multifactorial. That’s part of the nature of complex systems – they aren’t simple! This sets the tone for the whole book. The thrust of the argument is that it’s whole people who get ill, body and mind, inextricably interfunctioning, and not only that, but it’s whole people, embedded within the environments of their lives who get ill. I use the plural there deliberately. We are embedded in multiple environments, not just physical ones, but also social, cultural and narrative ones. We are meaning-seeking creatures and the fascinating examples in this book illustrate that point beautifully.

The question the authors ask of us is to consider not just what is this disease? but doctors should ask their patients to talk about themselves

No hospitalised patient should be deprived of the opportunity to speak about themself.

Intruigingly they explore the potential for illnesses to emerge at symbolic times and in symbolic ways

Human culture is built up of symbolic structures, involving language, social laws and ritualised practices…..growing up involves the absorption of the social and linguistic structures into the very fabric of the body.

This is a plea for a more human, more humane practice of medicine. A plea for the recognition of the importance of a person’s narrative and the importance of human relationships. They question, for example, the wisdom of a system of delivering health care which results in the patient never seeing the same doctor twice. The current emphasis on protocols and targets is dehumanising. It assumes that every patient with disease “x” can be treated with therapy “y” and it doesn’t matter who actually delivers the treatment. How did we come to value drugs more highly than human beings? Technologies more highly than caring attentiveness?

The health services and bureaucracies of contemporary society are based on a rejection of the very dimension of human narrative.

Their final challenge is –

challenge the thesis that the disciplines basic to medicine are physics and chemistry. Would it be absurd to suggest that literature and philosophy would make better candidates, as they encourage the study of human beings living in a world of meaning.

Hear, hear, guys! Occasionally you read a book you wish ALL doctors would read. This is one such book. Sadly, a lot of doctors don’t read very much, claiming to be “too busy”. Suggest your doctor friends buy it for “holiday reading”.

Read Full Post »

Zombies aren’t free to choose

Posted in from the consulting room on March 30, 2007| 1 Comment »

In today’s British Medical Journal, GP, Dr Iona Heath writes about how while the government talks about patient choice and patient centred care, in fact it is increasingly delivering a standardised, rule and protocol driven one-size-fits-all service. She links this dehumanisation of the NHS to the power of the pharmaceutical industry.

Only if doctors have the freedom to explore and explain options can patients be free to make their own decisions. Doctors who actively elicit the patient’s own values and priorities and support an informed decision based on awareness of both the possible harms and the potential benefits of a proposed treatment will reduce levels of pharmaceutical consumption. But, of course, this operates against the interests of the medical-industrial complex. If doctors are encouraged to offer standardised care, as they are under the quality and outcomes framework, pharmaceutical consumption rises and patient choices become constrained.

The growing gap — Heath 334 (7595): 670 — BMJ

This is a worrying trend. With the bureaucratic drive to “standardise” treatments, probably with the intention of attempting to control costs, patients are not encouraged to make individual informed choices about whether or not to start taking some form of medication. One of the consequences of this, Dr Heath argues, is that pharmaceutical consumption rises. Why is the NHS struggling financially despite record investment by the government? Partly because of rising drug costs.

This zombie-form of health care is not sustainable and the solution to the problem? A hero-form of health care. Heroes make free choices. That’s how they grow and that’s how they increase their health. Encouraging individual diversity is not only healthy for people, it’s healthy for the health services too. Probably the main losers are the pharmaceutical companies whose sales may be hit by patients choosing non-drug solutions to their problems.

Read Full Post »

« Newer Posts