Heroes Not Zombies

Here’s a shot of one of Monet’s water lilies paintings in the Orangerie in Paris. Look at the size of it, and stand back and see it as a whole.

Now walk towards it and look at part of it close up.

Isn’t that amazing?

How different the details look from the whole painting! In fact, one of the things which makes such a big impression on me in the Orangerie is just this difference – how does a human being manage to create such a fabulous, whole image which works the way this work by placing small brush-fulls of paint one after the other.

It’s this kind of art which often comes to my mind when I think about the need to understand anything in its details and at the same time in its wholeness.

Recently, BBC Two, made an episode of “Trust me I’m a doctor” focusing on the question of is it possible to reduce your cholesterol level through diet. For the programme the presenter look at three different approaches – sticking to a low fat diet, not changing the diet but adding daily oats, and not changing the diet but adding daily almonds. As an extra, he, himself, did all three (referred to as the “portfolio diet”).

What happened?

A number of interesting things – including significant levels of reduction of cholesterol in many of the volunteers – the biggest effect being in the presenter himself (I’ll return to that later)

In the almond eating group they concluded there was no over all change – because the average of the group showed little change. In fact, this averaging out effect obscured the reality of what happened – some people in that group experienced a drop in their cholesterol level, but in some it actually increased.

For me, this is one of the most interesting findings.

First of all it shows how averaging out and taking only whole group effects obscures the reality of what happens for individuals.

Second, it shows that you can’t take a simple, linear approach to the complexity of a human being – you can’t just add a bit of this or subtract a bit of that and see the same specific effect in every single person. We are all different. And that uniqueness extends to the different results of the “same treatments” (including elements of the diet) in different people. I think the kind of reports which suggest that some particular foodstuff is “bad” or “good” are pretty much always over-simplistic – to the point of being nonsense.

Third, it shows how the “same treatment” can have directly opposite effects in different individuals. We find the same with many forms of treatment – what has a certain effect in some, can induce the exactly opposite effect in others.

So, this part of the programme confirmed for me that we are all different and if we want to help individuals we must always, but always, pay attention to individual experience – it’s no good saying “this works but that doesn’t” based simply on statistical interpretations. Ultimately we have to come back to the reality of a human being’s experience.

The other striking element for me is what the presenter did himself – this “portfolio” diet – which actually consisted of taking a balanced and combined approach.

Time and again when I read about diets I find myself thinking about Michael Pollan’s food rules – “Eat food. Mostly plants. Not too much”.

There are no magic bullets.

Not drugs. And not specific foods.

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“The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks. Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.”

I came across that passage recently in an article entitled “In Search of Joy in Practice“, published in the Annals of Family Medicine. In a strange kind of synchronicity, I read it the same day I read the reports of new guidelines for GPs in England which are intended to reduce the number of deaths from cancer. NICE, the English healthcare guideline factory, claimed –

There are 10,000 more deaths from cancer in the UK every year than the average in Europe as a result of diagnosis that may come too late for effective treatment. Half of those lives could be saved, the National Institute for Health and Care Excellence (Nice) said, if patients and their doctors used the guidance, which has taken three years to develop, on symptoms that could warn of one of 37 cancers. GPs will also be able to order more tests than at present, which should speed up a diagnosis.

Let’s set aside the arguments about whether or not earlier diagnosis of cancer does actually lead to “saving lives” which remains a contentious claim. This 378 page guideline which took a team of “experts” three years to put together gives GPs guidelines based on the symptoms which their patients might present to them. It argues throughout that with a “positive predictive value” of 3% or more, the presence of a particular symptoms should lead to the GP sending the patient for specific tests to exclude particular cancers.

I’m not a statistician but as I understand it a “positive predictive value” is pretty much the likelihood that what you are predicting will come true – in other words, it’s extremely unlikely that anyone with these particular symptoms has cancer.

But it’s not the statistics which bother me most about this guideline – it’s the fact that they have chosen to assume that symptoms are the signposts of disease – they aren’t. It just isn’t that simple. Maybe NICE isn’t aware of Kurt Kroenke’s extensive research on symptoms over the years (google him if you want to explore more). Time and again he has shown that symptoms are no such thing with from 30 – 85% of patients presenting with particular common symptoms never going on to demonstrate any related pathology at all.

Symptoms, used in some tick box fashion, are no substitute for a proper clinical history and examination. Interestingly, Kroenke has also shown that –

about 75 percent of information useful in making a diagnosis comes from the patient’s history – the story you tell your doctor about what’s been going on. Another 10 to 15 percent comes from the physical examination. Tests provide the least useful source of information.

…yet the basis for this NICE claim about saving lives from earlier diagnosis of cancer, is based on GPs referring for more tests.

But let me get back to where I started with this post – which is the impact such a numbers-based, algorithmic bureaucracy has on professionalism and job satisfaction.

Honestly, when I read the details of this particular guideline I began to wonder if it was guidance for doctors who had skipped medical school – are there really doctors out there who don’t get suspicious when a patient presents with bleeding from the bowel, unexplained weight loss, change of bowel habit and loss of appetite? Yet, NICE claims this guidance will be of “educational value”! Seriously, only if you skipped medical school first time around!

We are drowning our doctors in numbers.

We need to return to the values of good, caring doctor-patient relationships based on continuity of care and sufficient time to do a proper quality job with each and every patient. Human being based values, not numbers based ones. Let’s build an NHS on those principles and see what happens to doctors’ job satisfaction, patients’ experience of health care, and individual lifetime experiences of health.

As the author of the text I quoted at the beginning of this post said – “the current practice model in primary care is unsustainable”. We need to change direction.

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