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Lost in the system – Taylorism 2.0 and health care

Posted in from the consulting room, from the dark room, from the living room, from the reading room, health, life, philosophy, photography, psychology on August 11, 2015| 1 Comment »

a little galaxy
In 1911 Frederick W Taylor published the “The Priniciples of Scientific Management”. This approach to work had a profound influence, leading to the use of the term “Taylorism” to capture the essence of his message. It’s a message which still holds sway today. In fact, the term “Taylorism 2.0” is being used to describe the modern form.

It’s clear that Taylor’s idea of science was not that curious, exploratory discipline based on wonder, but the desire to control – the desire to produce pre-determined outcomes through systems created by measuring what could be measured.

Right there, in that text is his declaration of intent – one which chills me every time I read it!

In the past the man has been first; in the future the system must be first

If there was one thing I would say to try to improve health care, for example, it would be put the human beings first, and the system second – the system and the management created to deliver the system, should, in my opinion, be the servants of those human beings who are caring for, and trying to help, the other human beings (the patients).

Is it any wonder that professional satisfaction amongst doctors is so low when they’ve signed up to something they probably didn’t understand was “Taylorism 2.0”

So what is this “Taylorism 2.0”?

I first came across it in an article about workers in a French supermarket internet-ordering section. Let’s call it “click and collect” – in the UK, there are now many “click and deliver” services from supermarkets, but in France, the delivery bit doesn’t seem to have taken off yet. Instead you can order your shopping online, then you go to the “Drive” and pick up your order.

But what happens between clicking on the items you want on the web catalogue and finding your shopping at the counter in the “Drive” building of the supermarket?

Well, you have staff who are called “pickers” – they go round picking the products off the shelves  – either of a supermarket (often a “hypermarket”), or from a warehouse (more commonly the former so far) – and collecting them into boxes ready to be handed to the customer when they turn up at the “Drive” counter.

These pickers are managed not just according to the principles of “Taylorism” – which involves measuring whatever can be measured and setting the targets and goals to be achieved i.e. the time taken to get a particular item from the shelf, the number of items an individual “picks” in an hour, in a shift, or whatever. As the article made clear every aspect of the job which could be measured was measured and monitored. Each picker has a portable device strapped to their wrist and receives the instructions for what to pick next from the computerised control office. The device shows exactly where they are at all times of the day, and measures the time taken for each and every action. What can’t be measured and monitored this way is the interaction between the staff and customers, so that is controlled by teaching them scripts which they have to learn by heart and stick to – you’ll know the kind of thing – “have a nice day”, “happy to be of service”, “thank you for waiting” and so on….

What takes all this measurement and control to the next level is not just the introduction of the new technologies which allow better monitoring and measuring, but the introduction of game theory.

Yes, you read that right. Game theory. The big new addition is “gamefication” – or how to introduce principles from cognitive behavioural psychology and game theory to get the most out of the workforce.

Just to give you a taste of this, it can include awarding points for numbers of items picked and delivered, numbers of customer orders completed, shortest times taken to get frozen goods from the shelf to the customer and so on. The points are fed back to individuals and teams and the scores are ranked. So an individual can see instantly at all times their best times, their highest number of order completions and so on….which inspires them to try to always get personal bests. But more than that, the team, or all the members of a particular shift will get collective scores and be ranked against other teams, other shifts or even other stores across the country – an enormous expansion of the “employee of the month” idea.

There can be a number or rewards attached to the rankings as extra incentives.

There’s a lot more involved than this but maybe this introduction will give you an idea.

So, what’s this got to do with health care?

Again, just as an example, let’s look at one particular system – the application of “QOF” (“Quality Outcomes Framework”) points in Primary Care in the UK.

General Practitioners have a substantial amount of their income pegged to their “QOF” points – these are points allocated for achieving particular targets on management-set protocols, mostly they related to the numbers or percentages of patients in a practice who have been entered onto particular disease registers, who have been asked about smoking habits, have had a BP check and so on, or the numbers of percentages of patients with specific conditions who have been prescribed the recommended drugs.

Not only does this prioritise the things in health care which can be measured at the expense of things which can’t (like communication skills, empathy, creation of therapeutic alliances, depth of understanding, caring etc) but it gamefies the whole system by awarding points, ranking individuals and practices, and rewarding points with income. So the doctors motivate themselves to try to achieve what the management want them to achieve.

Welcome to Taylorism 2.0 – where the system comes first – more now than ever before.

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What I was taught

Posted in education, from the consulting room, from the living room, health, life, philosophy, science on July 31, 2015| Leave a Comment »

I graduated from Edinburgh University, with my medical degree, in 1978. The next four years were my foundational training to become a General Practitioner (I still think “Family doctor” is a nicer title).

Here’s four of the core teachings which I received.

Don’t practice “a pill for every ill”.

There was an assumption that drugs should only be prescribed if you thought they were really necessary. If you issued a prescription at the end of every consultation you weren’t practising good medicine.

Underlying this teaching was to prescribe as sparingly as possible.

If you refer your patient to a man with a knife, he’ll use it.

There were two aspects to this teaching – firstly, that you shouldn’t refer a patient to a hospital consultant unless you expected that doctor to treat the patient with their particular specialist skills. Secondly, a specialist was likely to try to treat your patient using only the particular specialist skills they had.

Underlying this teaching was to refer to secondary care as sparingly as possible.

Don’t arrange an investigation/test unless you think the results are likely to change what you otherwise propose to do.

I was taught that most diagnoses could be made on the basis of a good medical history supplemented with relevant clinical examination. Tests were only for when you couldn’t do that.

Underlying this teaching was to test as sparingly as possible.

The doctor is the drug.

This was a big one. Back in the 1980s Balint’s teaching still influenced General Practice, and Balint proposed that one of the most powerful therapies a doctor could offer was him or herself. The doctor-patient relationship was the most important part of therapy. Active listening, understanding, compassion, care and good communication were the core daily tools, employed with a sound knowledge of the natural history of diseases, the risks and harms of various potential treatments, and the ability to help patients to understand what they were experiencing, what this illness meant in their lives, and what they might do cope and to become well.

Underlying this teaching was to pay as much attention to, and to spend as much time with, each and every patient as was possible.

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The Power OR the Glory – two approaches to science

Posted in from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, science on July 28, 2015| 1 Comment »

Sunlit raindrops on hollyhock
Ever since I was a child I’ve had a fascination with science. For me, science was, and still is, a form of exploration. It’s about learning and knowledge. Finding out how something works, how a creature lives, or learning the names of clouds, constellations, trees and birds. I’d say science is about wonder and curiosity.

Many, many years later I came across the writings of the French philosopher, Gilles Deleuze, who wrote that there were three ways to think – science, philosophy and art. I was a bit surprised when I first read that, but the more I came to understand it, not only the more it made sense, but it became, for me, a basic tool.

Briefly, he said that science was thinking about function – how something worked; philosophy was thinking about concepts – our frameworks and our world views; and art was thinking about percepts and affects – what we perceive and what we feel. I took all of that into my daily medical practice, figuring out what wasn’t working in somebody’s body, mind or life; developing my concepts of health, illness and disease; and working with both what I perceived and what I felt in a consultation.

A couple of years ago I had an experience on my daily commuter train which really woke me up – you can read about it here – but, let me just rehearse it for those of you who don’t want to diverge off down a link – I was sitting next to a student who seemed to be revising notes (I presume for an exam. Her subject was “clinical research” and what struck me was her key points about the “scientific method” – they were – Observation, Description, Explanation, Prediction and Control.

Well, I am very, very keen on observation and I like to describe what I observe. I’m also very keen on finding explanations for things (I think one of the definitions of a doctor’s job is “a person who tries to understand” – but that’s another story!). I also know that I was taught how to diagnose (which I see as a level of understanding) and to prognose (predict).

To be honest, neither diagnosis nor prognosis are nearly as simple as they are often taught. The older and more experienced I became the more I came to realise that diagnosis is never complete (you can always understand more deeply and/or more widely), and that prognosis is about possibilities and probabilities not about certainty.

So I was particularly surprised to find the student’s notes on “clinical” research describing the final step of the “scientific method” as “control”.

Since then, I’ve come to see that for many science is exactly about this – control. Scientism, the belief that everything can be explained using science, seems to be about power. This way of understanding and approaching science seems to be what has been adopted, not only by the industrial-commercial-military complexes, but by all those who seek control over others and over the world. It seems to be based on an understanding that if we take enough measurements, collect enough data, analyse it with statistical and computing tools, then we will be able to make accurate predictions which allow us a high degree of power to control.

Well, for some reason, I woke up this morning with this phrase in my mind – “The Power OR the Glory – two approaches to science” – and so, this post!

I’d like to re-state the case for a science based on wonder and curiosity instead of one based on power and control. For me, the joy of that scientific method is the revelation of, and the revelling in, the GLORY of this Universe and of our lives.

I was looking for some paper to start to jot down some thoughts about this and stumbled across an old notebook where I’d made some notes about the book “Planet Narnia” by Michael Ward (haven’t even thought about that book for a long, long time) – and here’s what I read –

The glory of science is to progress as new facts are discovered to be true, and such progress meanest that ‘factual truth’ is a provisional human construct. Which is why the wise man does not think only in the category of truth; the category of beauty is also worth thinking in.

Wow! How does that happen? How do I stumble across exactly the phrase “the glory of science” in a notebook stuffed away in a drawer full of scrap paper on exactly the morning I wake up with the phrase “The Power OR the Glory – two approaches to science”? In fact, who on earth wakes up with a phrase like that in their heads anyway? OK, I do!

Seriously, there’s way too much to explore there than I can write a post about this morning, so let me just finish with what I wanted to say in the first place –

There are two approaches to science – power (what I’d say is our current dominant model) OR glory – based on a humble curiosity and a joy in the awe and wonder of this life.

My hunch is, we could do with cultivating more of the latter, and less of the former!

 

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Information does not equal story

Posted in from the dark room, from the living room, from the music room, from the reading room, health, life, narrative, perception, personal growth, philosophy, photography, science on July 25, 2015| Leave a Comment »

The Mission

I recently received my first “Discover Weekly Playlist” from Spotify and so far, I’ve really enjoyed every single track. So, does Spotify “know” me?

We have more and more services like this around us – Amazon telling us what other people who bought “this” also bought (or even looked at!), Apple telling us what other apps other people bought who bought this particular one….and so on. This is something which Maria Popova has written about in her excellent Brain Pickings –

I recently found myself in an intense conversation with a friend about privacy — why it matters; how much of it we’re relinquishing and what for; whether it is even possible to maintain even a modicum of control over our own privacy at this point…….It suddenly struck me that our cultural narrative about privacy is completely backward: What we really fear is not that the internet — or a prospective employer, or a nosy lover, or Big Brother — knows too much about us, but that it knows too little; that it fails to encompass Whitman’s multitudes which each of contains; that it reduces the larger, complex truth of who we are to a few fragmented facts about what we do; that it hijacks our rich, ever-evolving personal stories and replaces them with disjointed anecdotal data.

I hadn’t thought of it that way around when it comes to the internet, but she is definitely onto something. The underlying truth of what she is referring to is similar to what I read years ago in Mary Midgley’s “Wisdom, Information and Wonder” where she wrote –

One cannot claim to know somebody merely because one has collected a pile of printed information about them

That observation seemed absolutely true to me in the domain of health care where sadly, far, far too often, “data” or “information” is ALL that is known about a particular patient as individual narratives are dismissed as “anecdotes” or “unscientific subjectivity”. That dominant way of practising Medicine always seemed to me to be just the opposite of how it should be done. Information, or data, can tell you something about some aspect of a person’s disease but it’s a long way from the person’s own narrative.

One of the dangers of substituting data for narrative is the presumption of knowing – I used to say to patients that each of us spends a lifetime trying to really know ourselves (and I’m not sure any of ever complete that task!) so how can I presume to know them from hearing just a little of their story over the course of an hour or so? Frankly, reducing their stories to a few data points just takes doctors and nurses even further away from knowing their patients.

Maria Popova’s recommendation to counter this is to “master the art of personal narrative” –

Perhaps the most potent antidote to this increasingly disempowering cultural shift is to grow ever more thoughtful and deliberate about how we tell our own stories

Thought provoking, huh?

Even when someone uses the personal data we’ve shared to offer us more music, books, restaurants etc, that we may like, I think its best to keep these things as hints. That’s why “discover weekly” works for me – it doesn’t assume the impossible – they don’t know me – but I’m happy to have them help me discover new music. And I’ll use some of their suggestions to continue to make my own playlists.

Where are you with this issue of information, privacy and how we make ourselves known to the world?

 

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Bigger picture and details

Posted in from the consulting room, from the dark room, from the living room, health, life, personal growth, philosophy, photography, science on July 22, 2015| Leave a Comment »

Orangerie

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.

Monet

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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Networks

Posted in creativity, from the dark room, from the living room, health, life, personal growth, philosophy, photography, science on July 20, 2015| Leave a Comment »

“Everything comes down to the struggle between the network and the hierarchy”

That particular line in Paul Mason’s Guardian article about post-capitalism really jumped out at me.

It jumped out at me because for a long time I’ve become very disatisfied with the contemporary emphasis on hierarchies, bureaucracies, organisations and societies modeled on machines. The mechanical model with all its emphasis on measurement and its basic assumption that nothing is more than the sum of its parts has been useful in some ways, and remains useful in some areas of life – parts dealing with machines!

But when it comes to Nature and, in particular, to living organisms, that model just does not add up. With sufficient power and resources the mechanical model can be imposed on natural systems – but only for a while. Eventually, the mechanical model diverges too much from natural reality to be useful.

That’s where we are now – our economies, our societies, our systems of health care and education, our politics – are all being changed as the network model undermines the hierarchies.

With new information, communication and collaboration technologies we have more and more opportunities to work with others to create different ways of learning, different ways of healing, different ways of living.

That’s pretty exciting but for many people it’s more frightening than anything else. We have to support each other to build our ability to hope and to innovate or we’ll remain suppressed, controlled and stuck.

It’s going to be fun to imagine and create our new ways together. Are you up for it?

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Control freakery

Posted in from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, science on July 18, 2015| Leave a Comment »

Leaf veins

If it’s true that we are in the beginnings of major change, then I’d like to hope that we are moving towards more “natural”, more “realistic” ways of living.

This industrial, capitalist age, has not been based on either natural or realistic premises. Nature doesn’t produce anything like the machines and organisations we have created in the world. Why not? Because nature is not mechanical, it isn’t a closed system where everything can be controlled and outcomes can be reliably predicted in all circumstances. It’s just not true that if only we have enough data we can figure out the future in detail and then the way to get there.

What alternative is there?

For me, the alternative is found in reality. It’s found in Nature – including in our own bodies.

How do our bodies work?

They work by developing a diversity of elements which then create mutually beneficial bonds between them – think of the organs of the body for example. A human being has a liver, a heart, a pair of kidneys, a brain….and so on. Each of these organs grows from the same original seed cell, but each develops as a tight network of specialised cells which, when they work together, perform incredible feats. But when the different organs work together (NB NOT in competition with each other) in mutually supportive ways, then they become something else entirely – they become part of the workings of the body in which we find them.

So diversity is a key feature of Nature. Mutually beneficial bonds are a key feature. Networks of connections between the elements are a key feature. As we extrapolate this model up we find more and more elements and more and more complexity – the best model I know to represent this is the “complex adaptive system“.

Here’s an important feature of complex adaptive systems (exactly the kind of phenomena we find in living organisms everywhere in Nature) – they don’t have a central controller who is in charge of a hierarchy, setting the goals, laying out the strategy, tasks and jobs and the ensuring they are delivered to it’s own particular levels and standards.

Might sound attractive if it was like that, but it isn’t.

Instead we have networks of nodes, systems, feedback loops, influences, clusters, organs and so on, which TOGETHER ensure the integrity of the organism – self-defence, self-repair, reproduction, growth and maturity are functions of the entire system – not the prerogative of one particular part.

Take this model and scale it up to groups of organisms, to societies, to ecosystems, to an entire planet even – the principles remain the same – diversity and the creation of mutually beneficial relationships.

So, the industrial, capitalist, dare I say it, inhuman, system based on machines and hierarchies is probably coming to an end because, well it just ain’t natural!

Here’s a piece about control which I read a few years back –

The industrial age and the work of Frederick Winslow Taylor made control popular as we used humans to mechanize our factories.  Control permeated society down to the education systems that eliminated variability, encourage conformity, and produce the mechanized humans for the industrial machine.  But the control mentality does not have utility in a world that is co-creative and cognitive.  We must replace control with the creation of shared value, a fondness for contribution, appreciation for human uniqueness, and the embrace of uncertainty.  We need to create an atmosphere of humility where co-creative energies are released instead of subdued.  Our future depends on the cultivation of new ideas and shared knowledge — a future easily smothered by control.

Mike Rollings.

As I think about Paul Mason’s piece which I posted about yesterday, I think the important thing for us to do now, is look around and look within – the answers are here already – and they don’t include the creation of more controls.

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A time of major change

Posted in books, from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, science on July 17, 2015| 3 Comments »

The world is changing.

Fact is, it’s never stopped changing since it came into existence. But what I mean is it seems as if we are in one of those phases of major and multiple interconnected change.

You can think of it in terms of economics, of social structures, of ways of living and thinking – wherever you look, there’s major change underway.

As the eras change the transitions can be hard to pin down. But when you are living it, you can feel it and you can see the signs.

One of the clearest signs for me is the unsustainability of many of our current paths – whether it’s the world economic order driving faster and faster towards ever greater inequality and unfairness, or “growth” which consumes ever more of our limited resources and heats up our planet. Or whether it’s our system of health care which costs more every single year as it struggles to keep up with increasing demand from patients with more and more chronic, incurable diseases. Or, well, you fill in the blanks.

The second clearest sign for me is the increase in command and control systems as societies, governments and enterprises struggle to keep human beings acting as obedient cogs in the machines.

Paul Mason writes about this in today’s Guardian (and he has a book on the subject coming out soon). He takes the perspective of economics and politics and by standing back and seeing the trends over a long period of time he describes the changes from feudal societies to capitalism to our current era of – well, what to call it? – he calls it “post-capitalism”.

What does he mean by that? –

Postcapitalism is possible because of three major changes information technology has brought about in the past 25 years. First, it has reduced the need for work, blurred the edges between work and free time and loosened the relationship between work and wages. The coming wave of automation, currently stalled because our social infrastructure cannot bear the consequences, will hugely diminish the amount of work needed – not just to subsist but to provide a decent life for all. Second, information is corroding the market’s ability to form prices correctly. That is because markets are based on scarcity while information is abundant. The system’s defence mechanism is to form monopolies – the giant tech companies – on a scale not seen in the past 200 years, yet they cannot last. By building business models and share valuations based on the capture and privatisation of all socially produced information, such firms are constructing a fragile corporate edifice at odds with the most basic need of humanity, which is to use ideas freely.Third, we’re seeing the spontaneous rise of collaborative production: goods, services and organisations are appearing that no longer respond to the dictates of the market and the managerial hierarchy. The biggest information product in the world – wikipedia – is made by volunteers for free, abolishing the encyclopedia business and depriving the advertising industry of an estimated $3bn a year in revenue.

So the new information technologies are the game changer. I think this is true, but underlying those technologies is the greater discovery, which he talks a lot about in his article – networks.

The main contradiction today is between the possibility of free, abundant goods and information; and a system of monopolies, banks and governments trying to keep things private, scarce and commercial. Everything comes down to the struggle between the network and the hierarchy: between old forms of society moulded around capitalism and new forms of society that prefigure what comes next.

Let me highlight that phrase again – “Everything comes down to the struggle between the network and the hierarchy” – that’s it in a nutshell.

I think the change which is underway is a different kind of freedom from the one espoused by neoliberals – not the so called freedom of the individual to exist as if nobody else exists and to pursue their own selfish interests at all costs. Instead, it’s the freedom to collaborate and co-operate – to build effective informal networks to solve problems or to bring aobut change.

This is what is really exciting, because it’s the almost untold story of evolution – the most succesful species of life are those which develop the strongest collaborations. That was the message in “The Bond”, by Lynne McTaggart, and it was the message in “Global Brain” by Howard Bloom.

I think once you understand networks and the particular type of network found in all forms of life – the “complex adaptive system” – you realise that “command and control” management systems, “one size fits all” institutions, monopolies and the delusion of separateness are all about to hit the buffers.

Paul Mason does point out that things can go badly, just as he calls for a new utopian thinking, and as we look around it can seem the potential for disaster outweighs the potential for utopia – but, hey, I, for one, am up for making a contribution to the utopia scenario.

Only time will tell which way it’s going to go, but the key is – the world is changing and we, at this stage in history, can contribute positively to the direction it takes next.

The power of imagination will become critical. In an information society, no thought, debate or dream is wasted – whether conceived in a tent camp, prison cell or the table football space of a startup company.


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Drowning by numbers

Posted in from the consulting room, from the dark room, from the living room, health, life, personal growth, philosophy, photography, science on July 11, 2015| 1 Comment »

Out of our depth

 

“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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Healing consultations

Posted in books, from the consulting room, from the dark room, from the living room, health, life, personal growth, photography, psychology, science on July 1, 2015| 1 Comment »

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When medicine is practised in a fully human way, employing all parts of the doctor’s brain, not just the thinking/analytical knowledge-based functions, then something deeper and more powerful than mere symptom-relief can occur.

As far as I know there are no “artificial healing agents” in the world. Drug companies may claim their products can cure, but it’s only the individual human organism which can cure. As a complex adaptive system, like all other life forms, we have the ability to defend ourselves, to repair damage, to recover from illness and even to adapt and grow. All of those abilities are natural and innate. If a drug, an operation, or any other medical procedure helps it does so by supporting, or better, stimulating these natural mechanisms of self-healing.

But how does that happen?

One element is what Lewis and colleagues, in “A General Theory of Love”, describe as the limbic connections between two human beings. In their book they explore three aspects of this – limbic resonance, limbic regulation and limbic revision.

Every person broadcasts information about his inner world…..If a listener quiets his neocortical chatter and allows limbic sensing to range free, melodies begin to penetrate the static of anonymity. Individual tales of reactions, hopes, expectations, and dreams resolve into themes. Stories about lovers, teachers, friends, and pets echo back and forth and coalesce into a handful of motifs. As the listener’s resonance grows, he will catch sight of what the other sees inside that personal world, start to sense what it feels like to live there.

That’s a beautiful description of what I think is necessary in any good doctor-patient consultation. It’s not so much a matter of the doctor “getting out of the way”, but of “tuning in”. Quite literally. “Getting on the same wavelength”. Why? Not just to communicate effectively but to understand more fully. In an older fashioned way of expressing it, it’s about “putting yourself in the patient’s shoes”. And from a perspective of “heart rate variability” it’s about achieving not just limbic resonance, but heart and brain resonance too.

The first part of emotional healing is being limbically known – having someone with a keen ear catch your melodic essence.

I don’t know if there has to be emotional healing for their to be bodily healing too, but I suspect that to be true. Sure, suturing a laceration may be all that is required for the skin to be restored, but why do some apparently simple lesions heal quickly, and others fester and scar? Might that have something to do with the depth or breadth of the healing?

After resonance, comes regulation.

Our neural architecture places relationships at the crux of our lives, where, blazing and warm, they have the power to stabilise…..But people do not learn emotional modulation as they do geometry or the names of state capitals. They absorb the skill from living in the presence of an external modulator, and they learn it implicitly.

There’s something about a really good consultation which involves safety, confidence and hope. However, I do think all of those qualities are more likely to emerge from a place of love, care and compassion. Maybe those are the key “regulators” which calm, soothe and stabilise the patient’s limbic system.

People who need regulation often leave therapy sessions feeling calmer, stronger, safer, more able to handle the world.

How often have I had that feedback? Very often. Perhaps because that was a conscious aim of holistic, “integrative” practice.

The third element Lewis describes is “limbic revision” –

Knowing someone is the first goal of therapy. Modulating emotionality is the second. Therapy’s last and most ambitious aim is revising the neural code that directs an emotional life.

I think what he is referring to making lasting structural changes – in his, psychotherapeutic, context that’s about changing the patterns of neural connections in the brain to change the person’s emotional life. I didn’t work as a psychotherapist, but as a general practitioner with homeopathic and integrative skills. As such I didn’t separate problems into “mental” or “physical” categories, so while I see exactly what this “limbic revision” is and agree that it is important, I think a holistic doctor, whose patients are often seeking help with problems in different parts of their bodies, it was a broader “neurobiological revision” which was required.

Understanding the “limbic” aspect of medicine, is, however, an excellent place to start.

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