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Archive for the ‘health’ Category

The wounded rock

Posted in from the consulting room, from the dark room, health, perception, photography on May 16, 2013| 3 Comments »

 

 

water carving

 

I took this photo a few weeks back and the image keeps popping back into my head.

It’s amazing for a number of reasons. First of all it looks as if the rock has been virtually split in two by a single blow. But not in the more usual way. If a rock is split in two the cut is usually narrow, as if done by a knife, but look how wide this cut is! It’s almost as if its been done by some giant axe. Secondly, I’m pretty sure this wound in the rock has been inflicted by water, and isn’t that in itself, incredible?

That water has the power to cleave a rock.

Well, we know it does. But look again. Where is the water? It is rushing, powerfully, past, right NEXT TO the rock!

So, what happened here? Did the water split this rock apart then veer aside to thunder down to the side of it? And how long did this take to happen? A moment? A year? An aeon?

Before I go, one more thing keeps me coming back to this image. It’s a kind of symmetry. There’s an echo, a shadow, a fractal, or something here. The flowing water and the wounded rock……

Life’s like this. In so many ways.

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Practical holism – making it happen

Posted in from the consulting room, health on May 13, 2013| 2 Comments »

How can a doctor practice holistically? Intention and attention are certainly fundamentals but there are concepts and mental frameworks which set up holistic care. Here are three key ways to make holistic care happen.

1. Looking for connections

If a human being is considered as a complex adaptive system, then symptoms and physical changes in individual are understood to be connected. Every part of a complex adaptive system can act on, and, in turn, be acted upon, by other parts. So what’s the connection between this symptom and another one? How are all the symptoms connected up? Looking to see what connections there are develops the focus from parts towards the whole.

Within a human being we can become aware of whole systems of interconnection. The fields of psychoneuroimmunology (the interaction between the mind, the nervous system and the immune system), psychoneuroendocrinology (the mind, the nervous system and the endocrine system), and in more recent times, interpersonal neurobiology (the links between the mind, the brain, and others), have all advanced our understanding of the interconnectedness within a human being, and between an individual and their environment.

2. Looking for context

Every living being is in constant active relationship with multiple environments, physical, social, cultural, temporal. A holistic approach entails seeing the individual within their particular environments and understanding how they are related. In other words, exploring the contexts of the person, their health and their illness.

A reductionist approach de-contextualises phenomena. Randomised, controlled trials, for example, claim to “control for” contextual factors and study individual phenomena without those influences and relationships. I have serious doubts if such approaches are ever really achievable, but even if they were, the findings would need to be re-contextualised to make sense of an individual life.

In a holistic approach, context is always important.

3. Stories and metaphors.

I’m particularly fascinated by individual stories. Every person I see tells me a new story, and its always a fascinating one. We make sense of our lives through story. We understand the present in the light of both the past, and of future hopes and fears. We gain a sense of Self through story. We understand each other through the shaking of our stories.

For me, narrative is the core of a holistic approach.

There is also one very intriguing element of an individual story which, when it manifests itself is like a nugget of gold, the embodied metaphor. For example, the person who presents with an eye problem whose core issue is that “my family don’t see things the way I see them”. The whole area of embodied metaphors is a fascinating one and if it appears in someone’s story, it can be the key to resolving the problem.

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Practical holism – attention and intention

Posted in from the consulting room, health on May 12, 2013| Leave a Comment »

I think of myself as a holistic doctor. But what does that mean, and how can I practice holistically?

One way to understand the holistic approach is to consider what we attend to, and what we intend.

By attend to, I mean what do we pay attention to, or focus on. In training I was taught to focus on parts and pathologies and that’s the core focus for most medical care. We create our health care systems around parts and pathologies. That’s why hospitals have a Dermatology Department, a Chest Clinic, a Gynaecology Department, a Gastrointestinal Clinic etc. All of these services focus on body parts (which are members of certain body systems or regions) and on trying to treat the pathologies discovered in those parts. General Practice, in the time of Balint and the creation of GP Training Schemes in the UK, was built around a focus on the person and the relationship between the doctor and the patient. The core of good General Practice was seeing this patient not as another case of disease x, but as John Smith, the 52 year old farmer, whose wife died last year in a car accident, and whose dairy farm is barely paying its way, whose father died of a heart attack aged 52, and who has phoned you to say he has been getting pains in his chest for the last three days. However General Practice has been reconstructed in recent years around pathologies and diseases. Now the average GP Practice has an Asthma Nurse, a Diabetic Clinic, a target to check blood pressure readings and smoking activities and an appointment system created to facilitate fast, problem-orientated consultations.

Holistic care involves a focus on the person, not the part. Any problems or pathologies are considered within the context of the person, not the other way around. Who is this person who I am speaking to? How do they live? And what are experiencing that is disturbing or distressing them? How is this disease experienced by them, and when and how did it appear in their life?

I attend to the person, and the person’s individual experience (revealed through the telling of their story, through their non-verbal communications and through the changes in their bodies)

What do I intend? The therapeutics taught in medical training is intended to manage disease. Doctors might talk of cures (rarely, in my experience) but particularly in the area of non-communicable chronic illness the intention is to control symptoms or limit further progress of pathology. There are no cures for asthma, diabetes, high blood pressure….. or any chronic disease. Diseases are managed by the prescription of drugs, and those drugs are for life, because they are not intended to produce healing.

Healing – there’s another word you don’t hear doctors use much. But surely all health care should be about healing (if healing means moving in the direction of greater health). Health, if it improves in patients receiving these treatments, is a kind of side effect. It appears, hopefully, as the disease or pathology reduces.

In my daily work, I, and my colleagues, intend to heal. Does that mean we try to cure? Well, to answer that would open a debate about what is cure, and I’ll leave that for another day. Let’s say we intend to maximise health. I don’t know any cures for MS, or asthma, or diabetes, but I do know that patients with those illnesses can experience different degrees, or levels of health.

My intention is to maximise health through stimulation and support of self-regulation and self-repair, and in so doing the patient will experience the care as healing. The way we try to mobilise self-healing is through care which is integrative. Integrative care is any intervention or therapy which increases the amount of integration, or coherence, in the person.

I do not believe that holistic = good, and disease management = bad. We need good disease management. Good disease management in acute care will save a life today. Good disease management will improve the quality of someone’s life by controlling symptoms and inhibiting the progress of pathology. But it takes holism to maximise healing and bring the best possible health experience to a person.

If we are providing health care, surely somewhere in the system, there needs to be the intention to heal, and is there ever a case for not attending to the person, but only attending to the pathology?

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Resilience

Posted in from the consulting room, from the living room, health, life on May 8, 2013| Leave a Comment »

One of the characteristics of health is resilience. But what is resilience?

One definition is –

Resilience is the capacity of a system to absorb disturbance and reorganise while undergoing change so as to still retain essentially the same function, structure, identity, and feedbacks.

I like this definition. It captures the essential elements of reorganisation and change whilst retaining integrity and coherence. In other words, when something disturbing happens (and in health terms that can be anything which is a biological stressor – infectious organisms, chemicals, drugs, injuries or operations, or psycho-social stresses ie significant life events) then the system, or the organism, makes an adaptive response. The response has two aspects – defence, which tries to maintain the internal status quo, and reorganisation, which produces change within. Both are necessary, and whilst they can seem like opposites, both functions are required.

When someone is resilient they are less likely to be infected when a bug is doing the rounds, less likely to be overwhelmed or blown off track by major life events, AND they are more likely to recover and repair when damaged, but, more than that, are more likely to change, develop and grow.

As Prigogine demonstrated with his concept of “dissipative structures”, living forms develop and grow by falling apart. Reorganisation involves elements of breaking down, or dis-organising what is already there, and of putting things back together but in a new way.

How do we maximise resilience?

I read a paper recently which considered the phenomenon of resilience in relation to “fragile states” and the author highlighted two ways to maximise resilience.

Firstly, to develop “resilience-sensitive” policies (or actions), and, secondly, to create the conditions which support resilience. I think both of these ideas are useful in thinking about resilience in health care.

Our treatments should be “resilience-sensitive” ie if a drug, or an operation, or whatever other treatment is used impairs resilience it is less likely to be effective than one which at worst is neutral, but at best, is stimulative or supportive of resilience. How often do we think of this aspect in health care?

Secondly, how do we create the conditions to foster resilience? That’s a question that crosses the boundaries from the personal to the social and political. There are environmental, societal and economic aspects to that question. Is a polluted environment going to be conducive of resilience? What about an unsafe community? And what about the increasing inequality in income distribution? At a personal level, what about emotional intelligence? What about food? What about exercise? What about Nature?

What do you think?

What could you do to foster and maximise your resilience?

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What’s your doctor been doing today?

Posted in from the consulting room, health on April 24, 2013| 1 Comment »

OK, so I’m getting older and I guess I’ve reached that age where I think some things aren’t as good as they were. In particular I’m concerned that the practice of Medicine has become more technical and less human. So, it wasn’t really a surprise to read the details of a study which measured how much time doctors were spending on different activities through their day. The details however are, frankly, shocking.

The study of first year internists at two of Baltimore’s largest academic medical centers, showed that the doctors spent 12% of their time examining and talking to patients, and 40% at a computer.

Now, I reckon only just a tenth of your working time as a doctor spent in direct face-to-face work with patients is surprisingly low, but to be spending almost four times as much time at the computer as you spend with patients?!

Here’s what the researchers thought about their study –

“One of the most important learning opportunities in residency is direct interaction with patients,” says Lauren Block, M.D., M.P.H., a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of General Internal Medicine. “Spending an average of eight minutes a day with each patient just doesn’t seem like enough time to me.” “Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training,” says Leonard Feldman, M.D., the study’s senior author and a hospitalist at The Johns Hopkins Hospital (JHH).

The researchers are concerned that the trainee doctors aren’t getting enough time in direct patient care to learn their trade. But worse than that, what are they learning about the way to work as doctors?

Although this isn’t a perspective expressed by the authors, I do wonder if the whole drive towards a mechanistic, reductionist approach to health, coupled with a shift in emphasis from patient experience to group-based statistics, isn’t partly to blame for this finding.

Isn’t it time to organise the practice of Medicine in way which would allow doctors to spend most of their time talking to, examining or directly caring for, or treating, their patients?

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Mind over the threshold – after death experiences

Posted in books, from the consulting room, from the living room, health on April 18, 2013| 2 Comments »

I was really struck by an article in The Observer the other day. Dr Sam Parnia, a doctor specialising in resuscitation techniques, has studied the experiences of patients who die and are later brought back to life.

Pardon? Yes, people whose heart stops (a cardiac arrest) and whose brains stop working due to oxygen lack, but who are successfully resuscitated and fully recover. Not only does the person return but he has found that about half of them report very similar death experiences (people refer to these experiences as NDEs – “near death experiences” – but he says they are, in fact, ADEs – “actual death experiences”). These two phenomena raise interesting questions – where does the “person” go while they are dead? And how does this “person” observe and remember observations which they make while they are dead?

This particular paragraph really gripped me –

All I can say is what I have observed from my work. It seems that when consciousness shuts down in death, psyche, or soul – by which I don’t mean ghosts, I mean your individual self – persists for a least those hours before you are resuscitated. From which we might justifiably begin to conclude that the brain is acting as an intermediary to manifest your idea of soul or self but it may not be the source or originator of it… I think that the evidence is beginning to suggest that we should keep open our minds to the possibility that memory, while obviously a scientific entity of some kind – I’m not saying it is magic or anything like that – is not neuronal

Now, I’m very familiar with the idea that whilst there are neuronal correlates of mental activity, we cannot say that its the neurones which produce the thoughts, feelings, and indeed consciousness which we all experience. But what a way to put it!

That the mind uses the brain to express itself.

I had to get the book. (The Lazarus Effect. Dr Sam Parnia. ISBN 978-1-84604-307-9)

I raced through it. In the book, Dr Parnia describes his work in resuscitation and reports on his AWARE study into the reported experiences of those who return. The heart of the book, for me, is Chapter 6, “What it’s like to die”, which describes many of these reports in detail. I’ve read this kind of thing before but I had never, ever read reports from children as young as 3 years old. Those stories stunned and moved me. They are amazing. And the story told by the Consultant of his first experience of a patient’s cardiac arrest where he tells how once recovered the patient told him in detail not only what the doctor had done in the room whilst the patient was unconscious, but even what the doctor had thought, but hadn’t verbalised…….

Dr Parnia goes through the possible scientific explanations for these reports and shows how none of them actually credibly explain them. He believes we will uncover a scientific explanation one day, but not until we start to accept these phenomena as real.

Here are a couple of sentences which really struck me

Reality is not neurologically determined, then, but rather it is largely socially determined.

and

The bottom line is that no brain-based chemical change can define whether a sensation or feeling is real or not

I don’t see things exactly as he does – for example, he uses a machine model to explain how the body works – it isn’t a machine, its a complex adaptive system – and the crucial difference is that only complex adaptive systems demonstrate both emergence and self-organisation – ie the whole cannot be explained by the parts. And he says “the goal of Medicine is cure” – well, I wish! But in fact, what does Medicine these days cure? Rather, Medicine manages disease – there are no cures for asthma, multiple sclerosis, Parkinsons Disease, etc etc etc

However, these are not the key points of the book.

Let me just finish with a reference to Chapter 5, “The Orphan” where he says

Asthma has a home in pulmonary medicine. Cancer is in the domain of oncology. Parkinson’s belongs to the neurologist. But cardiac arrest is an orphan by virtue of the fact that it cuts across many specialities because it is death, and death happens in all specialities of medicine but is parented by no-one.

See, this is what I find so wrong about health care – we divide health care into specialities which focus on parts and diseases – not only does death then become an orphan, but so does health.

 

 

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Patterns

Posted in creativity, from the consulting room, from the dark room, from the living room, health, life, perception on March 23, 2013| 2 Comments »

We are a pattern-spotting, and pattern-creating species. This is a brilliant quality to possess. It allows us to make sense of very complex systems, to engage with Life and phenomena holistically and to see (or create) the meaning behind our daily perceptions and experiences.

eye of the tree

Margaret Wheatley, in her Leadership and the New Science, says

Wholeness is revealed only as shapes, not facts. Systems reveal themselves as patterns, not as isolated incidents or data points.

Further, she says,

It is the nature of life to organise into patterns

morse moss

 

What patterns do you see today?

What patterns touch you, capture your attention, or help you make sense of things?

Every consultation I do, I sit with a patient and we have a conversation. It’s best if I do most of the listening, and stimulate the odd reflection when I begin to discern patterns. At the simplest of levels I was taught diagnosis at Medical School. I still think we make the best diagnoses by quickly spotting the patterns – the connections and inter-connections between the elements of a story, the symptoms expressed, the signs and changes manifested, and recognising the pattern which holds this all together.

At the deepest level there are a multiple of patterns in every person’s life, each interacting and interweaving to create ever more beautiful and amazing spiralling narratives. This is how we get to know each other. This is how we get to know ourselves.

Let’s make some new patterns together……how about it?

 

zen garden

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Battles and wars

Posted in from the consulting room, health on March 19, 2013| 4 Comments »

What’s with all the war language these days? The War on Terror. The War on Drugs. The War against Cancer. Winning the battles against bacteria and viruses. And all the disease-focused charities – “beating cancer”, a recent one in Scotland “let’s take this outside, cancer”, “help win the war against heart disease”, “beat obesity” and on and on and on……

What are these wars exactly? And what would winning them look like? A world which eliminated these “enemies”? When it comes to bacteria, have a read at the chapter in Howard Bloom’s “Global Brain” about bacteria – is there any other life form on the planet which has been able to adapt to, and colonise such an incredible diversity of environments? Some live in us. Some live in the mouths of volcanoes which are erupting miles under the oceans! They demonstrate fabulous adaptive powers…..we see that in how they “learn” to resist toxic drugs which we throw into the environment and they can spread that knowledge around the globe with fantastic speed. Anyway, we don’t want a world without bacteria. We’d die. Did you know that apparently there is ten times as much bacterial DNA in YOU than there is your own DNA? Pretty mind boggling.

I enjoyed Howard Bloom’s “Global Brain” but he did emphasise the competitive element of Life too much for me.

But wait, I hear you say, surely competition is the ESSENCE of Life! At least, isn’t that what we learned from Darwin and from his followers? “Nature red in tooth and claw” and all that?

I think that’s partly where we’ve gone wrong. Yes competition is a strong part of Life. To deny that would be to deny reality. But that is not the same as doing battle or waging war. Think about sports like athletics, cycling or ice skating for example. The winner of those competitions is the person who performs the best. Usually the person who does the best and wins the medals is achieving their “personal best” too. They win by being the best they can be. They don’t win by waging war on the other competitors. Competition, in other words, can bring out the absolute best in people by being focused on the self – by trying to achieve one’s personal best. Yes, I know other sports are not like that. There are sports where you have to harm your competitors to win – boxing being the obvious example. But most sports, it seems to me are not like boxing. Maybe we should award “personal best medals” at competitions as well as “best competition performance medals”?

But the other big thing that is missing in this focus on war and battle is co-operation and collaboration. No, I’ll go further, it neglects the importance of the inextricable links between us, about our co-evolution, our co-dependence. Read books like, The Bond, Connected, Linked and you might start to see things differently. What matters in the evolution of complex adaptive systems is the connections, the relationships between the parts.

We won’t win these so called wars. What we should be doing is trying our best to be the best us we can be. We should be encouraging diversity, flexibility, autonomy, the building of mutually enhancing bonds between us and between ourselves and other aspects of Nature. Only down that road will we adapt, grow and thrive…….

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Principles of living systems

Posted in books, from the living room, from the reading room, health, life, perception, philosophy, science on March 6, 2013| 4 Comments »

Margaret Wheatley works in the area of leadership and organisational change from the perspective of what we can learn from living reality. She has the complex adaptive systems concept at the core of her work. I recently stumbled across her writings, particularly her four “principles of living systems”. Here they are –

  1. Participation is not a choice
  2. Life always reacts to directives, it never obeys them
  3. We do not see “reality”. We each create our own interpretation of what is real
  4. To create better health in a living system, connect it more to itself

The first principle relates to the reality that everyone, every thing, every aspect of our world, our universe, exists inextricably embedded in the contexts of its existence. A living organism is an “open system”, with information and energy constantly flowing into and out of it. A living system is dynamic and perpetually changing and “co-evolving” with the other elements of the ecosystem in which it lives. You can’t change a part of a person without producing changes in the rest of that person, and you can’t change a person without setting off a cascade of unpredictable changes in the world in which that person lives (and vice versa – you can’t change something in someone’s world without setting off changes in that person). Participation is not a choice, it’s an inevitability.

The second principle is the core of adaptation. Every individual is unique and cannot be controlled like a robot or a machine. You can force people to behave a certain way for a period of time, but ultimately all the organisations and political systems based on force collapse. You can’t force the sun to shine, the wind to blow, the rain to fall, or Life to obey your commands.

The third principle is something we often forget. Iain McGilchrist, in The Master and His Emissary, highlights how the left cerebral hemisphere is particularly well developed to “re-create” reality. It creates “re-presentations” of the raw information and energy which flows into the person. These representations allow us to make sense of the world and to literally to grasp things better. It’s a fantastic development and is probably at the core of our industrial and technological development as a species. We also know now that the part of the brain just behind the forehead, the mid-prefrontal cortex, has many, many functions, but amongst them is a map-making facility. It’s crucially involved in creating, what Dan Siegel calls, “a me map, a you map and a we map”. We never know any of this reality directly. Rather we constantly create our perceptions and our understandings, influencing those creations with our memories, our hopes, our beliefs, our values and our desires.

The final principle is Margaret Wheatley’s way of talking about integration. When a system is well integrated there are healthy, mutually beneficial relationships between all the connected parts. That produces coherence and harmony. It’s the basis of health.

When I first created this blog, I wrote a permanent page on “ACE” – “Adaptation, Creativity and Engagement“. It was really interesting for me, therefore, to discover this quote from Margaret Wheatley (which I believe, essentially highlights the same characteristics)

Over many years of work all over the world, I’ve learned that if we organize in the same way that the rest of life does, we develop the skills we need: we become resilient, adaptive, aware, and creative. We enjoy working together. And life’s processes work everywhere, no matter the culture, group, or person, because these are basic dynamics shared by all living beings

 

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What can you expect from your doctor before they hand you a prescription?

Posted in from the consulting room, health on February 16, 2013| 1 Comment »

The GMC has recently revised its guidance on prescribing. Here’s the relevant paragraphs related to what a doctor is expected to do before they issue a prescription –

3. For a relationship between doctor and patient to be effective, it should be a partnership based on openness, trust and good communication.  Each person has a role to play in making decisions about treatment or care.
4. No single approach to discussions about treatment or care will suit every patient, or apply in all circumstances. Individual patients may want more or less information or involvement in making decisions depending on their circumstances or wishes. And some patients may need additional support to understand information and express their views and preferences
5. If patients have capacity to make decisions for themselves, a basic model applies:
a. The doctor and patient make an assessment of the patient’s condition, taking into account the patient’s medical history, views, experience and knowledge.
b. The doctor uses specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which investigations or treatments are likely to result in overall benefit for the patient. The doctor explains the options to the patient, setting out the potential benefits, risks, burdens and side effects of each option, including the option to have no treatment. The doctor may recommend a particular option which they believe to be best for the patient, but they must not put pressure on the patient to accept their advice.
c. The patient weighs up the potential benefits, risks and burdens of the various options as well as any non-clinical issues that are relevant to them. The patient decides whether to accept any of the options and, if so, which one. They also have the right to accept or refuse an option for a reason that may seem irrational to the doctor, or for no reason at all.
d. If the patient asks for a treatment that the doctor considers would not be of overall benefit to them, the doctor should discuss the issues with the patient and explore the reasons for their request. If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient, they do not have to provide the treatment. But they should explain their reasons to the patient, and explain any other options that are available, including the option to seek a second opinion.
What interests me most about this is that the GMC is absolutely clear that health care is a partnership. We often seem to deliver health care as if the expert knows everything and the patient knows nothing. But, in fact, the GMC expects that doctors will act more as expert advisors to enable patients to make their own choices, and that whilst the doctor does not need to defer to the patient’s choice, neither does the patient have to defer to this particular doctor’s choice.

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