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Lub dub

Posted in from the consulting room, from the living room, health, life, personal growth on January 2, 2013| 1 Comment »

“lub dub, lub dub, lub dub”

That’s what I was taught to listen for when I was first shown how to use a stethoscope. This was the natural sound of the heart. It was a beautiful rhythm. I think you can’t help being impressed, or even moved by it. I remember the first time I was taught to use another, similar, but different device – the pinna. A pinna was a plastic cone which you placed on a pregnant mum’s tum to listen to the baby’s heart beat. So fast, but so amazing. Thrilling every time. But it was a kind of private thrill because nobody else could hear it. These days, we use technology to show the beating heart of the baby, or to play the fast lub dubs through speakers so everyone can hear it.

The heart beat is a constant alternation of opposite states – systole, where the heart muscle is contracted and the chambers of the heart are emptied, and asystole, where the muscle rests and the chambers fill with blood. There is a such an amazing truth in that observation.

At the heart of the universe there is creation. There is a story of the universe, from The Big Bang, to the emergence of hydrogen and helium, the cycles of growth, expansion and contraction of the great billions of stars, to the creation of Planet Earth, at first lifeless, then rapidly (in universe timescales!), creating simple, single celled life forms, complex, multicellular ones, plants, creatures of the sea and the land, right up to our continually developing, evolving human race with its most peculiar characteristic of consciousness. This story is the the story of constant becoming. It’s a story of ever increasing amounts of uniqueness. The universe loves diversity. And it loves to make connections.

This is the heart of the universe. Two opposite processes, tightly bound together – diversification and integration.

We need both the diversity generators and the conformity enforcers as Howard Bloom refers to them in The Global Brain.

Can you hear it?

This constant creative heart beat?

Lub dub, lub dub.

yin yang

Right here inside you, right here and right now, in your unique and singular life, the amazing, constant rhythm of becoming…..

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Heart of the universe

Posted in from the consulting room, from the living room, health, life, perception, personal growth, science, tagged , , on January 1, 2013| Leave a Comment »

Sometimes (quite often actually), I wake up with a word or phrase in my head. This morning it was “heart of the universe”. The particular word or phrase can set off all kinds of different thoughts and where this one quickly went was “It’s 2013. It’s 40 years since I dissected a human heart. Second year, Medical School, Edinburgh University. That year we learned Anatomy and Physiology. I was amazed at the structure of the heart. It’s four chambers, the valves, the specialised heart muscle cells which each had their own rhythm, the conduction pathways from the “AV node” which carried the co-ordinating electrical beat to produce the two, opposite states of the heart – systole and asystole.

It was two years later before they told us to put on white coats, buy a good quality stethoscope, and led us on ward rounds, to stand collectively around patients’ beds, and one by one, place our shiny new stethoscopes on their chests to listen for the “lub dub” of the “normal” heart, and listen carefully for the clicks and sounds which filled the silences and revealed the disorders of the valves.

Over the years as a GP, I prescribed the drugs to slow hearts down, to regulate disordered rhythms, and to improve the blood supply to get the oxygen to the cells starved by blocked arteries and causing angina. I also found people presenting with pain, flutters and skipped beats of the heart whose investigation results showed no obvious pathologies. What were we to do with them? And where was the explanation for their symptoms? If their symptoms weren’t signposts to pathology, then what were they?

Gradually, I became aware of how we use heart in our language, as people told me about “broken hearts”, “heart ache”, “longings of the heart”, “an emptiness in my heart”, “getting to the heart of the problem”, “filling my heart with joy”. Of course, from early years I became familiar with the shape of a heart as we would draw it to communicate love. We see that shape everywhere.

three leaves

cafe love

tree

wishes

Why the heart? Why not the liver, or the pancreas, or the spleen? Why not the kidneys?

I knew there were intimate connections between the brain and the heart, mainly channeled through the “autonomic nervous system”. Then only in the last few years did I learn we’ve discovered that there is a neural network around the heart and associated with that is the production of neuropeptides (the small proteins which act on the brain) within the heart and its neural network. So, the links are more intimate than I realised, and, most importantly, more two way than I realised – the brain acts on the heart, but the heart also acts on the brain. In fact, it seems we do some of our mental processing using these neurones around the heart. (That dismissive phrase which I never liked – “it’s all in your head” – turns out to be even more stupid than I always thought it was)

And as time passed, and I experienced encounters with more patients, I began to see that sometimes (not always but often enough to always consider), there were direct links between “heart issues”, “heart language” and “heart symptoms”, irrespective of the presence or absence of pathologies.

So, here’s something to consider as you think ahead into 2013. How about building your “heart intelligence”? That’s a concept that means somewhat different things to different people, but let’s just use it as it is, without detailed definition.

Try the Heartmath technique. Sit quietly, focus on your heart area, take three deep, slow heart breaths, then recreate for yourself a heart feeling (you can find the details here). In this state of “coherence”, ask your heart a question, and wait to see what answer appears. Write it down.

What does your heart tell you about 2013?

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Out of your head…and into your other brain

Posted in from the consulting room, health, tagged , , on December 21, 2012| Leave a Comment »

Your other brain?

You probably imagine that you do all your mental work – perceiving, analysing, thinking, feeling and so on – with your brain – that organ inside your skull. However, we’ve known for some time that there are networks of neurones around the hollow organs of the body, especially around the heart and the intestines. We’ve also discovered “neurotransmitters” originating from those parts of the body. So, at very least, we are aware that there are two way connections between the heart and the brain, and the gut and the brain.

A recent article in New Scientist magazine described the network around the gut and named it the “Enteric Nervous System” (ENS). There are around 500,000 neurones around the gut (where there are about 85 billion in the brain). Most surprisingly, alongside the 40 or so neurotransmitters in this network, two chemicals known to affect mood and mental functions, dopamine and serotonin, are also present. In fact, it is now thought that 50% of all dopamine is produced in the brain, and 50% in the ENS. Only 5% of serotonin is produced by the brain, and 95% of it in the ENS. This is quite astonishing when you consider the roles these hormones can play in our behaviour.

The other fascinating fact the author of the New Scientist article highlights is the presence of Lewy bodies in the ENS (these are the pathological lesions seen in the brains of patients with Parkinsons Disease), and patients with Alzheimer’s have characteristic lesions on both their brain and ENS neurones. Do those “neurological” diseases begin in the brain, or in the gut?

It’s good to see scientists discovering how interlinked our bodily systems are, and how difficult it is to reduce a person to parts – even the two parts of Mind and Body. Are those parts really such separate parts of they are so connected and inter-related?

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The National Drug Service

Posted in from the consulting room, health on December 17, 2012| 1 Comment »

An ad on STV caught my eye the other day. It was a public service ad from NHS Scotland and was exhorting people to be prepared for the Christmas and New Year holidays as their GP surgeries would be closed Tuesday and Wednesday on each of the next two weeks. So, “don’t run out of your repeat prescriptions”!

And I thought, this is the big idea in health care? Make sure patients realise their doctors won’t be working for two days in a row so DON’T RUN OUT OF YOUR DRUGS.

I thought I’d pop across and see what NHS24 were saying. They have a whole section called “Be Ready for Winter”. It’s got three pieces of advice –

1. Restock your medicine cabinet

2. Order repeat prescriptions

3. Note when your GP’s surgery closes

Then, on Friday, I read an article in New Scientist, entitled “A humane solution” which was advocating more human drug trials instead of animal ones, as the animal ones don’t show the potential problems when drugs are taken by humans. But here’s the bit in the article that whacked me between the eyes….the first sentence….

Adverse drug reactions are a major cause of death, killing 197,000 people annually in the European Union and upwards of 100,000 in the US

Why do we tolerate this?

How did a “Health Service” become a “Drug Service”?

 

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Flu

Posted in from the consulting room, health on December 6, 2012| 1 Comment »

At this time of year there are queues of patients in the GPs’ surgeries standing in line waiting for flu jabs. I routinely receive emails from my employer (the NHS) exhorting me to have the flu vaccine.
I’m not joining in.
An elderly patient told me recently she attended her GP for a routine BP check from the nurse who asked her if she had been vaccinated for the flu yet. She said no, and as last year she had felt unwell for a few days afterwards, she said she would come back for it after a planned weekend break. The nurse said, nonsense, the flu jag doesn’t make you feel unwell, picked up a syringe in injected it into the patient’s arm. She was furious, and said she wasn’t well enough to enjoy her weekend away afterwards. I’m sorry, but this is no way to deliver health care.
Here’s where the story gets worse.
The Center for Infectious Disease Research and Policy in Minnesota has reviewed the evidence for the claims made about flu vaccination. What did they find?
Based on a comprehensive review of data published from 1967 to 2012, they found evidence for “consistent high-level protection is elusive,” the researchers concluded. Although vaccination was found to provide modest protection from infection in young healthy adults who rarely have complications of flu, the authors found that “evidence for protection in adults 65 years of age and older [who represent over 90% of deaths from flu] . . . is lacking.” Apparently in otherwise fit, healthy young adults flu immunisation can reduce their experience of illness by half a working day. In the elderly there is no evidence is protects them. (This study was reported in the BMJ with the headline “Belief not science is behind flu jab promotion, new report says”)
Yet, the NHS heavily pushes this immunisation.
On a related subject let’s think about Tamiflu which Roche persuaded governments around the world, including the UK, to stockpile supplies costing billions of dollars, on the basis of an evidence base which they continue to refuse to publish. In 2005, the UK agreed to buy £200 million of Tamiflu.
However, the evidence that Tamiflu would actually significantly prevent either the spread of flu, or the incidence of complications has all been based on studies carried out by Roche itself. The BMJ and the Cochrane Collaboration are leading a campaign to get Roche to release the data from their 8 out of 10 unpublished trials. In fact, the BMJ has set up a website.
When it comes to flu, the government seem prepared to promote and purchase, at huge cost, treatments with very, very sparse evidence bases.

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Life and death and choices

Posted in from the consulting room, from the reading room, health, life, tagged , on November 21, 2012| 2 Comments »

There was an amazing story recently in the NY Times about a Greek man living in the US. He was diagnosed with lung cancer in his mid 60s and given the prognosis of 9 months to live. He decided that instead expensive treatments and a costly funeral in the US, he would return to his native Greek island of Ikaria.

He moved back in with his parents and went to bed to be cared for by his wife and mother. But he started to feel strong enough to go out so reconnected with childhood friends and re-established his Sunday trips to church.

As the months passed he felt strong enough to do some gardening (a common activity on the island) and planted vegetables thinking he might not live to enjoy them, but he would enjoy growing them. Not only did he live to enjoy them but with his regular routines now of plenty of sleep, regular walks up the hill, spending time in the garden and in the evenings with his friends at the bar, and his weekly visits to the church he began to feel well enough to tackle the old, neglected family vineyard.

Three and a half decades on he is now 97, producing 400 gallons of wine a year from his vineyard and seems to be cancer free.

What can we learn from this inspirational story? Well, the author of the story in the NY Times concludes this –

If you pay careful attention to the way Ikarians have lived their lives, it appears that a dozen subtly powerful, mutually enhancing and pervasive factors are at work. It’s easy to get enough rest if no one else wakes up early and the village goes dead during afternoon naptime. It helps that the cheapest, most accessible foods are also the most healthful — and that your ancestors have spent centuries developing ways to make them taste good. It’s hard to get through the day in Ikaria without walking up 20 hills. You’re not likely to ever feel the existential pain of not belonging or even the simple stress of arriving late. Your community makes sure you’ll always have something to eat, but peer pressure will get you to contribute something too. You’re going to grow a garden, because that’s what your parents did, and that’s what your neighbors are doing. You’re less likely to be a victim of crime because everyone at once is a busybody and feels as if he’s being watched. At day’s end, you’ll share a cup of the seasonal herbal tea with your neighbor because that’s what he’s serving. Several glasses of wine may follow the tea, but you’ll drink them in the company of good friends. On Sunday, you’ll attend church, and you’ll fast before Orthodox feast days. Even if you’re antisocial, you’ll never be entirely alone. Your neighbors will cajole you out of your house for the village festival to eat your portion of goat meat

 

Those are probably reasonable conclusions but what inspires me most about this this story is the series of simple, pragmatic choices this man made. He didn’t set off to “beat cancer”, or to find the elusive magical cure. No, what he did was chose, moment by moment, day by day, to live. He might have died in his bed within days of returning to Ikaria. He would have had the death he chose, if that were the case. But he was not at any point focused on trying to determine the detailed outcomes.

Here is what inspires me about this story – at each stage he was focused on how he would live today and at no point did he think how to escape death.

Read the whole article here.

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Health in healthcare training

Posted in education, from the consulting room, from the reading room, health on November 20, 2012| 1 Comment »

I’ve long been bemused by the lack of reference to health in healthcare training. The standard clinical textbooks of Medicine not only have no chapters on health, books like Davidson, still a standard medical school text don’t even have an index entry for health.

Then the other day I stumbled on an old document from 1938 entitled “The Wheel of Health”, by G T Wrench MD. The content of the text is not what I want to mention today, but I’d like to share the following paragraphs from the author’s introduction.

Why was it that as students we were always presented with sick or convalescent people for our teaching and never with the ultrahealthy? Why were we only taught disease? Why was it presumed that we knew all about health in its fulness? The teaching was wholly one-sided. Moreover, the basis of our teaching upon disease was pathology, namely, the appearance of that which is dead from disease. We started from our knowledge of the dead, from which we interpreted the manifestations, slight or severe, of threatened death, which is disease. Through these various manifestations, which fattened our text-books, we approached health. By the time, however, we reached real health, like that of the keen times of public school, the studies were dropped. Their human representatives, the patients, were now well, and neither we nor our educators were any longer concerned with them. We made no studies of the healthy–only the sick.

 

1938! He could have written that today!

Does this not surprise you?

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Stories and power

Posted in from the consulting room, health, narrative, tagged , , on October 28, 2012| 1 Comment »

The Scottish Storytelling Centre in Edinburgh hosted the International Storytelling Festival last week and I participated in a series of workshops entitled “Stories and Cures”. What a fantastic, stimulating, rich experience with a diverse range of nationalities and disciplines taking part. Right at the start of the week I heard something I’d never heard before.

Back in the 18th and early 19th centuries throughout Europe when a person wished to consult with a doctor, there was a practice of letter writing. Someone would write a letter to the doctor whose advised they wished to receive. The letters were typically the person’s story, in their own words, describing what they were experiencing and the contexts of those experiences. In other words, the letters weren’t just lists of symptoms, and certainly weren’t tables of figures or readings, but, rather, they were highly personal, unique life stories.

The doctor would then write back, commenting on parts of the person’s story and giving a range of advice , often touching on issues of morals, hygiene or spiritual life. This was the beginning of a conversation which might be followed up with further exchanges of letters and/or with meeting up for face to face consultations.

Joanna Geyer-Kordesch, whose research as a Professor of the History of Medicine was the basis for this series, has read hundreds of such letters in English, German and French.

I didn’t know such a practice had ever existed.

Just think for a moment how different this practice was from our current doctor-patient relationships.

First of all, the record of the person’s illness is now created and held by the doctor. The stories have been turned into case notes and typically it would be extremely difficult to gain any understanding of who the person is if you were to read these notes. Doctors notes (I don’t think they usually could be stretched to be considered as stories) are mainly lists of symptoms, physical findings and results of investigations, then diagnostic labels based on pathology. The advice recorded certainly isn’t in the form of a conversation or exchange with the patients. In fact advice is more likely to have been replaced by a list of drugs prescribed.

What are the consequences of this change?

There has been a shift in power – from the person to the doctor, or the institution. This shift in power is so great that the words recorded are much more likely to be the doctor’s words and his or her interpretations of the person’s experience, rather than any record at all of the story the person has told (it’s not like that where I work because we have a tradition of writing down the patient’s actual words as much as we can – however, it’s still the doctor making and holding the record, not the person whose life it is)

There has been a shift in focus – from the person to the pathology. As Eric Cassell so beautifully describes in his “The Healer’s Art”, and “The Nature of Suffering”, illness is what the person goes to the doctor with and disease is what he comes home with.

It seems to me we’ve lost sight of the human being in the process. By reducing someone to a mere physical body to measured and imaged, we have dehumanised Medicine. The PERSON has been lost. How do we get the PERSON back into the centre of the stage? How do we get the individual’s agenda back at the heart of the medical engagement? How do we regain the truth of the uniqueness of every single human being and move away from the mass production processes of reducing people to diseases, diseases to “managed”, rather that people to be healed?

A good starting place would be to enable people to tell their stories – in their words, in their order of priority, in their own style – to reveal not just their sensations and experiences, but also their choices, their values and their beliefs (and what about the creation of the record? How and where would you create the record of your illness and your healing?)

Maybe valuing each individual’s story would begin to let us re-humanise Medicine?

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What placebo isn’t

Posted in from the consulting room, health on October 25, 2012| 1 Comment »

The placebo effect is not a zero effect. It’s an effect. It induces change.
Irving Kirsch in his The Emperor’s New Clothes prints a simple bar chart comparing antidepressants, placebo and doing nothing in terms of clinical improvement in patients with depression. That chart shows two things.
The difference between antidepressants and placebo is so small he argues there is no clinically significant difference (apart from in patients with severe depression).
The difference between doing nothing and the effects of giving a patient an antidepressant or a placebo is huge.
In other words, despite the fact there is a barely discernible difference between antidepressants and placebo, he does not recommend doing nothing instead.
Some claim that if a treatment shows no significantly greater effects than placebo we should stop providing that treatment. But if the treatment is replaced with doing nothing there will be a reduction in the benefits experienced by the patients.
All drugs work partially through the placebo effect. In fact, every treatment contains a placebo effect. Randomised controlled trials (RCTs) comparing one group which receives the drug, and one which receives a chemically inert substance (termed placebo) mislead people into thinking there is no placebo effect in the drug group. But there is. The placebo effect is embedded, inextricably.
It is impossible to discern, in an individual case, what proportion of the improvement is due to the direct effects of the treatment and which are due to the placebo effect.
RCTs don’t help clarify that in individual cases. Don’t we need more comparative studies instead? Comparing treatment A to treatment B raises a different set of questions from comparing either to a “placebo group”. As does comparing either treatment group to a “no treatment” group.
I repeat. The placebo effect is not a zero effect.

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Diagnosis

Posted in from the consulting room, health, Uncategorized on October 11, 2012| 3 Comments »

I’ve always taken great pleasure in making a diagnosis. But for me, I go back to the roots of the word. A diagnosis is an understanding. It thrills and delights me to be able to understand people. I think that’s the beginning of the journey to health, because as I concentrate on trying to understand someone, they usually increase their understanding of their condition and even of themselves. That’s powerful and I think, as we are all meaning seeking creatures, it’s a key goal of most consultations – to make sense of our lives (through the creation of our stories) But I reject the reduction of diagnosis to labelling or categorising. For me, that’s just not good enough. I want to know more than the name of a disease. I want to know a person.

Iona Heath writes eloquently about diagnosis in this week’s BMJ

Beyond the technical expertise of those in the craft specialties, the key skill of all doctors is diagnosis. However, diagnosis itself poses profound problems of scope and usefulness. Every experienced clinician is fully aware that no two people ever experience the same diagnosed disease in exactly the same way, and yet the taxonomies of diagnosis and the international classifications that underpin them ignore this underlying truth. The diagnoses tabulated in this way are theoretical abstractions, but we are inclined to give them a level of credence and reality that tends to exceed that granted to the patients so labelled. In this way, our diagnoses begin to condone structural violence and to excuse social injustice

Good diagnosis is an individualising process, not a generalising one.

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