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Just say no

Posted in from the consulting room, health on June 28, 2012| Leave a Comment »

I remember a few years back there was a Public Health campaign directed at young people who were offered illegal drugs – “Just say no” – was the campaign slogan. Turns out the bigger problem is prescription drugs….

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According to the UN report referred to in this sensationalist heading women are more likely to be “abusing” prescription drugs than illegal ones. And the problem is getting worse and worse….

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The rate of increase in prescribing is colossal. It simply isn’t sustainable.

The excellent David Healy, author of “Pharmageddon”, points out that in the 1960s it was unusual for a doctor to prescribe more than two drugs to the same patient. Now, 50 years on, ten to fifteen drugs for a patient is not uncommon. That’s truly astonishing.
David Healy has an interesting take on this today. He points out that there was a shift in focus and law in the 19th Century which resulted in doctors, rather than patients, becoming the prime “consumers” of drugs.

Doctors who for centuries had being trying to push quacks and hucksters out of the medical marketplace were being offered the means to conclusively do so. You would only be able to get the drugs that really worked from your doctor. But the bargain was Faustian. Few if any doctors seemed to spot that patients would no longer be the consumers of drugs. If by consumers we mean those who are the targets of pharmaceutical company marketing, then doctors were the new consumers. These new consumers moreover would consume by putting drugs into their patients’ mouths and so would consume without side effects. This was a win-win of which Mephistopheles would have been proud.

As he rightly says

Left to their own devices few of a doctor’s patients would ever take 10-15 over the counter drugs at the same time for indefinite periods no matter what the supposed benefits.

He quotes Pinel as saying about the Art of Medicine –

“It is an art of no little importance to administer medicines properly: but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them”.

That’s what I was taught, but it seems this principle has lost ground rapidly. Nowadays doctors don’t only prescribe to suppress almost every symptom a patient presents, they prescribe for the healthy to stop them becoming sick!

This is not sustainable. It has to stop.

…..doctors are going to have to come up with something extraordinary. They may even need to become a revolutionary class, partisans, who create a space that markets do not readily understand – a space where No is the operative word.

I don’t want to be completely negative here. Understand I’m not arguing for doctors to refuse to help patients. I’m arguing for doctors to rediscover the Art of Medicine, to become patients’ partners in health, helping them to flourish in their lives, during health, and during sickness. I’m arguing for a reality check, instead of reflex prescribing of substances that only dope, and dull, and mask.

Let’s learn how to be discerning and only prescribe as a contribution to the work of assisting a person’s natural self-healing.

The Life Force – the only known way to health.

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Subjective (invisible)

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

Kat Duff, in “The Alchemy of Illness”, says

There is a curious paradox that surrounds pain. Nothing is more certain to those afflicted, while nothing is more open to question and doubt by others.

It’s strange, isn’t it? How often is pain intensified by the refusal of others to believe it exists? How helpful is it for someone with pain to be told “Don’t worry, the tests are all normal”, with the implication being the pain “is in your head” ie it’s imaginary?

It’s not only pain which cannot be seen, and so, cannot be known by another person. Nausea is the same, as is fatigue, blurred vision, dizziness, itch. Patients present to doctors with symptoms which are descriptions of subjective experience. Why should those experiences be dismissed because any physical changes in the body cannot be detected using our current technologies and tests?

The failure to take pain seriously is part of our ranking “objective” as more important than the “subjective”, but, in my view, it’s the invisible which is the most important…..

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Changed

Posted in from the consulting room, from the dark room, from the living room, health, life, photography on June 20, 2012| 2 Comments »

lightning strike

The long marks on this tree were caused by a lightning strike.

Although struck by lightning, this tree didn’t die, it survived. But it survives changed. The marks of the strike become part of the beauty and uniqueness of its bark.

Illness is like that.

Stuff happens. Bacteria are inhaled or swallowed, bones are broken, hearts are broken. Often we blame these external events or stimuli for our illnesses. We say we have an infection when our bodies develop a fever, pain, inflammation in response to bacteria or viruses. In fact we give the infection the name of the bacteria or virus – we say the patient has “E Coli”, or “TB”, or “measles”, despite the fact that most people who inhale or swallow that particular “bug” might not actually develop any fever, pain or inflammation. Thinking this way externalises the illness. It’s something that happens to us and we are the victims.

But it’s more complicated than that. The particulars of our illnesses are the results of our responses, our adaptive responses, to these events, or, more commonly in chronic illnesses, to multiple, often long distant factors/events. Not everyone with the same diagnosis will have the same symptoms, and certainly no two people with the same diagnose will narrate an identical story of their experience of this illness.

Understanding that illness emerges from within our lives changes the power balance. We reject the victim mindset and open up the possibility that this experience of illness presents us with an opportunity to learn something about who we are, what’s important to us, and how we adapt to the changes in our lives.

We are changed as a result of these responses. Kat Duff, in “The Alchemy of Illness”, puts it beautifully –

Our bodies remember it all: our births, the delights and terrors of a lifetime, the journeys of our ancestors, the very evolution of life on earth………in fact, every experience, from the sight of a field of daisies to the sudden shock of cold water, leaves a chemical footprint in the body, shimmering across the folds of the cortex like a wave across water, altering our attitudes, expectations, memories, and moods ever so slightly in a continual process of biological learning.

 

lightning in the forest

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How do we get to know someone?

Posted in from the consulting room, from the reading room, health, life, narrative, perception, personal growth on June 17, 2012| Leave a Comment »

Every day at work I’m focused on trying to understand another person. Every patient who comes to our hospital is seeking, amongst other things, an explanation.

If someone has been given a diagnosis of, say, Multiple Sclerosis, amongst the many questions they are likely to have, are “What does this mean?”, “What does it mean to me, and to my life?”, “How has it come about?”, “Why me?”, “What is this illness and what things are going to make it better, or worse?”

We all have many other questions too, but these questions are amongst the ones to do with explanation.

It’s perhaps even worse when a clear diagnostic label hasn’t been given. When someone suffers chronic pain, chronic fatigue or chronic low mood but “all the tests are normal”. What then? What’s going on?

Explanation involves getting to know someone. If we limit the explanation to a tissue level e.g. “arthritis”, or to an organ level e.g. “angina”, then we stop before we explain this illness in this particular person’s life. And if we want to help the person, not just the “arthritis” or the “angina”, then we’re going to have to take into account the uniqueness of this person’s experience of this particular illness.

A major way we can do that is through story.

It’s through the telling of a story that we gain our insights, and our explanations. For me, two of the questions I want to answer with every patient are “what kind of world does this person live in?” and “what are their coping strategies?”

The kind of world we live in is fashioned by our beliefs, our values and our circumstances (our contexts or environments, physical, relational, cultural), and the way we try to adapt to the changes in our lives are manifest in our default and learned strategies.

In an article entitled, “What do we know when we know a Person?”, Dan McAdams points out that the explainer, or the observer is also important  –

One must be able to describe the phenomenon before one can explain it. Astute social scientists know, however, that what one chooses to describe and how one describes it are infiuenced by the kinds of explanations one is presuming one will make. Thus, describing persons is never objective, is driven by theory which shapes both the observations that are made and the categories that are used to describe the observations, and therefore is, like explanation itself, essentially an interpretation.

In other words, my world view and my coping strategies will influence what I see, what I hear and what sense I make of the patients who consult me. I’ll return to that issue in another post, but Dan McAdams article starts with an interesting conceptual framework for what we know about another person.

Individual differences in personality may be described at three different levels. Level I consists of those broad, decontextualized, and relatively nonconditional constructs called “traits,”…….At Level II (called “personal concerns”), personality descriptions invoke personal strivings, life tasks, defense mechanisms, coping strategies, domain-specific skills and values, and a wide assortment of other motivational, developmental, or strategic constructs that are contextualized in time, place, or role……..Level III presents frameworks and constructs that may be uniquely relevant to adulthood only, and perhaps only within modern societies that put a premium on the individuation of the self…..Thus, in contemporary Western societies, a full description of personality commonly requires a consideration of the extent to which a human life ex- presses unity and purpose, which are the hallmarks of identity. Identity in adulthood is an inner story of the self that integrates the reconstructed past, perceived present, and anticipated future to provide a life with unity, purpose, and meaning.

You can read the full article by Dan McAdams here.

So, how do we get to know someone? Partly it involves knowing ourselves, being aware of our own way of seeing and experiencing the world, knowing what we pay attention to, what we are fascinated by, disinterested in, what we believe and what we value.

And, partly, it involves a focus on the telling of a story – one which “integrates the reconstructed past, perceived present, and anticipated future to provide a life with unity, purpose, and meaning”.

That’s a good start, I reckon.

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Two hearts

Posted in from the consulting room, from the dark room, from the living room, health, life, personal growth, photography, psychology on June 16, 2012| Leave a Comment »

I’ve been thinking recently (again!) about two inter-related dimensions of being human – a creatureliness and a symbolic self, as Becker describes it, or as a visible and in invisible self, a body and a soul….an so on. Then yesterday I read in the superb “The Alchemy of Illness” by Kat Duff –

The Nahuatl peoples believed that we are born with a physical heart, but have to create a deified heart by finding a firm and enduring centre within ourselves from which to lead our lives, so that our hearts will shine through our faces, and our features will become reliable reflections of ourselves. Otherwise, they explained, we wander aimlessly through life, giving our hearts to everything and nothing, and so destroy them.

That set off my thought patterns down several roads…Heartmath and the intelligence of the heart – learning the ways to use our heart-thinking (yes, there is a neural network around the heart which we use to do a kind of thinking). Then I got to thinking, reflecting on a conversation my wife and I had on waking this morning, “imagine what it would be like if what was in your soul actually shaped your face so everyone could see it” – how would you appear to others if what was in your heart shaped your appearance?

Then that last line, “Otherwise, they explained, we wander aimlessly through life, giving our hearts to everything and nothing, and so destroy them.” brought me right back to heroes not zombies, and to Kierkegaard’s line about tranquillizing ourselves with the trivial.

Two hearts……..

two hearts

 

So, what’s in your heart right now?

Are you in touch with your soul’s purpose?

How are you responding to what your heart has to tell you?

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Heroes not zombies

Posted in books, education, from the reading room, health, philosophy, psychology on June 11, 2012| 1 Comment »

This blog name grows on me with the passage of time. People like it, and they tend to “get it” very quickly. I came up with it because I saw that an awful lot of people seem to live life on autopilot, but when you sit down with them in a consultation, you discover one hero after another. People are truly amazing. And every person is the hero of their own story. It’s wonderful to hear the stories unfold and see the heroes emerge.

In Becker’s “Denial of Death”, he writes

Modern man is drinking and drugging himself out of awareness, or he spends his time shopping, which is the same thing. As awareness calls for types of heroic dedication that his culture no longer provides for him, society contrives to help him forget. Or, alternatively, he buries himself  in psychology in the belief that awareness all by itself will be some kind of magical cure for his problems.

And he refers to Kierkegaard who criticised the tendency to live a “safe” life by living at “a low level of personal intensity” as a form of

Tranquilising itself with the trivial

……..there’s a lot of that about!

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Lessons from economics

Posted in from the consulting room, health, science on June 10, 2012| Leave a Comment »

There are interesting discussions taking place on financial and economics blogs mainly in relation to questions of control, complexity and the impossibility of certainty. Here’s an example from an article discussing computerised financial trading technologies.

Here is the conclusion of a US study of computer-generated trading recently concluded: “Financial markets are alive, but a model, however beautiful, is an artifice. …To confuse the model with the world is to embrace future disaster driven by the belief that humans obey mathematical rules.” The powers that be have been embracing future disaster on this belief in a manner which goes far beyond financial markets. But in that shrunken context, individuals everywhere have already abandoned that belief. Wall Street and its global counterparts have been trying to do that too, but their problem is that they have nothing to replace it with. The “belief” that humans can be managed by obeying arbitrary rules of any kind is the last bastion of our rulers. It is waning on the financial markets, just as it is everywhere else, with results that no computer program can predict. That’s why the “market model” no longer “works”.

Think of health care from this perspective. The tendency to confuse models with real life is everywhere in contemporary medical practice. Human beings just don’t follow mathematical rules at an individual level. So why treat statistics as if they are not only TRUTH but the only TRUTH?

It’s not only the “market model” which no longer works……

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Fancy a dose of Vitamin N?

Posted in from the consulting room, from the reading room, health, life, science on June 7, 2012| 8 Comments »

Vitamin N?

It’s what Richard Louv, author of “Last Child in the Woods”, and “The Nature Principle” , refers to as the therapeutic agent we call Nature. It’s a clever idea, as is his diagnosis of “Nature-deficit Disorder” which he claims is widespread in our urbanised societies.

He writes about how exposure to nature is healing and mentions that in Japan “Forest Medicine” and “Forest Bathing” are becoming recognised medical treatments.

He even has his own definition of nature – ” human beings exist in nature anywhere they experience meaningful kinship with other species”

A 2008 study published in American Journal of Preventive Medicine found that the greener the neighborhood, the lower the body mass index of children. “Our new study of over 3,800 inner-city children revealed that living in areas with green space has a long-term positive impact on children’s weight and thus health,” according to senior author Gilbert C. Liu, MD

And….

A study of 260 people in twenty-four sites across Japan found that among people who gazed on forest scenery for twenty minutes, the average concentration of salivary cortisol, a stress hormone, was 13.4 percent lower than that of people in urban settings.6 “Humans . . . lived in nature for 5 million years. We were made to fit a natural environment. . . . When we are exposed to nature, our bodies go back to how they should be,” explained Yoshifumi Miyazaki, who conducted the study that reported the salivary cortisol connection. Miyazaki is director of the Center for Environment Health and Field Sciences at Chiba University and Japan’s leading scholar on “forest medicine,” an accepted health care concept in Japan, where it is sometimes called “forest bathing.” In other research, Li Qing, a senior assistant professor of forest medicine at Nippon Medical School in Tokyo, found green exercise—physical movement in a natural setting—can increase the activity of natural killer (NK) cells. This effect can be maintained for as long as thirty days.7 “When NK activity increases, immune strength is enhanced, which boosts resistance against stress,”

I like these ideas – a lot! You can read more here and here.

Our hospital, the NHS Centre for Integrative Care at Glasgow Homeopathic Hospital, is built around a beautiful garden, and patients frequently comment about the increase in well-being they feel gazing out into, or wandering around in, the garden.

My recent trip up to Crarae Gardens gave me a similar experience. Don’t you feel better after spending some time in natural environments? Which ones are especially good for you?

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What kind of world do you live in?

Posted in from the consulting room, health, philosophy, science on June 7, 2012| 1 Comment »

Here are two questions which are in my mind during every consultation I have with a patient.

What kind of world does this person live in? and What coping strategies does this person use?

Of course like every doctor I will have a number of questions in mind during a consultation. The primary goal of undergraduate Medicine is to teach diagnosis (as best I conceive it, “diagnosis” is an “understanding” – an explanation for what the patient is experiencing). So that is likely to be one of the main goals of all consultations – what’s the diagnosis? Having achieved an understanding/explanation/diagnosis, the doctor then wants to answer the question “what am I going to do about this?” What the doctor does might be to further examine, investigate, or seek the opinion of a specialist. Or what the doctor does might be a therapeutic act – the most common being either the prescription of a drug, or the carrying out of a surgical procedure.

In other words, the same two questions are important for the doctor too. What kind of world does the doctor live in? And what are his or her coping strategies?  The world view frames the diagnosis, and the coping strategies determine the actions.

The current dominant practice of Medicine has emerged from a particular world view, and this world view is the basis of the actions chosen. So what is that world view? (I’m not going to try and nail down a label for the current Medical orthodoxy, but others have termed it “biomedicine”, “Western Medicine”, or even “scientific Medicine”. Whatever the label, I’m referring to the type of Medicine most commonly practised in the UK, and, yes, of course, you’ll see that is very similar to the commonest practices in many other countries too)

The world view from which the current orthodoxy emerges is based on certain postulates –

  1. There is only one reality.
  2. Reality can be “partialised”. It can be divided into parts which can be studied separately in order to know the whole.
  3. Knowledge can be acquired by an observer who is separate from, and stands apart from, reality.
  4. Observing has no influence on what is observed. (or the influence can be isolated or “controlled”)
  5. The observer’s values and meanings can be isolated and suspended.
  6. Two events related in time can be assumed to be causative – “A is the outcome of B”.
  7. Specifics can be generalised i.e. an explanation from one time and place can be applied to other times and places.
  8. Reality can be described in terms of “laws” and “norms”.

I don’t find these postulates either helpful or convincing. What are the postulates behind my world view as a doctor?

  1. There are multiple realities. No two individuals experience identical realities.
  2. The multiple realities are inextricably interconnected to create the whole. As such no single part can explain the whole.
  3. No-one is outside of reality.
  4. Every act of observation influences (creates even) what is observed.
  5. The observer’s values and meanings create their reality. They can’t be suspended. (Points 3 and 4 are connected to there being no object which can be known without the active involvement of a subject)
  6. Complexity and chaos theories show us that reality is non-linear. Causation can never actually be proven.
  7. Specifics always occur embedded in multiple contexts and as such are always unique. Generalisation involves ignoring the contexts.
  8. Laws and norms are cultural constructions to describe common patterns. Nature is diverse and natural phenomena are emergent (continually evolving and developing into different patterns)

How do you think these different world views affect firstly the diagnosis, and secondly the actions taken?

 

 

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Making the healthy sick

Posted in from the consulting room, health on June 2, 2012| 1 Comment »

There’s an excellent article published in the BMJ this week highlighting the increasing problem of “over diagnosis” (defined as “when people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death”)

Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy. A burgeoning scientific literature is fuelling public concerns that too many people are being overdosed, overtreated, and overdiagnosed. Screening programmes are detecting early cancers that will never cause symptoms or death, sensitive diagnostic technologies identify “abnormalities” so tiny they will remain benign, while widening disease definitions mean people at ever lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them. With estimates that more than $200bn (£128bn; €160bn) may be wasted on unnecessary treatment every year in the United States, the cumulative burden from overdiagnosis poses a significant threat to human health.

Where’s the problem coming from? The authors discuss a number of the factors, but they pretty much boil down to an overly reductionist view of illness, commercial and vested interests in technologies and drugs, and fears of under diagnosis.

Drivers of overdiagnosis

  • Technological changes detecting ever smaller “abnormalities”

  • Commercial and professional vested interests

  • Conflicted panels producing expanded disease definitions and writing guidelines

  • Legal incentives that punish underdiagnosis but not overdiagnosis

  • Health system incentives favouring more tests and treatments

  • Cultural beliefs that more is better; faith in early detection unmodified by its risks

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