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The importance of the person in medicine

Posted in education, from the consulting room, from the reading room, health on February 4, 2008| 8 Comments »

Sometimes these days, with the dominant biomedical model of health and illness it can seem like people don’t actually matter. The individual stories of patients are dismissed as anecdotes and treatments are divided into one of two categories “proven” or “unproven” on the basis of statistical analyses of clinical trials (experiments on pre-selected groups of volunteers). The implication is that what works in health care is the intervention, be that a drug or a surgical procedure. Who the patient is, and who the doctor is, seems to be of secondary, or, sadly frequently, of no importance at all.

Yet, if you are ever unwell, I bet it matters to you who you consult and how they behave. I think we all want to consult a doctor who, frankly, gives a damn! I know I do. How many of us would seek a health care system based on dispensing machines which dole out drugs after you input your symptoms?

Amazingly, this idea of the importance of the person in medicine is having to be fought for. So, it was with great interest that I read a review of a book in the BMJ this week. The book is “When Doctors become Patients” by Robert Klitzman (ISBN 978 0 19 532767 0). The author is a psychiatrist who became depressed and was so shaken by his experience of becoming a patient that he set about interviewing other doctors who had become patients too.

Time and again Klitzman found that becoming a patient transformed the doctors’ views (and of practice) of medicine.

Non-specific complaints, side effects such as weight gain and fatigue, fear, humiliation, and spirituality acquired new significance. Struggling to adhere to burdensome schedules, they became less draconian about poor adherence to treatment. In presenting medical information, they became aware of the importance of framing the information sensitively.

I guess this is not a surprise. You’d expect experience to change your views. However, you’ll probably find it more than a little shocking that the doctors needed the illness experience to figure this stuff out. We’re clearly missing something in medical education.

The phrase that really hit me between the eyes though was this –

In choosing their own doctor, most interviewees preferred bedside manner over technical skill.

It’s what I’ve always felt personally. I’ve always felt that what’s really important is that you find a person who cares, listens and puts your interests at the heart of the consultation. I take the technical skill bit as kind of a given. ALL doctors should have the technical skills they need to do the job and the processes of continuing education, annual appraisal and the coming revalidation procedures of the General Medical Council are all designed to ensure that. But what about the human bit? What about the importance of the person? We need to make this case more clearly. Too often, the technical skills are attended to, and then we stop.

Finally, the BMJ reviewer concludes –

Klitzman, like Gawande and Groopman, is part of a contemporary group of reflective doctors who, through their writings, contribute to the less palpable but nevertheless crucial moral, social, and experiential dimensions of medicine.

We need more of this. Maybe we are building a body of knowledge and opinion but we’re sadly lacking in the areas of research into the “experiential dimensions of medicine” and in providing medical education which considers this as of equal importance to the knowledge of drugs, trials and the technical skills required to do surgical procedures.

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The statins debate

Posted in health on February 1, 2008| 10 Comments »

Des Spence highlighted the rather selective way statistics are used to support promotion of drug treatments to prevent disease. In particular, he has focussed on the heavy promotion of statins to control cholesterol levels in the blood. Several doctors have written in to the BMJ in response to this article.

Malcolm Kendrick, who has written The Great Cholesterol Con, says (in referring to the statistic that to prevent one death a year you have to treat 700 people)

let us assume that you do gain one entire extra year of life for every 700 years of taking a statin. Then, clearly, if you treat for 700 years you will create one added life year.

Using this (overoptimistic) figure means that if you treated someone for 30 years you can expect to provide them with 30/700 added years of life. This is 15.64 days, or, a shade over two weeks.

In short, if a 50 year old man asked you how much longer he could expect to live if he took a statin for 30 years you can inform him “just over two weeks—max.”

(it’s also worth watching his exploration of what DOES cause heart disease – here it is……………it’s for a medical audience so is pretty technical!)

Peter Davies asks for inclusion of statistics of relevance to the patient who will actually be taking the medicine –

Any trial generates four summary numbers: relative risk reduction, absolute risk reduction, number needed to treat, and personal probability of benefit.

Each number is useful and gives some information, but no one number gives us the whole truth about the information. Using one figure on its own, particularly the relative risk reduction above all others, is very risky.

Each figure takes a different viewpoint on the evidence. The relative risk reduction is a public health (area wide) prediction.

The absolute risk reduction puts the starting risk back into the frame.

The number needed to treat measures the workload needed to achieve the relative risk reduction. It’s the beginning of health economics.

The personal probability of benefit answers the patient’s question, “What’s in this for me?”

Peter Davies has written an excellent piece in the studentBMJ about this problem with interpreting the value of “evidence”, with this excellent conclusion –

Acknowledging the various perspectives on data will lead us away from simple statements such as “this works” and “the evidence shows” towards more specific statements of what works for whom and when. It leads us away from guidelines and back to intelligent negotiation, to distinguish treatment of an established disease from treatment for reducing the risk of a disease, whether as primary or secondary prevention. The gradual reclassification of risk factors as diseases, “risk factoritis,” has lead to confusion over applying evidence derived from populations to individual patients who may not need or want our help.

The parties involved all need to admit that they know part of the truth, but never the whole truth—whether about the evidence, the patient, or the disease. The next time anyone tells you that “the evidence shows that this treatment works,” ask, “From what perspective does this seem to work?” If they do not understand your question, then they do not fully understand the evidence.

It’s good to see this discussion in a mainstream medical journal. There are some hard questions about the direction of medicine which need to be asked. The reliance on medication for a “healthier” life is one of them.

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Response to another attack on homeopathy

Posted in from the consulting room, health on January 30, 2008| 18 Comments »

Sunday 13th January, the Sunday Times in Scotland published an attack on homeopathy by one of their journalists, Joan McAlpine. (Sorry I can’t put a link in cos the Sunday Times doesn’t bother to put their Scotland-only articles on their website) The “stimulus” for the article was a written answer to a question in the Scottish Parliament which showed the cost of GP prescriptions for homeopathic medicines in Scotland. There was nothing really new in the attack – same old arguments really – but what bothered me most about it was the headline describing homeopathy as a “sick fantasy”, the claim that homeopathy was “dangerous” and the dismissal of patients’ reports as being just about feeling better (the implication being they were not really better).

The paper published an edited version of my letter on Sunday 20th but I thought I’d just put the full letter here for you to read.

Dear Madam

£250,000 spent last year by the Scottish NHS for “alternative” drugs? What an outrageously small amount! In the same year the Scottish NHS drugs footed a £1 billion pound bill to the drug companies for prescribed medicines. Yet, 90% of all drugs only work in 30 – 50% of the people who take them. Deaths from homeopathic medicines in the whole of the UK in 2006? Nil. Deaths from prescribed drugs? 1013 reported (over 10,000 estimated). Cost of Adverse Drug Reactions to homeopathic medicines? Nil. And to prescribed drugs? About £500 million a year.
Let’s be clear. Human beings are not machines. What works for one person may not work for the next. Health care needs to be diverse. We need more research into non-drug, non-surgical treatment options and we need to make more available on the NHS inexpensive, safer treatments, such as homeopathy which two out of three patients report is of benefit to them. And while we are at it, Joan McAlpine, let’s stop the arrogance of dismissing the relief of human suffering as “sick fantasy”. If someone says their pain has gone, it has. Prove it hasn’t! If someone says their depression has lifted, it has. It’s time to start putting patients first. At Glasgow Homeopathic Hospital we are, like all good doctors everywhere, successful because we listen to patients and believe what they tell us. We could do with more of that on the NHS.

yours faithfully

Dr R W Leckridge

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Happiness the Confucian way

Posted in from the consulting room, from the reading room, health, life, psychology on January 28, 2008| 5 Comments »

Psyblog has a good post about happiness from the perspective of Confucian teaching in the light of modern discoveries. I was particularly attracted to the quote by Confucius at the start of the post –

“The one who would be in constant happiness must frequently change.”

I’ve often said that one guaranteed “fact of life” is that everything constantly changes. Nothing stays the same. There’s an old story told of a ruler asking for a speech which he could use in ALL situations, and several of his philosophers and teachers taking on the task and failing, until finally, one man gives him the speech which works in all situations (another version of this story involves King Solomon looking for a ring which will relieve his suffering which he fears will go on forever, and he is given a ring with a few words carved into it) What was the speech? Same as the words in King Solomon’s ring –

THIS TOO SHALL PASS

That’s a recognition of the reality of constant change. Japanese culture holds transience in much greater esteem than many other cultures. That’s partly why they greet the blossoming of the cherry trees every Spring with such enthusiasm. (if you’re ever in Japan in the Spring you’ll see thousands of people out photographing the cherry blossom and photos of the earliest blossom will appear on the front pages of the national newspapers). To be in touch with the cycles of the seasons and to celebrate the changes between them can bring great pleasure.

A fundamental characteristic of a complex adaptive system (CAS) is that it constantly changes, constantly adapts.

The first two lessons in the Psyblog post are “Invest in intimate ties” and “Embrace society”. Both of these emphasise the importance of engagement – along with adaptation, one of the key characteristics of a healthy CAS.

The other lessons are interesting too, including “have fun” and “educate yourself” – both of which are about creativity and growth – the third of the characteristics of a healthy CAS.

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Healing trees – Cinchona

Posted in health on January 27, 2008| Leave a Comment »

In an earlier post I wrote about significant trees and said I’d tell a couple of healing tree stories. Here’s one of them.

The Cinchona Tree is famous in the history of medicine. It’s a member of the Rubiaceae family (the same family of plants which coffee comes from). Actually there are 25 different species of Cinchona trees, and the one in question is “Cinchona officinalis“, which is native to Peru. Here’s the story –

The wife of the Viceroy of Peru, the Countess of Chinchon, fell sick with a high fever shortly after arriving from Europe in 1630. The local Spanish Jesuit priests had been taught to treat fevers by the indigenous Peruvian people. They used a preparation of the bark of the Cinchona tree. So, they treated the Countess with this and saved her life. It’s most likely that the fever she suffered was malaria, and we now know that the Peruvian tree bark contained a lot of “quinine”, which is still a staple treatment for malaria.  Whether or not, the Countess of Chinchon ever really did get sick and was successfully treated with the bark of this tree will never be known but most historians think it is a myth.

Whatever the truth of the matter, the key players in the discovery of this tree’s power to cure malaria and the spread of that knowledge is down to the Jesuits. It was a Jesuit apothecary in Peru who heard about the local use of this bark to stop “shivers” in fevers and knowing the severity of the “shivers” in malaria he decided to try it out on sufferers with spectacular results. The Jesuits brought the bark back to Spain and Italy, where it became known as the “Jesuits’ powder“. It’s interesting that aligning the medicine so definitely with the Jesuits led to it being a highly controversial and contested form of medicine for decades. The Protestants were none too keen to accept a Catholic medicine! However, it was successful in case after case of fever, and it was produced, cultivated and distributed worldwide by the Jesuits.

The story of the discovery of quinine is beautifully told in “The Miraculous Fever-Tree” by Fiammetta Rocco (ISBN 0-00-257202-8). It’s a great read and brilliantly researched. In her book she gives many examples of the enormous impact of malaria on events in world history showing how both the disease itself, then, later, the successful treatment of the disease with this drug, probably determined the course of history on a number of occasions.

This “fever tree” is also a key part of the origin of a whole therapeutic practice. Dr Samuel Hahnemann, 1755 – 1843, a German doctor, was translating Cullen’s Materia Medica (the guide to medicines prescribed by doctors at that time) and he read of Peruvian Tree Bark (Jesuit’s powder) as a treatment for “Swamp fever” (malaria). Cullen said it worked by being an astringent (it dried the body up) and Hahnemann wondered if that was true, so he prepared some and took it himself to study its effects. Much to his surprise he developed all the symptoms of a patient with Swamp Fever. This was his discovery of the principle of “like cures like” which led to the creation of a therapy known as homeopathy.

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Drugs work best when diet and lifestyle is good

Posted in health on January 23, 2008| Leave a Comment »

This rather technical study has suggested one of the reasons why drugs work better in some people than they do in others is down to the rest of that person’s life.

We’ve known for a long time that most drugs don’t do what they are designed to do for many of the people who take them. This is not just drugs like painkillers which are trying to modify a subjective experience, but even drugs whose effects are mainly objective right down at cell level, like anti-cancer drugs.

Some researchers are pursuing a genetic explanation for this and a whole new area known as pharmacogenomics has arisen with the hope of combining genetic testing with prescribing so that a particular drug can be chosen in the light of the patient’s genetic make-up which may make them more responsive to the drug in question.

This study is interesting because it looks to an environmental explanation instead and shows that diet and lifestyle strongly influence the effects of particular drugs.

As always, we’ll find that both explanations are partly right and partly wrong. The trick will be to understand how to use these discoveries in the best interests of patients.

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Happy Birthday Biopsychosocial! Pardon?

Posted in from the consulting room, health on January 22, 2008| 2 Comments »

The Biopsychosocial approach to health is thirty years old this month. The what? Yeah, I bet it doesn’t mean much to you, does it? And that’s pretty amazing really. It shows how tenaciously orthodoxy clings to its old models. The dominant model in Western Medicine is the “biomedical” one, which seeks a biomolecular explanation for all illness. This is a materialistic and a reductionist understanding of illness. In fact, proponents deny the very reality of any illness which cannot be explained by molecular, physical changes in a body.

Thirty years ago, George Engel proposed the term “biopsychosocial” as an alternative mode of understanding. Essentially this approach considered that “the study of every disease must include the individual, his/her body and his/her surrounding environment as essential components of the total system.” It situated the individual in the inextricable contexts of his or her life. It proposed that the way to understand illness required a holistic understanding of a person, with every single person being different and unique. It was an argument against reductionism and for insights gained from understandings of the links and influences which exist within our living networks. More than that, it opened the door for psychosomatic medicine – the joining back together of the body and the mind, for so long considered as separate, almost vaguely related entities. There’s an awful lot of illness which is not explainable from a disease focussed approach. We can’t really reduce individual illness experience to a set of physical entities or lesions. And the other side of the coin is that Engel’s approach demanded a holistic understanding of health. From this perspective health is so much more than the mere absence of disease.

So why hasn’t it become the dominant model? And why do we still consider most illnesses as physical entities which we call diseases which can be treated with surgery to remove the lesions and drugs to fight the disorder?

Well, Engel himself gave us the explanation in advance. He said

… nothing will change unless or until those who control resources have the wisdom to venture off the beaten path of exclusive reliance on biomedicine as the only approach to health care

Those who control the resources still like to consider the world as made up of physical, separate objects; still think of disease as an entity to be fought and expelled. We have a better scientific explanation now but it’s still a long way from being the dominant model.

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The power of placebo

Posted in from the consulting room, health, psychology on January 21, 2008| Leave a Comment »

David Corfield posted about an interesting study of the placebo effect. It describes a piece of research into the power of language to effect physical change. Hotel maids burn up a lot of calories through the very nature of their work which is physical from start to finish. But interestingly most of them reckon they do no exercise and their body size and shape isn’t much different from the average woman. The researchers took a group of hotel maids and divided them into two sub-groups, one of which received information in an interview about how many calories they were using up in their different chores. The other sub-group received no information. They found that all the maids’ body fat, waist-to-hip ratio, blood pressure, weight and body mass index measurements were consistent with their perceived level of exercise. One month later they found that in the educated group there was a decrease in their systolic blood pressure, weight, and waist-to-hip ratio — and a 10 percent drop in blood pressure. Observations by the team hadn’t shown any changes in the maids’ routines or physical exercise. So it was changing the state of mind which changed the state of the body.

In the report of this study, the writers find a critic who says that such a placebo effect cannot effect a physical change as placebo can only effect subjective changes. That’s such nonsense! And the article concludes with a great example of asthmatics being given a drug which would make their asthma worse, but being told it would make it better. They not only claimed their asthma was better but the objective lung function readings improved.

Words were originally magic

— Sigmund Freud

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Is being bitter a medical condition?

Posted in from the consulting room, health, psychology on January 20, 2008| 7 Comments »

I just came across a paper about “Post-traumatic Embitterment Disorder”. Apparently “embitterment” is a new term in psychological classification and this study aims to demonstrate that by using new questionnaires (what psychologists call “scales” to introduce a sense of measurability to what is a purely subjective phenomenon) they can show  “Post-traumatic Embitterment Disorder” is a “sub-type of adjustment disorders”. What they are trying to show is that some people who are so severely psychologically injured by a life event that they become “impaired” by it exhibit more bitterness about their experience than others do and the claim is that this constitutes a definable category of disorder.

I am so in two minds about this.

Here’s the positive side. I think everyone tries to make sense of their lives. It’s what we do. We want to understand our experience, to make some sense of it, and, unless we do that, it’s hard to be an effective “agent” of your own life. In other words, first we need to understand a situation, then we can make some choices to engage with it differently and so develop our own particular paths forward. If we can’t do that for ourselves, we need to get the help of others. Those others might be friends or loved ones, or might be other people in the community who have different skills and who might be able to help. One of those groups of people in the community is the professional health carers – a doctor, a nurse, a psychologist or a counsellor for example. If you take your story to one of these people, they’ll try to interpret it from a medical perspective.  A doctor, for example, is skilled at making a diagnosis – finding out whether or not you have a disease. But, diagnosis is about more than naming a disease. It’s a kind of understanding. It’s a kind of making sense of a patient’s experience. Without a diagnosis, a doctor can’t treat you effectively. So, if this new “diagnosis” helps some people to be better understood, then it’s useful.

Here’s the downside. First of all, a diagnosis declares an experience as a disease or illness. It’s not a healthy experience. Once the experience becomes classified as a disease or illness, then the way to change it, the way to provide help becomes one of treatment. Treatment of psychological illnesses tend to involve either prescribing a drug, or undertaking a talking therapy of some kind. A talking therapy which releases someone from a stuck way of thinking and therefore helps them understand their situation can well help that person to make different choices and so have a different experience. A drug solution makes sense if you can explain the experience materially – by showing some imbalance of chemicals in the brain for example – in such a situation a drug can be part of a solution too. It can help a person to find new ways of thinking by changing the way the brain functions. But when you take every experience of life and try to classify it and declare some of it as disorder or disease then you risk medicalising life and you risk reducing human experience to chemical imbalances which can be addressed with drugs. I don’t find that either life-enhancing, or a personally empowering way to live.

Bitterness? Is this a medical disorder? Is this a disease to be treated? Or is it part of an experience which needs to be understood in order to release someone from a stuck place? If someone is bitter, they are usually stuck. And without help they can find it hard to see things differently. So bitterness needs to be addressed, but do I need something like the “Bern Embitterment Scale” to be able to see this?

What do you think?

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A doctor’s job – helping people

Posted in from the consulting room, health on January 17, 2008| 2 Comments »

In an earlier post, I showed this page from my notebook and explained the left hand page – the one about making a diagnosis. Once we understand someone, then we can begin to help them. The right hand page is my mind map to think through some of the issues related to that.

doctor's job

Most diagnoses focus on the physical, measurable “disease”. This naturally leads to treatments being designed to address pathology. In acute disease this is highly relevant. If you’ve broken a leg, you want a treatment which will lead to repair of the bone. If you’ve had a heart attack, you want a treatment which will address the damage done to your heart, and so on. Most drugs and most surgical procedures are designed to do just that – they address the damages tissues and attempt to effect a repair. A repair is either the removal of a lesion, for example, a wart, or a tumour. Or it is a restoration of a necessary balance in the body eg replacing insulin in diabetes. Actually, this is a commonly misunderstood element of medicine. Drugs and operations don’t actually repair anything. They simply, at best, assist the body in effecting its own repair. It’s not the orthopaedic surgeon who heals the bone, it’s the body. Similarly, we tend to think antibiotics cure infections. They don’t. They kill bugs. It’s the body which heals the inflamed lungs, or throat, or bladder, or whatever was infected. This whole approach accounts for much of modern medical practice. It’s materialistic, reductionistic and focussed on measurements of change and definable outcomes. Yet, the misunderstanding about how healing is actually coming about means that the focus is too narrow and overplays the role of the treatment at the expense of the individual human being.

What if helping someone who is ill, is more than a matter of repairing? Well, the next part of the diagram shows how we can focus instead on resilience. By resilience I mean the human capacity to adapt and to cope. The body’s natural defences and systems of repair are a manifestion of a person’s resilience. You know how if your general energy and mood is low, your immune system is compromised and you catch more minor infections? Not only that, in such a state it takes longer to get over something. An intervention which explicitly seeks to foster resilience, fosters repair too. I think this is a concept you’ll understand very quickly, but, clinically, it’s a lot harder than repair. For a start, the contexts of someone’s life plays a big part in their resilience. We see this in work which shows how dates of deaths are often related to significant personal dates – like anniversaries, birthdays and so on. We also see this in work on the effect of the physical environment on recovery rates after operations in hospitals. Resilience is a fundamental part of self-recovery and self-repair. It’s probably a part of the explanation for placebo effects. But it is terribly poorly understood and researched – probably because there are no simple resilience drugs to be marketed!

The final part of the right hand page above is about “growth”. The most amazing result from an illness is when a patient doesn’t re-establish a status quo but where they actually become stronger and more resilient through the experience of the illness. A classic example of this is the Lance Armstrong story – “It’s Not About the Bike” – where he shows how overcoming cancer actually made him into the man who could win the Tour de France more times than any other man in history.

What interventions would explicitly support and encourage growth? Well, that’s even more complex than the resilience issue and even more personal and individual.

But I think that’s our challenge.

I think we need to develop systems of health care which explicitly address the issues of resilience and growth. If we don’t do that, we just end up fire fighting again and again and again. We don’t want to just fight infections, we want to develop people’s capacity to remain healthy and well-defended against infection and other diseases.

So, here’s my wondering and, I hope, some of you will wonder about this too – what would a health service look like if it was more than a repair service? What would we do to encourage and support resilience and growth?

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