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Archive for the ‘health’ Category

The art of medicine and the value of experience

Posted in from the consulting room, health, philosophy on December 8, 2007| 3 Comments »

There’s a doctor and bluegrass musician called Dr Tom Bibey left a comment on one of my posts and you know how it is with the net…..you can’t resist following the trails, so I popped across and browsed his blog. What a treat! Here’s a quote from one of his posts –

Folks who believe they know a patient by the paper they keep are so naive.  The impact of sitting at someone’s kitchen table and sifting through the array of pills from different Docs the patient ”thinks” they might be taking is powerful.  Everyone trying so mightily to pass rules to govern human behavior needs to make a few house calls before they get so dadburn high and mighty as to their perceived importance.

See, to me, that’s wisdom. Yes, we need our statistics and our research, and our science, but there really is something called the art of medicine, and people who have no experience of it, probably don’t understand it. To be a good doctor though I think involves making use of the whole self – the brain and the heart – understanding how things work, how to interpret science, but also learning how to relate, how to be compassionate and caring every single day, with every single patient. Without that, you never really get to know anyone and without knowing them, you’ve no way of understanding them, and without understanding you’re working in delusion not reality.

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How scientists give science a bad name

Posted in health, science on December 7, 2007| Leave a Comment »

The irrational claims of “scientists”

Some people claim the term “scientist” as a label of authority. It drives them crazy when people don’t accept their authority. They believe that their views are the correct views and any alternative views are wrong views. I find that attitude horrendously arrogant. And far from rational.
Sir David King, the UK government’s Chief Scientist was complaining yesterday about people who promote views which are different from his own. Specifically he was complaining about people not supporting GM crops and nuclear power but decided to throw his hat into the anti-homeopathy ring while he was at it. Here are two of the irrational claims he made against homeopathy.

First he said homeopathy was not safe. This is a very hard claim to justify if you really claim to be objective and rational. I have heard it said that homeopathy won’t be taken seriously until it kills someone. Well, two hundred years on and there’s still total failure on that one!

Drugs are not safe. An estimated 10,000 people died from serious Adverse Drug Reactions in England in one year. £466 million was spent on hospital treatment of patients suffering serious reactions to drugs.

Surgery is not safe. My trainer when I was a trainee General Practitioner said to me “Be careful and remember if you send your patient to a man with a knife he’ll use it!” It was good advice. At an inquest into the death of a patient after cosmetic surgery –

Dr Steven Chan, who conducted the inquest, did not mince his words. “I have no doubt of the determination of the deceased when she agreed to go through with major surgery,” he said, “but the point must be made that all surgery could result in complications with devastating effects. There is no safe surgery.”

Hospitals are not safe. You wouldn’t want to be in hospital unless you really had to be.

But homeopathy is safe. Nobody has ever died from the effects of a homeopathic medicine. What people actually mean when they say homeopathy is not safe is that some practitioners who use homeopathy are not safe. Well you can say the same of doctors and surgeons, but the way to deal with that issue is training, clinical governance and regulation. The issue is the practice of unregulated or poorly regulated health care. “Where is the evidence that a homeopathically trained doctor is more dangerous than one without homeopathic training?” I recently asked the Editor of the Lancet who had claimed homeopathic practice was dangerous practice. So far, his reply is a deafening silence.

Second Sir David said there is not a jot of evidence that homeopathy works. Well, he can only say that if he hasn’t looked. There is evidence. Go here and read it for yourself. Having read and considered the evidence you might conclude that there is not enough evidence to be convincing enough to change your beliefs. But that’s not the same as saying there is no evidence. You might conclude that there is some evidence that homeopathy is more effective than placebo. Or you might critique the published research and highlight its methodological weaknesses but that’s normal in science. There isn’t a single piece of research into anything which is ‘perfect’. Every study can be, and should be, reviewed, analysed and criticised. What you can’t do is say the research doesn’t exist. What you can’t say is that “there is not one jot of evidence supporting the notion that homeopathic medicines are of any assistance whatsoever” which is what Sir David King said. Not unless you don’t know any better.

Scientists who claim to know The Truth and to tell the rest of us that they know absolutely certainly what is best for us give science a bad name. I enjoy science. It’s fascinating to explore and to learn about how things work. We need good science and good scientists. But science is increasingly showing us that life is complex and that if we want to understand how the world works we need to move away from the old habit of reductionism and simplification which promotes a two-value, unhelpful view of the world dividing everything into right or wrong, proven or unproven, true or false. Understanding and knowledge are never finished, never complete.

(thanks to mo79uk for drawing my attention to Sir David King’s remarks and for commenting –

A fair number of people, I think, have a fairly good or neutral opinion of homoeopathy because the swimming money pool of conventional medicine isn’t delivering all we hope for. And there’s no guarantee and infinite amount of time ever will. At least not for those of us living now. It’s fine to believe in conventional medicine, but when it doesn’t believe in making you better, it’s not foolish to entertain something we don’t understand.

People laughed when it was suggested the earth was round.)

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MacNamara’s Fallacy

Posted in from the consulting room, health on December 7, 2007| 5 Comments »

I just came across something called the MacNamara Fallacy – as best I can see it was first described by Charles Handy in his book, The Empty Raincoat (haven’t read it yet but just ordered a second hand copy through Amazon marketplace for a penny!) – Robert MacNamara was US Secretary of Defence during the Vietnam War.

One of the worst characteristics of the current approach to health (an approach shared in other spheres like education, management and so on) is the tendency to measure what can be easily measured and then base every decision on that, disregarding as unimportant whatever cannot be easily measured.

Here’s the quote (this time referred to by Dr David Haslam in the RCGP journal –

Haslam D (2007). British Journal of General Practice 57:545, 987-993.)

  • The first step is to measure whatever can be easily measured. This is OK as far as it goes.

  • The second step is to disregard that which can’t be easily measured, or to give it an arbitrary quantitative value. This is artificial and misleading.

  • The third step is to presume that what can’t be measured easily isn’t important. This is blindness.

  • The fourth step is to say that what can’t be easily measured doesn’t exist. This is suicide.

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Hospitals can be dangerous places

Posted in from the consulting room, health on December 7, 2007| 2 Comments »

I guess most people would agree with my attitude that if you can manage to avoid hospitals you should. Yes, they are necessary, but, yes, they are dangerous too. How dangerous? Well, a study from the University of York has taken the approach of reading through the records of a thousand patients admitted to one hospital and found almost one in ten of those admitted suffered from an adverse event. They reckon about 30 to 50% of these could have been avoided.

“Our research does confirm though that hospitals are not completely safe places, and that people should try to steer clear of them unless absolutely necessary.”

A Department of Health spokesperson said

“As the study suggests, many adverse events could be avoided if lessons were properly learned and fed back into practice.”

That’s the challenge and that’s part of the answer. Medicine is a person-intensive activity. We should be investing in the training and practice of everyone who works in hospitals. Not just the clinicians. The people who work in hospitals all have important jobs to do and if they don’t do them to the best of their ability all the time, patients suffer. We need to foster a culture of reflection and learning, of continual improvement, not of blame. It’s not about targets. It’s about people.

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Drug companies and the threat to Evidence Based Medicine

Posted in from the consulting room, health on November 27, 2007| Leave a Comment »

Evidence Based Medicine has three principles – consider the evidence for an intervention; consider the relevance of this evidence for this particular patient based on clinical experience and; thirdly, in consultation with the patient respecting their values and perspectives – to draw up a therapeutic plan. That first part about the evidence base is weakened if the evidence itself is distorted. There are a number of ways to distort it.

One is to spin the findings, as was highlighted in this research –

Previous studies have shown that randomised controlled trials with financial ties to single drug companies are more likely to have results and conclusions that favour the sponsor’s products, and a recent study suggests that the same holds true for meta-analyses.

So researchers in the US set out to determine whether financial ties with single drug companies are associated with favourable results or conclusions in meta-analyses on blood pressure lowering (antihypertensive) therapies.

A total of 124 meta-analyses were included in the study, 49 (40%) of which had single drug company financial ties. Differences in study design and quality were measured.

Meta-analyses with single drug company financial ties were not associated with favourable results but were significantly more likely to have favourable conclusions, even when differences in study quality were taken into account.

In fact, the data show that studies funded by a single drug company have a 55% rate of favourable results that is transformed into a 92% rate for favourable conclusions, representing a 37% gap. The gap shrinks to 21% (57% to 79%) when two or more drug companies provide support. Yet the gap vanishes entirely for studies done by non-profit institutions alone or even in conjunction with drug companies.

These findings suggest a disconnect between the data that underlie the results and the interpretation or “spin” of these data that constitutes the conclusions, say the authors.

Another method is not to publish negative trial findings. Bayer, has just suspended one of its drugs because a trial showed it carried a higher risk of death.

The BART study was the latest in a series of worries about Trasylol’s safety in past years. In 2006 a study published in the New England Journal of Medicine showed increased risks of kidney failure, heart attack, and stroke (2006;354:353-65).

As a result, safety warnings for Trasylol were strengthened in 2006, and approval for use was limited to patients who were having heart bypass graft surgery and were at increased risk of blood loss and blood transfusion during the operation.

In October 2006 international drug regulators’ worries heightened when it became known that Bayer had failed to disclose to the agencies or their advisory panels the results of an unpublished study that had been sponsored by Bayer. Indeed, Bayer scientists had defended Trasylol at an FDA panel hearing but had not mentioned their own study.

Bayer announced that it regretted the mistake and that according to an internal investigation the findings of the trial had been withheld by two Bayer employees and not been passed on as necessary.

Evidence Based Medicine only works well for patients if it is applied in full, and the issue of pharmaceutical company influence on what becomes known and how it is presented required constant vigilance. The more we can have non-drug company funded experts involved in careful peer review the better.

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Meditation and good outcomes in psychotherapy

Posted in from the consulting room, health, psychology on November 21, 2007| 1 Comment »

Here’s an interesting study which looks at the influence of meditation on patient care. It wasn’t the patients who did the meditating however. It was the therapists. The researchers took a group of trainee psychotherapists and split them into two groups. One group practiced mindfulness meditation and the other didn’t. The patients they were treating showed improvements as follows –

the [patients treated by the meditation] group showed greater symptom reduction than the [no meditation] group on the Global Severity Index and 8 SCL-90-R scales, including Somatization, Insecurity in Social Contact, Obsessiveness, Anxiety, Anger/Hostility, Phobic Anxiety, Paranoid Thinking and Psychoticism.

So, who therapist is, and how they learn to focus their attention seems to matter. I’ve never learned meditation but I do think that care is a human activity and the current drive to homogenise medicine as if human individuality is not important is misguided. It is important who your therapist is and it is important that the therapist learns and practices focussed attention and active listening whatever the actual therapy being used.

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What’s the role of a doctor?

Posted in from the consulting room, health on November 18, 2007| 3 Comments »

The BMJ Editor’s column this week asks what readers think is the role of the doctor –

In his report into specialist training in the UK, John Tooke asks, “What is the role of the doctor?” The answer may be too various for a single coherent answer. So much depends on context—the clinical setting, the patient’s preferences, the doctor’s experience and seniority. But is there an irreducible core to the doctor’s role, regardless of the context? Tooke calls for a debate that will redefine the doctor’s role.

They point out that this is an important question for three reasons – first the role makes clear what attributes a doctor should have; second because it will set the standards against which their performance is judged; and third it affects the way we design health care.

I’m only just beginning to think this through, but I’d appreciate your own views – what do you see as the doctor’s role? what do expect the doctor to do? and what attributes do you think are important?

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Changing perspectives. Paradoxes

Posted in from the consulting room, from the reading room, health, science on November 18, 2007| 19 Comments »

I think the only controversial principle of homeopathy is the degree of dilution of the medicines but one of the other principles that at first glance doesn’t make sense is that a smaller amount of something can have a greater effect. I think there are a number of reasons why that’s counterintuitive at first. One is that with poisons and drugs we’ve got used to the common phenomenon of bigger doses having more powerful, usually more toxic effects. You can be sure that if a small amount of a substance poisons you then a larger amount will poison you even more. In fact, it will probably kill you. That’s absolutely true. But if you reverse the direction, is it also true that a smaller amount of something will do the same as the larger amount did, but just more weakly? Strangely, the answer is……not always!

Here’s a couple of examples. Aspirin in large amounts increases body temperature. In fact, one of the signs of an aspirin overdose is hyperthermia. But a small dose of aspirin doesn’t put up the body’s temperature just a little bit. In fact it does the opposite. It lowers the body temperature, which is why we use it to treat a fever. Digoxin (from the Foxglove plant) in a high dose causes a highly irregular heart beat, but a small dose of digoxin doesn’t cause a small amount of irregularity, in fact it does the opposite. It produces a regulation of an irregular heart. An old term for this phenomenon is ‘hormesis’. It’s a term which fell into disuse but which has begun to reappear in two interesting areas.

First of all, in the area of toxicology. There’s an organisation called the International Dose-Response Society which seeks to promote research into hormesis. They distribute a newsletter from a scientific grouping which studies BELLE (Biological Effects of Low Level Exposures). You can find a radio item about this on CBC.

Secondly, Richard Bond, an Associate Professor of Pharmacology at the University of Houston, has proposed the term “paradoxical pharmacology” ( Bond, R.A.: Is Paradoxical Pharmacology a strategy worth pursuing? Trends Pharmacol. Sci 22: 273-276, 2001). This is a proposal for research to be done into the use of smaller amounts of drugs given intermittently in some situations to produce curative effects instead of the tolerances and toxicities which come from the use of large amounts constantly. His main area of interest is into the effects of beta blockers, which are drugs which are designed to block adrenaline and noradrenaline which increase the contractility of the heart. Logically, in a condition like heart failure where the body responds to the changed heart function by releasing more adrenaline and noradrenaline to increase the contractility of the heart, beta blockers should have made the situation worse. And in the short term they can do exactly that, but in the longer term they actually improve the situation. As he says –

Therefore, the paradox remains as to why impeding a contractile system results in an increase in contractility.

He cites the use of stimulants such as amphetamines to treat hyperactivity in children and skin irritants such as retinoic acid and benzoyl peroxide are used to treat acne, which is an inflammatory skin condition as other such paradoxical examples. (it’s also known than giving sedative antihistamines, like ‘phenergan’ to children who don’t sleep makes them more awake!) His potential explanation for these effects is interesting –

acute and chronic effects of drugs often produce opposite effects. This is particularly true for receptor-mediated events. For example, acute agonist exposure can produce activation of receptors and increased signaling, whereas chronic exposure can produce desensitization and decreased signaling

We tend to think of the chronic effects of something as just being a linear extension of the acute situation but that’s actually not true. Here’s his rather startling conclusion –

if acute versus chronic responses are often opposite in nature, and if the contraindications [of drugs] have been made based on the acute effects, there is a suggested list of where basic research can begin to look for clues to investigate paradoxical pharmacology. It is the list under ‘Contraindications’ because the opposite of contraindicated is indicated. This is the list where one would have found β-blockers in CHF just a short time ago. I suggest we test the first precept of medicine, ‘do no harm’, and determine its validity by performing basic research with paradoxical pharmacology. If medicine and pharmacology behave as other areas where short-term discomfort produces longer-term benefit, it might well be that we have paid a high price for accepting a presumption.

This is really another example of the non-linear nature of reality. You can’t take a simplistic notion like more of something will do more of the same so less of something will just do less of what more is, and declare it as a Truth. Life, it turns out, is more complex, and way more interesting! It’s Good Science.

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Different perspectives – what do symptoms mean?

Posted in from the consulting room, health on November 17, 2007| 6 Comments »

Most people don’t go to see a doctor unless they feel that something’s not right – in other words, they have a symptom. However, you might go and see a doctor just for a check up or for some screening, even if you’re feeling well. Maybe the following graphs will provoke some thoughts about this.

basic.jpg

If you’re healthy, let’s assume you can place yourself in the bottom left hand quadrant. However, if you’re feeling OK but you go to your doctor and he or she finds something not right, say raised blood pressure, or raised cholesterol level or something then you’re in the bottom right quadrant (where the red star is)

obj.jpg

If you’re not feeling well, say you’ve got some pain, or maybe nausea, or you’re feeling unusually exhausted or something, and either there’s something you can see wrong – a lump, or swelling, or a rash, for example – or your doctor examines you or does a few tests and finds some abnormalities, then you’re up there with the
blue star in the top right corner.

objsubj.jpg

But if the doctor examines you and does tests and finds NO abnormalities then you’re in the top left with the green star

subj.jpg

Doctors are most comfortable dealing with patients who fall into the right hand side of this chart. When we can make objective findings we can diagnose a particular disease.

dis.jpg

This is the main goal of undergraduate medical training – to be able to make diagnoses (in the sense of being able to identify or exclude the presence of a particular disease).
Two things follow this clinically. First of all, treatments are specifically targeted towards the disease. Secondly, symptoms are assumed to be in direct, linear relationship with the disease, so if the disease is reduced, there is an expectation that the symptoms will be reduced accordingly, and, on the other hand, if symptoms are reduced then that can be taken as a sign that the disease is on the wane.
But, actually, human beings are more complex than that. Symptoms and disease are not in direct linear relationships. In fact, in all complex systems, we find that non-linearity is a key characteristic.
Let me give you an example. A woman may complain of severe recurrent or chronic pelvic pain. Tests show that she has some of the tissue which normally lines the uterus lying outside the uterus – a condition known as endometriosis. The surgeon removes the offending wayward tissue but after recovery she finds she still has the pain. I’ve seen patients who have had large portions of their bowel removed for bowel pain who continue to have bowel pain and patients whose spinal abnormalities are treated surgically but whose back pain remains as severe as ever. That’s the downside. On the upside, if a patient has, say diabetes, then getting the dose of insulin right is highly likely to improve ALL of their symptoms. Or if a patient has a broken leg then repairing the fracture is highly likely to remove the disability and the pain. There are relationships between symptoms and diseases, they’re just not simple, linear ones!

But what about the patients who present with symptoms but where the doctors can’t find any objective abnormalities? Well, they are part of a group of patients who can be understood from a different perspective from the disease one – illness.

ill.jpg

Eric Cassell puts it very nicely in his “Healer’s Art” where he says that illness is what a man has, and disease is what an organ has; illness is what you go to the doctor with, and disease is what you come home with! In other words, illness is the whole picture of the patient’s symptoms and their disease.

Sure, if their illness does at least include an indentifiable disease process, the treatments can still be targeted against that disease (in the hope that such an approach will solve the whole problem), but what about the patients who have symptoms but no identifiable disease?

subj.jpg

In Glaswegian there’s an expression for this “It’s in yer heid!” But this is more than a little unfair! It implies that if you’ve got a symptom which remains “medically unexplained” then it’s either imaginary, or due to a psychological problem. This is overly simplistic. First of all because there may indeed be a physical disease process going on that’s just not been uncovered yet. Secondly, because as complex organisms, disturbances of the inner healthy functions are often vague and hard to pin down, but become clearer as they become more severe. And thirdly, because we are all embedded creatures, you can’t consider us in isolation. If you want to understand someone’s symptoms, you need to understand something about their life, especially their changes, challenges and stresses. Changes, challenges and stresses can impact on the mind and the body in diverse ways.

How often does this latter case appear in the working life of a doctor? Well, an American physician by the name of Kroenke, has done a lot of research into this and here’s a slide which summarises one of his key findings –

kroenke.001.jpg

Kroenke has found that of the top ten commonest symptoms presented to doctors by their patients, almost 9 out of 10 of them will fall into this category. As I heard him say once – medical school teaches you how to treat the 1 in 10 with a medical diagnosis, but how are you going to treat the other 9 in 10?

This illness perspective presents a completely different set of challenges from the disease one. I’ll say more about them in another post cos this one’s gone on long enough I think.

But, tell me, what do you think about this?

Oh, and just in case you were wondering, the bottom left segment does represent health, but that feels strangely unsatisfying. Health is just the absence of the bad stuff? It was this diagram which led me to explore what health actually is.

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Homeopathy

Posted in from the consulting room, health on November 16, 2007| 14 Comments »

Some of you who have been around this blog for a while will be aware that I’m a medical doctor and that I work in the National Health Service in Scotland at the Glasgow Homeopathic Hospital. I blog with a hope that my photos and my writings might add a little to the lives of people who browse here. I want to make a contribution. I want my contribution to the intricate net of connections between us to be one of positivity, something which you might find life-enhancing, or inspiring, or thought-provoking, or interesting, or moving.

You know what I hate? Negativity and cynicism. There are people who like to pour their energies into tearing things down. I’m not one of them. I don’t know what you’d think constitutes a good life, but for me, it’s something to do with being the hero of your own story, not a zombie in somebody else’s. What do I mean by that? Well, you can read more about these ideas on the permanent pages (see the tabs, Hero or zombie?, and AdaptCreateEngage, above the banner photo at the top of the blog).

There is a concerted campaign to drive homeopathy out of the National Health Service. This is a campaign to tear something down. I had a brush with it today and the experience has provoked me to write down my views about this therapy which I practice – to explain it a bit.

I wrote a post about homeopathy once before, but what I’ve done now is copy that text into a new permanent page entitled “Homeopathy“. You’ll find that first post under the heading “Part One”. Then I’ve added my thoughts on some of the points which are raised in this debate. You’ll find them under the heading “Part Two”.

These two parts make for an article that’s way too long for a post and I hope there are some points in there which will make a positive contribution.

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