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Archive for the ‘health’ Category

Too much optimism is bad for you

Posted in from the consulting room, health, psychology on October 30, 2007| 14 Comments »

There’s an enormous literature these days on happiness, and pretty much all of it pushes some variety of positive thinking. The Happiness Hypothesis is one of the most thoughtful of these books, and Stumbling on Happiness is a fairly good read too, and Professor Layard’s Happiness is worth reading if you want to understand why the English NHS is about to spend millions on CBT.

But I’ve never been a fan of either bandwagons or one-size-fits-all treatments so I read this study about optimism with interest.  Two professors at Duke University’s Business School have come up with an interesting way of measuring optimism – they asked people how long they expected to live and then compared these estimates with actuarial tables of life expectancy. Optimists were classed as those whose self assessment of longevity was beyond that of the statistical predictions and 5% of them were classed as super-optimists – people who reckoned they’d live a good 20 years longer than the statistics would predict! Interesting method, huh?

What they then did was interview people about their behaviours (being a business school they were most interested in financial behaviours). They found the following –

Puri and Robinson find that optimists:

  • Work longer hours;
  • Invest in individual stocks;
  • Save more money;
  • Are more likely to pay their credit card balances on time;
  • Believe their income will grow over the next five years;
  • Plan to retire later (or not at all);
  • Are more likely to remarry (if divorced).

In comparison, extreme optimists:

  • Work significantly fewer hours;
  • Hold a higher proportion of individual stocks in their portfolios, and are more likely to be day traders;
  • Save less money;
  • Are less likely to pay off their credit card balances on a regular basis;
  • Are more likely to smoke.

In other words, while a dose of optimism might be good for you, too much optimism was associated with riskier and less healthy behaviours. I guess it’s this kind of thing that makes it very difficult to do health education with teenagers – trying to tell them smoking will shorten their lives means nothing to most of them – they think those problems are highly unlikely to happen to them.

I think that all coping strategies in life are good if they work for you, but that any coping strategy which is pushed to an extreme will start to harm you. So a little optimism is no doubt a good thing but optimism which is way beyond the probable can disengage a person from reality.

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Squeezing the world into pigeon-holes

Posted in from the consulting room, from the living room, health, life on October 30, 2007| 6 Comments »

Don’t you hate it when people judge you? And don’t you hate it when people assume they know all about you because they’ve stuck you in some pigeon hole? You know the kind of thing. I mentioned in another post sitting on the train recently next to two men who spent the whole journey dismissing huge swathes of humanity – doctors they said were only interested in one thing – money; Iraq was always a hell-hole, now it was just a hell-hole with less buildings; everyone who lives below the Mason-Dixon line is an in-breeder……and on and on and on. These are not uncommon conversations.

One way we function as human beings is to focus on part of reality, classify it and judge it. We do that to try and get a sense that we understand the world and we also do it to try and control our experience of reality. The thing is this strategy brings loads of bad side-effects. For a start, generalised judgement stops thought. Once you judge a whole class of something, you stop thinking about it. By that I mean you stop seeing, stop hearing, stop experiencing the context-sensitive reality of the individual member of that “class”.

I find this way of thinking very, very disturbing. I understand why it’s there, and I know that human beings are incapable of experiencing the totality of experience as it is. We can only perceive and experience aspects of reality at any given moment. But when we are not aware of the enormous down-side of this human function then we are no longer living in the real world. Instead we limit our experience of reality to our pigeon-hole set. We see everything through the thick discoloured lenses we’ve made for ourselves.

This happens in all areas of life. In Medicine, it happens with diagnoses. How sad it is to see people classified as a “case of X” and how much more sad it is to meet a person who can only see themselves as a “case of X”. When we squeeze every patient into a tightly defined diagnostic box we stop seeing them as who they are. People with mental illnesses experiences this a lot. Once they’ve been given a “diagnosis” they often find that all of their experience is interpreted by the doctors as part of that diagnosis. This is what leads to bad and dangerous prescribing. I recently saw a patient who had suffered from a variety of symptoms for the last couple of years. He was investigated at the outset of the illness and given a particular diagnosis. The diagnosis was wrong. But despite the fact that every time he saw his doctors he told them that certain treatments weren’t working they wouldn’t listen. The doctors said they were prescribing the right medicine for his problem. But they weren’t! Luckily, he got sicker and ended up with other doctors and a different investigation which revealed the true diagnosis. Since getting the appropriate treatment for that condition he’s not in a wheelchair any more.

We also stop experiencing the reality of the rich uniqueness of every human being when we classify them according to race, religion, accent, or life-style. It’s sad and it’s such a stupid way to live. Next time you catch yourself, or somebody else, saying that “all X are Y”, challenge them. All X are never all Y! And if you think they are, you’ve lost touch with reality.

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Conversations with sugarmouse

Posted in from the living room, health, writing on October 27, 2007| 1 Comment »

One of the great and surprising joys of blogging is the making of connections with people who you’d probably never ever have met in any other way. It’s one of the best reasons to blog in my opinion. I’ve made a good new friend with a fellow blogger who goes by the name of sugarmouseintherain. We’ve been having email discussions as well as sharing things on our respective blogs and one of his ideas was to have a conversation on the net. (the newer Web 2.0 technologies really make this possible – we used google documents – if you don’t know this tool, google it and explore it!)

Sugarmouse has posted our first conversation about health and healing on his blog today. Please follow this link to go to his blog and read it. We’d both be really keen to have your feedback which you can do by either commenting on the post on his site or by emailing us.

And why is he called sugarmouseintherain? You can find that out on his blog too!

Thankyou for taking the lead on this sugarmouse. It’s really great to make new friends this way.

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Inspiring fictional doctors

Posted in books, from the reading room, health, life on October 26, 2007| 8 Comments »

Did you know that Mills and Boon, the publishers of romantic novels, have a whole section dedicated to medical romance stories? Well, an Irish psychiatrist, Dr Kelly, has analysed about twenty of them and come up with some interesting findings. He found

marked preponderance of brilliant, tall, muscular, male doctors with chiselled features, working in emergency medicine.

He said they were commonly of Mediterranean origin and had personal tragedies in their pasts.

Oh well, that rules me out!

A spokesperson for Mills and Boon said

the medical setting offered much potential for human drama.

“We see exactly the same on televised medical dramas. In these kinds of professions, there is the need to remain emotionally distant, which spills over into private lives – there’s nothing more thrilling than a damaged hero.”

Hey, isn’t that all of us? Aren’t we all damaged heroes?

This little piece got me thinking though about the way doctors are portrayed in fiction and what kind of influence that has. I’ve wanted to be a doctor all my life. First stated that intent at the age of three! And it wasn’t a family connection. There were no medics in my family ever. What I do remember though is watching a soap opera on TV when I was a child – “Dr Finlay’s Casebook”. Dr Finlay was a Scottish GP working in the fictional village of ‘Tannochbrae’ (actually Callander, very close to where I was born and live now – Stirling). I was hugely impressed with Dr Finlay and I have deep seated memories of wanting to be a doctor like him. There were other doctors on TV then. Dr Kildare, for example. Couldn’t stand him! Waltzing around in his white coat like God’s gift to medicine! So, I guess, fictionalised doctors made an impact on me.

How about you? Which fictionalised doctors impress, or impressed you? Did any of them inspire you to become a doctor? or a nurse? Or even put you off the idea for life? Which doctor in fiction would you most like to be your personal doctor? Go on, tell me.

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Better medicines, or money-making medicines?

Posted in from the consulting room, health, Uncategorized on October 26, 2007| 3 Comments »

The BMJ has published a report criticising the way drugs are regulated in Europe

Silvio Garattini and Vittorio Bertele of the Mario Negri Institute for Pharmacological Research in Milan are critical of the dominance of pharmaceutical industry priorities in bringing drugs to market. They appeal for a more patient and doctor led priorities.

There are two common issues which doctors and patients have about prescription drugs – firstly, the drugs which are available often don’t work for individual patients, so there is always a desire for drugs which work better than the ones currently available; and secondly, drug company priorities are more market driven – they are more likely to fund research into drugs for developed countries problems than developing countries problems, even though many more people die from common diseases in those latter countries. The reason why the first problem is not addressed by the current system is summed up in the article –

New drugs have only to show they are of good quality, effective, and safe, independently of any reference or comparison to drugs already on the market. This results in overuse of trials against placebo. Even when new drugs are compared with existing treatments, the trials often seek to show equivalence or non-inferiority rather than superiority to those already available. Such trials could allow drugs into the market that are less active or safe than those in current clinical use. This is because the non-inferiority limit includes a higher incidence of adverse events. The wider the limits the smaller the sample needed and consequently the higher the chance of missing a difference and concluding for non-inferiority. Sometimes limits are so wide that what is considered non-inferior statistically may be worse clinically

They conclude

It is unethical to experiment on patients with the sole aim of obtaining a marketing authorisation. New drugs should be required to have some added value (greater efficacy or less toxicity) to current treatments or be cheaper

So true. This is a European perspective but exactly the same problems are present in the US. And what about the majority of people in the world? How could the system be improved to meet the most pressing health needs in the world, rather than just in developed countries?

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Drug company money paying for medical education. No problem. Nothing to see. Move along there.

Posted in from the consulting room, from the reading room, health on October 24, 2007| 3 Comments »

JAMA (The Journal of the American Medical Association) has published a survey of the links between Medical Schools and the pharmaceutical industry in the US.

They found that 60% of departmental heads had a financial relationship with a drug company as a consultant, member of a scientific advisory board, a paid speaker, an officer, a founder, or a member of the board of directors.

Two thirds of departments at medical schools and large teaching hospitals had relationships with industry that involved research equipment, unrestricted funds, support for research seminars, residency and fellowship training, continuing medical education programmes, discretionary funds to buy food and drink, support for professional meetings, subscriptions to professional journals, and intellectual property licensing.

Overall, they say, 80% of clinical departments and 43% of non-clinical departments had at least one tie with industry.

Now, I don’t know about you, but that concerns me. That’s an awful lot of influence. What do you think the teachers think about it?

Despite these ties “more than two thirds of all chairs with a personal relationship with industry reported that their personal relationships had no effect on the various types of departmental functions. A similar percentage claimed that there was no effect on their personal financial status,” the authors say.

No problem. Nothing to see. Move along there………..

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Poetry and health

Posted in creativity, from the consulting room, from the reading room, health, writing on October 22, 2007| 2 Comments »

When I was recently on holiday on the Isle of Skye I popped in to An Tuireann for a look around, a bite of lunch (had fabulous home-made, thick chunky oatcakes and crab pate), and to log on to the net via their free wifi connection. While uploading photos to flickr, and writing a post or two for this blog, I got chatting to Mark Goodwin, the Literature Development Officer. A delightful and gentle man. He gave me a few postcards from the Poetry Box and I read the poems on them. They were so good! Here are some extracts I noted –

from At The Shrink, by Angela McSeveny –

I can hear the whisper of his pencil

Against the paper

As he jots down notes.

The point jerks like a seismograph

Measuring the impact of my answers.

I blurt out some startling truth

And watch, baffled,

When his right hand doesn’t move.

Well, I can tell you, that little segment got me re-thinking how I take notes! Amazingly, it had never occurred to me, until I read this, that the movement of my pen on the paper of the patient’s case record might be having an impact on the patient. But more than that, these lines also highlight for me how we all discriminate, categorise and judge what we see, hear, experience. A patient tells their story. I listen, hearing some parts more clearly than others, interrupting, or leading this way or that, according to my interest, and in the process create my version of their story…….which turns out, hopefully, to be similar, but, for sure, will be new, unique and different, co-authored by the pair of us.

from…Night Sister, by Elizabeth Jennings

How is it possible not to grow hard,

to build a shell around yourself when you

have to watch so much pain, and hear it too?

………..

You have a memory for everyone

None is anonymous and so you cure

what few with such compassion could endure

I never met a calling quite so pure.

Reading this again just now, made me think again about that study which measured doctors’ responses to others’ pain. But the last line is the one which really struck me – ‘I never met a calling quite so pure’. You don’t hear much about ‘calling’ any more. Sadly, the current ethos is one of reducing every health carer’s job to a list of tasks and competencies, then assuming that any person who can tick all the correct boxes will be able to carry out exactly the same job. It’s not like that. People matter. The personality, the values and the motivation of a health care worker will shine through, for good or for bad! The new way of selecting young doctors for training posts in the UK uses a computer-based questionnaire system and does not accept the submission of a cv for example, and the candidates for GP training are referred to only by their numbers (to prevent prejudice on the part of the selectors from the candidates’ surnames). How many have a ‘calling’, and would any selector rate such a claim?

And finally, from Elma Mitchell’s, ‘This Poem” –

……even the simplest poem

may destroy your immunity to human emotions

All poems must carry a government warning

Words can seriously affect your heart.

Oh, so true! How a word can sting, burn, wound, comfort, move, excite, quicken or slow the heart! One of my favourite writers is Raymond Carver. He can write both poetry and prose in a way that you can be moved to tears by a tiny handful of his words.

So, what do you think about the relationship between poetry and health? Have you any experiences you’d like to share?

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Deaths from prescribed medication up 155% in 10 years

Posted in from the consulting room, health on October 21, 2007| 11 Comments »

The Independent on Sunday today carried a special report on adverse drug reactions to prescribed medication in England.

Between 1996 and 2006 in England the number of prescriptions issued by doctors has risen 51%, from 498 million to 752 million. Over the same period the number of reported deaths from adverse reactions to these drugs has shot up 155%, from 382 to 973 (actually they estimate the number of deaths reported is only 10% of the real number – this would give 10,000 deaths a year!) Also over this period the number of serious reactions to drugs has increased 214%, from 5,022 to 15,760, resulting in the occupation of 5,600 beds by patients with these serious problems. This has an estimated cost to the NHS in England of £466 million a year. This is an astonishing sum of money. I can’t help but think about the arguments used against Tunbridge Wells Homeopathic Hospital claiming the cancellation of a contract with them would save about a quarter of a million pounds a year. They could save a lot more than that if drugs were prescribed less frequently and more carefully.

A British Medical Association spokesperson said –

The British Medical Association said last night that the figures amounted to a “wake-up call” and is calling for better training in the medical profession. Dr Peter Maguire, deputy chairman of the BMA Board of Science, said: “This big rise in fatal and serious adverse drug reactions should be a wake-up call to all doctors. We have a large number of new medications, but there are also fake drugs coming into the market, and more and more people are using herbal and over-the-counter drugs, as well as all the existing prescription drugs. On top of that, people are living longer and we have the situation of polypharmacy, where we treat people with several medications.

These figures are quite shocking aren’t they? The contemporary paradigm of medicine is to focus on the disease and try to treat either the pathology or the symptoms with drugs in the first instance. Despite the rise of Evidence Based Medicine, drug trials do not typically identify the adverse reactions to drugs. We have to wait until people in the real world start to experience them before we see the problems. We should be cautious about prescribing, and we need to put more effort into understanding and developing non-drug solutions to health problems (after all, four out of ten of the top reported drugs are prescribed for mental health problems). However, drugs can make a huge difference to peoples’ lives. They are often necessary. So we have to train doctors to be better prescribers. One of the main problems identified in this report is that patients often complained that a drug was causing them problems but the doctors didn’t pay heed to what the patient said. This is fundamental. Doctors should listen to their patients. Carefully. And should trust what they tell them.

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Following the connections

Posted in from the reading room, health, life, music, Uncategorized on October 18, 2007| 2 Comments »

This headline caught my eye in today’s Guardian – ‘I was trapped into being alive’. It’s an interview with Robert Wyatt. Ah, Robert Wyatt…….now that takes me back to the late 60s, early 70s, when my friends and I were great Soft Machine fans. So I immediately start to think about that band and head off to youtube to see what I can find. Oh, delight, delight! In two vids there is a live recording of the Softs performing Out-bloody-rageous from the glorious Third album – now this might, or might not, be your cup of tea, but here’s the second part – with Robert Wyatt on drums, Elton Dean on sax, Hugh Hopper on bass and Mike Ratledge on the keyboards. I have this on vinyl (must get round to digitizing my three or four hundred albums!) but haven’t heard it for years!

I’ll leave you to explore more of you like, but this music was revolutionary in its time. It was fresh, exciting and innovative. It was real musicianship. Well, Robert Wyatt fell out of a window and broke his back paralysing him from the waist down for the rest of his life. In his solo career though, he has produced some of his greatest work. He has a most unusual singing voice. Here he is singing Elvis Costello’s Shipbuilding –

In the interview, he says that during his deepest depression in the 90s he was

quite unable to sleep. Couldn’t lie still, revolving in the bed all night, and Alfie had to go upstairs to sleep. Wheeling up and down the corridor at 20 miles an hour, I couldn’t stop. I couldn’t write. I lost my sight, I suddenly needed glasses. It felt like dying, but that would have been a release. Physically, as it turns out, I’m very resilient. I was trapped in having to be alive.

Wow! I think that’s an amazing statement. In fact, I meet quite a lot of people who have this kind of experience. Even in the midst of the most awful suffering they discover that they have some kind of life force, some determination to be alive, some resilience, which keeps them toe to toe with the struggle of living and denies them the escape of non-existence.

The final part of the interview really grabbed me too –

Wyatt says his work is instinctive. “A French journalist asked if my music was spiritual, and I said, ‘Only in the original sense of spirit meaning breath.’ I am a breathing animal. If anything, I get lower, not higher, in art to work things out, relying on animal instincts to guide me through what sounds right. Beyond that, it’s unknowable, verbally inaccessible.” He adds, with characteristic self-effacement: “That’s why I work with musicians.”

What a wonderful exploration of the concepts of spiritual versus animal instincts, weaving them together, blurring their distinctions, to focus on what he calls the “unknowable, verbally inaccessible”. Now, I love stories, and I love to write. I am a great fan of words and it delights me to hear my patients’ stories every day but one of the other bigger loves of my life is music. And I think dear, old Robert Wyatt has just hit the nail on the head and explained some of that to me. I know I’ve mentioned here a few times, Deleuze’s three ways of thinking, but this makes me realise that two of my most favourite ways of experiencing the world are through stories and through music.

So, from this little headline in the Guardian, I take a wander down memory lane, accessing almost forgotten parts of my being, find myself singing along to Shipbuilding, and musing about the totally bloody amazing thing it is to be a human being.

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Improving health by aiming at something else….

Posted in education, from the consulting room, from the living room, health, life, science, Uncategorized on October 18, 2007| 1 Comment »

 Now, here’s an interesting study. It’ll soon be published in the November issue of the American Journal of Public Health. There’s a way of considering the amount of health benefit from an intervention. It’s to assess the number quality-adjusted life-year gains per dollar invested. That is, not just benefits in terms of greater life expectancy, but also a measure of quality of life in those years. It’s a cost benefit analysis so the economic payoff is measured by assessing how much the intervention costs so you can work out how much it would cost to get the benefit of the better, longer lives. These researchers claim to have found an intervention which brings greater payoffs in these terms than most other interventions. What amazing new drug is this? Or is it a life-style change?

Nope.

You’re going to be surprised.  It’s reducing class sizes at school!

The class size reduction was from 22 – 25 kids per class, down to 13 – 17. From kindergarten through to Grade 3. The better education, produced better educational outcomes leading to better, less hazardous jobs and the ability to move out of poorer housing etc. I won’t bother you with the details of the figures here (you can follow the link and read more yourself if you like). But what I think makes this study especially fascinating is thinking out of the box.

These days we hear endless claims for technological fixes – from wonder drugs, to vaccines, to new claims for possible genetic engineering. But, historically, the greatest improvements in the health of populations do not come from medical interventions, they come from things like improving water supplies, sanitation, reducing overcrowding and so on. There’s been an enormous movement towards looking at smaller and smaller parts over the last couple of hundred years – reductionism. In the future we’ll see the greatest health gains by focusing holistically, considering the environments and contexts in which individuals are embedded and studying what happens within these systems instead of exclusively studying what happens at molecular levels.

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