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Music and recovery from stroke

September 8, 2008 by bobleckridge

On the BBC site there is a fascinating story. Cyril Merle, aged 86, suffered a massive stroke just four days after his wife’s funeral. Now aged 91, he has not only recovered but he is able to do more than he could before his stroke. He credits his love of music as being the main reason for his remarkable recovery.

He didn’t just listen to music, but music became a motivator and a framework for his action. He took up “tea dancing” (this was a very popular tradition in England years ago where couples would enjoy afternoon tea and a dance to a live band) and playing the keyboards (having not played for 30 years). Despite his wife having described him in the past as a “rotten dancer” he says he can now dance better than he can walk and he regularly plays for community sing-songs in the residential home where he lives.

I think there are a number of interesting aspects to this story. Firstly, it does remind me of Edwyn Collin’s story, which is also a remarkable story of stroke recovery involving music. Secondly, right at the beginning of this story is the fact that this man’s stroke occurred within 4 days of his wife’s funeral. A powerful example of the strong psychological, emotional and social determinants of disease. We will never understand illness or health if we think of them in strictly physical/material terms. Thirdly, all three characteristics of health are present in this story. This man suffered a significant incapacitating event, but he adapted. He coped. He survived. But he didn’t just adapt, he grew. Through creative expression of dance and playing a musical instrument he enlarged his life. He developed. In fact, he developed to a point beyond the one he’d reached before his stroke. Finally, he was engaged with life and his community. Tea dances in particular are fundamentally social affairs and he didn’t just play his keyboards for his own enjoyment, he used his new skills to entertain and encourage others in the home where he lives.

What a great story!

Posted in from the consulting room, health | 4 Comments »

Season of mists…..

September 4, 2008 by bobleckridge

season of mists

I looked out the window this morning and saw this. And outside the temperature of the air has taken a dip – 7 degrees C it said on the car dashboard. I’m guessing Autumn’s arrived. It’s funny but years and years after I was taught poetry lessons at school I still can’t see a scene like this without hearing in my head –

Season of mists and mellow fruitfulness,
Close bosom-friend of the maturing sun;

Here’s the whole poem –

Keats. To Autumn

Season of mists and mellow fruitfulness,
      Close bosom-friend of the maturing sun;
Conspiring with him how to load and bless
   With fruit the vines that round the thatch-eves run;
To bend with apples the moss'd cottage-trees,
   And fill all fruit with ripeness to the core;
      To swell the gourd, and plump the hazel shells
   With a sweet kernel; to set budding more,
And still more, later flowers for the bees,
Until they think warm days will never cease,
      For Summer has o'er-brimm'd their clammy cells.

II                                  

Who hath not seen thee oft amid thy store?
   Sometimes whoever seeks abroad may find
Thee sitting careless on a granary floor,
   Thy hair soft-lifted by the winnowing wind;
Or on a half-reap'd furrow sound asleep,
   Drows'd with the fume of poppies, while thy hook
      Spares the next swath and all its twined flowers:
And sometimes like a gleaner thou dost keep
   Steady thy laden head across a brook;
   Or by a cyder-press, with patient look,
   Thou watchest the last oozings hours by hours.

III

Where are the songs of Spring? Ay, where are they?
   Think not of them, thou hast thy music too, -
While barred clouds bloom the soft-dying day,
   And touch the stubble plains with rosy hue;
   Then in a wailful choir the small gnats mourn
   Among the river sallows, borne aloft
      Or sinking as the light wind lives or dies;
And full-grown lambs loud bleat from hilly bourn;
   Hedge-crickets sing; and now with treble soft
      The red-breast whistles from a garden-croft;

      And gathering swallows twitter in the skies.

Funny how the swallows were twittering hundreds of years before people started doing it!


									


				

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Getting the most from your doctor visit

				
September 2, 2008 by bobleckridge  

				


				

					
I never go to see a doctor. Unless I have to. I’m guessing most people feel the same way. So when you do feel you have to visit a doctor, how do you get the most out of your visit? There are many ways to consider that question but I want to share three small drawings with you here. You might want to use one or more of them next time you go to see a doctor.


If you’re going to see the doctor because you feel something is wrong, then it’s pretty likely your first goal is to find out what the problem is. In medical terms, that’s a diagnosis, but in more general terms, it’s an understanding. You want to understand what’s going on. The point of asking the doctor is that doctors are well trained in doing exactly that – they are specialists in making diagnoses. At best, they specialise in understanding people and understanding peoples’ experiences. But you don’t just want a label for your condition. It’s not like naming flowers or trees. You want to know what that’s likely to mean and whether or not you should do anything about it. Here’s the first drawing –


Do I need to do anything?


The question is “Do I need to do anything?”


You can figure that out by asking your doctor first of all how serious this problem is…..in other words “how much of a threat does this pose to me?” If the pain you are experiencing is likely to be a pulled muscle, the threat level is low. If it’s angina (heart pain), it could be pretty high. So where, along the left to right axis of this drawing would you place the threat level? Second, how rapidly is this likely to get worse? This determines the urgency of action. If the condition you’ve got changes over minutes, something needs to be done right now. If it changes only over many years, you can take your time and consider what to do about it.


Having understood this, you and your doctor will be thinking about possible treatments. Before you leap into any treatments however, maybe you should consider whether or not ANY treatments are necessary. This second drawing might help you figure this out.


How much of a problem is this for me?


The question is “How much of a problem is this for me?” And the answer to that depends on how much you are suffering. There are at least these two aspects of suffering – restriction and distress. Health is a kind of flow experience. When things are flowing you’re pretty much unaware you even have a body. When something’s wrong, there’s usually disruption of flow. You get stuck, or inhibited by pain or stiffness or weakness or something. The more you feel restricted, the less able you are to live your life. So, it’s worth thinking where you’d place the degree of restriction you are experiencing on the axis from left to right. How much is this suffering inhibiting, preventing, impeding my life? That restriction contributes to the amount of distress you are feeling but I think distress is more than that and you should consider it as a separate aspect. How great is your distress? The more you plot yourself up and to the right of this little chart, the greater the suffering you are experiencing, and the more important it is to you to do something about it to change the quality of your life.


We don’t just visit doctors for an understanding though. We are probably seeking change. We’d like something to be better. So the second main priority of the doctor is to consider which treatments to offer. This isn’t as straightforward as it might appear and the doctor can’t decide this all by himself (or herself). That’s because different treatments will be best for different people with the same problems.


Most treatments offered are drugs or surgery. All drugs and all surgical interventions carry risks of harm. So here’s my third drawing to help you work out which treatment you’d like to try.


How safe is this treatment?


The focus here is on harm. The old adage “First do no harm” is still of great relevance to the practice of medicine. It’s unlikely your doctor will offer a treatment unless he or she believes that treatment has the potential to help you. Doctors use both clinical epidemiology (“Evidence Based Medicine”), their knowledge of YOU and your condition, and their own clinical experience to work out what treatment to offer you. But it’s always worth considering the aspect of harm. First of all, what potential has this treatment to harm? Has it ever killed anyone? How seriously can it do damage? Secondly, what’s the chances of that harm occurring? That is what is the risk – to me – of that harm?


Having considered all of these issues there’s still a lot to decide and it’s still the very beginning of a journey for you. A good working relationship with a doctor is a continuing conversation. It’s not an event, or just a series of events. As things move on and change you’ll be in continuing conversation with your doctor and both understandings and treatments will change as a result.


I hope you find these helpful.


What about you? Have you found any ways to make a doctor visit more successful for yourself?

									


				

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What does your workplace look like?

				
September 1, 2008 by bobleckridge  

				


				

					
You’ll have seen a few of the photos I’ve taken in the garden of Glasgow Homeopathic Hospital on this blog. I’m very lucky to work in such a lovely environment. But look at these guys! How would you like to work where they work?!


bridge builders

									


				

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Things look different with a bit of imagination!

				
September 1, 2008 by bobleckridge  

				


				

					
)


What’s this?

A UFO?


Well, no. It’s one of the platform lights at Stirling station.


Do you ever do this? Look at something you see every day and imagine it’s something completely different?


(well, it passes the time while waiting for a train!)

									


				

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Time flies

				
August 31, 2008 by bobleckridge  

				


				

					
As I was walking to the station the other morning I noticed something weird about the digital clock on one of the buildings. I stopped and captured it using the video function of my digital camera. Then, just for fun, I imported it into imovie8 and plopped the opening bars of a Jimmy Nail song into the soundtrack.


Here it is……..weird, huh?


									


				

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It’s not about you

				
August 31, 2008 by bobleckridge  

				


				

					
This is rule number three in Daniel Pink’s “Johnny Bunko” book which I mentioned a wee while back. There are two reasons why both the Johnny Bunko rules and this particular rule came to my mind this week.


Firstly, I’ve just been finding that in recent times this little phrase has often popped into my mind. “It’s not about you”. The value of this phrase is its power to re-orientate you. It’s only natural that our inner subjective experience is dominant. So when we feel certain strong emotions – anger, frustration, sadness, and, yes, even happiness – our default understanding of what is going on tends to emerge from the emotions themselves. It’s only a short (unconscious) step from there to “Why is he (or she) treating me this way?” or “Why is he (or she) upsetting me?” or some such similar question. The assumption is that the other person is behaving the way they are with the intention of having an effect on us. Not just an intention, but, a primary intention. We find ourselves thinking that the person is behaving this way because they want us to have a certain emotion. In other words, if it wasn’t for me, he (or she) wouldn’t be behaving this way. Well, you know, maybe in some instances, it’s true. But in many more instances it isn’t! Whether it’s true or not, however, this train of thought gives away our personal power to the other person. We give them the ability and the will to effect the emotions that we are experiencing. An easy, and a quick, way to undermine this whole reaction is to say to yourself “It’s not about you”. Just considering this as a possibility can be liberating. It allows you to shift your conscious focus from yourself to others. At best, it opens the doors to the possibility of a more empathic and more understanding interpretation of the other person’s behaviour.


“It’s not about you” also came into my mind recently when considering the advice a French philosopher, Hadot, who writes in his book “N’oubliez pas de Vivre”, about the almost spiritual exercise of taking a view from on high. When you climb a mountain and survey the world from the mountain’s heights you have an intense shift of perspective. Take this a little further and consider the viewpoint of one of the astronauts looking back at the Earth from the Moon. (Whenever I think that thought, I can hear Nanci Griffiths singing “From a Distance” inside my head!) Whether you physically climb or fly high above your daily world, or whether you take a journey in your mind using your imagination, this experience of looking down on life from on high also has the potential to give you an “It’s not about you” moment. You can become aware of your smallness and of the brevity of your own life in the grand scheme of things.


There’s another sense too in this “It’s not about you” perspective. Time and time again I hear patients tell stories of great suffering which shrinks or even, at least temporarily, disappears, when they connect to others, when they feel, express and act their love for others and in doing so feel a surge of love and meaning in their own lives. Managing to focus on others is not easy when your suffering is so great that it is overwhelming all aspects of your life, but those who manage it, even for short periods, often report feeling transformed.


There was a second reason why Johnny Bunko came to mind this week and that was the post by Daniel Pink on the Johnny Bunko blog where he related Barack Obama‘s Presidency bid to the six Bunko lessons. Go read it for yourself. It’s a good introduction to Johnny Bunko!

									


				

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Should this drug be available on the NHS?

				
August 28, 2008 by bobleckridge  

				


				

					
There’s an organisation in England known as NICE – The National Institute for Health and Clinical Excellence. Many countries have their equivalent organisations. Their job is to inform health service policy but in fact their advice tends to be taken as the definitive word……if NICE says “no” then that drug will NOT be available on the NHS.


Their decisions cause controversy. Most recently they’ve been in the news over treatments for a cause of blindness and anticancer drugs which are indicated for kidney cancer. In trying to defend their decisions I’ve seen NICE spokesmen struggling to insist that they don’t make a decision on the basis of cost, but on “clinical cost effectiveness”. What does this mean?


Across on the NICE website you can find a very clear explanation. It’s all about QALYs – Quality Adjusted Life Years. This is an international formula for calculating the cost of improving the length and quality of a person’s life. Here’s the detail – (the FULL detail) –


Although one treatment might help someone live longer, it might also have serious side effects. (For example, it might make them feel sick, put them at risk of other illnesses or leave them permanently disabled.) Another treatment might not help someone to live as long, but it may improve their quality of life while they are alive (for example, by reducing their pain or disability).


The QALY method helps us measure these factors so that we can compare different treatments for the same and different conditions. A QALY gives an idea of how many extra months or years of life of a reasonable quality a person might gain as a result of treatment (particularly important when considering treatments for chronic conditions)..


A number of factors are considered when measuring someone’s quality of life, in terms of their health. They include, for example, the level of pain the person is in, their mobility and their general mood. The quality of life rating ranges from 0 (worst possible health) to 1 (the best possible health). (See the box below for an example of how this works in practice.)


What about cost effectiveness?


Having used the QALY measurement to compare how much someone’s life can be extended and improved, we then consider cost effectiveness – that is, how much the drug or treatment costs per QALY. This is the cost of using the drugs to give someone an additional year of life..


Cost effectiveness is expressed as ‘£ per QALY’.


Each drug is considered on a case-by-case basis. Generally, however, if a treatment costs more than £20,000-30,000 per QALY, then it would not be considered cost effective.


How a QALY is calculated


Patient x has a serious, life-threatening condition.


    

  • If he continues receiving standard treatment he will live for 1 year and his quality of life will be 0.4 (0 = worst possible health, 1= best possible health)
    • 

  • If he receives the new drug he will live for 1 year 3 months (1.25 years), with a quality of life of 0.6.
    • 



The new treatment is compared with standard care in terms of the QALYs gained:


    

  • Standard treatment: 1 (year’s extra life) x 0.4 = 0.4 QALY
    • 

  • New treatment: 1.25 (1 year, 3 months extra life) x 0.6 = 0.75 QALY
    • 



Therefore, the new treatment leads to 0.35 additional QALYs (that is: 0.75 –0.4 QALY = 0.35 QALYs).


    

  • The cost of the new drug is assumed to be £10,000, standard treatment costs £3000.
    • 



The difference in treatment costs (£7000) is divided by the QALYs gained (0.35) to calculate the cost per QALY. So the new treatment would cost £20,000 per QALY.


—————————————————————————————–


What do you think about this?


I think it’s riddled with problems!


In reality, nobody can tell how many months of life any particular individual human being will live. In fact, the greater the length of the prediction, the less accurate it is. So, not only are we unable to predict accurately how long a person with a particular disease will live, we are also unable to predict how long a person with a particular disease will live if they take a particular treatment. We can work out the averages, work out the probabilities, but we cannot KNOW these figures for any single real person. The use of definite figures such as “8 months without treatments and 13 months with drug X” convey a false sense of certainty. They pretend to be “scientific” and therefore some kind of believable truth. But they are guesses. Informed guesses no doubt, but guesses none the less. If YOU are the patient, are you prepared to make your decisions on the basis of what happens to the statistical average person? Or do you still hope that you might be one of the people who do better than the average? After all, there are always people who will have a better than average experience and nobody can tell you whether or not you are going to be one of those people.


So, the QALY is based on an estimate of a life course. The length of life part of the calculation is a guess. It always is.


Secondly, what about the “quality” part? Who decides that on a scale of 0 to 1 (0=death and 1=perfect health) your quality of life can be assessed as 0.4 or 0.8 or whatever? The questionnaires used have been heavily criticised for picking life values which the authors of the questionnaires rate as important, not the life values which a particular patient might have. Who, in fact, can judge quality of life better than the person whose life it is?


These are not only my criticisms – here are few from the National Library of Health –


    

  1. Values assigned to the quality of life component of the QALY may not reflect the values of patients receiving the interventions.
    2. 

  2. They may lack sensitivity in some disease areas.  For example for chronic disease or mental illness, as quality of life measures largely focus on physical rather than psychological or social disability.
    3. 

  3. Some feel that QALYs can over-simplify complex healthcare issues and suggest ‘quick and easy’ resource allocation decision.
    4. 

  4. In QALYs, all the emphasis is placed on the size of the health improvement, without taking into consideration the starting point.
    5. 

  5. There is an issue with distribution – it is thought that the QALY approach maximises total welfare without regard to how such welfare is distributed between people.
    6. 

  6. There is also criticism that conventional QALYs don’t account for attitudes towards risk.
    7. 

  7. There are several technical assumptions that are implicit within the QALY model, and there is evidence that these do not accurately reflect real life
    8. 



But my doubts don’t stop there. Did you read the part about considering the actual cost of the QALY? £20,000 – £30,000 is the limit. If a treatment costs more than that, then it will not be allowed. Who decided that? Why not £10,000 – £20,000? Or £30,000 – £50,000? Doesn’t this make you uncomfortable? That we decide whether or not a treatment should be available on the basis of this financial limit? It certainly makes me uncomfortable. Should we accept that there has to be a limit at all? We make plenty of other decisions as a society about how money is spent without considering these kinds of limits – fighting wars in Iraq, Afghanistan, building nuclear missiles which know will destroy us all if we use them, paying some footballers more than £30,000 a week, increasing economic inequality…….you can choose your own pet spending decision.


We do need a debate about all of this, but let me ask you to think about this. If the patient with the disease under consideration is someone you love, someone you really, really care about, will you still be happy to accept a decision on the basis of QALYs?

									


				

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8 miles apart 28 years difference in life expectancy

				
August 28, 2008 by bobleckridge  

				


				

					
There was a headline item on the morning news which, even though, it wasn’t really new, was still shocking. In Lenzie, Scotland, the life expectancy of a child who lives there is 81 years. Eight miles away, in the East End of Glasgow a child of the same age as the one in Lenzie has a life expectancy of 53 years. It’s not just the fact that such premature death is so common in present day Scotland, but the difference! 28 years! Neither of these facts are trivial. Wouldn’t you think that such a problem would command the attention and action of a society? What’s the problem? Funnily enough, it certainly isn’t a problem to be pushed off into the NHS to solve. Yes, the NHS has to provide the services to help the people who are suffering from the illnesses which cut their lives so short, but this is a much more complex problem than one which doctors and health care teams can effectively address.


Research by Prof Wilkinson and others has made it crystal clear that economic and social inequality is the heart of the problem. If we don’t address that as a society, we will never bring about any significant change to consign such shocking headlines to history.


These startling facts come from the WHO’s Commission on the Social Determinants of Health. 


Sir Michael Marmot, chairman of the commission, said: “The key message of our report is that the circumstances in which people are born, grow, live, work, and age are the fundamental drivers of health, and health inequity.” He added: “We rely too much on medical interventions as a way of increasing life expectancy.”


And what kind of response has come from the government to this report? Ann Keen, health minister for England said –


The UK is at the forefront of tackling health inequalities, but the challenge of reducing the gap in life expectancy is still very much an issue.


Really? At the forefront? In fact, over the lifetime of the present UK government, inequality has increased significantly, not decreased. Isn’t it time to deal with this issue more honestly?

									


				

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Rudbeckia in the GHH garden

				
August 26, 2008 by bobleckridge  

				


				

					
rudbeckia


Rudbeckia are from the Aster family. These ones growing the garden at Glasgow Homeopathic Hospital (GHH) struck me as particularly lovely.

									


				

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