Heroes Not Zombies

It’s an old adage in medicine – “First do no harm”. I really think this must be our first consideration when thinking of all therapeutic interventions. The first question I have is what harm might it do? The next question is what good might it do? Then it’s a matter of weighing the one against the other. Is the potential pay-off worth running the risk of the possible harm?

When I started as a General Practitioner it was common for us to do serial injections of tiny amounts of allergens to reduce somebody’s allergic disease symptoms. Hay fever and allergies to house dust mite were probably the commonest allergies treated. A series of injections would sometimes bring some relief from sneezing, runny noses, itchy eyes and so on. The trouble was, that the potential harm turned out to be sudden death. Not that it ever happened to any of my patients, but the authorities rightly decided that the risk of death was too high a price to pay for possible relief from itchy eyes and runny noses, so they withdrew the treatment from GPs.

Well today there was a report about GlaxoSmithKline having evidence that one of their drugs (seroxat) increased the suicide risk in under-18s but they didn’t tell the authorities about this concern for a long time. This created the false belief that it was a safe drug when it wasn’t. Prescribers were likely to fall at the first hurdle – the first do no harm hurdle. What makes this case worse is that they also had evidence that their seroxat wasn’t even effective in treating depression in the under-18s so prescribers then fell at the second hurdle too.

It’s not good enough.

In this time of pushing drug solutions for all health problems through claiming that published trial evidence (usually paid for by the drug manufacturers) will reliably guide doctors, this type of bad behaviour by the drug companies undermines trust and shakes the very foundations of Evidence Based Medicine.

Can I just take a minute to clear something up?

This is an issue that comes up for me with patients probably every week if not most days. It’s about pain. Many patients present to the doctor with a main problem which is about pain. The way doctors are trained is to focus on making a diagnosis. Now, that’s a good idea. I always tell people we can’t figure out what might help until we understand what’s wrong. But the problem arises with the dominant medical paradigm, which is known as the “biomedical model”. This model has been around for three or four hundred years now and it focuses on the concept of disease as a lesion. By lesion I mean something objective which can be observed, or measured.

Two problems arise from this rather mechanical model. First is that if a lesion can’t be found the patient’s symptoms tend to be dismissed as psychological (or worse – pretended!) Anyone who understands health and illness will know that this is nonsense. You don’t need to find a lesion to accept, understand and attempt to alleviate a human being’s suffering. Second is that symptoms and lesions do not exist within a linear relationship.

Pardon?

Well, let me take the example of pain. Let’s imagine someone has a disease where we can see and measure the lesion – cancer would be a good example. There is no simple relationship between the cancer and the amount of pain a person experiences. Two people with the same cancer of the same size in the same part of the body can have utterly different experiences of pain. And any one person can have a cancer that changes size (getting bigger or smaller) without any significant change in their experience of pain.

There is no direct, linear relationship between a pain and a lesion.

Strangely, a lot of people don’t understand that (and I include a lot of doctors there) but it should never be forgotten. Pain needs to be addressed, understood, and managed as pain. It cannot be understood, and managed effectively as a manifestation of a lesion.

This is the value of a holistic, patient-centred approach to illness. The focus is on the person and their experience, not exclusively on their lesions. Pain is real. It doesn’t become unreal in the absence of a lesion.