Heroes Not Zombies

Every time I see a patient for a first consultation I draw the following diagrams to explain what I’m trying to do and how it might fit with whatever other treatments they are receiving.

First I draw two simple shapes –

I say, “The circle on the left represents health and the disordered looking circle on the right represents ‘not health’. In acute diseases, it’s usually pretty easy to understand what’s caused the problem (represented by the red arrow). For example, along comes the flu virus and gives you flu, or along comes the number 6 bus and knocks you down and breaks your leg”. “The whole purpose of undergraduate training in medicine is to teach doctors how to recognise the disordered circles. It’s called ‘making a diagnosis’. This training focuses on the disease or the lesion. The doctor says ‘I know what this is. It’s the flu.’ or ‘You’ve got a broken leg’ or whatever. Whatever the problem, the body sets about its normal activity of trying to repair damage and restore health. This process is represented by the sweeping purple arrow –

“Interestingly, because doctors are trained to diagnose the problem in terms of the disease, all the treatments you are offered are intended to fight, suppress, or remove the disease. What the treatments are not designed to do is enhance the process represented by the purple arrow. Benjamin Frankin understood this. He said ‘God heals and the doctor takes the fee’. It seems strange to me that at medical school we only learn about pathology, about diseases and how to fight them, when, in reality, nobody, but nobody, gets better from any illness without the healing process working. It’s the body’s own capacity to self-repair, self-heal and self-restore which returns, or attempts to return you to health. Treatments directed against diseases might give the body a better chance to do that. In fact, with many diseases, the problem may be too serious for the body to manage to self-heal without the support of fighting the disease. Fighting the disease isn’t a bad thing. It’s just not enough. We need to see what we can do to support and promote your self-healing.”

I then add the following elements to the diagram –

What this shows is the addition of arrows, representing treatments, on the top right directed against the disease. The horizontal lines represent the kind of wall these treatments attempt to put between the disease and the outside world. Many, many treatments are called “anti-something” – anti-biotics, anti-inflammatories, anti-depressants, anti-hypertensives – that’s because most treatment is intended to act against the disease. I point out that, that may be important to do, but that what is missing are the treatments represented by the arrows added on top of the big purple arrow. These represent any treatments intended to support and stimulate the processes of self-repair and self-recovery. (I might then have a discussion with the patient about what factors influence these processes). The final element of this little diagram is the addition of the arrows around and within the circle which represents health.  What I say about them is “In acute disease, as we already discussed, the cause is often obvious and single. In chronic diseases, however, the factors which have produced the problem are typically multiple. The aetiology, or origin, of chronic disease in a person is multifactorial. Some of these factors may be internal – genetic factors, hormonal and nutritional factors for example. Some of them will be external – impacts from the environment, viruses, bacteriae, physical trauma, emotional and psychological traumas and so on. Really anything which impacts on you as a person can impact on your health, and may be a factor involved in causing the illness.’

I find this introduction opens up a holistic, mind-body approach to any illness, empowers the patient, allows for their to be hope, and takes away any “either/or” thinking about dealing with illness from a biomedical perspective of fighting the disease or a biopsychosocial perspective of helping a person with an illness to recover better health.

What do you think? Tell me if this is clear and whether or not you think it is helpful. It’s easy for me to adjust the conversation with the patient at the time, but in a little post like this it might not be so clear?

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.