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Posts Tagged ‘healthcare’

Keeping our attention fixed on the whole

Posted in Uncategorized, tagged , , , on March 11, 2025| Leave a Comment »

The nature of any system cannot be discovered by dividing it into its component parts and studying each part by itself, since such a method often implies the loss of important properties of the system. We must keep our attention fixed on the whole and on the interconnection between the parts

Planck 1936

The Physicist Max Planck wrote this almost a hundred years ago, and he wasn’t the first to make such an observation. Despite that breaking things down into parts and studying them separately is still the predominant approach in the world.

When I studied Medicine at the University of Edinburgh in the 1970s we were taught “Medical Sciences” for the first three years of the six year course. We dissected bodies in the Anatomy class, studied pathological change in tissues and organs in Pathology, learned chemical pathways in Biochemistry and so on. In fact, the first time I saw “cirrhosis” was a diseased liver stored in formalin in a plastic box marked “cirrhosis”. It wasn’t until year 4 that I met an actual patient who had “cirrhosis of the liver”. Maybe all that has changed. But we still practice Medicine by focusing on parts. I often hear from relatives that on a visit to their GP, they are told they can only discuss one problem per visit….so, their asthma today, but come back to talk about their joint pain.

It seems the modern management techniques applied to health care chop the system and the patient’s experience into pieces, sending them to one person for a diagnosis, another for a blood test, another for a prescription, another for advice…..it’s horrendously disjointed. When my dad was in his last month of life in hospital, every single doctor I asked about his progress started their reply with “I’m not your father’s doctor, but I’ll look up his records….” I never found the person who seemed to actually know him.

Yet, we know from research that continuity of care increases both outcomes and satisfaction ratings of patients and practitioners.

In this age where so many people experience multiple “co-morbidities” we need to keep our focus on the whole even more than ever. If we only focus on the parts we begin to believe we know exactly what each drug will do when we prescribe it, yet, not only are the effects different for different people, but in reality, many people are taking multiple medications at the same time (for a multiplicity of disorders)

We need to focus on the whole, and that means giving priority to human beings, their uniqueness and their relationships. It involves trusting doctors and nurses to practice professionally focused on their patients, not on their protocols and clinical guidelines. And we need a lot more whole of life research, which will help us to understand the complexity of the effects of any drug, and the course of any disease in a real person over their lifetime.

It was never a good idea to ignore, or to relegate holistic knowledge. Learning about the parts should include learning about the limitations of learning about the parts.

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Self healing and adaptation

Posted in Uncategorized, tagged , , , , on December 9, 2024| Leave a Comment »

You know if you cut yourself that, in the vast majority of cases, the cut will heal itself just if you keep the area clean. You know how, if you break a bone, that the fracture never heals without the body using its ability to knit back together the broken edges of the bone (sometimes you need something to hold the edges together – a plaster, nails or a plate – but the actual healing of the bone is done by the body). Well, in fact this is what all living organisms do – they self-heal, self-repair, and self-organise.

One model for living organisms is a “complex adaptive system” (search that term on this site and you’ll find several articles I’ve written about it). Complex adaptive systems have a key, core characteristic – they adapt. Self healing is an aspect of adaptation.

Yet, in Medicine we rather take self-healing for granted. We know that nobody recovers from anything without self-healing. We need the body’s abilities to repair, and to adapt and grow, in order to heal. Every single time. But how many treatments, specifically, how many drugs do we use which are developed to target the capacity to self-heal? How many drugs directly stimulate or support the natural processes of self-healing? I don’t know any. Instead we direct our treatments “against” – we use lots of “anti”s – antidepressants, anti-inflammatories, anti-hypertensives, antibiotics etc etc – you get the idea – and hope that in the background the body will self heal. I don’t mean these anti drugs are useless. Clearly they are not. In many cases they can rescue someone suffering from a life threatening episode of illness. But they aren’t enough. We also need to stimulate and support the natural systems of self healing and repair.

What are they?

Well, largely, they are environmental, psychological and social. We need light, clean air, clean water, nutritious food, shelter. We need hope and encouragement. We need to feel cared for and loved. We know that forests can help us heal. We know that time spent in natural environments can help us heal. We know that music, and art, and stories can help us heal.

So do we need drugs? Well, we do. The thing about self-healing is that it is limited by natural biological limits. We are mortal beings. None of us will live forever, and none of us will go through life without experiences diseases and illnesses. Drugs can help us by easing symptoms, addressing imbalances, and countering pathologies. But Medicine is, and always has been, more than just drugs.

But there is something else about self-healing that we should pay attention to and that is…..in common with all forms of adaptation, it is unpredictable at the level of the individual. Sometimes we pretend that all we need to go is a give an “evidence based” treatment and the outcome can be assured. That’s not the case. There is no treatment which produces the same outcome time and time again, in patient after patient. Adaptation teaches us to accept uncertainty. It teaches us to stick with a patient, to follow through and follow up, because only time will tell whether or not the treatment is proving to be useful or not for this person.

And there’s the other key lesson for Medicine from the science of adaptation and self-healing – patients do better when they experience continuity of care.

Over time, we have to adapt our treatments and our care, as the individual patient adapts to the changes brought about by the disease or injury which has made them ill.

It’s good to learn how to deal with uncertainty, because life isn’t predictable.

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General Practice

Posted in Uncategorized, tagged , , , , , , , on November 12, 2024| Leave a Comment »

A wide ranging review of General Practice in the UK has just been published in the British Journal of General Practice. It makes for disturbing reading. Here’s one of their conclusions –

Overall, these findings reveal a system that is approaching — or, in some cases, beyond — breaking point. Staff members are stressed, demoralised, and leaving; clinical care appears to be compromised; and many patients are dissatisfied, frustrated, and unable or less willing to seek care. We believe there are significant risks to patient safety and to the future survival of traditional general practice in UK.

Here’s another –

Quality efforts in UK general practice occur in the context of cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that is unfit for purpose, and physically distant and asynchronous ways of working. Providing the human elements of traditional general practice (such as relationship-based care, compassion, and support) is difficult and sometimes even impossible. Systems designed to increase efficiency have introduced new forms of inefficiency and have compromised other quality domains such as accessibility, patient-centredness, and equity. Long-term condition management varies in quality. Measures to mitigate digital exclusion (such as digital navigators) are welcome but do not compensate for extremes of structural disadvantage. Many staff are stressed and demoralised.

I first expressed the desire to be a doctor when I was three years old. The role model I had was the family doctor who attended the home birth of my younger sister. I was trained according to the dominant values of the time (which are referred to within this study) – “relationship-based, holistic, compassionate care, and ongoing support to patients and families”. The authors of this study find that it is increasingly difficult, and in many cases, impossible, to practice according to these values, even though, GPs still hold them. This results in stress, frustration, and burn-out which impacts adversely on both recruitment and retention of doctors in Primary Care.

So, what’s going on? How did we get here? This paper outlines several factors, not least financial austerity, underfunding, increasing inequality, increasing complexity of illness and an ageing population. But it also highlights a problems which arise from a particular management philosophy – the authors don’t actually use that term – where on the grounds of so-called greater efficiency, health care teams have become more diverse, digital and both algorithmic and protocol-driven services delivered by less qualified staff have increased, and the whole service is disintegrating. The efficiency actually goes down, the dangers increase, and dissatisfaction mounts (in both patients and staff).

The authors don’t give any quick and easy solutions but they shine a bright clear light on the problems, and put their finger on at least one issue at the heart of the problem – the loss of continuity of relationship-focused care delivered by holistically and compassionately.

They do use the word “dehumanised”, and that’s long been my experience. We need to get back to those traditional values and stop doing what impairs them. We need to get back to a health service which puts patients and their GPs at the heart of the system, and stop thinking we can use new technologies and industrial management practices to make things better.

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Informed consent

Posted in Uncategorized, tagged , , , , on May 1, 2024| 2 Comments »

“Informed consent” is a fundamental principle of good, ethical, medical practice. In the UK, the General Medical Council has specific guidance about informed consent in its guide to shared decision making, which begins –

This guidance explains that the exchange of information between doctor and patient is essential to good decision making. Serious harm can result if patients are not listened to, or if they are not given the information they need – and time and support to understand it – so they can make informed decisions about their care.

They specify what information should be shared –

You must give patients the information they want or need to make a decision.

This will usually include:

  1. diagnosis and prognosis
  2. uncertainties about the diagnosis or prognosis, including options for further investigation*
  3. options for treating or managing the condition, including the option to take no action
  4. the nature of each option, what would be involved, and the desired outcome
  5. the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action.
    By ‘harm’ we mean any potential negative outcome, including a side effect or complication.*

When did you last receive a treatment from a doctor? Before you received it, did they gain your “informed consent”?

In my personal experience, informed consent before surgery has always been present, but over the years the information given has improved considerably. When I saw a urologist last year he offered me different options for treatment, discussed the potential benefits and harms, and included a discussion about the option of doing nothing. He then gave me a pack of literature to read and insisted I didn’t decide which treatment to take until I’d read the information and reflected on it before my next appointment with him.

That’s not my experience when it comes to drugs. I have never been given options, nor had the potential benefits and harms discussed, before receiving a prescription, and, in fact, I’m not sure I’ve ever heard of any patient who hasn’t shared exactly that same experience. It’s far more likely that a doctor will write a prescription, and say, take this and come back and see me in x days/weeks. Once the patient picks up the drug from the Pharmacy, inside the pack is an information sheet, which is usually a longer piece of paper than you’d find anywhere else, but where there is a lot of information about what the drug is, the precautions you should take, potential side effects and harms, and exactly how to take it. I’ve never seen any “other options” described on such an information sheet (unlike the information pack I was given before surgery).

I just don’t think this is good enough.

It’s not good practice, as defined by the GMC, and it doesn’t fit with the “Evidence Based Medicine” approach, and it certainly doesn’t meet with the constantly repeated claim to provide “person centred” or “patient centred” Medicine.

If you are a prescriber, maybe you will say, but this just isn’t feasible. There isn’t sufficient time available in each consultation to obtain “informed consent”. I think there are ways to address that. Firstly, there should be enough time, and if there isn’t, then the system is not working. Consultations which are routinely too brief to make a good diagnosis and obtain informed consent are inadequate, and fail to meet the standards of good practice. Secondly, if surgeons can produce comprehensive information about their procedures and the potential benefits and harms, then so can physicians and generalists. Thirdly, as the GMC points out, informed consent is a dialogue and not a single event. Continuity of care has a wealth of benefits, and one of them is enabling an ongoing dialogue between doctor and patient. Many clinics are not designed to facilitate continuity of care, but they could be if we all agreed it was important.

I just don’t think it’s good enough in this day and age to have a doctor write a prescription and say “take this”, without giving any information about potential benefits, harms or other treatment options. And without facilitating a discussion/dialogue with the patient to obtain truly “informed consent”.

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