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Posts Tagged ‘medicine’

Rebecca Solnit wrote, “Categories too often become where thought goes to die. That is, there’s a widespread tendency to act as if once something has been categorised, no further consideration is required. But, often, it is.”

When I read this I thought of some of the writings of the General Semanticists, especially the phrase, “Judgement stops thought”.

We humans have a tendency to privilege the work of our left cerebral hemisphere which is our powerhouse for stripping out details, generalising what it encounters and applying labels, before setting its work into categories…..neat, separate, distinct, categories.

The trouble is, once we’ve done that, and once we start putting whatever we encounter into one of those categories, we stop seeing the uniqueness of “here and now”. We stop seeing the uniqueness of this particular person. We stop seeing a person at all.

There was a strong element of this in my training at Medical School, where they taught us pathologies before they taught us about people. Teachers and students would say things like “Have you seen the hepatomegaly in Ward 2”, or “Have you listened to the heart murmur in bed 14?” I first encountered cirrhosis of the liver in pathology class. It was in a perspex box filled with formalin so the diseased liver inside wouldn’t deteriorate any further. It was a good three years later before I encountered a human being suffering from cirrhosis of the liver (in Ward 2). This kind of thinking is still pretty dominant in Clinical Medicine. When I was a visiting a relative in hospital I overheard a nurse in the corridor say to a colleague “Have you taken blood from bed six yet?” (and I thought, good luck with that, getting blood out of a bed!)

I recently read an interview with a Paris-based oncologist, who was describing how he was using “Integrative Medicine”. He said he realised that all his chemotherapy, his radiotherapy and his surgical procedures were directed at pathology, but nothing he was doing was specifically directed towards patients. So, he began to explore, learn about, and use, a variety of interventions which engaged with the individual, unique patients, to hear their stories, to understand what they were experiencing in their lives, and to support their recovery and healing. This isn’t a new idea, but it still gets reported as if it is new.

The tendency to label and categorise seems to be on the rise. “Asylum seekers” become “illegal immigrants” become “immigrants” who should be denied the rights and privileges of those whose ancestors arrived in the country before them. In the apparently increasingly divided USA, billionaires, politicians, and evangelicals, talk about “Good vs Evil”. The President frequently applies the label “hard Left” to anyone who disagrees with his policies. Derogatory labels like “libtard” are thrown around. People are accused of being “woke”, although it seems nigh impossible to get anyone who uses that term to describe exactly what it means…..and so on. All of these terms, all of this way of thinking, tends to dehumanise….and that makes it easier to hate, easier to be cruel, easier to make life difficult for whoever is being targeted.

What’s the way out of this?

I suspect it will involve using our whole brain instead of only half of it.

The right hemisphere helps us to appreciate the whole, helps us to see connections and contexts. Looking for connections and contexts is a great way to punch holes in the labelled boxes. It’s a great way to make impermeable categories, leaky and permeable.

The reality is we are not all separate, living in entirely different boxes. We are unique, and that uniqueness arises from our individual complex web of connections and relationships. When we start to look for connections, we see the ways out of the separated boxes. We start to see humans again.

But it isn’t just uniqueness which emerges from these connections and relationships, it’s a discovery of what we have in common, of what we share. It’s a realisation that our similarities matter just as much as our differences, and, luckily, our brains have evolved to be able to handle such paradoxes magnificently…if only we would resort to using our whole brains and not stopping thought at labels and categories.

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I have long been a critic of reductionism. I mean, I get how it brings something to the table. Our ability to isolate a certain element from within the flux of phenomena and experience, to focus on that element closely, allows us to further our understanding of the world. I suspect it also does, what Iain McGilchrist describes as a left hemisphere trait….it allows us to grasp, to manipulate and control. Therein lies its power.

But it all goes wrong when we fail to integrate our new understanding of a part back into the reality of the whole.

In her novel, Elixir, Kapka Kassabova, writes –

Medicine emerged from alchemy’s noble attempt to marry the subjective and the objective, matter and mind, inner and outer, and in this way, to lift humanity out of superstition and senseless pain. 

But like magic, the bias of modern medicine went too far in the opposite direction. Like magic, it assumes too much and has many blind spots. 

These blind spots come from its many uncouplings, one of which is the uncoupling of psyche from soma, the soul-spirit from the body. Another is the uncoupling of one organ system from another, and another is the uncoupling of the human being from her environment. 

Both Folk Medicine and Western Medicine discourage you from taking ownership of your well-being through knowledge. Both of them keep you dumb and dependent. 

In this passage she critiques both Modern and Folk Medicine for taking power away from individuals. Too often Medicine, in all its forms, comes across as a body of secret knowledge, with an expectation that patients will have faith, and hand themselves over to the practitioner with the superior knowledge.

Personally, I think this is a terrible way to practice Medicine. Diagnosis, prognosis and potential treatment should be a joint process emerging out of a caring, open relationship between a practitioner and a patient. Ultimately, the goal should be to increase an understanding of the self, and to empower individuals towards greater knowledge and autonomy.

I love how Kapka describes Medicine as emerging “from alchemy’s noble attempt to marry the subjective and the objective, matter and mind, inner and outer, and in this way, to lift humanity out of superstition and senseless pain.” That’s exactly how it felt to me. Medicine, at its best improves the lives of others by “marrying the subjective and the objective, matter and mind, inner and outer.”

But in fact what really strikes me most in this passage is “These blind spots come from its many uncouplings, one of which is the uncoupling of psyche from soma, the soul-spirit from the body. Another is the uncoupling of one organ system from another, and another is the uncoupling of the human being from her environment. ” It’s that use of the word “uncoupling”.

I’ve never used “uncoupling” in this context before. But it resonates with me much more deeply than “reductionist”. This, surely, is the heart of the problem – when we “uncouple” one organ system from another, “uncouple” the mind from the body, “uncouple” ourselves from each other, and from the rest of the lived world with whom we share this one, finite, interconnected, little planet.

Here’s to undoing as much “uncoupling” as we can.

Isn’t that something to aspire to?

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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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One of the things which frustrates me most about Medicine is this question – “Is it physical?”, which may be asked in a slightly other form – “Is it organic?”, (or, the apparent opposite – “Is it functional?”), “Is it a problem of the body or the mind?”. This way of thinking which divides illnesses into two categories, separating out the mind from the body, is still way too common. It’s common in patients who refuse to accept their illness could have anything to do with their mind – “it’s a virus”, “it’s a hormone problem”, “it’s my genes” – usually because they have been led to believe that a problem involving the mind is a “mental problem”, which strangely continues to carry a stigma that an infection, or a broken leg don’t carry. Separating out the mind from the body is a common misunderstanding not least because it is promoted by doctors who should really know better by now.

The human being is a living, multicellular organism. Starting from a single, fertilised egg cell, the foetus doubles and doubles and doubles the number of cells, until the fully formed human being is born with trillions of cells on board. Trillions. It’s too big a number to visualise. In fact, the number of cells in a human body are estimated, not accurately counted, partly because cells die and are replaced constantly. None of these cells exist in isolation. They are all in constant communication with, and respond to, other cells within the organism, so that although we each have a heart, two lungs, a stomach, a liver, a brain etc, none of these organs exist by themselves. Every single one of them is “integrated” with all the others – that means each is in an active two-way relationship with other organs, tissues and cells. The cells of your body don’t compete with each other. They collaborate. They work together to make the whole organism healthy, so that it can adapt and to grow.

The mind, as best we understand it so far, is more than a function of the brain. It’s embodied. There are extensive neural and endocrine networks throughout the body which work together to produce what we call the mind. This understanding of mind is sometimes referred to as “embodied mind”. Search for that term online to learn more if you like. It’s a useful concept which allows us to see that the mind is not confined to the skull.

It turns out that terms like “heart felt”, and “gut feeling”, are not mere metaphors, but reflect biochemical activities and phenomena which involve, not only the heart and the digestive system, but the whole organism.

I used to say to patients and medical students, I only ever saw a body without a mind in the mortuary, and I never met a mind without a body.

It makes no sense to me to separate out the mind from the body, because when illness occurs, it might arise in a specific tissue, or organ (or it might not), but the response to the disorder is a whole being response – we use the powers of every system within the body, and our abilities to think and to feel (I mean emotional feeling), to defend and repair.

The big problem with separating off the mind from the body and looking for “physical” or “organic” problems is that if all the lab tests and imaging comes back within normal limits, an illness ends up being classed as “mental” – and treatments for mental disorders are then offered. Or worse, it is dismissed as “not real”.

But there is another way to look at all of this – a holistic way – where we don’t separate out the mind from the body and whatever the disease, we seek to address the person, not simply some of their cells or organs. Yes, maybe there are cellular pathologies which can be, and should be addressed, but healing and repair always involves a whole person.

Wouldn’t it be better if we never limited ourselves to addressing “pathologies” in cells and systems, but, rather, in addition (and not or, remember), we engaged with the whole person through their story, their actions, their thoughts and feelings? Shouldn’t we address the circumstances of their lives, because nobody lives in isolation from environmental influences?

It makes no sense to me to address only a pathology found in a particular tissue or organ. Medicine isn’t a kind of mechanics. It’s an art, and science, of understanding and relating.

By the way, do you think you can see the suggestion of a heart on the bark of that sequoia in the photo I’ve posted above?

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Sometimes (quite often actually), I wake up with a word or phrase in my head. This morning it was “heart of the universe”. The particular word or phrase can set off all kinds of different thoughts and where this one quickly went was “It’s 2013. It’s 40 years since I dissected a human heart. Second year, Medical School, Edinburgh University. That year we learned Anatomy and Physiology. I was amazed at the structure of the heart. It’s four chambers, the valves, the specialised heart muscle cells which each had their own rhythm, the conduction pathways from the “AV node” which carried the co-ordinating electrical beat to produce the two, opposite states of the heart – systole and asystole.

It was two years later before they told us to put on white coats, buy a good quality stethoscope, and led us on ward rounds, to stand collectively around patients’ beds, and one by one, place our shiny new stethoscopes on their chests to listen for the “lub dub” of the “normal” heart, and listen carefully for the clicks and sounds which filled the silences and revealed the disorders of the valves.

Over the years as a GP, I prescribed the drugs to slow hearts down, to regulate disordered rhythms, and to improve the blood supply to get the oxygen to the cells starved by blocked arteries and causing angina. I also found people presenting with pain, flutters and skipped beats of the heart whose investigation results showed no obvious pathologies. What were we to do with them? And where was the explanation for their symptoms? If their symptoms weren’t signposts to pathology, then what were they?

Gradually, I became aware of how we use heart in our language, as people told me about “broken hearts”, “heart ache”, “longings of the heart”, “an emptiness in my heart”, “getting to the heart of the problem”, “filling my heart with joy”. Of course, from early years I became familiar with the shape of a heart as we would draw it to communicate love. We see that shape everywhere.

three leaves

cafe love

tree

wishes

Why the heart? Why not the liver, or the pancreas, or the spleen? Why not the kidneys?

I knew there were intimate connections between the brain and the heart, mainly channeled through the “autonomic nervous system”. Then only in the last few years did I learn we’ve discovered that there is a neural network around the heart and associated with that is the production of neuropeptides (the small proteins which act on the brain) within the heart and its neural network. So, the links are more intimate than I realised, and, most importantly, more two way than I realised – the brain acts on the heart, but the heart also acts on the brain. In fact, it seems we do some of our mental processing using these neurones around the heart. (That dismissive phrase which I never liked – “it’s all in your head” – turns out to be even more stupid than I always thought it was)

And as time passed, and I experienced encounters with more patients, I began to see that sometimes (not always but often enough to always consider), there were direct links between “heart issues”, “heart language” and “heart symptoms”, irrespective of the presence or absence of pathologies.

So, here’s something to consider as you think ahead into 2013. How about building your “heart intelligence”? That’s a concept that means somewhat different things to different people, but let’s just use it as it is, without detailed definition.

Try the Heartmath technique. Sit quietly, focus on your heart area, take three deep, slow heart breaths, then recreate for yourself a heart feeling (you can find the details here). In this state of “coherence”, ask your heart a question, and wait to see what answer appears. Write it down.

What does your heart tell you about 2013?

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There was an amazing story recently in the NY Times about a Greek man living in the US. He was diagnosed with lung cancer in his mid 60s and given the prognosis of 9 months to live. He decided that instead expensive treatments and a costly funeral in the US, he would return to his native Greek island of Ikaria.

He moved back in with his parents and went to bed to be cared for by his wife and mother. But he started to feel strong enough to go out so reconnected with childhood friends and re-established his Sunday trips to church.

As the months passed he felt strong enough to do some gardening (a common activity on the island) and planted vegetables thinking he might not live to enjoy them, but he would enjoy growing them. Not only did he live to enjoy them but with his regular routines now of plenty of sleep, regular walks up the hill, spending time in the garden and in the evenings with his friends at the bar, and his weekly visits to the church he began to feel well enough to tackle the old, neglected family vineyard.

Three and a half decades on he is now 97, producing 400 gallons of wine a year from his vineyard and seems to be cancer free.

What can we learn from this inspirational story? Well, the author of the story in the NY Times concludes this –

If you pay careful attention to the way Ikarians have lived their lives, it appears that a dozen subtly powerful, mutually enhancing and pervasive factors are at work. It’s easy to get enough rest if no one else wakes up early and the village goes dead during afternoon naptime. It helps that the cheapest, most accessible foods are also the most healthful — and that your ancestors have spent centuries developing ways to make them taste good. It’s hard to get through the day in Ikaria without walking up 20 hills. You’re not likely to ever feel the existential pain of not belonging or even the simple stress of arriving late. Your community makes sure you’ll always have something to eat, but peer pressure will get you to contribute something too. You’re going to grow a garden, because that’s what your parents did, and that’s what your neighbors are doing. You’re less likely to be a victim of crime because everyone at once is a busybody and feels as if he’s being watched. At day’s end, you’ll share a cup of the seasonal herbal tea with your neighbor because that’s what he’s serving. Several glasses of wine may follow the tea, but you’ll drink them in the company of good friends. On Sunday, you’ll attend church, and you’ll fast before Orthodox feast days. Even if you’re antisocial, you’ll never be entirely alone. Your neighbors will cajole you out of your house for the village festival to eat your portion of goat meat

 

Those are probably reasonable conclusions but what inspires me most about this this story is the series of simple, pragmatic choices this man made. He didn’t set off to “beat cancer”, or to find the elusive magical cure. No, what he did was chose, moment by moment, day by day, to live. He might have died in his bed within days of returning to Ikaria. He would have had the death he chose, if that were the case. But he was not at any point focused on trying to determine the detailed outcomes.

Here is what inspires me about this story – at each stage he was focused on how he would live today and at no point did he think how to escape death.

Read the whole article here.

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The Scottish Storytelling Centre in Edinburgh hosted the International Storytelling Festival last week and I participated in a series of workshops entitled “Stories and Cures”. What a fantastic, stimulating, rich experience with a diverse range of nationalities and disciplines taking part. Right at the start of the week I heard something I’d never heard before.

Back in the 18th and early 19th centuries throughout Europe when a person wished to consult with a doctor, there was a practice of letter writing. Someone would write a letter to the doctor whose advised they wished to receive. The letters were typically the person’s story, in their own words, describing what they were experiencing and the contexts of those experiences. In other words, the letters weren’t just lists of symptoms, and certainly weren’t tables of figures or readings, but, rather, they were highly personal, unique life stories.

The doctor would then write back, commenting on parts of the person’s story and giving a range of advice , often touching on issues of morals, hygiene or spiritual life. This was the beginning of a conversation which might be followed up with further exchanges of letters and/or with meeting up for face to face consultations.

Joanna Geyer-Kordesch, whose research as a Professor of the History of Medicine was the basis for this series, has read hundreds of such letters in English, German and French.

I didn’t know such a practice had ever existed.

Just think for a moment how different this practice was from our current doctor-patient relationships.

First of all, the record of the person’s illness is now created and held by the doctor. The stories have been turned into case notes and typically it would be extremely difficult to gain any understanding of who the person is if you were to read these notes. Doctors notes (I don’t think they usually could be stretched to be considered as stories) are mainly lists of symptoms, physical findings and results of investigations, then diagnostic labels based on pathology. The advice recorded certainly isn’t in the form of a conversation or exchange with the patients. In fact advice is more likely to have been replaced by a list of drugs prescribed.

What are the consequences of this change?

There has been a shift in power – from the person to the doctor, or the institution. This shift in power is so great that the words recorded are much more likely to be the doctor’s words and his or her interpretations of the person’s experience, rather than any record at all of the story the person has told (it’s not like that where I work because we have a tradition of writing down the patient’s actual words as much as we can – however, it’s still the doctor making and holding the record, not the person whose life it is)

There has been a shift in focus – from the person to the pathology. As Eric Cassell so beautifully describes in his “The Healer’s Art”, and “The Nature of Suffering”, illness is what the person goes to the doctor with and disease is what he comes home with.

It seems to me we’ve lost sight of the human being in the process. By reducing someone to a mere physical body to measured and imaged, we have dehumanised Medicine. The PERSON has been lost. How do we get the PERSON back into the centre of the stage? How do we get the individual’s agenda back at the heart of the medical engagement? How do we regain the truth of the uniqueness of every single human being and move away from the mass production processes of reducing people to diseases, diseases to “managed”, rather that people to be healed?

A good starting place would be to enable people to tell their stories – in their words, in their order of priority, in their own style – to reveal not just their sensations and experiences, but also their choices, their values and their beliefs (and what about the creation of the record? How and where would you create the record of your illness and your healing?)

Maybe valuing each individual’s story would begin to let us re-humanise Medicine?

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