giant snowdrops

giant snowdrops, originally uploaded by bobsee.

Just because they’re beautiful…..
Actually, one of the reasons I love flower photos, is that I SEE much more in the photo than I usually notice when out walking. The photos seem to actually help me SEE better. In fact, I find carrying a camera changes the way I see the world and somehow stimulates me to notice what I’m sure I’d otherwise just not notice at all. But when I get home and upload my photos to my Mac I can gaze at these flowers on the big screen for AGES.
I hope these simple flowers bring you as much pleasure as they bring me.
Tell me if you get similar experiences with your camera. Does it change the way you SEE the world?

litter

litter, originally uploaded by bobsee.

I went for a walk in the forest yesterday. It appears some school group have been round getting the kids to some kind of exercise. There were a few labels here and there - like “Are mushrooms and berries safe to eat?”
But THIS was my favourite!
Don’t you think they might have cleared up after them???

Patient-centered Interviewing

I’ve just read Patient-centered Interviewing. An Evidence-based Method, by Dr Robert C Smith (ISBN-13 978-0-7817-3279-6). This is one of the best medical textbooks I’ve ever read. I really hope that even in medical schools where the teachers haven’t even heard of this approach, that they will be teaching something very, very similar.

The premise of this book is very simple, and it is that the doctor-patient interview is at the heart of all medical practice. Unlike sick plants or animals, human beings are able to reflect on their own inner experience and to convey that experience using language. These latter qualities make medical practice different from other sciences and crafts. One of the first doctors to make this so very clear was the great George Engel, who proposed, back in the late 1970s, that we move from a biomedical model of human health, to a biopsychosocial one. It is this understanding which underpins “patient-centered interviewing”.

The subtitle of the book is also striking, however, “An evidence-based method”. Much is made of “evidence” these days, and it is arguable that the great ideals of Sackett and his colleagues for “Evidence Based Medicine” has become distorted at the hands of both managers who want to control finances and the practice of doctors, and those who have a narrowly materialistic view of the world, who only value what can be objectively measured. This book, however, takes meets that issue head on by presenting a truly evidence-based approach to the commonest medical procedure on the planet, the one which the average American physician carries out between 140,000 and 160,000 times in his or her working life - the interview.

The patient-physician relationship is the center of medicine. Relationships are central to medical practice…..At the core of any therapeutic relationship is the feeling that an individual can safely expose his or her vulnerability and that he or she is genuinely cared for. These qualities are not merely a matter of having a good bedside manner or of being nice. They have actually been associated with outcomes of care…….The core skill of relationship-building is empathy, which is an accurate recognition and acceptance of another’s emotional state.

Scientific methods usually involve the concept of data. As Smith says,

Although uniquely private and subjective, symptoms and concerns are the primary data - the hard data of the science of medicine - and clinicians and students can enhance their scientific value by good interviewing. These human data lead to most diagnoses and determine most treatments. By “human data”, I mean information that the patient communicates either in words of by nonverbal, but uniquely human, ways, such as a frown. These data are found in no other domain.

He makes what he terms the “humanistic argument” which is that we should “hear and understand our patients in a way that validates them as human beings rather than as objects of study” He points out that this leads to increased patient autonomy which in turn helps them to communicate more clearly what they are actually experiencing and, when it comes to treatment, are much more likely to follow through in their own interests. The biomedical model has produced a doctor-centered approach to interviews - the aim is for the doctor to establish the physical diagnosis - so, the doctor asks lots of questions and the patient is expected to give short, focussed answers. Studies of this method have shown that in over two thirds of interviews, the patient does not manage to complete their opening statement of concerns, being interrupted, on average, 18 seconds into their account. However, Smith is not derogatory about the doctor-centered approach and recognises its value in establishing urgency, clear physical diagnoses, and treatment plans. However, he argues, it often goes wrong because it fails to allow the doctor to comprehend the patient’s personal concerns and, in particular, the psychosocial contexts of their symptoms. This book lays out a method for a medical interview which begins with a patient-centered approach then moves to a doctor-centered one, concluding with a comprehensive, balanced summary of what has been understood through both approaches together. Crucially, he argues that a solely doctor-centered approach is unscientific because it produces biased data about the patient which is not so reliable and not so valid.

The patient-centered interview has five steps

1. Welcoming the patient, introducing yourself, making them comfortable.

2. Capturing both the patient’s and the doctor’s agendae.

3. Facilitating the narrative by using open-ended questions to explore the presenting complaint

4. Developing the personal story and the emotional story through relationship-building skills of emotion-seeking and emotion-handling.

5. Summary and transition to doctor-centered part of interview

I particularly like his little mnemonic of NURS for emotion-handling skills -

N = Naming - saying what the emotion is - “sad”, or “frustrated”, or whatever

U = Understanding - accepting and validating the emotion

R = Respecting - emphasising the positive elements of the patient’s coping

S = Supporting - offering support and partnership to work to bring about improvement

In Appendix B, Smith has included George Engel’s Foreword to the First Edition - which is a short essay worth buying the book for! In it, Engel explains how he developed the concept of the biopsychosocial approach. He quotes Heisenberg - “What we observe is not nature itself but nature exposed to our method of questioning”

Physicist Heisenberg’s dictum exemplifies a fundamental distinction between 17th- and 20th-centure scientific thinking, the latter of which is derived from such conceptual developments as evolution, relativity, quantum mechanics, general systems theory, far-from-equilibrium thermodynamics, and, more recently, chaos and complexity theory. Loosely speaking, we are applying biomedical and biopsychosocial as labels to contrast the two positions. Actually, what Heisenberg enunciates is what clinicians have known from time immemorial - namely, that the answers you get from a patient depend on the questions you pose and how you do. More broadly, it exposes the fallacy of the 17th-century natural science position that what scientists discover exists entirely external to and independent of themselves. In fact, rather than simply examing or observing something “out there”, scientists devise mental constructs of their experiences with the observed as a means of characterising their understanding of its properties and behaviour. This change in perspective began in physics with relativity theory, which required acknowledgement that the location of the observer cannot be ignored relative to what is being observed. The rediscovery of the obvious occurred in that transformation - namely, that science itself is a human activity. The lesson is that humanness and human phenomena cannot be excluded from science.

I find this book very timely. It might be over 30 years since Engel showed how the practice of medicine should change, and in that time both systems approaches, chaos and complexity theories and discoveries should have transformed our understanding of both health and disease. But we are only at a beginning, and the dominant viewpoint is still the 17th-century mechanistic one. Medicine needs to catch up with some of the new findings from science. Evidence, it turns out, is produced within the complex web which stretches from the subjective to the cosmological.

What is this?

purple flower, originally uploaded by bobsee.

Does anyone know what this plant is called?
It’s about 12 inches tall and grows in the verges at the sides of the road. This one is just outside Aix en Provence
I’ve never seen a flower like this in Scotland and I’d like to know what it is.
Can you help?

Judas Tree

Judas Tree, originally uploaded by bobsee.

This lovely tree is known in France as l’arbre de Judea - which probably relates to its prevalence in the Middle East. However, in English, is has come to be known as the “Judas Tree”. Many authorities believe this is a mistranslation from the French.
However, the story which goes with the name is that Judas hanged himself from this particular variety of tree and it produces its blood red blossom each year after Easter in some kind of remembrance of that.
I find these kinds of stories associated with trees fascinating, and this is one of the first I’ve come across where the story either evolved after the tree’s misnaming, or whether the story influenced the naming.
Does anybody know how this tree really got its name?

by the way, I framed this shot to include the church nearby to heighten the religious connection!

The Flower Constellation

Aren’t these amazing?
I thought they looked like little constellations - of seedheads, not of stars - and in the grassy verge instead of the sky

Book market

In Aix en Provence last weekend there was a regular book market in the main square opposite the Hotel de Ville. It’s lovely to be able to browse a book market outside under a blue sky and these photos show how the books attract such a diverse range of people.

When was the last time you went to a book market? Do you have favourite book markets you’d recommend?

Chronic Fatigue Syndrome (or ME) what is it?

I see a lot of patients with the diagnosis of “Chronic Fatigue Syndrome” or “ME”. I probably see a lot of them because most the health service doesn’t quite know what to do with them and, like most patients who come to Glasgow Homeopathic Hospital, everything else they’ve been prescribed hasn’t worked for them.

However, it’s a hugely contentious illness. Some people don’t even believe it exists. Others dismiss it as a psychological problem at best and a frank psychiatric problem at worst. Why is that? Well, the key reason is there isn’t a test for it. The biomedical model of illness recognises problems with objective, measurable “abnormalities” - preferably in some tissue somewhere. It’s actually a rather old-fashioned way of thinking about illness - as if it’s an entity which can be observed, measured, then expelled or conquered; an entity which is some kind of alien presence in the human body. Modern, complexity science has shown us that illness is about maladaptation or malfunction somewhere within the complex, and that measurable, objective pathologies are more often the results not the causes of illness. Beware the doctor who names your illness with the word “syndrome” attached - chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome, premenstrual syndrome, idiopathic urticarial syndrome - if it’s called a syndrome, you can be pretty sure medical science doesn’t really understand it.

If there’s nothing measurable, the physicalists tend to prefer to conclude “there’s nothing wrong”. But when a person is incapacitated by pain, fatigue and other symptoms there is certainly something wrong! To assume that must be a mental problem is very wrong-headed and often ostracises and stigmatises the sufferer.

For those who can’t quite manage to believe the stories patients tell, there is some hope. Scientists claim to have identified seven genetic types of ME. Each type (genetic pattern) seems to be related to a particular pattern of ME symptoms -

Type one had the worst anxiety and depression levels, along with poor sleep and high pain levels. Type two was characterised by significant post-exercise fatigue and joint and muscle pains, while type three was the mildest form of the disease. The research identified type four as linked to moderate levels of body pain and sleep problems, with type five having stomach complaints and the most marked muscle weakness. Type six was specifically connected to fatigue, and type seven had the most severe symptoms including pain, swollen glands and headaches. Type four and type six were the most common forms of the condition.

I think it’s a shame that “tests” are considered more reliable indicators of illness than patients’ narratives, but I do think if these patterns are confirmed, and IF (big if here), that can be turned into a test, then maybe some patients with one of these syndromes will at last be taken seriously.

However, the fact that the researchers have identified six different types confirms a suspicion I have. Most “syndromes” are at best a mixed bag, and, at worst, a kind of dumping ground for a wide range of disorders which happen to share some common features. I don’t think we’ll ever find a “thing” or an “entity” called “chronic fatigue syndrome”. However, we might find a whole set of disorders which currently sit under the same label.

One paper I read a while back about disorders like chronic fatigue, fibromyalgia and irritable bowel syndrome demonstrated the amount of overlap which existed between these illnesses and posited the idea that underlying all these disorders is a more fundamental problem - a dysfunction of the complex adaptive system. This is the explanation I understand best - these disorders seem to be disorders of the whole organism. They aren’t disorders of bits of people, they are disorders of the way the organism functions as a whole complex system.

By coincidence, today, the Guardian published a first person account of chronic fatigue syndrome. Have a read. It’s a clearly written account and it highlights many of the common things patients say about their illness. I know some people will read that account and dismiss it in a way they would not dismiss a patient’s account of cancer. And that’s just one of the problems these patients have to face. In the hierarchy of diseases, ones without abnormal test results rank pretty low! That strikes me as neither rational, nor reasonable.

The Last Lecture - choosing to live

I posted about Randy Pausch’s Last Lecture before.

If you haven’t watched it, please go do that now. You won’t regret it.

Yesterday morning Amazon delivered a copy of the book of the lecture. I had decided on the spur of the moment to make the most of the long holiday weekend and fly to Aix so I took the book with me on the plane. Finished reading it this morning. It was a GREAT read. Randy Pausch, for those of you who don’t know this story is a computer scientist who gave a lecture on the “Last Lecture” series at his university. (The idea of the “Last Lecture” is to deliver the lecture you’d deliver if it were to be your last ever). In Randy’s case, he was diagnosed with terminal pancreatic cancer before delivering the lecture, so it really is his last lecture.

The lecture is about how to live life. How to live life abundantly. It’s a true inspiration. And the book covers the same ground but adds some other ideas on the same subject. I’m pretty much in tune with this thinking. I’m a positivist. In fact, one of my colleagues this week put it nicely “You’re ALWAYS bloody positive!” Oh well, hey, I took it as a compliment!

So what lessons did I take from the book that were new to me? The one that hit home was “Ask”. I’m not good at that. Randy tells a great story about going to Disney with his family and his dad saying how great it would be to ride the monorail train up front with the driver. He said to his dad that as he had worked as an Imagineer he knew the secret of how to get to do that and did his dad want to see? Sure, his dad said. So Randy went up to the driver and said “Excuse me, could we ride up front with you?” Sure, said the driver.

Randy’s dad was astonished but Randy said “I said it was a trick. I didn’t say it was a hard trick”.

Ask. You might receive.

At last, some thoughtful reflection on placebo

Today’s BMJ carries three articles about the placebo effect.

Firstly, in an Editorial by Spiegel and Harrington, they discuss a paper published by Ted Kaptchuk and colleagues where patients with Irritable Bowel Syndrome were randomised into three groups - those who were simply observed, those who were given sham acupuncture, and those who were given sham acupuncture with an enhanced doctor-patient relationship. 3% of the first group got good improvements, 20% of the procedure alone group an 37% of the “augmented intervention group”. As the authors point out,

the doctor-patient relationship in the sham acupuncture only group sounds like a caricature of procedure based medicine practised under strict time limitations:the practitioners explained that this was “a scientific study” and they had been instructed not to talk about it with patients.

and

Clearly the group with the greatest relief of symptoms was the one that received not only sham acupuncture but 45 minutes of quality contact with a clinician. This contact involved questions about the patient’s symptoms and beliefs about them, a “warm, friendly manner,” empathy, and communication of confidence and positive expectations

This is a powerful argument for practising medicine with care and attention. As the authors say -

Perhaps the ratcheting down of the time that doctors spend with patients and our modern overemphasis on drugs and procedures is “penny wise and pound foolish.” Patients might respond better to real as well as placebo interventions if they were associated with a good doctor-patient relationship. Although the increased time and concern may enhance the effects of the placebo, it also changes the context of associations with the treatment—the doctor may enhance the effect of the sham needle, but the needle also becomes a reminder of the enriched relationship.

Here’s their “take home message”

We treat patients in a social and psychophysiological context that can either improve or, alas, worsen outcome. The meanings and expectations created by the interactions of doctors and patients matter physically, not just subjectively.

Human beings cannot be reduced to mere physical components. We are thinking, feeling, meaning-seeking creatures. Health care should be founded on that understanding.

Then, in a reflective article, Pittrof and Rubenstein, consider the ethics of using placebo. They make the point that randomised clinical trials of drugs vs placebo show real effects in the placebo groups -

Published evidence only applies to patients if they have similar characteristics to patients in the study population. Even if this is the case, their response can rarely be accurately predicted. This is one of the problems with evidence based medicine: often its application to the individual is under less than ideal conditions. However, where the study shows that placebo results in a response, when compared with baseline, then that is precisely what the study shows. It is possible to state with confidence that, were the conditions of treatment to be replicated as in the study, the patient would have a statistical likelihood of responding to the placebo, just as we can say that the patient is statistically likely to respond to the active intervention. There is thus a response whose cause is debatable but the response is genuine. On strictly scientific grounds no deception would be involved in referring to this response as an evidence base.

They also point out that full disclosure of information to patients should include a discussion of potential harms -

For example, when advising a patient about treatment for mild to moderate depression clinicians might explain that use of SSRIs may be associated with a higher risk of suicide attempts and that about 80% of the benefits of SSRIs might be attributable to a placebo effect.

and go on to say

we have seen many risk averse patients who would happily accept reduced benefits for much reduced risks.

In other words, if you were told that a treatment had a chance of helping but hardly any chance of harming you, would you choose it first over a treatment that had a greater chance of doing both - helping and harming?