JHH-12.3.pdf - British Holistic Medical Association

Volume 12 Issue 3 Winter 2015

ISSN 1743-9493

holistichealthcare

J O U R N A L O F

The power of relationshipOver-diagnosis on thefrontlineRethinking general practiceOsteoporosis: self-care notdrugs The NHS needs temperedradicalsArt and heartThe star of compassionIt’s time to re humanisemedicine

Plus• Update • Research• Reviews

Beyond peak medicine?

ISSN 1743-9493

Published byBritish Holistic Medical AssociationWest Barn, Chewton KeynshamBRISTOL BS31 2SREmail: [email protected]

Reg. Charity No. 289459

Editor-in-chiefDavid [email protected]

Editorial BoardDr William House (Chair), Professor David Peters, Peter Donebauer, Dr ThuliWhitehouse, Dr Antonia Wrigley

EditorEdwina [email protected]

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Contents

Volume 12 � Issue 3 � Winter 2015

holistichealthcare

J O U R N A L O F

Unless otherwise stated, material is copyright BHMA and reproduction for educational, non-profit purposes is welcomed. However we do ask that you credit the journal. With thisexception no part of this publication may be reproduced in any form or by any other means –graphically, electronically, or mechanically, including photocopying, recording, taping or informationstorage and retrieval systems – without the prior written permission from the British HolisticMedical Association.

Every effort is made to ensure the accuracy of material published in the Journal of Holistic Healthcare. However, the publishers will not be liable for any inaccuracies. The views expressed by contributors are not necessarily those of the editor or publisher. 1

Editorial 2

Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Moving beyond peak medicine: understanding the power of relationship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Sarah Stewart-Brown

Over-diagnosis: a GP’s experience of industrialisationWhat it’s like to be stuck in a dysfunctional system. . . . . . . . . . . . . . . . 7

Mark Lown

Tackling overdiagnosis: supporting the re-emergence of generalist expertise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Joanne Reeve

Overdiagnosis and osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Peter Donebauer

Five windows on suffering – knowing and celebrating who we are. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

William House

Speaking from and of the heart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Fiona Hamilton

The star of compassion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Eleanor Tanner

Rick and Ajita: How may we reconcile systems of healthcare with our subtle humanity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

David Zigmond

William House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Letters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

© Journal of holistic healthcare � Volume 12 Issue 3 Winter 20152

Editorialadvancement, bigger salaries and power. With so muchdepending on individual research track record, smallwonder if, as Horton believes, the feeding frenzy fornational assessment points lures some researchers intounethical practices.

More proof that skeletons are rattling their bones inBig Pharma’s cupboard came in the form of PeterGøtzsche’s (2015) broadside against biological psychiatry.In a May BMJ he claimed that psychiatric drugs kill morethan half a million people every year in the United Statesand Europe and that 98% of psychotropic drugs could bestopped without causing harm. Several of Gøtzsche’sCochrane Collaboration colleagues published theirdissent, but they did agree that the benefits ofpsychotropic drugs have long been exaggerated, and thatharms (including suicide) have been underestimated.

Evidence-based medicine and industrial scale healthcare are based on the assumption that scienceworks. But behind the scenes it is widely understood thatall is far from well. So we should thank Gøtzsche andHorton for pointing their searchlights at these twinicebergs. For though the consequences of changingcourse are perhaps too alarming to contemplate, theyhave been drifting for many years in the darkness towardsBig Pharma’s luxury liner.

Horton concludes that iceberg one – bad scientificpractices – could be avoided if researchers were incentivised to prioritise being right rather than puttingacademic productivity and innovation first. Horton saysscience is starting to take its worst failings more seriously,but nobody is ready to take the first step to clean up thesystem. Iceberg two – medicine’s over-reliance on thepharmaceutical industry and acceptance of collateraldamage, reminds us of an addict’s capacity to deny there’sa problem. Is healthcare’s addiction to pharmaceuticalsjust too deep?

Battling with crises of cuts, cost, cure, care andcommitment the NHS has simply had to carry on doingthe same old thing, not necessarily expecting a differentoutcome; peddling ever faster just to keep the lights on as the demands and expectations multiply. For 12 years,JHH has been commenting on biomedicine’s journey intoa gathering storm, trying at the same time to be a shopwindow for other ways of thinking and doing healthcare.In the spirit of lighting a single candle rather than raging atthe darkness, this issue of JHH takes a look at some ideasand innovations that could be part of the solution. Gøtzsche P (2015) Does long term use of psychiatric drugs cause more harm than good? BMJ, 349, h2435 doi: 10.1136/bmj.h2435

Horton R (2015) Editorial. The Lancet, April 11. Available at:http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2815%2960696-1.pdf (accessed 21 November 2015).

Biomedicine: has science taken aturn towards darkness?Not long ago many of us were talking about ‘peak oil’;thinking that the world order would have to change radically as petrochemical costs rose through the roof.Impossibly expensive oil, we thought, was just around thecorner and it would mean cold turkey from oil addictionand an end to global warming.

We can play around with the obvious drug addictionparallels: an addict’s physical decline, moral compromiseand crimes committed to ensure unceasing supplies. Forchilling examples of where oil addiction has taken us seerecent military adventures and a string of failed climatechange summits.

Falling oil prices have muted the transitionista conversation about low carbon imperatives, human flourishing post-oil, and small is beautiful local economies.We can afford our oil junkie ways for a while longer – atleast until OPEC hikes up the price again. Meanwhile thepusher-man, seeing the stupid addict doing so little to getclean, is rubbing his hands with glee, because low-costcrude has pulled the rug from under our renewablesindustry.

All the same, peak oil is coming despite the timetablechange, and so is peak medicine: a time when – if wecarry on doing medicine the same way – the state won’tbe able to afford healthcare free at the point of delivery.Why so? Chancellor George Osborne would probablyblame having to pay an extra £8 billion a year into the NHS on inefficiency, perverse incentives, agency staff, PFIs,junior doctors, old people with long lives etc. But hewould be wrong; the NHS needs ever-deeper pockets inits struggle to deliver excellence a million times every 36 hours, because its way of doing medicine is no longerfit for purpose.

Lately, to make matters worse, two dark clouds arelooming on medicine’s horizon: the first, growing cynicism over medical research; the second, mountingalarm at the extent of medicine-related harm. RichardHorton, fearless editor of The Lancet, recently wrote, ‘The case against science is straightforward: much of thescientific literature, perhaps half, may simply be untrue.Afflicted by studies with small sample sizes, tiny effects,invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science hastaken a turn towards darkness’ (Horton 2015).

Right now, university finances are bolstered by thebrownie points they get for academic staff ’s publishedoutput. Points mean prizes because they turn into departmental top-up funding, star ratings, academic career

David PetersEditor

© Journal of holistic healthcare � Volume 12 Issue 3 Winter 2015 3

Launch of Portland Centre forIntegrative Medicine

Portland Centre for Integrative Medicine (PCIM) wassuccessfully launched during Bristol’s Green CapitalHealthy City Week. Dr William Bird gave an inaugural talkhighlighting the scientific evidence that connecting peopleto green spaces improves health and wellbeing.

PCIM also co-ordinated a Bristol Kitchen onPrescription Partnership event with community foodeducators and the centre’s nutrition team who talked tomembers of the public and healthcare professionals aboutthe benefits of cooking from scratch. The PCIM educationteam gave an inspirational talk about integrative medicalapproaches for a healthy heart. A video of the event isavailable at https://www.youtube.com/watch?v=BBp4DKinP24&feature=youtu.be. The BHMA homepagewill carry links for future events and the development ofthe integrative medicine diploma – coming in 2017.

Arts in Health Conference and showcase

This conference at the Royal Festival Hall on 5 February2016 is the first of its kind and will be showcasing 24examples of where the arts are already involved in thehealth service and showing outcomes. The Secretary ofState for Health and various other Department of Healthmandarins are scheduled to speak. Despite this, the day’sevents (CPD accreditation for professionals) should be ofreal interest to anyone who wants to explore how the artscan be harnessed to improve healthcare. A choice of up to six 'tasters' from 24 available programmes show arts inhealth programmes in action. Booking open now at:www.southbankcentre.co.uk/whatson/national-arts-in-health-celebr-94344?dt=2016-02-05

The inexorable rise of antidepressants

A report from the NHS Health and Social Care InformationCentre revealed in July that GPs wrote 57.1millionprescriptions for antidepressants in 2014: almost doublethe number in 2004 (29 million). A new study from King’sCollege London research team showed a huge range ofantidepressant use across the EU: from 16% in Portugal to3% in Greece. At 9% the UK population takes significantlymore antidepressants than the EU average (7.2%). Thestudy suggests antidepressant prescribing is increasing at a rate of 20% every year across Europe as a whole.

Paul Farmer, chief executive of the mental healthcharity Mind, said: ‘This is worrying as, while anti -

depressants can be very effective for some, they are notthe solution for everyone and should never be used as afirstline treatment for mild depression. These numberssuggest a crisis in Britain’s mental health services, wheremany people wait up to a year for CBT or counselling.’

Depression linked with nutrientdeficits: chicken or egg? (no punintended)

For the first time, several healthy dietary patterns havebeen compared for their association with the risk ofdepression. Researchers in the Canary Islands comparedthe Mediterranean diet, with the Pro-vegetarian DietaryPattern and Alternative Healthy Eating Index-2010. Dietquestionnaires were completed at the start of the projectand again after 10 years. Over this period 1,550 out of15,093 participants were diagnosed with depression orhad used antidepressant drugs 1999–2009. Nutrients andfoods associated with the greatest reduction of risk ofdepression were omega-3 fatty acids, vegetables, fruits,legumes, nuts and moderate alcohol intake. Even amoderately healthy diet was associated with an importantreduction in depression risk, but an even healthier dietconferred no extra benefit. Does this absence of a dose-related effect suggest that eating healthily preventsdepression, or more likely that people who are lessdepression-prone bother about eating well? Clearly, more research is needed to predict the role of diet inmental health. http://www.sciencedaily.com/releases/2015/09/150916215535.htm

Social prescribing is coming!

Social prescribing aims to link people up with non-medicalsources of support within the community that couldimprove their health and wellbeing. Well known modelsinclude: arts on prescription, books on prescription,education on prescription, and exercise on prescription.Lesser known ones are green gyms and other healthyliving initiatives, information prescriptions, supportedreferral, social enterprise schemes and time banks.

Museums on prescription – MoP – will connect lonelyolder people at risk of social isolation to partner museumsin central London and Kent. Phase 1 of MoP was to reviewsocial prescribing schemes across the UK and abroad. Thereview is now completed and available at www.ucl.ac.uk/museums/research/museumsonprescription/Social-Prescribing-Review.pdf.

MoP is a three-year research project funded by the Artsand Humanities Research Council investigating the valueof heritage encounters in social prescribing.

UPDATE


Moving beyond peakmedicine: understanding thepower of relationshipSarah Stewart-Brown Professor of Public health, Warwick MedicalSchool, University of Warwick; Chair MentalHealth Committee of the UK Faculty ofPublic Health

My main job is Professor of Public Health at Warwick Medical School and in this role Ihave led the development of the part of public health practice called public mental health.With awareness of and concern for the intense stress on doctors I have enabled thedevelopment of a universal course on personal wellbeing and mindfulness for Warwick’sgraduate medical students. I am also a practitioner and teacher of a body work practicecalled zero balancing which works at the interface of body structure and energy.Nowadays my most interesting ‘research’ is conducted as a reflective observer of my ownmind, body and spirit, seeing how completely integrated they are, how they respond tothe world about me and how they are influenced by a variety of personal practices.

IntroductionThis edition of the journal is devotedto reflecting on the possibility thatorthodox medicine has reached itspeak capability and that its usefulnessto society could be declining. In myfield of public health a similar idea has been proposed by a group ofacademics and professionals workingwith the International Futures Forumbased in Glasgow. In their book TheFifth Wave they explore the rise andfall of the four different waves ofpublic health practice and propose theneed for a fifth way to emerge. Centralto the proposals of The Fifth Wave arehuman relationships, the dehumanisingof our current way of life and thepotential transformative effects onhealth of bringing relationships backonto centre stage. The importance ofdoing this in the context of health careis explored by one of The Fifth Waveauthors, Margaret Hannah, in herrecent book Humanising Healthcare.Other key contributors to publichealth thinking in the last two decades

include Richard Wilkinson and KatePickett, who have explored the powerof human relationships at the collective level to impact on health for better or worse. In a series ofbooks on social inequality they haveprovided a wide range of evidence that it is very bad for our health. Indoing this they have built on a longertradition of social epidemiology inwhich the protective effects of socialtrust and trustworthy governance onhuman health have been clearly demonstrated.

The impact of relationships startsearlyAnother world where relationshipshave long been known, and morerecently shown scientifically, to befundamental to human health is in the context of the parent–infant relationship. Here it is now acceptedthat a warm and caring relationshipwith another human being is as

Summary

One of the reasons

medicine is losing its

usefulness is its failure to

embrace mind–body links

and the power of

relationship to transform

health. Relationships in

societies, health care

systems and families are

profoundly important for

human development and

health, and although it will

involve a major change in

mindset and culture, the

potential to transform

health care effectiveness

through relationship is

immense.

BEYOND PEAK MEDICINE


fundamental to infant development and even survival asfood. Recent research in neuroscience has shown that theinfant brain is wired through experience; pathways thatare used frequently become enhanced and those that arenot used atrophy. This process is at its most intense in thefirst year of life but continues throughout childhood andundergoes another period of rapid development in adolescence. Together with the discovery of mirrorneurons, this research has shown how the emotional stateof the people with whom infants, children and youngpeople spend their time, and their capacity for sensitivity,attunement, concern and appropriate response providesthe template on which the nervous system grows. Thedevelopment of the autonomic nervous system and theextent of resting ‘vagal tone’ established in the infant is akey determinant of reactivity and resilience to stressthroughout life.

These three worlds of relationships of relevance tohealth and healthcare – between governments and the societies they govern, between health professionals andtheir patients and between parents and their infants –have a certain amount in common and can potentiallyinform each other. One key similarity is an element ofhierarchy of power. Getting relationships right in thiscontext is perhaps more tricky than getting them right in relationships between equals.

How do we use this knowledge in practice?In order for any of this knowledge to have traction inmedicine and healthcare, one key aspect of the medicalmindset needs to change. Students of orthodox medicineare still taught, and the great majority of doctors practice,as though the mind and the body were separate entities. If I had not trained in and practiced medicine, I would findit hard to believe that it was possible to work in the worldof healthcare and maintain this mindset. But, incrediblethough it now seems, I have to accept that I did and so Ido. It is incredible because it does not take more than acursory observation of one’s own or other people’s bodiesto notice the effects of emotions on basic physiologicalprocesses including the heart and circulation, respiration,digestion, skin and musculo-skeletal system. It takes asignificant level of cognitive dissonance to believe thatthese emotional effects have no relevance to diseaseprocesses, particularly when we start to factor in theresearch on the influence of emotions on the immunesystem and the complex role that the immune system isnow known to play in chronic as well as infectious

disease. Even genetic expression is now being shown tobe influenced by our emotional states.

If this outdated mindset were to change then manythings could fall into place that would transform medicineand health care and offer potential great potential for thefuture.

The doctor–patient relationship iscentralWe would stop thinking of the doctor–patient relationshipas an add-on; something that makes healthcare feel nice.We could start to take seriously the belief which manypsychotherapists and practitioners of complementary andalternative medicine espouse that an authentic, empatheticand respectful relationship with patients is fundamental toeffective care.

We could start to understand the necessity of enablingpeople who are unwell or have discovered some diseaseprocess in their bodies to feel safe so that their autonomicnervous systems can switch out of the threat response andinto a state in which healing can take place. And we canrealise the power of relationship to do this. Then doctors’other skills can be used to decide what action, operation,drug or other intervention could support the self-healingprocess best and to carry it out. This may differ for different patients with the same disease process.

The conditions for health enhancing relationshipsWhen this happens, as it surely must if medicine is tosurvive, we can start to become interested in the nature of health enhancing relationships. As soon as we do that itwill become evident, as it has to generations of psycho-therapists, that the process is not quite as simple as itsounds; and certainly not as simple as those who writepolicies for the NHS, saying that NHS staff will providecompassionate care, believe. Psychotherapists, have knownfor a long time that there are limits to their capacity forcompassion and they have also discovered the necessity tobe in a therapeutic relationship themselves to practiceeffectively. They have found that they need to create aspace for their practice in which they themselves feelcomfortable and safe; many alternative and complementary therapists have found this also. But themedical profession has quite a long way to go to under-stand this perspective. The psychological environment inwhich health professionals work in the NHS is not safe.Aside from physical and psychological violence frompatients reported by a quarter of NHS staff each year, aculture of mistrust has grown up around appraisal andrevalidation, constant reorganisations disorientate people,and bullying and harassment are seemingly common. Notall of these things are apparently under doctors’ control.However, were it to be taken for granted that you couldnot be helpful to patients unless you yourself were able to feel safe, things would start to change.

Moving beyond peak medicine: understanding the power of relationship


We could start to take seriously the belief that an empathetic andrespectful relationship with patients is fundamental to effective care

��


The nature of health enhancingrelationshipsThe next step might be to start to understand whichaspects of relationship enhance patients’ capacity to carefor themselves. Most disease in the Western world today isattributable to a failure of self-care. We live in a way that isnot optimum for our health – we tolerate stress waybeyond its capacity to stimulate and challenge, we dealwith stress by self-medicating with alcohol, drugs, cigarettesor food we don’t need and we don’t find the time to dothe things that are optimum for our health – social orcreative activities, physical activity in its various guises,meditating or being in nature. Doctors are not very goodat caring for themselves and even less good at helpingpatients to do so. Those who do manage to do this wellwork in a way that is similar to the way skilled parents dowith their children. They demand personal responsibilityfrom their children but in a way which takes account ofdevelopmental stage and vulnerability. Letting adolescentstake responsibility for crossing roads safely is an importantpart of their development but it is negligent to expect thisof two year olds. The skilled parent titrates responsibilitydemands against developmental, not chronological age,believing in the child’s capacity for development and offering plenty of patience and encouragement in thelearning phase. It is possible to do this with patients too,but it runs contrary to the need to act which is endemic inmost doctors. If you want someone to take responsibilityfor themselves it is imperative that you do not take thatresponsibility on yourself. It is also vital that you are ableto carry the belief that the patient is capable of taking onresponsibility even when they do not think so themselvesand it is important to be realistic about the appropriatenext steps and titrate these with developing capacities.

Acceptance and judgementAnother important component of health enhancing relationship is unconditional positive regard. This is apowerful medicine but it is not that simple to deliver. Tohave unconditional positive regard for someone who isclearly making a mess of their life or damaging others,requires me to really put myself in their shoes and tounderstand the effects of their life experience. I need tobelieve that I am capable of behaving in a way that isdamaging and that had I had that person’s life experienceI would be doing just what they are doing now. That isnon-judgemental acceptance which is different fromcondoning the problem behaviour. Most of us are able todo this to some extent, but we get caught up short whenwe meet our own inner critic. The stronger the latter theless able we will be to accept others. To do this we need to allow ourselves to be vulnerable and inadequate and we need the capacity for self-compassion. And that is noteasy to do in a profession where we are expected to be professional, capable and in charge, increasingly on a 24/7 basis.

AuthenticityUnderstanding and allowing vulnerability takes a highdegree of emotional self-knowledge or emotional intelligence; not a skill that is currently taught much aspart of medical education or one that is encouraged aspart of CPD. But without this self-knowledge it is notpossible to capitalise on the power of relationship to transform health. This is because another strand of relationship that is fundamental to healing is authenticity.Pretending compassion or respect just doesn’t work. Andreal compassion or real respect take time, so they cannotbe offered in the context of the time pressure which hasbecome the norm in the NHS in a rush. Put yourself onthe receiving end of pretend relationships and it willbecome plain to you that they do not work. Pretendcompassion and pretend respect feel patronising. Theydon’t have that essential quality that empowers you tobelieve you can change.

Where do we go from here?There is some evidence that things are beginning tochange. Much has been written on the need for compassion in healthcare at least in the UK. Mindfulness is being spoken of as a valuable skill for healthcare professionals in many quarters of the health service; andresilience or wellbeing training that includes an introduction to mindfulness is being offered in somemedical schools and some medical training programmes.This awareness raising is an important and essential firststep. It will take a lot longer for fundamental change tohappen in the medical profession. It has taken many yearsfor me to move from my old mindset to one in which Itake holism for granted and am deeply aware of the influence of relationship on my own and others wellbeing.It will take me a lot longer before I have developed thelevel of relationship skill to which I aspire. Change theculture and mindset in medicine; that process needs tohappen in the majority of the profession and that couldtake a while.

Further readingBerkman LF, Kawachi I, Glymour MM (2014) Social epidemiology.Oxford: OUP.

Hannah M (2014) Humanising healthcare: patterns of hope for asystem under strain. Axminster: Triarchy Press.

International Futures Forum http://www.internationalfuturesforum.com

Lyon A (compiler) (2003) The fifth wave. Available at:www.davidreilly.net/HealingShift/5th_wave.html (accessed on 30November 2015).

Norcross JC, Lambert MJ (2011) Psychotherapy: relationships thatwork. Oxford: OUP.

Rizzoletti G, Sinigaglia C (2008) Mirrors in the brain: how our mindsshare actions and emotions. (Translated by Frances Anderson)Oxford: OUP.

Shonkoff JP, Phillips DA (eds) (2000) From neurons to neighbourhoods:the science of early development. Washington DC: National Academy ofSciences.

Wilkinson R, Pickett K (2010) The spirit level: why greater equalitymakes societies stronger. London: Bloomsbury Publishing.

Moving beyond peak medicine: understanding the power of relationship



Over-diagnosis: aGP’s experience ofindustrialisationWhat it’s like to be stuck in a dysfunctional system

Mark LownGP

I was originally an engineer when my interest in integrated medicine began after experiencing musculoskeletal back pain which was successfully treated with osteopathy,nutrition and acupuncture. I also discovered yoga and became fascinated by the subtleyet powerful effects it has on physiology and one's interaction with the world. I thendecided to train as a doctor and am now a GP and a researcher at the University ofSouthampton with projects in nutrition and cardiovascular medicine. I am a keen cyclistand other interests include modern jazz and electronic music, and the teachings of J Kirishnamurthi.

Medical diagnosis is the process ofdetermining which disease or conditionexplains a person’s symptoms andsigns. The diagnostic challenge thatdrives work in teaching hospitals iscertainly one of the appealing aspectsof medicine and no doubt that challenge can be very rewarding, andespecially so if effective treatments areavailable. However, to apply the diagnosis and treatment model toeveryday primary care inevitably leadsto ‘over-diagnosis’. For it has to be saidthat many (perhaps most?) patientswho come to GPs bring problems andconcerns that don't easily conform tothis labeling process. They may be sador distressed people mired in insolublepredicaments, people with social problems who have nowhere else toturn, or very often people who find itdifficult to cope day-to-day with long-term mental or physical conditions.These are not patients who fit convenient diagnostic boxes. Butlacking the time and skills to supportand advise these needy folk, it may inthe short term be easier just tobamboozle ourselves with a ‘diagnosis’and to offer the sop of a ‘treatment’.

But if, as Dr Freud told us, ‘what is notresolved must be repeated’, patientslike these will inevitably keep returning.

Another way of making work forourselves is by diagnosing ‘disease’that will never cause symptoms ordeath. Although routine screening forearly disease can save lives (eg bloodpressure measurement), crucially, notevery preclinical disease will becomeclinical disease. And some forms ofscreening are frankly ineffective andserve only to turn people unnecessarily into patients and/or totheir being prescribed treatments thatdo no good, and may do harm.

Ironically the pursuit of longer lifethrough ‘better’ diagnosis leads toincreasing numbers of people beinglabeled as diseased. And arguably, incountries such as America, the health-care funding system itself encouragesunnecessary investigations and unwarranted interventions; somethingthat is borne out by research in the USsuggesting that virtually every family inthe country has been subjected tosome form of over-testing and over-treatment (Gawande 2015). Yet over-diagnosis is not necessarily a

Summary

Medical diagnosis is the

process of determining

which disease explains a

person’s symptoms.

However, the diagnosis and

treatment model inevitably

leads to ‘over-diagnosis’.

Many patients who come to

GPs bring problems that

don’t easily conform.

Lacking the time and skills

to support these needy folk,

it may be easier to

bamboozle ourselves with a

‘diagnosis’ and to offer the

sop of a ‘treatment’. But if,

as Dr Freud told us, ‘what is

not resolved must be

repeated’ patients like these

will inevitably keep

returning.

OVER-DIAGNOSIS


new phenomenon: in the 1970s in Middlebury, in the stateof Vermont in the US, 7% of children under the age of 16 had their tonsils removed, and in Stowe, also in Vermont,70% of children had the operation, despite the twocommunities being demographically similar (Brownlee2007). At the time of course tonsillectomy was almostuniversally agreed to be a necessary and effective ‘treatment’ for children subject to recurrent upper respiratory illness. Nowadays of course we know theprocedure is almost always unnecessary and ineffective.

H Gilbert Welch, a Dartmouth Medical School professor, is an expert on over-diagnosis, and in his book,Less Medicine, More Health, he explains that we haveassumed, for instance, that cancers are like rabbits whichyou want to catch before they escape the barnyard pen.But some cancers are more like birds – the most aggressive have already taken flight before you candiscover them, which is why many people still die fromcancer, despite early detection (Welch 2015). And otherforms are more like turtles: they aren’t going anywhere, soremoving them won’t make any difference. We have hadto learn these lessons the hard way over the past twodecades. In that time the number of thyroid cancersdetected and removed in the US has trebled, yet the deathrate from thyroid cancer remains unchanged. In SouthKorea, widespread ultrasound screening has led to afifteen-fold increase in detection of small thyroid cancers,making it the most often diagnosed and treated malignancy in that country. But, as Welch points out, thedeath rate has not dropped. Meanwhile, the number ofpeople with permanent complications from thyroidsurgery has skyrocketed. We’re just catching the turtles,says Welch. The whole exercise is just over-diagnosis.

The media have a very powerful influence on patientopinions and expectations. Recently a ‘celebrity’ on primetime television told how horrified he was when,having suffered prostate cancer, his son was refused a PSA test when ‘most prostate cancer is hereditary and hisuncle was also suffering from symptoms of prostatecancer’! He then quoted the price of a PSA blood testwhich resulted in the host of the programme describingthe decision not to test the son as ‘shocking’. Theprogramme triggered a spike in demand for random PSAtesting even though prostate cancer is not hereditary, andthe rate of false positives is rather high, and evidencesuggests that harms of PSA testing for prostate cancer inasymptomatic men can outweigh its benefits (ECC 2013).In an ideal world, GPs would have ample time to discussall this in detail, underlining the pros and cons of prostatescreening with patients who, fully obedient to the newterms of engagement in family medicine, had only everpresented with one problem during a single ten-minuteconsultation. In reality of course, GPs often run out oftime for this and so give in to a patient demanding testingwithout fully considering the consequences with them.

There are many drivers of over-diagnosis in a dysfunctional and industrialised system: the use of increasingly sensitive diagnostic tools like MRI scanning,

financial incentives to diagnose, or the commercial interests of large pharmaceutical companies. Doctors’ fear of litigation if they miss a diagnosis leads to moredefensive medical practice, especially when they are evermore urged on to follow rigid diagnostic/treatment guidelines. But it is well known that the diagnostic thresholds shift as panels of health professionals (whosometimes have financial ties to companies that benefitdirectly from any expansion of the patient pool) changethe criteria; a practice termed ‘disease mongering’(Moynihan 2011). The potential for dysfunction in theNHS can be judged by two recent policies which are indirect contradiction: first it was proposed to name andshame GPs who miss cancer diagnoses (Pulse 2014) butthis was closely followed by another Whitehall pronouncement offering GP practices incentives to cut the number of referrals they make including suspectedcancer referrals (Pulse 2015)!

The soaring increases in the numbers of patients diagnosed as having high cholesterol is widely debated,because there is scant evidence that prescribing statins en masse reduces all-cause mortality. Meta-analysis of themany existing statin trials found no benefit (Ray KK et al2010). A parallel rise in the number of people diagnosedwith depression may have been driven more by the availability of ‘more effective’ antidepressants than byNICE guidelines and payment for diagnosis (as has beenthe case for statins). Undoubtedly the growing temptationfor overstretched GPs to provide a prescription ratherthan a listening ear has made them favour the pharmaceutical quick fix.

GPs need time to explain the benefits and downsidesof drugs and screening, so that testing can be used effectively and treatment options explored in patients’best interests. The resulting double whammy could lessenthe burden on patients’ who would otherwise have to livewith a questionable ‘diagnosis’, while also avoiding unnecessary tests and reducing the likelihood of potentialharm from unwarranted treatments. But to achieve theseworthy aims and so free up NHS resources for people who really do need treatment, more GP time would haveto be available.

The increased demands on our NHS have led toradical ways of managing demands on the system. Thealgorithm-driven 111 system is possibly one of the leastefficient examples of what happens when you apply anindustrial flow-line model to triage and diagnosis. It is inefficient because it is designed so that non-medical staffwho lack clinical experience can assess the risk of callers’symptoms. Consequently far too many who ring 111 foradvice are told to see a GP or frequently get sent to A&E.For instance I saw two patients who had been triaged by111 and sent (in an ambulance) to A&E with pains in thechest. They were discharged by A&E many hours later and told to see their GP. Happily, they managed to getsame day appointments with me. Both were young andotherwise healthy and one of them – who had been liftingheavy objects – was describing classical musculoskeletal

Over-diagnosis: a GP’s experience of industrialisation What it’s like to be stuck in a dysfunctional system

OVER-DIAGNOSIS


pain. All the same, once on the A&E conveyor belt thestaff had to run an ECG on him, take a chest X-ray and doserial troponin blood tests – which would have been partof a strict triage guideline for anyone with acute chest paineven if their ECG showed no sign of heart damage. This of course meant a lot of waiting around in A&E becauseonly a second blood test at least three hours later cancompletely rule out a myocardial infarction (heart attack).The other lady went through the same drawn out process.When I’d finished seeing and reassuring the young man I asked, ‘Is there anything troubling you?’ and he, understandably responded ‘Yes. I’m concerned they keptme in hospital for so long’! On the other hand and incontrast to this investigatory overkill, this morning I wasasked if an extra could be added to my list at the end ofmorning surgery. In came a 67-year-old man who hadcollapsed. Though they had called 111 his symptoms hadclearly not triggered the ‘chest pain’ or another carved instone algorithm so they were advised to see a GP within afew hours. When I saw him he could barely walk, he had atemperature of 35 degrees, crepitations at both lung basesand subsequently a white cell count of 20,000. A very illman indeed, and someone who certainly did need urgenttreatment.

Speaking at a fringe session at the Conservative PartyConference this year, Health Secretary Jeremy Huntinformed delegates that Silicon Valley tech ‘gurus’ wereconfident that diagnosis by humans would be obsoletewithin two decades. This absurd statement illustrates the

sheer lack of understanding that is driving the dysfunc-tional industrialisation of our health system. The future isuncertain and uncertainty is a fundamental aspect of lifeand medicine. If it has to be managed by computers andguidelines, then the vast grey areas of possibilities circlingaround what is actually causing a patient’s symptoms willall too often lead to over-investigation and over-diagnosis.Wise, holistic and insightful diagnosis (and sometimesmasterly inactivity) depends on the sorts of pattern recognition and complexity that only humans and humanrelationship can provide. Good medicine transcends algorithms, computers and guideline systems. If we want a humane and cost-effective NHS, then we must defendtheir place in it.

Brownlee S (2007) Overtreated. New York: Bloomsbury.

Davis J (2014) GPs to be ‘named and shamed’ after missing cancerdiagnoses. Pulse, 30 June.

European Cancer Congress (2013) Organised screening for prostatecancer using the prostate-specific antigen test, does more harm thangood. Press Release: Moynihan R (2011) A new deal on disease definition. BMJ; 342:d2548.

Gawande A 2015) Overkill: An avalanche of unnecessary medical careis harming patients physically and financially. What can we do about it?The New Yorker, May 11.

Ray KK et al (2010) Statins and all-cause mortality in high-risk primary prevention: a meta-analysis of 11 randomized controlled trialsinvolving 65,229 participants. Arch Intern Med, June.

Welch HG (2015) Less medicine, more health; 7 assumptions thatdrive too much medical care.

Matthews-King A (2015) A moral dilemma: GP practices offeredincentives to cut urgent referrals. Pulse. 1 October.

Over-diagnosis: a GP’s experience of industrialisation What it’s like to be stuck in a dysfunctional system

OVER-DIAGNOSIS


Tackling overdiagnosis:supporting the re-emergence ofgeneralist expertiseJoanne ReeveAssociate Clinical Professor in GeneralPractice, Warwick Medical School

I am a generalist, GP and academic. My work tackles two of the biggest challengesfacing modern healthcare systems. Namely, finding primary care solutions for thegrowing burden of chronic, complex illness, and building capacity for high-quality, meaningful primary care scholarship to support the necessary changes. I lead an international collaboration (SAGE) to develop, implement and evaluate the provision ofthe individually tailored model of care that is expert generalist practice. Our approachis underpinned by the principles of complex interventions, research and translationalscholarship. As Chair of the Society for Academic Primary Care, I lead work to enhancethe capacity for advancing primary care through education and research. All of which issustained by my role as a non-principal GP in a busy inner city Liverpool practice.

IntroductionOverdiagnosis – the problem of toomuch medicine – is big business.Literally so, as described in the writingoffered by the pharmaceuticalisationand medicalisation critiques (Williamset al 2011). Transforming ever more of human existence into a medicalcondition to be diagnosed and treatedoffers promise of ever greater marketshare to big companies around theworld, but also figuratively speaking, if we look at the growing array ofpapers, journals, and conferenceswhich discuss and debate thephenomenon.

At the 2014 PreventingOverdiagnosis conference(www.preventingoverdiagnosis.net/OD too much medicine), we held aDangerous Ideas workshop(http://cmajblogs.com/dangerous-ideas/). The goal was to ignite somethinking about how we can tackle theproblem of overdiagnosis by

supporting the re-emergence of theexpertise of the medical generalist.Some might consider this goal adangerous idea in itself. In a world thatplaces great value on specialist health-care, and understands the generalist as‘simply’ a ‘jack of all trades’, the ideamay seem at best unintelligible and atworst ill-informed.

In the workshop, we started bycritically examining what it is to be ageneralist. There are pages and pageswritten on this topic – although all toooften they conflate the work thatgeneralists do in our healthcare system(which is broad and diverse) with whatit is to be an expert generalist (whichis a distinct expertise). In particular,we focused on recognising that ageneralist is an expert in assessinghealth needs. A generalist is an expertdiagnostician.

But we also considered that generalists do diagnosis differently.Their approach to making decisionsabout what is wrong (and so what

Summary • Emerging problems of overdiagnosis and treatment burden need usto rethink our approach todiagnosis and assessingneed for medical care.

• Expert generalist practiceoffers an individuallytailored assessment ofneed, using a distinct interpretive approach todiagnosis.

• Expert generalist practicecan be described, taughtand evaluated – as ways toovercome current barriersto delivery.

• Revitalising expert generalist practice offers usa way to regenerate, andmaybe even re-enthuse,general practice.

RETHINKING GENERAL PRACTICE


needs doing) uses a different form of clinical reasoning tothe diagnostic working of a specialist. It is this difference –but also the fact that it is poorly understood and so nottrusted by non-generalists – that arguably contributed tothe demise of the generalist; in particular, to the replacement of generalist diagnostic expertise with a technical bypass (Reeve et al 2013a), of which, moreshortly. But it is this difference which has the potential to contribute to a reversal of the growing problems ofoverdiagnosis and treatment burden.

Which musings sparked the beginning of some newthinking – about how we might support the continued re-emergence of expert generalist practice. Here, I willbriefly describe the diagnostic expertise of the expertgeneralist and why I see it as at least part of the solutionto overdiagnosis. I’ll describe some of my work looking atwhat is stopping people delivering generalist care at thefront line, before telling you a bit about the dangerousideas that came out of our workshop and how they linkwith some future directions of travel.

Rethinking the diagnostic processIf we want to tackle the problem of too much medicine,we need to think about how we define whether and whena person needs medical care. One way to define health-care need is in terms of a person’s capacity to benefit fromhealthcare. We don’t need care if we wouldn’t benefitfrom its effects – there is no point in healthcare for healthcare’s sake. One example might be weighingpatients in clinic – they have no need for care (weighing)if it does not benefit them.

In today’s health system, healthcare need is mostcommonly defined by disease status (or increasingly by a‘risk of disease’ status). The assumption is that if we have,or are at risk of, disease, then we need care. This shapes adiagnostic approach which asks, does this person have adisease (are they eligible for care), and is it medically safeto treat them (is care appropriate)?

More than ten years ago, Tinetti and Fried (2004)proposed that we need to rethink our diagnostic (needsassessment) framework. They were among the first tohighlight the now well recognised risks of overdiagnosis,treatment burden and underdiagnosis associated with anover focus on disease status in defining need (although we should of course recognise that the World HealthOrganization Alma Ata declaration effectively flagged thisup in 1978, as have multiple authors since). Tinetti andFried argued that we were reaching the ‘end of the diseaseera’. This was not a predication of eradication of disease,rather a recognition that this model of needs assessmentwas rapidly becoming less useful in an era characterised by chronic illness, multi-morbidty, and complexity.

They called on healthcare to ‘abandon disease as thefocus of medical care’ and instead seek the ‘identificationand treatment of all modifiable biological and nonbiological factors’ Tinetti and Fried (2004). Thisapproach recognises an alternative view of health – not

as the absence of disease, but as a resource that peopleneed and use for daily living. The goal for healthcareshould therefore be ideally to support, but certainly not toundermine, health as a resource for daily living (HARFL)(Williamson and Carr 2009). This creates a different viewof the process of medical needs assessment – definingmedical need not by disease status, but by the potentialimpact of care on HARFL. Diagnosis is then about interpreting whether medical care, medicalising this individual’s health or illness experience, might or mightnot support HARFL.

Iona Heath recognises this role in her Harveian lecture(2011), in which she describes the primary role of a generalist as a gatekeeper between illness and disease (see Figure 1).

People experience illness (a disruption to health as a resource fordaily living, HARFL), some of whom present to health services. Ofthese, a smaller proportion will be identified as having diseaseneeding medical management in primary care (1º). A smallerportion again will have disease that needs specialist input (2º). We thus see two gatekeeper roles. The traditional gatekeeping roleof the GP is in managing the interface between primary andsecondary care. Heath recognised the distinct expertise of themedical generalist is as a gatekeeper between illness and disease –in deciding when it is in the best interests of this individual to intervene medically (Reeve et al 2012).

Viewed in this way, the decision to medicalise an illnessexperience becomes much more than deciding eligibilityand appropriateness (as described previously). The generalist physician needs to know and understand thepros and cons for this individual of being on either side ofthe ‘medicalisation gate’. The expert generalist thereforeneeds to know about disease epidemiology in their population, medical diagnostic criteria, risks and prognosisassociated with a diagnostic status, and the nature andimpact of treatment options. But they also need to under-stand the pros and cons of remaining on the illness side of the gate; issues about resilience and salutogenesis, thenon-medical resources available to an individual and acommunity to deal with illness experiences, as well as theimmediate and longer term impact of iatrogenesis. Thelatter is more than the potential harms from side-effects oftreatment, but also the impact of medicalisation on ourunderstanding of health, wellbeing, the self, and our placein the world. For me, a key issue here is the extent to

Tackling overdiagnosis: supporting the re-emergence of generalist expertise


Figure 1: The GP versus generalist gatekeeper roles


which medicalisation potentially undermines personalresilience – replaces an individual’s understanding of theirrole in managing illness with an expectation of a ‘technicalfix’ from medical care (Reeve et al 2012).

This is no easy task. And it is certainly not easy todescribe, to standardise, to measure and so to fit in to thecurrent workings of today’s health system. It is not readilyunderstood by non-generalists. The failure to recognisethis distinct expertise of the expert generalist – due in partby the failure of the profession to describe it – hascontributed to the introduction of a ‘technical bypass’(Reeve et al 2013a) of this form of decision-making in theform of decision aids, protocols, and governance targetsto support adherence.

Describing generalist expertiseSo our first task in supporting the re-emergence of generalist expertise is simply to describe what it is, and ina way that others can recognise. The Royal College ofGeneral Practitioners described generalism as expertise inwhole person medical care (RCGP 2012). I expanded thisin my description of generalism as an approach to carewhich is person not disease oriented; taking a continuousrather than an episodic view; integrating biomedical andbiographical understanding of illness; to support decisionswhich recognise health as a resource for living and not anend in itself (Reeve et al 2013b). But we need to gofurther in describing what that means for the patient – interms of how the expert generalist will understand, assessand intervene with their healthcare needs. And so weneed to recognise that generalist practice is a form ofinterpretive practice – a way of providing explanation ormeaning to a phenomenon, and so assessing and addressing healthcare need. I have therefore definedexpert generalist practice as the critical, professional useof an appropriate range of knowledge (from both sides ofthe ‘gate’) in the dynamic exploration and interpretationof individual illness, in order to support and maintainhealth as a resource for living (Reeve 2010).

Expert generalist practice therefore uses a differentform of clinical reasoning to the medical diagnosticapproach used by a medical specialist. Specialist reasoningadopts a deductive approach: applying a theory (ofdisease) to examine a phenomenon (of illness) and usinga statistically informed approach to confirm or refute ahypothesis that this individual has this disease. Specialistdeductive reasoning states how likely it is that a person hasa disease. We assess the quality of deductive reasoning, andso specialist care, in terms of the precision and accuracy ofour diagnostic reasoning – how often we get it ‘right’.

By contrast, generalists use inductive reasoning.Starting with the phenomenon – an individual illnessexperience – exploring multiple elements in order to seekstrong evidence (but not certain proof) of a broadertheory. Generalists therefore seek to generate a defendabledecision. Since generalist reasoning is built on an interpretive process (Reeve 2010), it can be described,

and defended, with reference to the experience andexpertise of other inductive, interpretive thinkers. Indeed,my work draws on the work of Maxwell to describe fivekey elements needed to generate a trustworthy interpretation (including a clear viewpoint from which westart, the data we use, the analysis we make, our qualitycheck, and our evaluation of the utility of the decision)(Reeve 2010). Based on discussions with expert generalists, including those both teaching and learning the practice, I have therefore described a consultationmodel to help others recognise and practice as an expertgeneralist (Reeve 2015).

The expert generalist diagnostic approach generatesan individually tailored interpretation of the value andpotential harm of medicalising an illness experience forthis person and at this time. Generalist diagnosis thereforehas potential to address the described problems of overdiagnosis, underdiagnosis and treatment burden.

Addressing barriers to expertgeneralist practiceBut the literature on overdiagnosis and treatment burdenhighlights that patients aren’t receiving expert generalistcare, yet most of them will be seeing a GP. So why are GPsnot delivering generalist care?

This was a question we asked a couple of years ago(Reeve et al 2013b). Our study involved more than 200GPs from around the UK, and from across multiple careerstages. In a survey, focus groups and interviews, we askedGPs about the supports and barriers for working as anexpert generalist – for applying their diagnostic expertisein whole person medical care. Four themes emergeddescribing barriers to expert generalist practice. Inresponse, we are developing four areas of work. Firstraising the profile and understanding of the distinctexpertise of the generalist; second finding creative ways to make space for expert generalist practice (Reeve andBancroft 2014) including developing the researchevidence that shows why it matters and should be prioritised; third teaching the expertise (the SAGE consultation model (Reeve 2015); and fourth providingfeedback through SAGE groups (see Table 1).

Time for some dangerous ideas?Returning to our Dangerous Ideas workshop… Havingsuggested that revitalising expert generalist practice mightoffer a way to address overdiagnosis, I invited the group tobrainstorm their response to the question: “if you had 2minutes in the lift with your health minister, what wouldyou tell him/her to do differently in order to improve individually tailored healthcare?”

The creative sparks flew! Each group pitched their idea back to the main group. Ideas included shifting theresources used to develop protocols to invest in expertgeneralist training; publishing research on individuallytailored (generalist) care in the Daily Mail to mobilise the




public voice; switch risk stratification approaches fromassessing need for ‘extra’ care according to health servicepriorities (unplanned care use, disease status) to patientpriorities (eg treatment burden related disruption to dailyliving). A show of hands vote (not consistent with anyelection regulatory standards!) identified ‘stop dictating (iemeasuring) process of care so that the patient can choosetheir own path’ as the winner in the room on the day.

The talk in the room was very much focused on thecontextual and organisational factors limiting delivery ofgeneralist care. But I might add in some dangerous ideasof my own. First, I would suggest that to embrace theopportunities to revitalise generalist practice, general practitioners need to change. We need ourselves to let goof the ‘jack of all trades’ model as the defining view of thegeneralist. Our approach to medical decision makingmeans that we can be flexible in the problems we dealwith – the range of patients and problems we see. But weare not defined by our diversity. Seeing a large range ofpatients, but only to deliver care technically defined by

other people, does not make the best use of our expertise. We need as a profession to rethink what roleswe should be doing, and what can and should be done byothers (Reeve et al 2013c). At the same time as we rethinkwhat the organisation of general practice will look like inthe future, we also need to rethink what the professional practice of GPs will look like too. Second, wecannot assume that expert generalist practice will be theanswer to the problems (just as we shouldn’t haveassumed that specialist practice would). However I thinkwe need new research models to help us critically butcreatively develop and evaluate these new models of care.In Warwick, we are developing an approach to the co-production of complex interventions. In this, we proposecombining academic expertise in the development andinterpretation of trustworthy knowledge with clinicalexpertise in the process of care clinical practice to co-create practice based evidence. We seek a trustworthyaccount of a practice-based view of a ‘way forward’ –describing options rather than definitive solutions.


Table 1: Barriers and potential solutions to delivery of expert generalist practice

Perceptions GPs understood the generalist role as a ‘jackof all trades’. With a sense that my role is toknow and apply the specialist protocols tomy patient and to refer on when it isbeyond my area.

Work to raise understanding and the profileof the expert generalist diagnostician.

Workload GPs recognised their expert generalist role– to interpret the individually tailored needsof their patient. But this is only one of manyroles fulfilled by a GP (chronic diseasemanagement, health promotion, practicemanagement etc). GPs described that theydidn’t have the time and energy to also fulfilthe expert generalist diagnostician role.

Work to evaluate expert generalist practice– to demonstrate its merit and worth, andto develop the practice-based evidenceneeded to support prioritisation of thisform of practice over other roles performedby the GP.

Skills and confidence Some GPs described never having beentaught the skills of interpretive practice (eitherthrough formal training, or by apprenticeshipwith more senior GPs). Others recognisedhaving the skills, but often described the decisions arising as being ‘gut instinct’ – decisions that they would not be able to‘defend’ eg in a court of law. And thereforedecisions which they didn’t pursue.

Work to describe, and teach, the SAGEconsultation model – the five steps to trustworthy interpretative decision making.

Feedback GPs described that their work is constantlymonitored. They get continuous feedback.But this relates to the volume and quality offtheir care in other areas eg protocol definedchronic disease management. There is nosupport or feedback for this most difficultarea of practice. Or the feedback is negative(by doing this, they have missed othertargets eg on blood pressure management)

Work to establish new SAGE groups – anextension of the Balint group model tosupport professional critical reflection onthe interpretive process and its trust-worthiness.

Barriers Potential solutions



GPs are the largest group of potentially practisinggeneralists in the UK medical workforce. There is muchconcern about morale, recruitment and retention withinthe profession. Over the last two years, I have spent timewith GPs, trainers and trainees talking about, and teachingthe essentials of, expert generalist practice. I have left eachevent inspired by my colleagues – by their commitment todelivering high quality, individually tailored, whole personmedical care; and by their enthusiasm for the opportunitiesthe ideas described here offer them to revitalise the waysof working that brought them into general practice. Therevitalisation of the generalist role heralds a new era forGeneral Practice. Problems of too much medicine havebrought us to this crisis point of a dangerously over-stretched profession. But paradoxically, they may alsoprove to be the sparks that ignite a revitalisation of generalism and so of General Practice.

You can find out more about generalism and our work to revitalise practice at our website: http://primarycarehub.org.uk/sage

Heath I (2011) Divided we fail. Available at:https://www.rcplondon.ac.uk/sites/default/files/harveian-oration-2011-web-navigable.pdf (accessed on 21 November 2015).

Reeve J (2015) Supporting expert generalist practice: the SAGE consultation model. British Journal of General Practice 35 pp207–208.

Reeve J, Bancroft R (2014) Generalist solutions to overprescribing: ajoint challenge for clinical and academic primary care. Primary HealthCare Research & Development; 15(1): 72–79.

Reeve J, Blakeman T, Freeman GK, Green LA, James P, Lucassen P,Martin CM, Sturmberg JP, van Weel C (2013a) Generalist solutions tocomplex problems: generating practice-based evidence – the exampleof managing multi-morbidity. BMC Family Practice 14 (112). DOI:10.1186/1471-2296-14-112.

Reeve J, Dowrick C, Freeman G, Gunn J, Mair F, May C, Mercer S,Palmer V, Howe A, Irving G, Shiner A, Watson J (2013b) Examining thepractice of generalist expertise: a qualitative study identifyingconstraints and solutions. Journal of the Royal Society of Medicine,Short Reports 4: 2042533313510155.

Reeve J, Irving G, Freeman G (2013b) Dismantling Lord Moran’sladder: the primary care expert generalist. British Journal of GeneralPractice 63 pp 34–35.

Reeve J, Lynch T, Lloyd-Williams M, Payne S (2012) From personal challenge to technical fix: the risks of depersonalised care. Health andSocial Care in the Community 20(2) pp 145–154.

Reeve J (2010) Interpretive medicine: supporting generalism in achanging primary care world. London: Royal College of GeneralPractitioners Occasional Paper Series, 88.

Royal College of General Practitioners (2012) Medical generalism.Why expertise in whole person medicine matters. Available at:www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z-policy/Medical-Generalism-Why_expertise_in_whole_person_medicine_matters.ashx (accessed on 21 November 2015).

Tinetti ME, Fried T (2004) The end of the disease era. The AmericanJournal of Medicine 116(3) pp 179–185

Williams SJ, Martin P, Gabe J (2011) The pharmaceuticalisation ofsociety? A framework for analysis. Sociology of Health and Illness 33(5)pp 710–725.

Williamson DL, Carr J (2009) Health as a resource for everyday life:advancing the conceptualisation. Critical Public Health 19(1) pp 107–122.


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Overdiagnosis andosteoporosisA personal story, or perhaps a polemic, October 2015

Peter DonebauerLayperson trustee of the BHMA; pioneeringmoving image artist and media entrepreneur

I have been interested in alternative approaches to drug-based ‘treatments’ since beingprescribed tranquillisers for random panic attacks in my teens in the 60s. My instinctthen told me that this was not treating the cause(s) of my condition; this was verifiedsome five years later when I was one of the first people in the country to be officiallydiagnosed with hypoglycaemia. A week after the six-hour blood sugar test I had changedmy diet accordingly and that was the last time I needed help from the medical profession for my ‘symptoms’. Medical understanding has moved on since then, and theinternet is a powerful source of patient information, but my instinct remains to usedrugs only as a last resort. I have been a layperson trustee of the BHMA for the pastfew years as it remains the only organisation committed to promoting a person-centredrather than a symptom-centred approach to ‘illness’.

Given that bisphosphonatescan cause severe adverseeffects including fractures,which they are meant toprevent, it is urgent that theoverall benefits and harms of long-term treatment beclarified. The availableevidence suggests that thebenefit-harm balance may beunfavourable for their use inosteoporosis. Drug and Therapeutics Bulletin

I am a ’healthy‘ 68-year-old man whofour years ago was diagnosed withosteoporosis in the spine and osteopenia in the hip following aminor accident at home. I had noobvious predispositions, other than agenetic link on the female side withmy sister, aunt and grandmother,although in the preceding four years I had cracked a rib and broken toestwice. Following my DEXA scan I wasalarmed to be told I had an advancedmedical ‘condition’ and was urgentlyin need of drugs (I was recommended18 months of parathyroid hormone –PTH – followed by continuous bisphosphonates). I quickly acceptedthat my bones were less dense, strong

and healthy than was ideal, but what Icouldn’t accept were the various drugtreatments prescribed – for reasonsthat I will explain later. What I havesince learned is that I am far fromalone in suspecting that bisphospho-nates might do more harm than good,as I subsequently discovered when Isaw a highly sceptical critique of oneinfluential guideline:

Poole and Compston’s review(2011) overemphasises thebenefits of bisphosphonateand downplays the seriousharms. Given the smallmagnitude of benefit and thepotential that this estimateexaggerates true effects due to incomplete reporting, thisjudgment call is at odds withthat of organizations withoutfinancial links to these drugs’manufacturers (Musini 2012)

Beating osteoporosiswithout drugs?To keep you reading I will give you thepunchline now – in the first two yearswithout any drugs I increased my

Summary

A BHMA trustee tells of his own encounter withover-diagnosis. He raises the question of risk versusbenefit and the vexed question of NNT – ‘thenumber needed to treat’ –statistically how manypeople would have to betreated in order to preventa single severe outcome.Anyone thinking of embarking on a lifelongdrug regime whether forhigh cholesterol, raisedblood pressure or in thiscase ‘osteoporosis’ shouldask their doctor about NNTand, crucially, whether thedrug carries significant risksof severe adverse effects.The author having done so,rejected medication infavour of lifestyle changeswhich appear to have beenhighly effective.

SELF-CARE


spinal bone density by 7% (measured on the samemachine, before you ask). The individual machine accuracyis rated around 1–2% between scans. I am told that thislevel of improvement at my age is unusual, noteworthyeven. In the subsequent two years I held this position formy spine, and meanwhile the osteopenia I had been diagnosed with in my hips slipped back into the ‘normal’range when adjusted for my age, gender, race, weight etc.(I had maintained density while those around me, ageingat the same rate, had lost density. The statistics had mademe well again…).

Even a quick trawl on the internet revealed that osteoporosis is very much a statistically defined ‘disease’,related more to age (and the female menopause) than any pathogenic presences. For those who don't know, astandard deviation of -1.0 in bone density is defined asosteopenia and one of -2.5 as osteoporosis. The normalcurve is chosen as an average of ‘healthy’ 25-year-olds.Osteoporosis and its little sibling or precursor osteopenia,is pretty much defined as an increased risk of bone fracture as a result of this lower bone density. You mightthink this a very odd way to define a disease – that it is alikelihood of suffering from a future bodily dysfunction oraccident, and perhaps an even odder basis for prescribingdrugs. But of course on reflection this is precisely whymoderately raised blood pressure provokes so muchmedical attention, for though it’s usually symptomless itpoints to a greater risk of heart attacks and stroke.

An invented disease?So in a sense these are not diseases as such, but ratherbodily states that signpost increased risk of disease. Topush my point further, ought doctors to find some drugsfor those statistically very tall as they must have a greaterrisk of damaging their heads in normally designed environments? Or drugs for those with statistically slowerreflexes since they are surely bound to suffer from moretraffic accidents? In case drug companies might get to readthis I will defer from making further suggestions and leaveit to the reader’s imagination….

As a reasonably well-educated layperson, I began towonder whether all diseases are defined statistically? And I am perhaps just being too naive…? There do seem to be ‘normative ranges’ for pretty much any body-relatedmeasurement. For instance if my blood test results are tobe believed, there is a wide range which appears to be‘OK’. So some kind of standard deviation curve containing‘normal’ and ‘sick’ will apply throughout medicine. Butmust that imply the need for treatment, particularly drugtreatment wherever someone’s measurements overstepthe mark? Anyway, if there is a measurable factor, whodecides the cut-off point? And, if a person’s measurementis at the boundary end of a statistical curve, shouldn’t thisbe a signal – before reaching for the tablets – to aim atnudging them back into the normal range? In the circumstances, I was the one who had to call for atimeout. But surely this obvious first step back to

‘normality’ shouldn’t depend on the occasional inquisitive,perhaps stubborn layperson such as myself.

What does ‘normal’ mean?When someone’s test results lie outside the standardparameters there are surely some simple questions to askfirst, particularly does it matter? If a clinician can be sure –on the basis of well established criteria – that an abnormaltest result definitely increases some specific risk to health,there is obviously a discussion to be had about whether‘something needs to be done’. The first question to ask ishow many people would need to be treated in order toprevent one major disabling incident? This at least wouldlay down some certainty about a treatment’s likely effectiveness and efficiency. But on the other hand this hasto be set against the possibility that the treatment itselfmight cause impairment, suffering or even death. But it’smy impression that despite all the rhetoric about self-management not only are these risk–benefits too seldomdiscussed, also that across the board too little is knownabout the potential for lifestyle changes to improve theprognosis of many long term conditions. This strikes meas very odd: lifestyle changes are cheap, and should alwaysbe the first tactic suggested, given the current andpredicted pressures on health budgets.

Lifestyle changes may not work of course: perhaps acondition is unresponsive to them, or the particular riskprofile has been spotted too late, or the person at risk will not or cannot make the, perhaps rigorous, changesrequired. Then drugs might have a role. Anyway, ‘improvements’ from lifestyle changes are likely to be veryslow. After all it may have taken many years for a person toedge their way outside the statistical curve. Or perhapssome of us were always at the biometric margins becausethat’s the way are constituted: just as some folk are at thetaller end of the spectrum, some are going to be at theextreme end of a bone density curve.

Which brings me neatly back to a discussion on suitable drugs to treat osteoporosis; but perhaps not justyet, for two reasons. Firstly, who decided on this -1.0 andthe -2.5? It was actually WHO, the World HealthOrganization, that decided to set a world standard, (andperhaps this serves to help comparative research happen).But do these standard criteria truly signify whethersomeone with a statistically -1.0 less dense bone has a lessstrong or healthy bone than one at 0.0. As far as I candiscover, the answer is no: we can now easily measurebone density, but it is not at all easy to measure bonestrength or health.

Problems with bisphosphonatesI am sure you are impatient to move past this semantic-philosophical discussion of whether osteoporosis is adisease or not, or how many millions of people we shouldtreat or not, and get to the actual wonder drugsprescribed. After all if we can improve people’s bone

Overdiagnosis and osteoporosis

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density with them and reduce their fracture risk then whyam I being such a bore? Well, first off because the drugsprescribed – invariably bisphosphonates of some kind –don’t actually increase bone density. They just stop furtherbone loss by inhibiting the natural mechanism for dissolving bone back into the blood, which is normallybalanced by new bone being built from constituents in theblood (I am keeping this simple rather than technical).

So if you’re on bisphosphonates your bones get olderand inevitably less healthy overall, but that shouldn’tmatter because at least they don’t get less calcium-dense.And the real benefit of using the drugs is of course thatthey reduce the statistical risk of future fracture, which iswhere we started with all the definitions. But wait for it,there is a snag here too – the drugs do not in fact seem todecrease the risk of future fractures – some recent studieseven indicate an increased risk. This has not surprised meas the drugs anyway seem a poor solution to someone likeme who is interested in maintaining or achieving healthybone. A fairly recent review of the evidence in this year’sBMJ now tells us conclusively that after 15 years of thesedrugs being used by millions of people (mostly post-menopausal women), they actually don’t prevent fractures. (Jarvinen et al 2015).

The bisphosphonates do appear to reduce fractures among women with very low bone mineral density (BMD)and those who have had previous fractures, and should beconsidered. However in those without very low BMD orfractures no study has demonstrated a true benefit (theNNT, 2015).

For the record, I should state that my own specialistrecommended that, as my spinal bone density was so low,I should take a parathyroid hormone that was ‘guaranteed’to increase my bone density by some 5% over the twoyears allowed. This is a very expensive treatment not available on the NHS. When I questioned ‘why only twoyears and what happens then’ he said it was not proven tobe safe over a longer term(!) and at that point I wouldneed to take the bisphosphonates anyway. As I wanted mybones to stay in a healthy and natural exchange with myblood, I declined his advice.

What are the alternatives?I do not feel this is the right article, nor probably am I thebest qualified person, to go into serious critiques of thedrugs or alternative methods of treatment or the researchthat underpin them both. But as a gesture in that direction,the regime I independently developed is very close to one described recently in the Ageing Well e-book onwww.wddty.com/health-books.html. I would also recommend following two web resources – first, SusanBrown on www.betterbones.com and her daily betterbonesblog, with the small proviso that there are a lot of products to buy… She subscribes to the popular

alternative view that our modern western diets tend tocreate too much blood acidity, and that if too little dietarycalcium is available to rebalance this then the body willpull calcium from the bone to maintain optimum pHvalues. I am unsure that this theory is entirely evidence-based, but it remains an attractive explanation for theestablished fact that diets rich in dairy and calcium statistically correlate worldwide with increased rates ofosteoporosis (the argument being that all that dairycalcium is needed first to neutralise the acidifying effectsof all the protein in the dairy…) Second, VivienGoldschmidt on www.saveourbones.com has a wealth ofmaterial and also a daily blog that is a great reminder tokeep focused. She has an interesting new programme andbook called Densercise; a great exercise regime forincreasing bone density naturally, in just 15 minutes a daywithout apparatus – I have not tried this yet, but generallyrate her advice very highly. Both women have a ‘healthy’scepticism about drug treatments, and encouraging adviceon how to maintain self-sufficiency with this statistical‘condition’.

On the diet side, I chose to take an absorbable supplement of calcium, vitamin D, vitamin K, Boron etc –the NHS prescription tablets are not well absorbed by thebody, and I declined them. I cut down on dairy productsother than live yoghurt, greatly increased my consumptionof green leafy vegetables (and seaweeds!), and ate morenuts and seeds and less meat. On the exercise side, Iwalked most days for at least 30 minutes (I already swamand cycled moderately often, but these do not really buildbone as they are not weight-bearing). I also used a smallexercise trampoline and a vibration plate on a daily basis –self-prescribing additional gravity. Astronauts all lose bone density in space and these are part of what they have to do to regain bone density when back on earth. A trampoline should probably be used with caution bythose who are not confident of their level of fitness andbalance but to my knowledge the vibration plate is safe for all levels of physical ability.

On the research side, for those seeking ‘some facts’rather than my observations, pages 204–11 of the fascinating book China Study by Colin and ThomasCampbell (Benbella Books, Texas 2006) quotes plenty, and the two web authors Vivien Goldshmidt and SusanBrown previously mentioned do so too and alwayscritique relevant new research from all around the worldon their blogs.

On the personal side, DEXA scans and blood tests areprobably useful aids; I have mentioned the limitations ofDEXA results, and according to my reading blood tests areprobably only useful to identify those people with specificunderlying biophysical conditions that lead to the lowbone density. Measuring blood calcium levels for exampleis not much help, as the body needs the calcium levelskept at the correct level in the blood far more than itneeds it in the bones.

My own strategy for tackling the more general problemof over-diagnosis would not improve profits of some


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distant corporation; rather the reverse. First, research yourailment very carefully (check out quick summaries ofevidence-based medicine http://www.thennt.com).Second, listen to your doctor carefully. Third, questionwhether that doctor is interested in understanding yourailment to anything like the degree you are. Fourth, askyour doctor why they believe a drug might shift your riskin the direction of better overall health and well-being,and/or whether that would be the best way to achieve this.And look hard, with or without your doctor, at lifestyleand potential changes using any or all of the technologiesand regimes available for diagnosis, diet and exercise etc,including the web resources I have indicated. The extraordinary potential of engaging with self-care (betterexercise, relaxation and nutrition) cannot be overstated.The nation’s health requires an educated and motivatedpopulation, and the support of doctors who encourageboth these and maximum patient engagement, rather thana mounting dependency on an increasingly over-stretchedNHS.

In summary, I wish you an engaging time consideringthe more general problems of over-diagnosis and that youwill be grappling with the question of what might be doneabout it. I hope this paper throws some light into somemurky corners…

Erviti J (2009) Bisphosphonates: do they prevent or cause fractures?Drug and Therapeutics Bulletin of Navarre,17(4).

Jarvinen, TLN, Michaëlsson K, Jokihaara J et al (2015) Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ 350:h2088.Available at: http://www.bmj.com/content/350/bmj.h2088 (accessed on24 November 2015).

Musini V (2012) Bisphosphonates in the treatment of osteoporosis.Letter. BMJ 344 doi: http://dx.doi.org/10.1136/bmj.e3211.

Poole KE, Compston JE (2011) Therapeutics initiative. A systematicreview of the efficacy of Bisphosphonate. Therapeutics Letter,Sep–Oct. 83 pp1–2 (available at www.ti.ubc.ca) (accessed on 24November 2015).

The NNT (2015) Bisphosphonates for fracture prevention in post-menopausal women without prior fractures. Available at:http://www.thennt.com/nnt/bisphosphonates-for-fracture-prevention-in-post-menopausal-women-without-prior-fractures/ (accessed on 24 November 2015).


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Join us for a programme ofinnovative events during 2016We are delighted to have a lively programme for 2016. Tickets for our conference arepriced to be affordable to all and are expected to sell out – do book early to be sure of a place.

• Social prescribing networkfirst meeting House of Commons, 9th March 2016.

• First Arts in Health Celebration and ShowcaseSouthbank Centre, 5th February 2016.

• Conference 2016: Food – the forgotten medicineRoyal Society of Medicine, 9th June 2016. Early bird tickets are £75 for College members, £125 for non-members.

CollegeMedicine

of Guys Hospital, Ground Floor, West WingGreat Maze Pond, London SE1 9RTTel: 0844 873 7388 www.collegeofmedicine.org.uk


Five windows onsuffering – knowing andcelebrating who we areWilliam House William House is Chair of the BHMA, GP researcher, and also Chair of an experimental

community development organisation. Here William introduces this article and himself, for he is the toddler illustrated with ‘Window 4’, as he prepares for a life as an artist!

Now that I have retired after 30 years in general practice I am trying to understandwhat I was really doing all that time. This article is some of the fruit from this task: I ambeing the pathologist to my career. Of course, I tried hard to understand while I wasstill working as a GP, but some explanations reveal themselves only at the post mortemexamination. So now, like all those who dissect the past, I have the last word. But I cando little more than chide or cheer younger hapless clinicians as they struggle with thecut and thrust of real raw life and do or do not make sense of who they are and whatthey are doing.

Window one: medicaldiagnosisA few months ago I was at a meetingin the town where I practiced as a GPfor 27 years. I was approached by awoman in her 50s who I had got toknow in my new role in communitydevelopment. She reminded me of atime about 25 years ago when I hadbeen in my GP practice for about 10years. She had rung me late at nightabout her daughter, Jenny (not herreal name) aged seven. I began toremember. I was just getting ready forbed. In those days we five partnersshared the 24-hour emergencymedical cover for our patients and itwas my evening and night on call. Thephone rang and I heard an anxiousmother. I knew her vaguely but shewas not a frequent attender. She wasworried about Jenny who was very hotand seemed quite ill. I put on myclothes over my pyjamas and went tosee her. She had a high temperatureand was listless but quite lucid and I couldn’t find anything else on examination. So I gave my usual adviceand went home to bed.

At 6 o’clock the next morning themother rang again to say she’d got thespots I had told her about, and thesewere, of course, those of meningococcal septicaemia.

I wasthere in mypyjamas inabout 5minutesand she wasin hospital15 minutesafter that –ambulanceswere veryquick inthose daysand it was before GPs were advised to give a penicillin injection to suchpatients. I don’t remember hearing theoutcome but she wanted to tell me aswe stood by the coffee machine at theend of the meeting. Jenny had beenvery quickly treated at the hospital,and though she developed meningitisshe slowly recovered. About two yearslater she had a grand mal fit andturned out to have epilepsy. Maybeshe would have got this anyway, but

Summary This article is based on a talkgiven to the Ethics andPhilosophy Special Interest Groupof the British Pain Society in June2015. Chronic pain is a majorproblem in developed societiesand can provide insights intodeep issues affecting health services in these countries. Thefive windows refer to five pointsof view that I have selected: fiveways of understanding suffering.There could be many more. Ofcourse, we can also use windowsto look in from the outside, toinspect the viewer. In the case ofthe dominant point of view, themedical diagnosis, this article isvery inquisitive. This issue of thejournal is themed on ‘PeakMedicine’ – the notion that theway we think about and manageillness is unsustainable, that wemust diversify our vision and ouractions or face disastrous consequences. This is surely atime to be a very critical friendas we look back through thewindow of medical diagnosis. It isalso a time for finding alternativewindows through which to look.

BEING THE CHANGE


the mother continued: ‘She was never very good at takingtablets, but we made sure she did and she was OK. Butwhen she left school things started to go wrong for her;she started illicit drugs and stopped taking her prescribedanticonvulsants. One day she was found dead in her room.She was 27 years old. I didn’t know how to respond. Hermother told me this story calmly and there was no senseof blame attached to me. But I asked myself: would thistragic sequence of events happened if I had sent her intohospital the evening before? There is a sense in whichmedical diagnosis is a tyranny – a mother’s tyranny in this case. I was left profoundly moved by that little conversation, and thought about it a great deal.

I first told this story at a British Pain Society conferencethemed on the ‘Tyranny of Diagnosis’. Though a tyrannyto parents, meningococcal disease is well understoodthrough the medical model and (if caught early) can becured by the technological treatments. But many, perhapsmost, illnesses are not like this. Even most infectiveillnesses have other factors which are at least equallyimportant and must not be ignored. My purpose with thestory was to set a context in which to examine anothersort of diagnostic tyranny which wears down many of us in a different way: the tyranny of overdiagnosis: extending ‘diagnosis’ beyond its usefulness.

There is a growing global movement against theoveruse of diagnosis – effectively the medicalisation ofsociety and of ordinary human travails adding to theunsustainability of the NHS. The movement, known as‘Preventing Overdiagnosis’ or POD, is very exciting for usin the BHMA. Though it is not itself a window on suffering,it provides a space in which to introduce holistic under-standings of suffering. But POD is a fledgling rebellion anddiagnosis remains a powerful and dominant force.

Preventing overdiagnosis: strand 1

There are three strands within the POD movement. Thefirst focuses on medicalising well people by screening for

biochemical or radiological indicators of possible diseaseat a future date – or ‘pre-disease’. This leads to thecreation of numerous new ‘diagnoses’ which legitimisefurther investigations, the prescription of pharmaceuticals,such as statins, and other sometimes invasive treatmentsfor well people. There has been a vast increase in thenumber of officially recognised diagnoses and of expensive and potentially harmful treatments. Many ofthem are more beneficial to healthcare providers than topatients.


The second strand within POD is to question the dominantrole of evidence-based medicine or EBM, started as anattempt to ensure that the NHS in the UK uses only treatments that work. The EBM rationale is heavilydependent on diagnosis as a marker of illness and sciencein the evaluation of what works. Many now say that EBMhas squeezed out subtler forms of understanding illnessand wellness – that it has become ‘evidence dictated medicine’. Powerful academic and commercial institutionswith their own agendas have great influence over thegeneration and dispersal of scientific evidence. Practicingclinicians are deluged with protocols and guidelinesdevised by expert committees and, in primary care, linkedexplicitly to performance-related pay. Most fundamentally,this diverts the clinician’s attention away from the humanbeing – both patient and practitioner – adding a lack ofhumanity to the overuse of diagnosis as an explanation ofsuffering.


By the time I qualified as a GP in 1979 – nine years afterleaving university – I was already very interested in themore mysterious aspects of suffering. I could see thatmedical diagnosis worked much better for some illnessesthan others. Not deterred, the profession has persistedwith trying to shoehorn patients labelled with irritablebowel syndrome, chronic pelvic pain, chronic fatigue,fibromyalgia and many more into the medical model ofpathogenesis. These labels do little to help the sufferer.Some call them ‘mind-body illnesses’ evoking the problemwith relationship that is often at their core. But this termhas been very slow to catch on. More popular is ‘medicallyunexplained physical symptoms’ or MUPS. In September2014 the second international conference on PreventingOverdiagnosis was held at Oxford University. The BHMAheld a workshop with the title, ‘If we are diagnosing toomuch what are the alternatives?’ We asked the participants,GPs and consultants from all over the world, to bringstories about real patients for whom making a diagnosiswas not helpful. We divided them into groups to sharetheir stories and asked them to try to work out why diagnosis was not helpful and then what might help. Wewere struck most by the lack of ideas – the frustrationthat they did not know what else to do.

Five windows on suffering – knowing and celebrating who we are

BEING THE CHANGE


Windowtwo: labelsI have alreadymentioned thatsome diagnosesare no more thana label, but thisdoes not makelabels useless.PaddingtonBear’s labelfamously reading‘Please look afterthis bear’ wasvaluable to him inMichael Bond’scelebratedstories. Perhaps itwas Paddington’s vulnerability, as much as his label, thatendeared him to so many readers. Though we may notquite wear such an explicit label around our necks, theimage of ourselves that we display to the world has a bigimpact on how we cope, whether we become ill and howwe can thrive again.Maria Bello is an American lesbianicon. She talks a lot about labels. One of her memorablequotes is ‘Figure out which labels disempower you andwhich labels shine with the light of the beauty of who youare or are meant to be’. In the story with which I startedthis article, Jenny acquired the label ‘I am an epileptic’.What impact that had on what subsequently happened Ido not know but it made me think a lot about labels.

In 2006 I became a GP commissioner. As part of ourpreparation, the practice based commissioning executive,of which I was a part, were encouraged to undertake theBelbin team role inventory, based on Jungian personalitytypes. I learnt that I was a ‘plant’. This means that I am‘individualistic, serious-minded and unorthodox’. Plantsmay also have ‘genius, imagination, intellect and knowledge … and be impatient with and disregard practical details and protocols’. This description fitted melike a glove, though while many geniuses may be plants,not every plant is a genius! Nevertheless, this labelenabled me to make sense of the way I am, and I feltempowered by it. However, though I frequently pitch upat Paddington Station, I don’t wear a luggage label roundmy neck. Not yet anyway!

Then recently a friend called me a ‘tempered radical’:described by Meyerson and Scully (1995) as ‘individualswho identify with and are committed to their organisationand also to a cause, community or ideology that is fundamentally different from … the dominant culture oftheir organisation. Their radicalism stimulates them to challenge the status quo. Their temperedness reflects …what they see as injustices or ineffectiveness, and areinclined to seek moderation….’ So, being tempered, Iwould always stop short of causing serious trouble. Mystrategy has been tell whoever will listen what was crazy

about the way things are, but in the end, to knuckle downand get on with working the system as it is. So this wasanother label to add to my collection that helped me tocope with life.

It is interesting that both of these labels were given tome by others and they helped me to understand andaccept, perhaps celebrate who I am. This is a key part ofself knowledge. The label must be one that helps us toflourish as a person. Then we are not only healthy inourselves but acquire another way of helping others whohave lost their way in the world. As a practitioner we mayslip from scientist to diagnostician, priest, vulnerablefriend…. as the situation demands. I am sure this can behelpful but only if there is an underlying authenticity. Thelabel or identity we adopt must be about recognising ourown nature, not part of idol worship, of admiringsomeone you would like to be like but who is actually verydifferent.

Window three: psychological flexibilityIn December 2009 an international conference in theNetherlands took a fresh look at the definition of Health(BMJ 2011). It was suggested that health should be understood as ‘the ability to adapt and to self manage’.This is a big change. It is about action, not structure: thekey words, ‘to adapt’, ‘to self manage’ are verbs, notnouns. They depict health as dynamic and fluid ratherthan static and structural. They are positive attributes ofhealth, not the absence of disease. According to thisunderstanding, people with a long-term condition can beas healthy as any other person. In the same way it is possible be feel ill, and yet be healthy. Disease and illnessare not opposites of health, they are on different planes of experience. This sort of health is not the exclusiveprovince of experts and is naturally sustainable.

Using the term ‘psychological flexibility’ researchpsychologists have developed an understanding of healththat corresponds closely with the meaning that emergedfrom the Netherlands conference. The corollary, psychological inflexibility, is believed to be at the root ofmany behavioural and physical health problems. Thepsychological literature relevant to this is difficult for thenon-specialist but it relates to certain fixed ideas andbehaviours based on past experiences and held in theform of words:

‘The notion is that people often experience the worldfrom inside verbal constructions of the world, includingconstructions of the past, the future, or the self. Behaviourpatterns that emerge from these verbally based experiences are simply less flexible…. When behaviour isdominated by verbally based experience and under theinfluence of processes we might call ‘inside the head,’ itcan be inconsistent with what the environment affords inrelation to values or goals’ (McCracken 2011).

A therapy called acceptance and commitment therapy(ACT), has emerged from this research and has been


BEING THE CHANGE


successful in some forms of mental illness and in severechronic pain. Behind the difficult language is a set of ideas that combines Buddhist teachings with a holistic‘therapeutic stance’. It acknowledges that suffering is ubiquitous but not inevitable; that avoidance of sufferingperpetuates it – hence ‘acceptance’ in the name; thatcommitment is essential and requires attention to thecontext of the suffering and a process of letting go (seeFigure 1 and more in William House’s column in this issue).

Window four: creative artThis is about using some of the processes of creative art tounderstand suffering in a way that reveals new healingpossibilities. Though poems in the waiting room, dancefor postnatal depression or bibliotherapy are often very

helpful as therapy, they are not windows on suffering inthe way I mean it. This ‘window’ is about seeing everydaypractice as an art form.

In 2004 I attended a lecture in London by Rita Charon,physician, literary scholar and leader of the US narrativemedicine movement. It was a turning point in my life thatenabled me to understand that much of what I did as a GPcould be understood as creative art – you might call it ‘theart of medicine’. I captured this quote from the lecture(with resonance from the biblical book of Genesis):

‘When we see things in the world, we rescuethem from formlessness by giving them form.’

Then she drew on French philosopher Paul Ricoeur’sinterpretation of the Aristotelian concept of mimesis. Thisinvolves a threefold process expressed by Ricoeur asattention: taking notice, looking, listening; representation:in visible and/or audible form; affiliation: sharing therepresentation with others. This is a creative and imaginative process still pursued by most artists and withobvious resemblance to the medical consultation – historyand examination (= attention), establishing an inter -pretation or understanding (= representation), sharingwith patient and perhaps others (= affiliation) (House 2015).While the ‘representation’ is the ‘form’ or the ‘art work’, ina consultation it could range from a few words or a gesturethat signifies understanding, to a verbal explanation or astory that will have meaning for the particular patient or areferral for investigation or a specialist.

Ten years ago I led a small research project whichinvolved placing a novelist (who had been a nurse andmidwife in an earlier life) in 55 GP consultations (with fullpatient consent) and asking her to write a very briefvignette about each patient. We then shared selectedvignettes with the GPs in Focus Groups. Some of the writings triggered startling revelations, including onecomment that provided the title for the later publication:‘We are not human beings in medicine any more’ (House2012). Many of these ‘representations’ were rich withmeaning. An example is given with the picture.

Window five: the healerThe picture of the little boy in the Window Four section isme when I was aged three. I grew up in an isolated spotsurrounded by nature and art. My father was a painter, mymother sang opera, and my much older sister was apianist – at least in her youth. I tried quite hard with musicon and off, but wasn’t very good. Perhaps I could see thatI couldn’t compete with my sister, so despite the pose forthe photo, I spent my youth fiddling with machines andbeing good at science, both of which my sister was hopeless at. But the art never left me. At university Irevived the music society and formed an orchestra and achoir along with my talented violinist girlfriend, but I was


BEING THE CHANGE

Figure 1: Therapeutic process from ACT andprocesses encompased within mindfulness

From: McCracken (2011)

Psychological

Inflexibility

Committedaction

Mindfulnessprocesses(within box)

Psychological flexibility

Contact withthe presentmoment

Acceptance Values

Cognitivedefusion

Self-as-context


still searching for something else. It was not until manyyears later, after hearing Rita Charon speak, that I realisedthat much of what I did in the GP surgery was actuallybeing the creative artist I was born to be. I had found myartistic outlet without realising it. Now I understood why Iso much enjoyed what I was doing.

There is perhaps something special about vocation,about loving what you do. As I faced the need to saygoodbye to my patients at the end of my career, I realisedthat I felt a kind of love for them. Other doctors havewritten this too. In her heartfelt 2012 lecture, ‘Love’s


BEING THE CHANGE

If you want goodpersonal healthcare– see a vetBY DAVID ZIGMOND

• Why, as our technology gets better, does much of our human contact and understanding get worse?

• How does this happen in our publicly accountable healthcare, and what is its cost?

This anthology describes and dissects the author’s 40 years of encounters on the frontline of medical diagnosis and treatment.

Also available as three separate volumes: • The Psychoecoglogy of Gladys Parlett• From Family to Factory• Bureaucratyrannohypoxia

‘This remarkable book will invigorate

anyone interested in thepersonal meaning or politics of healthcare.’Professor André Tylee, Chair of Primary Care Mental Health,

Institute of Psychiatry, London

Details at www.davidzigmond.org.uk or buy from Amazon

Labours Lost’, Iona Heath talks about the different kindsof love for which the Greeks have four words, whereas inEnglish, we have only one. She suggests ‘agape’ is the bestword for the ‘disinterested but unconditional commitmentneeded by professionals’ (Heath 2012). Whatever wemight call it, I believe there can be a quality of connectionbuilt up over many years from which a mutual under -standing of suffering can emerge and exercise healingqualities. This is really quite ordinary. It is the power ofrelationship to understand and to heal.

Heath I (2012) Love’s labours lost: why society is straitjacketing itsprofessionals and how we might release them. Available at:http://www.internationalfuturesforum.com/u/cms/Iona_Heath_Lecture2012.pdf (accessed 16 November 2015).

House W (2015) Too much diagnosis and not enough art. Journal ofHolistic Healthcare 12(1) pp 26–29.

House W (2012) We are not human beings in medicine any more.Journal of Holistic Healthcare 9(2) pp 38–44.

Huber M et al (2011) Invitational conference ‘Is health a state or anability? Towards a dynamic concept of health’, report of the meetingDecember 10–11. BMJ 343:d4163. McCracken LM (2011) History,context, and new developments in behavioral medicine.Books.google.com

Meyerson DE, Scully AS (1995) Tempered radicalism and the politics ofambivalence and change. Organization Science 6(5). Available at:http://www2.massgeneral.org/facultydevelopment/owc/pdf/Tempered%20Radicalism%20and%20the%20Politics%20of%20Ambivalence%20and%20Change.pdf (accessed 17 November 2015).


Speaking from and of the heartFiona HamiltonArts Lead for the Portland Centre

The two poems printed below represent work that is about healthand wellbeing in different ways. Thefirst project was about communitywellbeing – connections formedbetween people expressing andsharing moments in their lives in acreative way. Some were patients inhealthcare settings and had accessedthe project – and different arts practices – through the healthcare environment. The second was aneducational event for healthcare

HeartYou stay awake while I am sleepingslowing your electric pulseto dance in the dark beneath my ribskeeping beats all through the night

lub dub lub dub lub dub

You urge my blood to find its routesto everywhere it needs to go, to flow, andsometimes when I climb a hill or runexcited, feeling anger, fear or love, you knock the soft drum of my earsreminding me you’re near, you’re here


Your name vibrates through all our livesconnective tissue that conveysshades of feeling, passion, moodYou, on a sleeveYou, made of stone, or goldYou, heavy, broken, sinking, steeledYou, skipping, pouring yourself out

You, warm cockle, intricate mollusk opening in sunOr cochlea, snailyour spiral ventricles’ continuous cycleoutand inand out again


Dear heartYou small robust generous pulsing plumdevoted resonating musclehostess to the dark red and the bright red riversthat flow through your four-chambered homeYou billion-beat non-stop percussionistholding the rhythm for my improvised melodiesharmonies and cacophoniesI want to listen to you

You’re the humble bassist in the shadowsthe essential instrumentalistnon-seeker of limelightand the lead singer of our universal song

ART AND HEART

professionals where I was poet in residence for the day.

I wrote Heart for the Heartfeltart project organised by artist JanConnett in 2010.The Heartfelt projectinvited contributors to make a heartthat represented a significant, life-changing moment, or an emotionalthread, running through life overtime; then to attach a label, telling thestory of that moment or thread.Together, these pieces created apowerful collection: unique events

that never theless touch us throughour common experience.

A Heart was written for IntegrativeMedicine for the Healthy Heart, arecent half-day seminar for healthcareprofessionals exploring the heart. This event was organised by the newBristol-based Portland Centre forIntegrative Medicine. As Arts Lead forthe Portland Centre I will be facilitatinga writing-for-wellbeing sessions forolder people from March 2016 as thefirst series in the unfolding arts-for-health programme.

www.fionahamilton.org


Speaking from and of the heart

ART AND HEART

The Portland Centre, with Crossfields Institute, is developing a Diploma for Integrative Medicinewhich will launch in January 2017. Additional IMseminars are planned for June and October 2016.Please contact [email protected] for details. © Kate Ireland

© ArThur

A heartA heartWas a shapeI drew and re-drewtwo swan’s neckscurving towards each othergraceful reflectionsbearing namesand words of loveA heartI discoveredwas not heart-shapedbut asymmetricalbulbous, dark redits chambers and tubesfunnelling life, messyand indispensableMy heartis full of surprises:how does it fold in, fracture, re-form?how, after a time of paindid it become a space?a window of light?a round openingletting warm air pass through?a slow release of joy?


The star of compassionEleanor TannerMedical student, University of Birmingham

I am a final year medical student at the University of Birmingham. I am particularlyinterested in paediatrics and loved my placement at Birmingham Children’s Hospital. I have also enjoyed a variety of activities working with children outside university,including regularly working with a young boy with autism. This has highlighted to methe importance of considering each individual’s needs. I also work shifts in a nursinghome to broaden my experience across the age spectrum. I have experience as a carerfor family members and as a patient myself; I aim to use all of this to enhance myunderstanding of patients I encounter.

‘Compassion’ is often cited as anessential characteristic of a holistic-focused practitioner (Gelhaus 2012),and indeed prospective studentsattempt to prove this quality to gainentrance to medical school(Shakespeare 2013; Leget and Olthuis2007). ‘Compassion’ derives from theLatin ‘to suffer with’ and the OxfordEnglish dictionary defines it as ‘sympathetic pity and concern for thesufferings or misfortunes of others’.The disability movement would regard‘pity’ as patronising, oppressive anddisempowering (Lang 2007). However,compassion is far deeper, reachinginto the heart of human emotions. Itincorporates empathy, kindness, andthe devotion of one’s time, energy andemotions to the needs of another.Healthcare professionals (HCP) bydefinition provide ‘care’ for patients,

but caring ‘for’ someone is not thesame as caring ‘about’ them. Truecompassion requires a personal,human-to-human connection, built onlove, under standing and commitment.

This essay examines the integralrole of compassion within healthcare,highlighting five key points of the ‘star’ from which compassion radiates(Figure 1). It draws on my experiencesas a patient, a relative and a medicalstudent.

Compassion of familytowards patientsCompassion from loved ones cangreatly improve patient healthoutcomes (Reblin and Uchino 2008).My grandfather, aged 85, recentlysuffered a basal ganglia stroke, resulting in apathy, lethargy and loss

Summary

Each year the BHMA

student essay prize provides

a new holistic challenge to

stimulate the students’

imagination and provoke

holistic thought. For the

second year running the

judges gave the first prize

jointly, to Lucy Brennan and

Eleanor Tanner. Both chose

to write about compassion.

Eleanor’s essay is printed in

this issue; Lucy’s essay

appeared in the last issue.

STUDENT ESSAY

Students were asked for an essay based on one of the words from the BHMA‘holistic thesaurus’. This is a collection of 11 words describing the holisticapproach to healthcare:

connected compassionate self-caring intuitive integrated empowered resilient balanced diverse meaningful community-minded

Together they encompass the qualities needed to become a holistic practitioner.We were looking for stories that illustrate one of these themes via the student’spersonal or professional life.


of ability to initiate activity. As a family, our concern anddesire to help was immediate, but demonstrated in different ways. My aunt focused on practicalities, bringinghim necessities, securing his house and arranging care forhis dog. She worriedly informed the consultant that hewould no longer cope at home. My mother and I spentmore time listening, trying to understand my grandfather’spsychological difficulties. Until his stroke, he had been awholly independent and active man. He was extremelyproud of never having had any health problems, nottaking any medication and still being able to touch histoes. The stroke robbed him of his confidence; he nowdoubted his physical and mental capabilities. Although thestroke had caused mild cognitive impairment, his despairand hopelessness were more related to his psychosocial realisations. This is where compassion was so essential insupporting my grandfather’s recovery; it restored his self-belief, gave him hope and showed him that he couldstill live an independent life. We worked with clinicians tofacilitate discharge, then stayed with him to support andencourage him to do as much as possible for himself.Gradually his confidence and mood improved. He is nowonce again a cheerful, positive, active man.

Compassion between patientsThe value of compassion between patients is often unnoticed. Supportive relationships between patients can provide companionship, understanding and hope(Kornhaber et al ). Patients can also learn from and motivate each other towards recovery. When I was aged18, I was hospitalised for anorexia nervosa. Away from myfamily in an unfamiliar environment, I felt vulnerable andinsecure, compelled to confront overwhelming emotionalchallenges. During our time in hospital, a small group ofus grew close, supporting each other through every battle.We became attuned to one another, able to detect thesubtle signs of someone struggling and in need of a jokeor a hug. When I was low, they reminded me that I wasloved and valued. When I did the same for them, itreminded me of my own significance, giving me a sense

of purpose and fulfilment from helping someone else.Benjamin Gray likewise describes his experience of wardfriendships being valuable for both parties (Gray 2013).However, while controlled support groups may offer adegree of peer support, they do not necessarily generatemutual compassion. Our numerous facilitated ‘grouptherapy’ sessions on the ward were silent, strained andsuperficial. Involving the whole ward, they failed to utilisenatural friendships which had formed between individuals.They felt forced and, under scrutiny, we were unable toshare our feelings. This may partly explain the pooruptake of some peer support programmes (Taylor et al2015). Compassion between patients can be encouraged,but not compelled.

Compassion of patient to selfSelf-compassion for some patients is enormously challenging (Allen and Leary 2010). It means acceptingillness and recognising that they are worthy of care. A fewyears ago, I was diagnosed with an auto-immune typecondition; unpredictable flares cause me extreme fatigue,fevers and widespread pain. When first diagnosed, I wasdetermined not to be fazed; my stubborn and pragmaticpersonality insisted on being resilient. When unwell, Ipushed myself into lectures, wearing multiple jumpers tocontrol my shivering and heat packs to comfort the pain.My concentration was poor, and productivity limited, but I was determined not to be ‘weak’. My attitude has sincechanged considerably. Through working with my psychologist, I have begun to accept my illness and ‘allow’myself to be unwell. He challenged my unrealistic expectations of myself, showing me that my self-worthshould not be determined by my productivity. While it isstill difficult and frustrating to force myself to rest whenunwell, I now acknowledge that it is necessary and important for my welfare.

Compassion of healthcare professionals to patientsCompassion seems an obvious requirement of healthcareprofessionals. Following the Stafford Hospital scandal,David Cameron called for nurses to be employed andrewarded based on their demonstration of compassion(Campbell 2013). But ‘compassion’ motivated by reward is surely no longer compassion. Dr Anna Smajdor writesthat compassion is ‘not necessary’ in healthcare, sincequality care can be delivered without it (Smajdor 2013).However, although compassionless care may effectivelytreat disease, it does not treat the individual. Holistic carealways has compassion at its centre; I have observed many examples of this in clinical practice. In one GPconsultation, a middle-aged lady presented with diarrhoea,visibly upset. Her symptoms were not severe and herdistress seemed disproportionate. A medically efficientresponse was to end the consultation briskly, identifyingher medication (metformin) as the cause. However, the

The star of compassion

STUDENT ESSAY

Figure 1: The star of compassion

Family to patient

CompassionHCP to self

Patient topatient

HCP to patient Patient to self


GP was genuinely concerned about her level of distress sogently probed further. With some embarrassment, sheconfessed to humiliating incidents of soiling her clothing.By understanding her mortification, the GP was able tooffer sympathy and support, promising they would worktogether to prevent recurrence. The patient then revealedadditional fears. It transpired that she had recently caredfor her husband through gruelling treatments for bowelcancer, which had also begun with diarrhoea. The GP tooktime to comfort and reassure the patient, showing her theresult of her negative bowel screening test and explainingthe gastro-intestinal side effects of metformin. Thepatient’s relief was tremendous; the whole room suddenlybreathed and relaxed. The outcome of the consultationfrom a medical perspective was identical with or withoutcompassion – a reduced dose of metformin. However theoutcomes achieved by the compassionate GP extendedmuch further. This will no doubt enhance the patient’scompliance, psychological wellbeing and future ability totrust physicians.

Compassion of healthcare professional to selfIt is not only patients who need to acquire self-compassion.It is acknowledged that physicians (and other HCPs) havea high rate of ‘burn-out’ due to a pressured culture whichdemands invincibility and self-sacrifice (Nedrow et al2013). Strategies have been proposed to boost physicianresilience, including stress management, supportive relationships and boundaries (Jensen et al 2008; Zwackand Schweitzer 2013). While these may be beneficial, itcan be argued that maximum effectiveness will only beachieved through self-compassion. Preserving physicianhealth is frequently justified on the grounds of improvedclinical efficiency (Wallace et al 2009). However, protecting our health purely to enhance productivitymeans we forget that we too are worthy of being well forour own sake, not just for that of other people. A doctorwho resentfully goes to the gym to maintain their workcapability will benefit far less than a doctor who embracesthis time as a well-deserved, satisfying leisure pursuit. Iknow a GP who keenly protects his leisure time to takepart in basketball and squash. He has learnt to prioritiseand delegate, and to accept that it is not always possible to complete tasks perfectly. He acknowledges that hedeserves time to unwind and the promise of an enjoyableevening keeps him motivated, fulfilled and satisfied.

Conclusion and implications forclinical practicePatient-centred medicine which retains compassion canimprove patient trust, satisfaction, compliance and health(Reynolds 2009; Stewart et al 2000; Epstein et al 2010).We cannot force professionals to display compassion, butwe can lead by example, displaying compassion in our

own practice. We can involve a patient’s family in theircare, inquiring about the patient’s premorbid characterand assisting the family to motivate and engage their lovedone. On the ward, we can introduce patients to eachother, recognising individuals who would appreciate peersupport and facilitating patient interactions over mealtimes.We can remind our patients of their intrinsic worth,encouraging them to prioritise their own welfare andeducating and empowering them towards self-care. Wecan take the time to listen, gently exploring patients’concerns and forming a genuine relationship which recognises their individuality. And finally, we can try torecognise our own innate value by protecting and embracing our own wellbeing. There may not be physicalrewards for professionals who demonstrate compassion,but the job satisfaction and personal fulfilment, not tomention the benefits to patients, are immeasurable.

Allen AB, Leary MR (2010) Self-compassion, stress, and coping. Soc Personal Psychol Compass 4(2) pp 107–118.

Campbell D (2015) David Cameron’s prescription for NHS failings:target pay of nurses. The Guardian Online, February 6. Available at:http://www.theguardian.com/society/2013/feb/06/david-cameron-nhs-nurses (accessed 2 March 2015).

Epstein RM, Fiscella K et al (2010) Why the nation needs a policy pushon patient-centered health care. Health Aff (Millwood) 29(8) pp1489–95.

Gelhaus P (2012) The desired moral attitude of the physician: (II)compassion. Med Health Care Philos 15(4) pp 397–410.

Gray B (2013) Peer support in hospital – a shared journey. SchizophrBull 39 (1) pp 3.

Jensen PM, Trollope-Kumar K et al (2008) Building physician resilience.Can Fam Physician 54(5) pp 722–9.

Kornhaber R, Wilson A et al (2015). Inpatient peer support for adultburn survivors-a valuable resource: a phenomenological analysis of theAustralian experience. Burns 41(1) pp 110-7.

Lang R (2007) Paper 3: The development and critique of the socialmodel of disability. Available at http://www.ucl.ac.uk/lc-ccr/lccstaff/raymond-Lang/developmment_and_critique_of_the_social_model_of_d.pdf (accessed on 2 March 2015).

Leget C, Olthuis G (2007) Compassion as a basis for ethics in medicaleducation. J Med Ethics 33(10) pp 617–620.

Nedrow A, Steckler NA, Hardman J (2013) Physician resilience andburnout: can you make the switch? Fam Pract Manag 20(1) pp 25-30.

Reblin A, Uchino BN (2008) Social and emotional support and itsimplication for health. Curr Opin Psychiatry 21(2) pp 201–205.

Reynolds A (2009) Patient-centered cre. Radiol Technol 81(2) pp133–47.

Shakespeare T (2013) A point of view: How important is compassionin healthcare? BBC news, June 7. Available at: http://www.bbc.co.uk/news/ magazine-22773043 (accessed on 2 March 2015).

Smajdor A (2013) Reification and compassion in medicine: A tale oftwo systems. Clinical Ethics 8 pp 111–118.

Stewart M, Brown JB et al (2000)The impact of patient-centered careon outcomes. J Fam Pract 49(9) pp 796–804.

Taylor F, Gutteridge R, Willis C (2015) Peer support for CKD patientsand carers: overcoming barriers and facilitating access. Health Expect,doi: 10.1111/hex.12348 (Epub ahead of print).

Wallace JE, Lemaire JB, Ghali WA (2009) Physician wellness: a missingquality indicator. The Lancet 374(9702) pp 1714–1721.

Zwack J, Schweitzer J (2013) If every fifth physician is affected byburnout, what about the other four? Resilience strategies of experi-enced physicians. Acad Med 88(3) pp 382–9.

The star of compassion

STUDENT ESSAY


Rick and Ajita: How maywe reconcile systems ofhealthcare with oursubtle humanity?David ZigmondGP

I have worked for 45 years as a frontline NHS doctor, as both a small practice GP andlarge hospital psychiatrist and psychotherapist. The last two decades have burgeonedNHS systems of management and computerised informatics. Few predicted the widercosts: for as our investment in such packaging and control has risen, so our capacity forpersonal engagement and understanding has declined. My response? To convert myangered fear and sorrow into wider analysis and debate.

A system is nothing more than the subordination of allaspects of the universe to anyone such aspect.Jorges Luis Borges, Labyrinths (1962)

Rick: chaos in vivoRick seats himself. I do not recognisehim.

‘My mum suggested I come to seeyou. She hasn’t been living aroundhere for years, but I’m still here andshe thinks you may be able to helpme…’ Rick’s self-introduction is determined, pushing through hisanxiety. I sense quickly the importanceof his risk.

‘Well, I hope so… Of course, I’llmainly want to know about you. Buttell me first: who is your mother?’

Rick, vulnerable but trusting,names his mother – Angela – andcontinues: ‘she’s now not in a goodstate – has a terrible chest from all thatsmoking – and now she’s lost herspirit and confidence: all the thingsthat happened to her … she hardlygoes out now. But she says you reallyhelped her, all those years ago…’ A slight brief shrug displaces a longer,

engaging smile: he signals both theabject and the fraternal.

Angela’s name rapidly unspoolsmany flashbacks from my years ofengagement with her. I recall an attractive but haunted woman, avortex of symptoms and distress, andthen the many interweaving lifedramas that both precipitated andmade some sense of her cacophonousdis-ease. Beneath that I discerned hertragic ‘choices’ in love: dangerouslycharismatic men whose sexual allurewas somehow generated by theircapacity to control, wound and humiliate. The rest followed from this:eruptions of jealous rage and beatings,sullen and tense suspicion, abjectpleas for reparation, alcohol and drugsto find palliation and peace, ‘anxiety’and ‘depression’.

By the time I first met Angela, Ithought the roots of her self-damagewere too deep for any insighted reversal or reclamation. While hoping I might just help her change her fate, I recognised that improbability. Butthen I could, at least, comfort, containand bear witness.

Her children, then, had alreadybeen taken into care and I did not

Summary

Systems – our ordering of

commonalities – have

contributed greatly to our

treatment of structural

disease. Elsewhere systems

are much more problematic.

Rick and Ajita show us how

and why.

HUMANISING MEDICINE


know them. Her Tree of Life seemed blighted: I hoped itsunseen fruit would fare better.

*‘So, Rick, what is it that’s not right for you…?’

Rick looks down and purses his lips. I sense himsearching intelligently. He looks up: ‘I don’t seem to beable to keep a job or a girlfriend for more than a month.It’s something to do with trust…’

‘Of course, I knew your mother a little… but tell me,from your point of view, what happened to you – whenyou were small – with the people you needed to trust?’

The earlier part of Rick’s answer I had imagined: hismother’s warmth but unaccountable (to him) lability, thealpha-males’ glowering explosions and furies, the homelike a flimsy boat in a perilous storm.

His time in care I had neither known nor imagined.With affecting directness he now describes a startlingvariety of foster parents: some kindly, patient and wise, butothers exacting a perverse revenge for some (presumably)hidden and ancient grievance of their own. Frighteningand unpredictable beatings, then being forced into alocked cupboard: these are among the dark and destructive memories he now retrieves for me.

As he leads me through his survival story of this dismalhuman hinterland I am buoyed up by something I had notexpected, and cannot explain: his resilience and spirit. Hiseyes flash and glow with animated intelligence, and a widerange of recognised feeling. He auras an inclusive warmth.

We humans are so paradoxical in our vulnerability andresilience.

I cast a baited long line; I think he will understand: ‘In the middle of the last century there was a Frenchphilosopher called Jean Paul Sartre. He said somethingvery interesting and simple that’s very important for us all:“Freedom is what we do with what has been done to us.”’

Rick’s apprehension and engagement are rapid. Helooks up and away to make sure he has understood, andto make it his own. He blows softly through his teeth, anexhalation of relief and recognition. His look to me iscanny and wise far beyond his youth.

I risk more, a variation: ‘Here’s another good one,especially for you – with all the adults who let you down inyour childhood. It’s from about the same period – EleanorRoosevelt, the American President’s wife: “Learn fromother people’s mistakes: you won’t have time to makethem all yourself.”’

Rick’s response is now even more immediatelyconnected: he throws his head back and laughs deeplywith mirth and relief and then rocks back to look at me,wiping away a small tear – a ductal expression of his bittersweet insight, his life challenge:

‘Wow! That’s wonderful. It’s so funny, but so true. Well,I’ve certainly had a lot of people showing me what not todo … And now you’ve given me so much to thinkabout…’

I offer Rick some more encouraging notions, as abridge, before suggesting he contacts a local youngperson’s counselling centre.

‘I’ll offer what I can to guide you in all this,’ I say.‘Come back and see me in two weeks.’

He leans forward to shake my hand and then standsand turns. His short walk to the door now has a confidentstride.

Humankind’s vulnerability is often complexly obscureand intractable, but now, with Rick, I feel both clarity andconnectedness: we are close to the source of both his painand his self-healing capacities.

As he leaves I feel hopeful.

Ajita: order in vitroAt the end of my working day Ajita is sitting with me. Shehas been in post for a year, yet already the mounting stressand weariness are evident. I think this is both because,and in spite of, her diplomatic skills. Her designation is‘Mental Health Commissioner’: her job is to define themental health needs of a large city area, then design remedial systems and then negotiate with various‘providers’ about their tenders: contents, packaging,timing and price.

Now in her late thirties, Ajita has spent several yearsworking in mental health services coordination andmanagement. Before that, at the beginning of her career,she used to work one-to-one with patients as a clinicalpsychologist. Her time is now spent with executiveabstractions: largely looking at computer screened documents and data, or sitting in meetings trying todevise the best ‘system’ to suit the kind of people sheused to know and tend as a therapist.

Her current task – to define, refine, purchase, packageand pipe 290,000 cubic metres of cognitive behaviourtherapy type help, equitably and appositely, to all thepsychologically anguished sufferers in her city sector – isproving much harder than anyone had anticipated or cannow understand.

To venture some leverage Ajita now focuses on onesmall part of the problem.

‘What’s wrong with the GPs? I don’t seem to be able to get them involved or interested. Am I flogging a deadhorse?’

‘Not dead yet, but certainly dying.’ I offer a morsel ofoptimism.

She becomes more engaged with her own figure ofspeech: ‘What is it that is dying?’

This is a relished question.‘Oh, Ajita. So much! Our art, our heart, our craft, our

wit, our philosophy…’‘Yes, yes. But how, why is this happening?’ She is

impatiently searching for her understanding, not mysophistry.

‘Well, in my last two decades of work what I have seenis a progressive loss of personal work satisfaction andidentification. We used to be nourished by vocationalmotivation, now we are controlled and (dis)incentivisedby managed careers and systems. I used to feel part of acolleagueial family, now it’s more like a coercive healthcarefactory.’

Rick and Ajita: How may we reconcile systems of healthcare with our subtle humanity?

HUMANISING MEDICINE


‘So, what has caused that?’‘All sorts of things that are themselves related. At the

centre is our wish to make things “efficient” by attemptingto control everything by systems: standardisation, proceduralisation, increased division of labour, restrictionand prescription of language…’

‘But if systems make things more efficient, how canthat be a bad thing?’ Ajita is wanting more efficiency frommy answers.

‘Because systems are by their nature limited and limiting. Systems deal only with specified designations ofbehaviour and events. Systems cannot engage with intelligent discrimination, with personal meaning, value,motivation or relationships.’

‘Meaning?’ I am unsure if this is stealthy irony fromAjita.

Well, if we overinvest in systems, we first displace, then destroy, these things: our personal relationships andmeaning – the very things that provide our gratificationand motivation.’

‘Why is that so?’‘Because systems can only deal with commonalities,

not personal differences. Yet it is the differences that giveus our identities. Knowing the commonalities is science:that’s the basis of our treatments. Our systems work wellwith these. But discerning and nourishing our difference isa very different territory: it’s the art in our practice – thebasis of healing, growth and palliation. Systems are heremostly ineffective, often destructive.’

‘Because?’‘Because our healing needs personal attachment,

knowledge and attunement: only then can we reach ourmost imaginative and intelligent judgement. Mostlysystems function by eliminating such human vagaries.’

‘So where does that leave us with mental health services?’

‘In a quagmire of paradoxes. Mental healthcare is fascinatingly humanly complex and thus relatively elusiveto systems…’

‘Surely we just need better systems.’ Ajita sounds irascibly brisk and chiding.

‘No. Because – particularly in mental health – thingsare most often not what they seem. One thing is betterunderstood in terms of something else, and that something else is individual and unpredictable. Systemsdo very poorly with such complex human processes;systems do much better with stable physical states.’

‘So, give me an example of how you can help peoplewithout such systems.’

I tell Ajita about my fertile and pluripotentialencounter with Rick, just a few hours before. How thenavigation and meaning of our meeting depended on the

nature and quality of our contact, and then our ignitedimagination. I explain to Ajita how I need not only thehead-space and heart-space to improvise like this, but alsothe personal continuity of care to be able to synthesisefrom such wide sources – my much earlier personalknowledge of Angela enabled healing flashes of insight inher son a dozen years later. Such transactions exemplifythe quintessence – the raison d’être – of the now almostextinct family doctor or general psychiatrist: they couldquickly discern what ailed and what might heal a well-known individual. How can institutionally managedsystems – eventually distilled to “procedures” – getanywhere near the kind of understanding and influencethat evolved rapidly between myself and Rick? What beginas transactions become transcendent through thetranspersonal. This subtle cauldron of human influenceneeds little informatics but much individual intelligence;sparse systems but rich personal attachments.

I sense Ajita’s detachment from my portrayal of theimportance of attachments. She glances furtively at herwatch and then rubs her eyes: such metapsychology iswasting our time.

‘Look’, she says, ‘this isn’t helping very much. The waywe all have to work now is with systems that are clearlyand properly managed, where we all know what we’redoing and we can see, even measure, what our outcomesare. Apart from anything else that’s how we secure ourfunding and future. I really can’t see how all the thingsyou’re talking about can fit in or be applied. It’s obviouslyvery interesting to you, but seems too chaotic to be usefulto me…’

Ajita leaves me with a discomfiting paradox: I mayconjure healing sense with patients, but my contact withcolleagues is increasingly glutinous with defensive anxietyand procedural pre-emption.

Ajita’s terra firma gives her back her path to a world ofmanaged clarity, but its reassurance is specious – for itquickly loses sight of those subtle paths to how we mightbest understand and heal one another.

The enlivening and heartening exchange I had withRick has been displaced – at the end of a very longworking day – by something very different.

*

Originality is unexplored territory. You get there by carrying a canoe. You can’t take a taxi.Alan Alda

Interested? Many articles exploring similar themes areavailable on David Zigmond’s website www.marco-learningsystems.com

David Zigmond would be pleased to receive your feedback.

Rick and Ajita: How may we reconcile systems of healthcare with our subtle humanity?

HUMANISING MEDICINE


�RCGPACCREDITED

University of Westminster115 New Cavendish Street, London W1W 6UW

A half-day doctors’course about resilienceHow are doctors to sustain the enthusiasm and effortneeded to maintain a high standard of care in a time ofausterity? This half-day workshop gathers together some facts about doctors’ resilience, andoffers insights and new skills. It starts with the assumption that doctoring is particularlystressful, for reasons that are rooted in our evolutionary biology. However, becausestress interferes with the faculties a doctor most needs – decision-making, empathy,connectedness and communication – patient overload will make an already difficult jobseem impossible, as burnout progresses from irritability and exhaustion into cynicismand dissociation. Neuroscience throws some light on ways to reduce burnout risks,stay sharp under pressure and regain the resilience and energy we need for creatingnecessary change.

Reflections � How resilient do we feel? � Why now? The stresses of clinical work � Clinician stress: impact on patients and colleagues � Reflections on self-management and lifestyle

Realities � Evolution and emotions � Neurobiology of stress and resilience� Survival instincts, empathy and communication � Burnout and how to recognise it

Resources � Regulating your autonomic NS: can it be done? � Building resilience and managing our own stress � Your resilience matrix � Setting goals for taking care of ourselves

If you think this course might be useful to you or your trainees or postgraduategroup, please contact Kate Fismer, Westminster Centre for Resilience at theUniversity of Westminster [email protected]


ACT is a blend of science, creative artand Buddhist practice. It is qualitativelydifferent from other therapies foremotional and physical health problems: it is holistic and addressessome of the root causes of ourcommon illnesses. It may have thepotential for much wider health andcultural improvement.

In my column in the last issue(12.2), Connecting and the flexiblemind, I wrote about the links betweenthe competitive pressures and theanonymity of our consumerist society.This is experienced by many people asdifficulty in being socially open andunwillingness to reveal vulnerability.This ‘retreat behind a cloak of appearances’ too often brings a senseof isolation and futility resulting inanxiety and stress. In turn, this hastensa host of chronic illnesses. Masking the anxiety and meaninglessness withretail and entertainment ensures thatthe vicious cycle will continue. Iargued that the answer is for us to beknown for who we are, not for whatwe have. The challenge for our societyhas been to find a way out of thisdestructive cycle. It has individual,local community and global elements.Perhaps ACT is part of the answer.

‘The goal of ACT is to create a richand meaningful life, while acceptingthe pain that inevitably goes with it.’This is quoted from a 2006 article byAustralian ACT therapist, Russell Harris(http://www.thehappinesstrap.com/upimages/Dr_Russ_Harris_-_A_Non-tech-nical_Overview_of_ACT.pdf).‘Accepting the pain’ corresponds tothe ‘acceptance’ aspect of ACT. It is aunique quality of ACT that it does not

assume a uniform ‘healthy normality’.Our Western mainstream psychologist’sand advertiser’s idealised notion, thatbeing ‘normal’ depends on being freefrom pain, misery and worry, isdiscarded in favour of a notion ofnormality much more in line with thecomplex characters of the literary anddramatic arts. We are passionate,miserable, ecstatic, loving, hating,cruel, kind, heroes and wimps. In thewords of Immanuel Kant, ‘Out of thecrooked timber of humanity, nostraight thing was ever made’. These,words were popularised by IsaiahBerlin in his 1990 book, The crookedtimber of humanity, in which heinvestigates the roots of fascism(http://www.theguardian.com/books/2013/jul/23/isaiah-berlin-crooked-timber-review). The current Islamicextremism shares with fascism a desirefor ideological purity. Such obsessivepurity alone is harmful to society. Butcrucially, these two movements alsoshare brutality and a disregard for thesanctity of human life. This makes adevastating cocktail. Berlin describesmany other examples. I would arguethat our consumerist society isanother form of ideological purity. Inmost Western nations its potential forsocial damage, though considerable, ismitigated by functioning institutionsand respect for law. But at a globallevel we risk the provocation ofdangerous polar opposites in placeswhere they cannot be contained.

So what is this ACT? Russell Harris(see web link above) briefly describesthe philosophy, relational frametheory, that sits behind ACT. Hesuggests that much human suffering

originates from the way we communicate with ourselves: ourprivate language. Suffering arises fromour misguided attempts to control thisinner dialogue, to avoid unwantedthoughts and feelings. This is knownas ‘experiential avoidance’. The firstprinciple of ACT is not to try to controlbut rather accept our thoughts andfeelings as part of our ‘crookedtimber’. This is done partly throughmindfulness training adapted fromBuddhist teachings – being ‘in touchwith the present moment’. Added tothis is a range of techniques for reducingthe impact of the thoughts and feelings through attention to context.This draws on fascinating creative artapproaches, such as turning thoughtsinto songs, and making jokes of thethoughts using metaphor. One of theACT resources is a list of poems tohelp in this process (https://contextualscience.org/act_relevant_poems).

The second principle of ACT – the‘commitment’ – refers to the need tobe committed to ‘action towards avalued life’. This requires an ability tocritically reflect on how we live ourlives in relation to our values. Thistakes us back to our consumeristsociety, its celebrity and its inequality.Much of this culture sits very uncom-fortably with the great world religionsthat have moulded our values, whetherwe are believers or not. It takesconsiderable courage to be trulyhonest in examining how we act in ourlives, but that honesty is an essentialpart of our individual journeys towardsbecoming more fully human, andperhaps towards building global peace.

Acceptance and commitmenttherapy (ACT) and the crooked timber of humanityWilliam House Retired GP; Chair of the BHMA


‘Skunk-like’ cannabis may damagethe brain The use of cannabis with higher 9-tetrahydrocannabinol contenthas been associated with greater risk, and earlier onset, ofpsychosis. However, the effect of cannabis potency on brainstructures has never been explored. Kings College investigatorsused diffusion tensor imaging (DTI), a magnetic resonanceimaging (MRI) technique to examine the corpus callosum, largebundles of nerve fibres which connect the left and right hemispheres enabling communication between them. The corpuscallosum is especially rich in cannabinoid receptors, where theTHC content of cannabis acts. The researchers found thatwhether or not a user experiences psychosis, frequent use ofhigh potency cannabis significantly affects the structure of whitematter fibres in the brain.Rigucci S et al (2015) Effect of high-potency cannabis on corpus callosum microstructure. Psychological Medicine; doi10.1017/S0033291715002342

Tai Chi improves fitness in olderadults with long-term conditionsThe researchers trawled databases for studies up to 2014 onthe use of Tai Chi in people with cancer, osteoarthritis, heartfailure, and COPD. The participants’ ages ranged from the mid50s to the early 70s, and the average length of Tai Chi trainingprogrammes was 12 weeks, with most sessions lasting an hour,usually two to three times weekly. Tai Chi was associated withtrends, or definite improvement, in physical capacity and musclestrength in most or all four long-term conditions, with improvement in pain and stiffness in osteoarthritis and in breathlessness in COPD. The results demonstrated that this typeof exercise can be performed by individuals with differentchronic conditions, including COPD, HF and OA.Chen Yi-Wen et al (2015) The effect of Tai Chi on four chronic condi-tions – cancer, osteoarthritis, heart failure and chronic obstructivepulmonary disease: a systematic review and meta-analyses. BritishJournal of Sports Medicine; bjsports-2014-094388; doi 10.1136/bjsports-2014-094388

Both Tai Chi and physical therapyimprove knee osteoarthritisHow well does Tai Chi compare with physical therapy – theusual treatment for knee osteoarthritis? In this RCT, 106 peoplewith knee osteoarthritis completed 12 weeks of classical Yangstyle Tai Chi twice a week, while the second of 98 had physicaltherapy twice a week for six weeks then six weeks of at-homephysical therapy exercises.

Participants (average age 60, BMI 33, predominately whitewomen) had suffered knee osteoarthritis for eight years. Bothgroups made similar improvement on their WOMAC painscales. Additionally, the Tai Chi group noted improvements indepression. Both groups reduced the amount of pain medicationand NSAIDs.

Lead researcher Dr Wang said, ‘Patients and their physiciansshould discuss Tai Chi as a therapy option, but it is importantthat patients work with a seasoned instructor with 5 to 10 yearsof experience working with people who have osteoarthritis toensure they are receiving proper instruction’.‘Tai Chi found to be as effective as physical therapy for kneeosteoarthritis.’ ScienceDaily, 7 November 2015.www.sciencedaily.com/releases/2015/11/151107172939.htm

Men having radiation therapy forprostate cancer benefit from yoga60 to 90% of patients receiving radiation therapy report severefatigue; 21 to 85% of all prostate cancer patients have erectiledysfunction; 24% of men with this disease report urinary incontinence. These symptoms usually get worse during cancertherapy. In this study, 45 prostate cancer patients undergoingoutpatient radiation therapy took part in an intensive Eischensyoga programme, attending twice-weekly yoga classes of 75minutes each during a six- to nine-week outpatient radiotherapyprogramme. Their symptoms remained stable. The benefits ofyoga in this study may be linked to physiological improvementsthat help reduce cancer-related as well as treatment-relatedfatigue and to strengthening of pelvic floor muscles and increaseblood flow, both of which would improve erectile dysfunctionand urinary incontinence. There must also be considerablepsychosocial benefits in a group fitness activity incorporatingmeditation and promoting overall healthiness. Though there is acommon perception that men would not be willing to do yoga,this pilot study found twice-weekly classes feasible for malepatients. The team is planning a randomised trial to compareyoga participants versus non-participants in a structured yogaprogramme.http://www.sciencedaily.com/releases/2015/11/151116181206.htm

Medical cannabis safe for chronicpainIn the first and largest study of the long-term safety of medicalcannabis use by chronic pain sufferers, a Canadian multicentretrial monitored patients with chronic pain using cannabis dailyfor one year. The cannabis did not have more serious adverseevents when compared to pain patients who did not usecannabis. Patients were given herbal cannabis containing 12.5%THC dispensed through the hospital pharmacies. The averageamount used was 2.5 grams a day whether smoked, vaporisedor eaten. The study found no evidence of harmful effects oncognitive function, nor blood tests and observed a significantimprovement in patients’ levels of pain, symptom distress, moodand quality of life compared to controls.Ware M et al (2015) Cannabis for the management of pain: assessmentof safety study (COMPASS). The Journal of Pain; doi:10.1016/j.jpain.2015.07.014

Research Summaries

8© Journal of holistic healthcare � Volume 12 Issue 3 Winter 2015 35

LettersHumanising healthcareWe should not be in any doubt that England is not only a nation, but in many of its activities and ways is a procrastination – except in those areas where ill-considered‘scale’ and ‘pace’ decision-making drive inevitable, and theusually entirely predictable, ‘unintended consequences’that derive from them. As Stever Turner said, historyrepeats itself – it has to, nobody listens.

Action for NHSWellbeing (AfNHSW, www.nhswellbeing.org) – a network of some 70 health and social care professionals includes trainers, GPs, public and patients,medical students. AfNHSW was convened by a number ofus two years ago and it exists chiefly to enable peer-to-peersupport for championing relation-based human-scalehealthcare and to encourage specific collaborative activitiesbetween network members. We keep in contact to sharepositive and promising practice and reports, interventionsand papers, and to champion, challenge, change andtopple (at least some!) of our shared national disablingand psycho-toxic hierarchies.

Specifically and in brief, over the last year, networkmembers have:

• Worked to enable the ‘dumping of Descartes’ inregards to the mental-physical schismatic thinking,behaviour, attitudes and behaviours that remainembedded in the content and process of NHS medicalcurricula and services. This in the context of workingin our various organisations, including Healthwatch,local government, trusts, third sector organisationsand royal colleges (especially RCGP and RCPsych). Weare currently in contact with the GMC and continuingto press this issue, together with questioning theirprocess of curricula validation and the redundant needfor separate curricula (in terms at least of content) thataddress the condition we all share; as Martin Seagerreminds us it’s the human one.

• Been in contact with the GMC regarding the importance of training doctors in self-care while ensuring that the unified curriculum we seek is relevant to doctors in terms of their appreciation thatthey ‘tick’ in exactly the same ways as those they willbe professionally caring for. We can, and should, createand stabilise the safe, sound and supportive workcontexts that enable our health and social care professionals to be healthy themselves, and to modelthe behaviours that we seek and need to encourage inthe public. All of this is consistent with the literaturewe share and discuss in the network and, in the lightof increasing knowledge of brain and psychological

functioning (our manmade divisions) and ensuringthat all those billions of mirror neurones and their trillions of synapses are gainfully occupied in the causeof self and mutual flourishing.

• Designed a survey of all medical school deans andtheir medical school councils to find out what theythink they are doing to address the need for self- (andmutual) care emphasis and training in their variouscurricula and trainings.

• Pressed, and continue to press, for a care helpline forsocial workers.

• Contacted NMC about their GMC-equivalentprocesses.

• Helped a number of medical schools to ‘wise-up’about already available training, including Dr CraigHassed’s from Monash in Melbourne at LeicesterMedical School – where students also have access toBig White Wall and Dr Kavita Prasad from the MayoClinic at St George’s who is working with their SMARTprogramme; and contacted Student Minds and anumber of medical schools with mindfulness trainingnow in place and are now (with permission) adaptingfor the UK a new resource designed for Australianmedical students.

• Benefitted from the addition of those members withexpertise in, for example, appreciative inquiry,emotional labour and patient voice and much elsefrom others too.

• Championed the relationship and attachment-basedcare that is consistent with all the principles of attachment theory (and why do we still call it that?),human biology and the laws of psychodynamics thatdetermine how human being ‘fly’. While servicedesigners might bang on about needing to have a‘single point of access’, we advocate a single point ofrelationship; that outcomes-based commissioning andpayment by results should ask ‘whose outcomes andwhose results?’, and that the only competition inEngland should be expressed in how competitively we collaborate.

Building the map together; knowing what we support;knowing what each and all are doing; working in co-ordinated and collaborative ways to create bubble-upchange and movement. This is what we are all about. Do join us and help us to help the NHS towards post-peakpractice!

Chris Manning, Convenor, Action for NHS Wellbeing, and Chair, Mental Health Group, College of Medicine

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LETTERS…

Re-enchanting the forest: meaningful ritual in a secular worldWilliam AyotVala Publishing Cooperative, 2015

There’s an art to self-revelation – a fine line to walk. Too much,or wrongly put, and it’s a massive turn-off. But just enough,straight from the heart, and it’s like clear water for the soul,however anguished the story.

It’s the latter sort of self-revelation you find in William Ayot’snew book, Re-enchanting the Forest. You learn as much about himas I would imagine any lover or confidante would learn. Hereally does bare his soul, but it feels like a privilege to walkalongside him as he talks about his discovery of the value andpower of ritual, weaving in discussions of our need for the rediscovery of its sacredness and its psychological necessity withvignettes from his own life – woundings and revelations thattransformed him, that made him who he is today.

He looks at our need for ritual to mark our rites of passage,to mark moments such as separation and divorce, to grievethose we have lost, to celebrate the seasons or our coming intoelderhood. And as he does this, William offers his insights intothe practicalities of ritual – the way one can make offerings,smudge a circle, call on the ancestors.

William has worked in the theatre, written plays, and hasbeen involved for years in the men’s work that began life with

Reviewsthe insights of Robert Bly, so hebrings with him an under standing of the magical potential of performance, as well as the necessityfor authenticity that men’s workevokes. Re-enchanting the Forest hasan inspiring foreword by MarkRylance, who writes that such is theimportance to his life of ritual thathe has marked the eight solar andlunar festivals of the year withfriends for the last 25 years – initself a fascinating insight into the lifeof one of our finest actors, which reinforces the point Williammakes that ritual can provide stability and connection with thepast and with tradition. And yet it also holds a contrary potentialtoo – the power to disrupt the status quo of the psyche or of a society. As Rylance points out: ‘William Ayot revives here thepotent and ancient role of ritual as anything but meaninglessroutine to keep the powerful in power. Quite the contrary.’

Ritual as a means to alter the way power flows in the psyche and in the world, ritual as healing, ritual as a means for self-discovery and for going beyond the self into a wider anddeeper sense of awareness, this is what Re-enchanting the Forestis all about. It’s powerful, soul-nurturing stuff.

Philip Carr-Gomm

Medicine needs a new badgeWhat is going on in medicine currently is a paradigm shift,and we need a new label for people to hang their thinkingon. ‘POD’ (preventing overdiagnosis) has some currency,but says nothing about overtreatment. ‘Choosing Wisely’has come to us from the US, but the claim to ‘wisdom’may be contested by proponents of different strands ofmedical thinking. The BMJ ’s ‘Too Much Medicine’moniker is commendable, but to my mind states only halfthe problem we're grappling with, in that it says nothingabout where the patient is in all this.

The problem we’re all grappling with is what evidence-based medicine (EBM) has become over the decades since its inception. David Sackett’s original 1990s EBMproposition has been progressively suffocated under ever-growing mounds of guidelines, protocols, QoF tickboxes, and pharmaceutical industry funded ‘research’,to become evidence-dictated medicine (EDM). At theheart of the POD/Choosing Wisely/Too Much Medicinemovement is a reclamation of medical wisdom that hasgot chucked out with the bathwater in this wave of enthusiasm for the allure of reductive science (or at least

what oftentimes purports to be science) in what shouldnever have stopped being an art.

So, I wonder about an entirely new label: PCM (person centred medicine). William Osler, and no doubtinnumerable other physicians of past eras, would beturning in their graves that we even have to be thinking inthese terms, but I do wonder if a new ‘badge’ like this isan important step.

Evidence still informs the practice of PCM physicians –of course it does – but it is just one of an array of thingsthat we bring to bear in our relationships with patients,and the wise practitioner recognises both its strengths and its many limitations and weaknesses. We use patientperspectives and priorities, clinical experience, professionaljudgement, interpersonal empathy, and good old intuition,and a whole lot more besides. David Sackett would recognise and endorse that wholeheartedly, and were healive today I believe he would see PCM as far closer to hisoriginal vision than the EDM that his movement has,grotesquely, morphed into today.

Phil Whitaker, GP, Radstock

JHH-12.3.pdf - British Holistic Medical Association

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Transcript of JHH-12.3.pdf - British Holistic Medical Association