doctors

It's time to reclaim holism

Holistic. It's one of those words that's sure to set any skeptic’s teeth on edge. It's basically a codename for woo, bandied about by supporters and pushers of all sorts of magic, unicorn tears, and snake oil.

But should it be? Is it time for the medical profession to reclaim the label holistic as its own, and start shouting from the rooftops about how we are holistic practitioners? I think it is, and here’s why.

holistic

həʊˈlɪstɪk,hɒ-/

adjective

Philosophy

adjective: holistic

characterized by the belief that the parts of something are intimately interconnected and explicable only by reference to the whole.

Medicine

characterized by the treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease.

There is a general perception, gleefully pushed by proponents of alternative healthcare,  that somehow conventional healthcare and holism are at odds with each other. The image of an uncaring, white-coated medical professionals hell-bent on simply treating that one particular symptom, with no regard for the fact that a patient is attached to that symptom seems pervasive.

We don’t help ourselves, I suppose. With a limited time on GP appointments, for example, its easy to feel like you’re being rushed through the system. Some surgeries ask that you book one appointment per ailment. Our health care professionals tend to specialise in one particular type of illness, and you can start to get the impression that they only care about that particular bit of your life, despite the fact that it’s very often all interconnected. You can feel passed from pillar to post, one day an appointment with a diabetes nurse, the next day an appointment with someone else for your arthritis, and two days later an appointment with a mental health specialist. So I do understand that it can seem like, as healthcare professional, we only care about your symptoms. 

But, even at the most basic level, it is impossible and really quite dangerous  to practice healthcare without looking at the patient as a whole. We’re all trained to do it, and its become so second nature to us that we have all sort of forgotten to be proud of it. As a result, we've lost control of the word holistic and we’re allowing unscrupulous charlatans to creep in to the public’s consciousness on the back of it. Of course, there are improvements to be made, but I think on the whole we do bloody well in the NHS, given the knowledge, funding and time constraints we’re lumbered with.

Now, in my day job as a medicines information pharmacist, I actually have no direct contact with patients. But I still, fundamentally, operate as a holistic practitioner. Here’s a basic example of what I mean:

GP: “Ah, hi there, I’m just wondering if there are any interactions between Champix and CellCept?”

In this sort of seemingly simple interaction enquiry, it is imperative that I look at the patient as a whole, rather than simply as two drugs out there on their own. 

  • Champix®▼(varenicline) is a drug used to help patients stop smoking
  • CellCept® (mycophenolate mofetil) is an immunosuppressive drug used to stop organ rejection in transplant patients. 

If I were to look at interactions of these two drugs,  I wouldn't find any,So fine, we’re good to go, right? I mean, I’ve answered the question, done my job, and all is well, yes? 

No, not at all. If I’m going to safely answer this question, I need to look at the patient as a whole. I need to acknowledge that they’re not simply a smoking machine that needs to stop but they’re a living, breathing complicated human.  I need to look at the patient holistically, not just as some isolated drugs.

So our patient is in his mid-forties, using the mycophenolate mofetil because he has previously had a heart transplant. He has a history of depression (understandable really, given how ill he has been in the past), and takes a couple of other medicines too (no major interactions on checking). He wants to stop smoking, which is great, a really positive step for him, but he’s failed a few attempts already whilst using nicotine replacement therapies. He's found these failed attempts frustrating in the past,which has then triggered bouts of depression. His liver and kidneys are working just fine.

So, looking at the patient as a whole, I need to think about how using varenicline will impact him as a person. Some of my thoughts go thus:

  • Stopping smoking itself might affect some drugs, as there are chemicals in cigarette smoke which can affect the enzymes that metabolise some drugs. Is this the case with any of these drugs?

  • Quitting smoking itself can be a trigger for depression or suicidal ideation. 

  • There is also an association between varenicline and changes in behaviour and thinking, including depression and suicidal ideation. Given this patient’s history, this will need to be discussed with him and he’ll need to be monitored carefully.

  • Certain cardiovascular events were reported more frequently with varenicline than placebo in trials: we need to bear that in mind and monitor him for any adverse reactions, especially given his heart transplant

  • Not succeeding in giving up smoking has made him depressed in the past. Continuing to smoke increases his cardiovascular risks. A good old risk vs benefit decision needs to be made.

So I discuss all this with the Dr, and her response is:

“Ah that's great. Yep, I knew about the depression stuff but to be honest I hadn't really thought about the cardiovascular risks. I'll discuss it all with him, and I think we'll go ahead and prescribe it but I'll make sure to keep him closely monitored”

By looking at the patient holistically, his Dr and I have made sure that he will know to look out for any cardiac effects and to report it as soon as possible if he does experience any side effects. We can make sure that he's also prepared for the fact that his mood might change, and knows to report any of that too. He’s willing to take these risks for the sake of stopping smoking, so we’re helping him to take a really positive step in his life, aimed with all the information he needs to do it safely.

That’s just a small example of how I practice holistic medicine in my daily life. All over the NHS, at every level, other healthcare professionals are doing the same thing in their practice. We don’t declare ourselves to be holistic, because its such second nature that we don’t even realise we’re doing it. Maybe its time to start reminding people-and ourselves- that conventional medicine does, fundamentally, mean holistic medicine. 

Hxxx

 

A comparison between medical and homeopathic information sources

Recently, I’ve been delving back into the world of homeopathy, and all of the nonsense that it entails.

Part of my research and preparation has been consulting homeopathic texts- materia medica and repertories that are still in use by modern homeopaths.

One thing that I have been repeatedly struck by is the stark differences in the quality of these information sources compared to those used in modern medicine. Let’s take a look at some of those differences.

Up To Date?

Part of my day job’s role is resource management. This means that I need to make sure that all of the resources that we use and have access to are present and up to date. Whenever I use a book as part of my work, I document which edition I have used. If I use a website, I make sure to include when it was last updated. When we get a new book in the office, I find the old copy and cover it in stickers saying “Out of date- do not use”.

I don’t do these things because I am weird, or because I enjoy it. I do it to ensure that I give the most accurate, up to date information so that the patient gets the best care. What we know about medicines is constantly evolving- new medicines, new safety information, and new evidence is emerging daily. What might have been correct to the best of our knowledge last year may now have been subsumed by more recent experiments, and so the information sources I use change accordingly. So, for example, I can reach for a copy of the British National Formulary from 2005, and find information that recommends sibutramine as a weight loss aid in certain patients. However, if I look at the current version, I won’t see it in there, as it has since been withdrawn for safety reasons. If I were to have used the 2005 copy to advise a patient, I might have given them the wrong advice, in the context of what we know today.

How up to date is the information used by homeopaths? According to The Homeopathic Pharmacy (Kayne, S. 2nd Edition, published in 2006 by Elsevier Churchill Livingstone, page 192- I did warn you about the documentation): ‘The most well known are Boericke’s Materia Medica with repertory and Kent’s Repertory of the Homeopathic Materia Medica’. Sadly, the author of this book doesn’t see fit to bother telling us when these were published. Neither does the online version of it, although there is a bit of a hint in that the “Preface to the ninth edition” on there is signed off by William Boericke in 1927.

Nineteen Twenty Seven. Medicine and healthcare is a pretty fast-paced industry, with new innovations and information coming out at an overwhelming rate. So much has happened in medicine since 1927 that there is no way that anyone should accept health care advice based on something written from that time. I know I certainly wouldn’t be too happy if my GP gave me health advice from a dusty tome, or if I went to the dentist’s to find them using equipment from the 1920’s.

Maybe Kent’s Repertory will be more up to date? A Quick look at the website gives us no clues. This time, the preface contains no date at all. The closest thing that we have to a publishing date is the fact that the website is copyright 1998, and appears to have been formatted by a default-font loving child in the early nineties.

Political Correctness

Over the years, medical terminology has changed and evolved along with society and scientific discoveries, and rightly so. In some cases, words that used to be considered as perfectly legitimate scientific terminology (such as ‘Mongol’, or ‘Mongoloid Idiocy’, used to describe a person with Down syndrome) are now considered downright offensive. Even whole swathes of what is now considered normal society (such as gay people) were once declared as illnesses- and of course we know better by now, or at least we should do, and if you don’t- grow the hell up, will you. We generally don’t refer to people as “hysterical”, or “insane” anymore, as we know a lot more about such conditions, so are able to categorise people more helpfully and professionally.

As a result, we healthcare professionals are very aware of how crucial the use of clear, concise, professional communication is, including the information in our resources. No self-respecting modern medical text would ever dream of using out-dated, offensive terms, and if it did, there would be an outcry.

Let’s have a look at the sort of thing that Boericke’s Repertory wants to help us to treat. There are things like “Brain-Fag”, “Cretinism”, “Masturbatic dementia”, “Fears of syphilis”, “hysteria”, “insanity”, “weak memory from sexual abuse”, “Haughty”, “Stupid”, and many others. These were just taken from the “Mind” section, but there are many other examples in the other sections too. These terms are just too outdated and are wholly inappropriate to be used in today’s society.

Having looked through various other Materia Medica entries too, I’ve found statements that are sexist, bigoted, and occasionally racist. Nice eh? You don’t find that sort of thing in an up-to-date copy of Martindale: The Complete Drug Reference.

Clarity

Good, modern medical resources are all about clarity. They need to be- after all if someone gives the wrong medical advice because they have interpreted something incorrectly, patients could be at risk.

Jargon is sometimes necessary, but nowadays medical jargon tends to use standardized, accepted terminology which keeps the risks of misinterpretation to a minimum.

Homeopathic repertories and material medica, on the other hand, are full of vague, odd terms which are massively open to interpretation. What, pray tell, is a “voluptuous, tingling female genitalia” when it is at home? (and I wonder whether Ann Summers offers free delivery on such a thing?). What does “expectoration, taste, herbaceous” mean clinically? How is one supposed to diagnose “Taedium vitae”? When would you class a person as “Obscene, amative”, and when would they be considered as merely “gay, frolicsome, hilarious”?

In Conclusion

Our health is arguably the most important asset that we have. Why would we entrust it to sources which are terribly out of date, inaccurate, and in some cases, offensive?

Homeopaths like to paint themselves as a caring, human alternative to the more business-like, clinical world of real health-care professionals. But when this alternative categorises people as being “stupid”, or “cretinous”, and is happy to use criminally out of date resources which can risk peoples’ health, I wonder just how caring and ethical it really can be.  

I've said this before, and I'll say it again: why would you continue to use an abacus when calculators exist, and are proven to have a better record at getting the right answer?

 

Teratology: an area where more critical thinking would be useful

(Teratology: Noun: The scientific study of congenital abnormalities and abnormal formations. From the Greek teras [meaning monster or marvel] and logos [meaning study])

"Hands up, who is afraid of advising someone takes a medicine in pregnancy?"

In the couple of training sessions I've delivered, this has been my opening line. And many hands go up. I regularly give advice on medicines in pregnancy in my job, and it strikes me that it is an area which could hugely benefit from more critical thinking and a reliance on evidence in everyday medical practice. I'm thinking might do a little series of blog posts on this subject. 

So why are so many people afraid of giving advice? One word: thalidomide. You'll all probably know what went wrong in the thalidomide disaster- a drug that was commonly used for morning sickness which unfortunately causes limb malformations when used at the time of pregnancy when women get morning sickness. That, coupled with the lack of post-marketing regulation ad monitoring back in those days- led to a perfect teratogenic storm, with obvious impacts for those affected, but which also shook the medical profession to its core. The good thing is that it forced a rethink in medicines regulation and triggered interest in pharmacovigilance, with schemes like pregnancy registries, teratology information services, and the MHRA's Yellow Card scheme being introduced in its wake. It's also left a lasting, deep-rooted fear of the potential of medicines to cause harm in pregnancy in pharmaceutical companies, patients and medical professionals alike. 

Why is this fear a problem? Well, primarily because some pregnant women do still get ill, and do still need medical treatment. I've lost count of the number of times I've heard a doctor say to me "my patient has (insert life threatening disease) and she's found out she's pregnant, so I've stopped all of her meds. What harm will that have caused?" And my first response is "how is your patient?", along with having to try very hard to stop myself saying "what do you think is going to be more of a teratogen, whatever the drug is, or having a patient who is dead?!" Such decisions to stop treatments are often done without consulting any evidence first, and there is a clear potential for harm to patients and their pregnancies in such situations. 

Another harm is that, in the event of something going wrong in a pregnancy, there's a tendency to way something to blame. I think it must be truly awful to have to think that because you have taken medicines, it's all your fault, especially as in many, many cases there will be no clear causality. 

I think we can pretty safely say that, because of the things that have been put in place since thalidomide, that another similar disaster won't happen again. There are drugs which can undoubtedly cause harm in pregnancies but as with all things in medicine, we have to consider a benefit vs risk balance. And we have to take into account what evidence we have access to, think about its limitations, and apply it to each individual situation. Just stopping all medicines because a patient is pregnant is not going to be the least risky option in most cases (and indeed in all those aforementioned cases that I've discussed, the drugs the patient has been on have turned out to have some pretty reassuring data sets). I even know of a dr who panicked so much when he found out his patient was pregnant that he put a note through her door telling her to have an abortion because he had prescribe her some drugs which turned out to have a pretty robust safety record in pregnancy. Imagine the emotional harm this sort of thing could cause. 

I don't want to end up writing a hugely long blog post so I'm going to end this one here as I'll cover some more aspects in future posts.

A tale of an excellent healthcare system

It seems that everywhere you turn these days there's another horror story about the NHS. In the wake of the Mid-Staffordshire report, press, patients and staff are reeling from what seems like a never- ending list of systematic failures. Some of us in the UK are no doubt left questioning the value of the NHS, wondering whether our taxes are being spent on nurses who are more about painting their nails and chatting than looking after patients and doctors who merrily stand by as scores of patients die while they discuss what they watched on TV last night. 

As with all things, the juicier media stories come out of negative experiences. There are major failings in the NHS for sure, and my goodness we need to address them. But we need to also realise that there are a huge amount of strengths associated with our healthcare system also. Alas, our current health secretary seems hellbent on destroying the good bits once and for all. Unless we start paying attention to the good, positive stories... Well, as the cliche goes, you don't know what you've got til it's gone.

So here is a little story of my recent experience with the NHS.

As you will no doubt know by now, given my incessant whinging on the subject, I currently have guttate psoriasis. You'll probably also know that it's completely freaked me out, and caused a bit of a flare up of anxiety. 

I registered with my local doctors, which I had been meaning to do for ages. I rang at 8am and had a registration appointment by 9:30am that day. The healthcare assistant i saw was warm, friendly, and very empathetic. By 10:15 I was seen by a doctor who was equally friendly, had a good proper look at my rash, and who explored my feelings about it and helped me rationalise my anxiety about it. By 10:30 I was out the door, prescription in hand, and feeling much better. 

Fast forward a few weeks and my rash is still getting worse. I pop back to the doctors and again am seen by a doctor who takes a lot of time and effort to find out how the rash is affecting me in myself. She made me feel totally justified in my feelings and went out of her way to arrange an urgent dermatology referral for me. I had a throat swab for residual strep with the same healthcare assistant who looked after me initially and she was brilliant, chatting with me about how often her mum had to scrub the bath when her sister had eczema as a child. We had a bit of a giggle, and that was exactly what I needed. I get the feeling that had I needed a good cry, she would have been equally happy to spend time listening. 

Some might say this is just them doing their job. Maybe it is, but I think in my case they've done their job brilliantly. I've felt like I've seen people whose primary aim is to help patients like me, and who genuinely care about my emotions and quality of life.

It's little stories like this that have kept the NHS going for all these years. They're also the kind of stories that are so easily forgotten. I know from experience that a little bit of positive feedback from someone you've made a difference to can really make your week, so if you've had a similarly positive experience, no matter how small, I urge you to share it. 

Hxxx

Red Wine as a painkiller... In babies?!

A couple of years ago, I was working a locum shift in a supermarket pharmacy. It was quite late at night, and a man came up to the counter to ask me if I did circumcisions. I assumed I had heard incorrectly, but no. "I thought you would be able to do circumcisions, since you can do healthcare services and you have a private room" he said, pointing at the extremely small and flimsy consulting "room" and the end of the counter. I couldn't help but notice the small boy cowering behind him as I politely explained that no, circumcision certainly wasn't a pharmacy service.

At the time, I remember being amazed that it would occur to someone to take their child to a supermarket for what is a surgical procedure. Whilst it may be considered minor surgery, I'm sure to the young boy himself it didn't seem all that minor, and I'm pretty sure he wouldn't be wanting a pharmacist to do it in the middle of a supermarket with only some thin plastic walls between him and the vegetable aisle.

Anyway, I shall leave aside the ethics of circumcision for now, and consider a tweet I saw this morning by Andy Lewis. One particular Doctor, on his website, is advising pain relief options for babies who are about to be circumcised. He advises loading the child up on red wine as a preferred option. Now hold on here, this is a GMC registered Dr advising on giving babies alcohol. Whilst he doesn't give any information about how much wine to give, i'm assuming it would have to be enough to get the child at least slightly intoxicated to have any painkilling effect. A quick google search suggests the 8th day after birth is a usual time for the circumcision to take place, e.g:

"To give the baby sweet, red wine prior to the procedure. (Kiddush wine is ideal). This is very effective in calming the baby. Ideally it is given about 15 minutes before the circumcision and I will give it on arrival if you wish. You will need to provide the wine." (http://www.mohel-circumcision.co.uk/1298.html)

At this point, let us consult TOXbase.org, the database of the National Poisons Information Service (NPIS). They advise that any children under the age of 10 who are symptomatic due to an alcohol ingestion (i.e. intoxicated) are taken into hospital for medical assessment.

Why is it dangerous to advise wine as a painkiller in a child of this age? Well, alcohol in children can be very nasty. It can cause hypoglycaemia, particularly in children, and a seemingly well child can sometimes suddenly and quickly go downhill fast- that's why NPIS recommend that they are observed in hospital.

Such advice, coming from a trusted Doctor, is very concerning indeed. It appears from the website that he expects the baby to be "prepared" prior to his arrival, so he is expecting the parents to administer and provide the wine (whilst he says he can give it "if they wish", to me this implies that its more usual for the parents to give it). He gives no directions as to how much wine to give, which could be easily misinterpreted by worried parents. 

I  emailled the GMC to ask what their stance on such advice is. They eventually got back to me to tell me that it wasn't a concern as usually only a tiny amount is given. This doesn't seem like a very satisfying answer, given that either a) the child is given so little that they don't have effective pain relief or b) they're given enough to be toxic. 

A childhood story

I was a fairly robust, risk averse nipper. But, like all kids, I got the odd sniffle and sickness now and then. And, like most parents, my Mum would usually take me to see the doctor when I was poorly.

I have a really vivid memory of going to see the doctor. He was a kindly, soft-spoken chap who, as I recall, had a caring manner. And what I remember more than anything was his large leather case, filled with pastel-coloured vials of what he described as "magic crystals". 

Depending on what was wrong with me, I was able to choose from a selection of colours of "magic crystals", which were then administered to me and which, in my head, made me feel a bit better. I think I only got one dose, when I was there in the surgery. Neither my mother nor I have any recollection of me taking home any "magic crystals" or having repeated doses.
 


Now, here's the thing. At no point did my dear darling mother actually bother to ask what the "magic crystals" were. We now assume (hope!) that they were some sort of homeopathic thing. They definitely looked like coloured sugar crystals and tasted like sugar. Or were they some sort of elaborate placebo designed to soothe children into believing they felt better? Or were they some suspicious hallucinogens? The point is, at no point did my mother think to question the doctor: he was in a position of caring authority and he knew best what would make me better, right? And from my perspective, a nice, caring man who my mother had trust in was letting me pick pink sweet-tasting crystals so YAY GIVE ME THE SUGAR! 

Out of interest, my memory is that yes, magic crystals did make me feel momentarily better. But this is a vague memory, which may well have been clouded by nostalgia and the many years that have since gone by. why could this have been? Well, power of suggestion and placebo. As a child I knew doctors made me better: ergo, I felt better when I was at the surgery seeing the doctor.

We hear a lot about patient choice in debates about homeopathy. I guess my point here is that this doesn't always come into the conversation with patients or their carers, and that's worrying. Admittedly it was longer ago than I care to admit, but I'm pretty sure similar practices go on today. I really do hope that medical homeopathists do allow their patients more informed consent, and I also sincerely hope that all homeopathists do the same. But they can't offer them full informed consent because the data isn't there to back up their claims, or they have misunderstood the data that is there, and most importantly, the science and theories don't make sense. What sort of benefit vs risk decision can happen for a patient when they simply pick up a pack of arnica 30C from the shelves of Boots?  What kind of choice was my mum able to make when it didn't occur to her to ask any questions, and no explanation was forthcoming?


Health care professionals have a duty of care to their patients. A large part of this is about communication. What homeopathists (and herbalists, and traditional chinese herbalists, and halotherapists, and anyone else who purport to change people's health) need to realise is that, in the eyes of the public, they hold the same amount of trust and duty of care. And even if regulatory bodies aren't in place to take you to court if you harm someone, your personal morals should step in before you sell a remedy made merely of hope for monetary gain. 

The air is nice up here on the moral high ground.Of course, it could always be the case that it's actually just the mind-altering effects of whatever mind control agents were in the magic crystals....

H xxx