Speed. Need. Greed.
Dr Iona Heath came to Vancouver, BC to talk about When Less is More in Healthcare, thanks to efforts by many, and particularly Dr Tracy Monk, of British Columbia's Center for Relationship Based Care.
I was humbled by Dr Heath's first slide: A screenshot of my website. That's right. Jaw-dropped, cheeks rosy, I stared at the front page of Less is More Medicine in all its glory on the screen at the front of the room.
And it got much better from there. Dr Heath wove clinical examples with philosophical perspectives to make the case for Less is More in Healthcare. Her essay along similar lines - The Art of Doing Nothing - can be read here.
To us she spoke about the barriers to achieving this kind of care and how or why things wound up as they have. Speed can be a problem in many ways. Rushing to cure and fix everything, we forget the patient and their wishes; an elderly woman goes to the hospital, gets poked and prodded and optimized, and dies two weeks later anyway. How efficient. ?. She would have stayed home and been cared for at home, if given the choice.
In the talk, as in the essay, Dr Heath makes reference to Christopher Rick's book Beckett's Dying Words. His reflections help illustrate the problem of our strange obsession with fighting death at all costs; later, she drew from Beckett himself:
Samuel Beckett understood more about futile doing than most. He is described by the literary critic Christopher Ricks as:
The great writer of an age which has created new possibilities and impossibilities even in the matter of death. Of an age which has dilated longevity, until it is as much a nightmare as a blessing.
In Malone dies, Beckett writes:
And when they cannot swallow any more someone rams a tube down their gullet, or up their rectum, and fills them full of vitaminized pap, so as not to be accused of murder.
(my German is not great but I believe the essay is a transcript from Dr Heath's keynote lecture at The Art & Science of General Practice and Family Medicine)
The most resonating part of the talk for me was the dissection of our persistent and inflated idea of "need." Dr Heath found many ways to point out the ridiculousness of our quest to create patients, including thoughts from post-war Polish poet Zbigniew Herbert:
I invented a bed with the measurements of a perfect man
I compared the travellers I caught with this bed
It was hard to avoid - I admit - stretching limbs, cutting legs
The patients died, but the more there were who perished
the more I was certain my research was right.
The goal was noble. Progress requires victims.
However, it was Iona's casual phrases, like "the contemporary distortion of need" that so eloquently stated the issue. By diagnosing "risk," like an increased risk of heart attack or stroke, we inflate the need. We create a responsibility to do something, do anything to prevent a potential thing that hasn't happened yet and might but probably won't.
We have done this in the case of mammography. For years we promoted self-exams and clinician breast exams. Then we realized those were a waste of people's time and encouraged worry about lumps that were nothings. So we said "just mammogram." In 2009 I read the New Zealand guidelines for screening for breast cancer. At that time, they were encouraging against clinician exams and even suggesting that mammography might not be recommended in future. I failed to convince one of my preceptors, a wise and thoughtful guy. For years he had helped women find "the lump" that ultimately was hacked off, irradiated, and chemo'd, and their lives had been saved. Patients, convinced by their doctors for years and years, still feel something must be done. "Early detection is key."
That anecdotal experience is hard to trump, but as the data floods in, we are discovering that less is more. It is the responsibility of physicians and the medical community to undo the messaging that we touted for years.
It never boils down to just randomized controlled trials, NNTs, or confidence intervals. We are caring for humans, and that cannot be reduced to just fighting disease or perceived risk.
Powerful words bear repeating and so we were given some of Annemarie Mol's to chew on.
The Dutch philosopher Annemarie Mol, in her book The Logic of Care, writes about how ‘the logic of choice’ now undermines ‘the logic of care’. She says: ‘Even if good care strives after good results, the quality of care cannot be deduced from its results. Instead, what characterises good care is a calm, persistent but forgiving effort to improve the situation of a patient, or to keep this from deteriorating’. The richness of that aspiration compared with getting the numbers to the correct point is incredibly important.
Mol goes on: ‘You do what you can, you try and try again. You doctor, but you have no control. And ultimately the result is not glorious: stories about life with a disease do not end with everybody ‘living happily ever after’. They end with death.’ Unless we as both a profession and as a society get over the idea of death as medical failure, we are doomed to torture our patients when we should be leaving them alone. (from The International Futures Forums)
Exploring need, the example of the overdiagnosis of ADHD and the medicalization of our children emerged. Dr Heath explained that labeling and medicating children teaches them 'that they are not normal, not responsible for their behaviour, and that answers come in pills.' It might be that our kids are not disordered - they just learn in a different way. See this snippet of Sir Ken Robinson's great Ted Talk on the subject:
Lastly, there is greed. Diseases are invented in order to market drugs. Normal behaviour is medicalized, or deemed pathological as we sterilize the definition of 'normal.' Those who have get more, and just because we can do something expensive and fancy and new doesn't mean we should. Christopher Ricks:
It is now almost impossible to die with dignity in USA unless one is poverty stricken
If you have the means, you'll be poked and prodded beyond your heart's desire. We've got it wrong most of the time. Doing more is not better, and fails to solve the underlying problem. "We seek technical solutions for existential problems" (Overdiagnosis: when good intentions meet vested interests—an essay by Iona Heath) and that leads us down a very slippery slope. Just one more test. Let's try this treatment.
Let's stop. Let's think of the patient and what matters to them. Or as the patient, what matters to us? Must we keep our numbers within normal parameters? Shouldn't we just strive to feel good, pursuing a "modified hedonism," in order that we might appreciate more the quality than the quantity of life we are given?
General practitioners would do better to encourage people to lead lives of modified hedonism,so that they may enjoy, in the full, the only life they are likely to have.
(J McCormick, Health promotion: the ethical dimension, Lancet, requires subscription)
I admire the strength of Dr Heath. She is an unapologetic champion for the right care, and explained to us with wisdom and compassion the reasons we've wound up in this state of aggressive care, and offered solutions for moving past it. The role of the Family Physician and the connection we share with patients is central to this.