Although I’ve heard of NICE somewhat disingenuously described as representing ‘Nazis Independent of Clinical Experience’, the acronym stands for the National Institute for Care and Health, an organization within the Department of Health which provides national guidance and advice to improve health and social care in the UK.
Inevitably there are doctors who feel that NICE guidelines are far too condition-related or focused on treating specific diseases rather than recognising that illnesses manifest in and affect people very differently. Believing that people usually need treatment plans tailored to their body/mind/spirit make-up is the essence of the Whole Person Medicine approach. However on this occasion I come not to bury NICE but to praise her.
The UK review concludes that ‘healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician.’ This triggered applause, thought, criticism and debate in the US (just read the comments section!) but in me it generated only nostalgia and joy. It was reading Frederick Leboyer’s poetic masterpiece, Birth Without Violence in 1978 that pushed me to see human beings primarily as subjects rather than objects (of science). I met this pioneer of natural childbirth in Paris 1n 1982 (and later another French pioneer of natural childbirth, Michel Odent in London) and obstetrics became the first area of medicine in which I saw how the generosity of spirit of Whole Person Medicine and the rigour of medical science can co-exist harmoniously.
NICE is better known for being evidence-based rather than ‘nice’, but on this occasion – for this doctor at least – it was both.
An exceptional review by NICE concludes that ‘healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician.’ This triggers a huge debate in the US.
Yes you read it correctly. That famous/infamous organisation that among other crimes, apparently makes 70% of our laws, has just issued one of the most pro-homeopathic directives in many years.
In a front page article,The Telegraph reports that the European Commission issued a directive for organic farmers stating “it is a general requirement…for production of all organic livestock that (herbal) and homeopathic products… shall be used in preference to chemically-synthesised allopathic veterinary treatment or antibiotics.”
The article is far from being as pro-homeopathic as the EU directive. Even I, a whole mammal physician (albeit all my patients are humans), have some problems with the wording quoted. I would prefer ‘used as a first choice wherever possible, practical and clinically viable to chemically-synthesised…’
The point is simple: Whole person medicine or whole animal veterinary medicine includes the use of antibiotics and pharmaceuticals. However if there is little risk of morbidity or mortality, there is an opportunity to try an intervention in the form of an holistic stimulus. This could be a change of diet, relaxation or yoga (in humans) an acupuncture treatment and ‘even’ a homeopathic remedy. If this fails or the condition worsens, it is absolutely mandatory for the practitioner to resort to pharmaceuticals or surgery. If this is what the EU Commission means, then they are to be commended for understanding and appreciating the principles and practice of all holistic vets and doctors.
The whole issue of veterinary homeopathy remains very interesting. For many people, the fact that owners of pets claim it works on their cats and dogs and farmers claim it works on their animals too – is powerful testimony to it acting over and above the derided ‘placebo effect’.
Dr R.D. (Ronnie) Laing (1927 – 1989) was a famous/infamous doctor, existential philosopher, poet, psychoanalyst, psychiatrist and anti-psychiatrist. The Divided Self (1960) is an examplar of his medical philosophy while the poetry of Knots (1970) was adored by the generation of the ‘New Age’.
What most impressed me about Laing was his view on the sort of ‘energy’ or ‘atmosphere’ in the consulting room conducive to effective psychotherapy. I was moved by this very short description of his approach to a depressed patient. Although before the time of Frank Farrelly, what Laing says here is typical of the approach of Provocative Therapy.
Provocative Therapy aims to change the behaviour of the client for the better. Laing concurs when he says that someone trapped in a room may be better off trying to walk out the door than spend years working out how he got in there. Similarly if one is trapped in a hole in the ground it may be less productive to dig deeper than to start climbing out.
Provocative Therapy believes the solution to a patient’s problems is in the patient. When Laing invites patients to ‘scan’ the previous 48 hours for moments of happiness, he is confirming that the patient – rather than any doctor or philosopher’s theories – is likely to come up with the answers to his/her issues.
Provocative Therapy uses Reverse Psychology and Humour to provoke the patient into improved behavioural patterns. Laing demonstrated this by getting the patient to whistle and share jokes thereby elevating his mood immediately.
Provocative Therapy aims to get patients to locate, articulate and enact the solution to the problems. This happened so blatantly in this case that the patient was reluctant to give Laing any credit – another scenario not unfamiliar to Provocative Therapists!
Provocative Therapy is the cutting edge in the use of Reverse Psychology and Humour in brief psychotherapy. It was discovered and developed by psychiatric social worker and psychotherapist extraordinaire, Frank Farrelly at Mendota State Institute in Madison Wisconsin. The brief clip below is about the pivotal moment in Frank Farrelly’s professional life.
I am definitely not advocating that schizophrenia be treated by Provocative Therapy, Humour or Reverse Psychology. I don’t treat schizophrenia or any form of psychosis with Provocative Therapy but find it very efficacious in a large spectrum of behavioural issues including achieving goals, breaking habits and losing weight as well as all relationship problems and the relationship problem of not being in a relationship when one would like to be in one.
Still, this is the true story of how Farrelly stumbled on to the central principle of Provocative Therapy.
An article in the Guardian makes some unfair generalisations about complementary and alternative medicine (CAM) but also makes one very good point.
The author is an Australian oncologist called Ranjana Srivastrana. Oncologists or physicians specialising in cancer do not have easy jobs. Having worked in an oncology ward myself, I know the sadness of seeing new empty beds each morning. Nevertheless her general attack on CAM is hopelessly biased. Whole person medicine and CAM are not about ripping patients off and forcing them to spend thousands of pounds on supplements. There may be some unscrupulous practitioners (and doctors) who do this, but in general my experience of non-doctor CAM practitioners is that they are caring people who appreciate patients as whole people and generally work hard to make a modest living.
Whole Person Medicine should always include orthodox medicine and this means anti-cancer drugs too. A whole person programme for a patient with cancer can easily involve radiotherapy, chemotherapy as well as CAM techniques such as Autogenic Training (for profound relaxation), homeopathy, acupuncture and creative visualisation. Many patient intuitively sense this and that is why Dr Srivastrana’s patients ask her the questions that so frustrate her. She should read Bernie Siegel’s book Love, Medicine and Miraclesin which the author, a surgeon, beautifully illustrates a whole person approach to cancer which of course does not exclude the tools of the oncologist, but harnesses the power of the mind of the patient in the therapeutic process.
Srivastrana does make a very important in that she notes doctors and alternative practitioners seldom talk to each other and many doctors don’t understand CAM at all. In the era of instant communication, this should not be difficult to remedy. Some CAM practitioners spend many hours talking to their patients and the doctors of those patients may learn a lot by making a quick call. As that old BT ad said: ‘It’s good to talk.’
In a recent interview, I drew attention to aspects in the ongoing debate about homeopathy, that I feel have been somewhat under-discussed.
The first is that our critics never seem to mention the patient and empathic way homeopaths listen to the story of their patients’ illnesses in the context of their whole lives, before even thinking of which ‘controversial’ white pill to prescribe. Critics and sceptics may believe that homeopathic benefits (‘if any’) derive solely from this. If this is what they believe, they should say so openly. If they are genuinely interested in patients’ well being, the next logical step would be a major medical investigation into trying to understand why patients who are listened to in homeopathic, way start dramatically improving!
The second aspect I believe does not get enough attention is Outcome and Patient Satisfaction. An outcome study is a study in which patients are simply questioned comprehensively on the outcome of any medical intervention. In this regard, homeopathy has scored very highly as in the Spence Outcome Study in Bristol. That study was attacked by critics – mainly due to their distaste for outcome studies in general.
But why? For patients outcome is everything. Patients care about getting better; how they got better is of secondary importance. What critics of homeopathy have done is to some extent deride the obvious beneficiaries of homeopathic treatment.
Just as homeopaths listen to suffering patients carefully and empathically, so critics of homeopathy should listen to what satisfied homeopathic patients have to say about their experiences. Outcome studies are no more than a collation of the voices of patients – the very people whose welfare this debate has apparently been all about.
Outcome studies are no more than a collation of the voices of patients – the very people whose welfare this debate has apparently been all about. Patients care about getting better; how they got better is of secondary importance.
Over the past few years homeopathy, has been the victim of many uncouth attacks in the media. The populist ‘wisdom’ of our time and place bleats that it’s ‘witchcraft’, lacks evidence for its efficacy and is a waste of NHS money. In fact it is no more controversial today than it was when invited to be part of the National Health Service at its inauguration in 1948. Appalled by the double standards being used by homeopathy’s critics and assisted by the Pie Man, I have called for a level playing field for all interventions on the NHS – ie one standard of evidence for all prospective treatments.That this has been scoffed at doesn’t surprise me. The makers of cough mixtures and a lot of other unevidenced, useless (and even potentially dangerous) medications sold over the counter in pharmacies and supermarkets would have a lot to lose if there was one standard for all. Eschewing a level playing field, opponents of homeopathy have ensured that the debate has focused on the ‘implausibility’ of homeopathic dilutions being able to have any clinical effect. I find it interesting that nothing has been written about the structured process of classical homeopathy starting with a comprehensive case taking and culminating in a homeopathic prescription that suits not only the condition but also the whole human being – physically and psychologically. Many homeopaths spend anything between 1 – 3 hours carefully listening to every detail of their patient’s symptoms and subjective physical and psychological experience of what is happening to them in any illness. It is a profound and empathic process culminating in a choice of medicine that suits the totality of a human being’s experience of being ill. While never a substitute for conventional medicine (which undoubtedly saves lives and does good) when responsibly practised (if possible with medical supervision) homeopathy has a huge role to play in people’s wellbeing all over the planet.
Homeopathy is not about small white pills or placebo. It is a profound process where you will feel fully received and listened to before you are prescribed anything. It is my belief most people going through this unique form of anamnesis would want to try the medicine prescribed thereafter – especially as everyone agrees it can certainly do no harm – and many millions of people are convinced that it has worked for them.
Ever heard someone saying they have a ‘bad back’? That’s a rhetorical question because ‘bad backs’ are responsible not only for enormous suffering but also have a huge impact on the economy.
In 1950 backache accounted for 1.5 million days of work last but by 1995 this had risen to 115 million (sic) days lost. What on earth are we doing differently? Sitting too long? Working harder? More stressed? Less robust? Less willing to work while in pain?
The very fact that there is such a condition as a ‘bad back’ tells us that we know very little about backs and back pain. Ever heard of a ‘bad heart’, ‘bad brain’ or ‘bad eye’?
Tests can sometimes help by showing a severely prolapsed disc or other very obvious damage but people with back pain can have abnormal MRI results and people in debilitating pain can have normal X-ray and MRI results.
Without accurate diagnoses, medical treatment tends to be speculative. Surgery, micro-surgery, steroid injections, manipulation, pain killers, alternatives such as acupuncture and osteopathy – all claim results but no one form of treatment can claim uniformly good results for back pain.
The problem may be that helping back pain may be something that often requires great commitment by the patient. Our bodies are supported not only by our backs but also by a host of abdominal muscles including the very important oblique muscles of the abdomen. Strengthening these muscles by a carefully structure exercise programme can be spectacularly successful and yet I see so many patients who have not been taught and encouraged how to do this.
Is this because programmes to strengthen the abdominal muscles and produce core stability are ‘boring’ and are not easily packaged or sold in bottles.
Back pain is a huge cause of suffering to humanity and often a very difficult problem to treat – or even properly diagnose – unless one can consider ‘a bad back’ a diagnosis. So it came as a bit of a surprise to see the front page of the Daily Express today which has the huge headline:
SIMPLE JAB TO CURE BACK PAIN
Now for me ‘cure’ is a very big word indeed so I eagerly bought the Daily Express – but my search for a ‘cure’ to the debilitating problem that apparently costs us £12 billion a year in sick leave was to end in disappointment.
The article refers to the work of Steven Cohen, an anaesthetist at Johns Hopkins Medical School (a fine institution) in which he shows that back pain relieved by epidural steroid injections (and that is by no means all back pain) the relief may be due to the injection and not the steroid. This is because injections of salt water appear to do just as well as steroid injections – not that steroid injections (or salt water ones) can ever be claimed as a ‘cure’ for back pain. Amazingly this is being presented as a medical breakthrough all over the net but at least one major TV news company led with a rather different headline on the same story.
Spinal Injections may not aid lower back pain
Notice the word ‘not’. That seems to be a more honest and intelligent appraisal of Prof. Cohen’s work than what appears in most of the media. But even this is misleading as the injections (with or without steroid) do seem to have some effect.
What Cohen might have shown is that the steroid in the epidural injections may have nothing to do any possible good effects of these injections because the placebo treatment (saline) has just as good effect.
However I can hear anybody trained in musculoskeletal triggerpoint acupuncture (as I am) screaming at their newspapers and computers: ‘It’s the acupuncture effect! Dammit!’ For 5000 years acupuncturists have known that the thin, safe and cheap needling that occurs in acupuncture can relieve many sorts of musculoskeletal pain. Indeed many books have been written on the subject.
This may not be the news that the makers of steroid injections were waiting to hear but it is certainly no miracle ‘simple jab’ breakthrough in back pain either. In my next post we will look at significant challenge to the medical profession posed by back pain and explore what can be done to help.
Last week I was delighted to attend a very special birthday party. Jane Gilchrist, a lifelong homeopathy supporter and active member of the Friends of the Royal London Hospital for Integrated Medicine, was celebrating her 100th birthday.
After Her Majesty Queen Elizabeth II and her family, Jane is probably Britain’s most famous user of homeopathic medicine and what an advertisement for homeopathy she is! Watch a few minutes of her birthday speech and you will quickly see that this is a very special 100 year old lady. I was particularly pleased to learn from her that Charles Dickens and William Makepeace Thackeray were patients of the founder of the hospital, Dr Quin in the 19th century. Oh to have those two literary geniuses write a bit of copy for us now!
Jane volunteered to work at the tearoom of the hospital for decades and is still available there for chats about homeopathy. She claims that her life achievement was to start the Bromley Homeopathic Clinic (NHS) which was immensely popular, lasted for 14 years but was unfortunately lost when the homeopathic hospital at Tunbridge Wells to which it was affiliated, was forced to close in 2009.
The party was well attended and Jane was her usual effervescent self, looking anything but her 100 years. As far as homeopathy is concerned, this is indeed anecdotal evidence – but then some!