If your eyes are opened you will see the things worth seeing….Rumi
Have we not learned anything from the Semmelweis affair? As a student doctor “Remember Semmelweis” was a short hand mantra reminding me that not everything that was being promulgated as sacred medical truth was in fact that. That any one of the fast held theories that had to be learned and then regurgitated on command, could be completely wrong. Completely. A mantra reminder to keep the mind scape open to other possibilities, to other ways of looking, and in fact, to listen closely, for dissenting views that made the professors and the opinion makers apoplectic with righteous anger, might in fact be right. Completely.
In one minds eye could be heard the sanctimonious Viennese professors in their 19th Century lecture halls exploding with indignity, “The very thought this Semmelweis is promulgating, that the filth and disease of puerperal fever could in any way be transmitted to the labouring woman by the hands of her Doctor, why gentleman simply consider how clean, how civilized are those hands helping in the torturous machinations of delivering the infant, and often from women, well Herr doctors we are all privy to the conditions that birth occurs in. That disease could in any way be carried on the hands of the very ones that are called upon to heal, is an abomination to our profession. An abomination gentlemen. It matters not Semmelweis’ numbers, his so called comparative studies. The very concept that disease could be carried on hands by invisible agents, is ludicrous. That we should be washing our hands between the morgue and delivery room. Bah. Semmelweis is mad. He is a danger. He needs be thrown out of our honoured profession.” Maybe there was, even, some pounding of the lectern with a shoe to make the point of how serious was this matter. And we all know how that matter ended. And who was on the right side of history.
Imagine that early shaman/doctor seeing one of his fellow tribesmen getting clubbed on the head by some raiding marauder, and some days later watching that same fellow staggering about and fading to this world. The shaman makes some connection between the blow to the head and evil spirits being pounded into the man’s head, which now have to be released. A sharpened stone, maybe heated to make the spirits release more easily, is applied to the area and a hole made to the skull and as the thick congealed blood of a subdural is released, Grog miraculously wakes up and it is clear to our doctor/shaman that releasing evil spirits by trepanning is the way to treat any malicious head malady. Have a headache? A hole in the head to release the evil spirits is the latest in medical technology. The modern day equivalent of trepanation is still with us, albeit applied for much more stringent reasons and in quite a different environment. Bleeding, that universal panacea of the past, is still found to be useful in cases of hemochromatosis, polycythemia vera, and a few other relatively rare situations, but we do not use it to treat pneumonia. Other treatments, widely viewed as a mainstay of medical practice during their times, we look upon with a certain degree of horror and ask ourselves, how could any rational physician not see that this was a harmful practice? Mercurial treatments for everything from dermatitis to STD’s, was a darling of physicians up until the early 20th Century. And how about ramming a 10 inch long ice pick through the orbital roof with a mallet, giving it a few back and forth motions as a treatment for depression and mental illness? Few of us want to remember that the inventor of the prefrontal lobotomy won the Nobel Prize for inventing such an illustrious medical procedure, that an estimated 70,000 people had such a procedure done and that it was touted as a medical wonder, in its day.
Primum non nocere. Pharmaceutical drugs taken as prescribed are now one of the leading causes of death and morbidity in our modern world. Given enough time our profession may well look back on this era, as a pharmaceutical disaster. Yes, beyond question, there are pharmaceuticals that are life savers and have helped relieve suffering in humankind; as physicians we know this well. But the marriage between drugs and Wall Street has been the cause of much suffering and death in our modern society. Anyone who doubts this statement needs to delve deeply into the literature on prescription drug addiction, adverse side effects of some of the most profitable drugs on the market and the suppression of such adverse effects by the pharmaceutical industry in the name of profits. A well researched summary of this can be had in the book “Deadly Medicines and Organized Crime”. This brings to mind a small book that was recommended reading when I was a resident 30 plus years ago, also provocatively titled, “There’s Gold in them thar pills”. Prescriptions seem to be a virtual extension of some physicians hands and like Semmelweis’ detractors, can seem too sanctified to cause harm. One of the primary psychological defences we humans have, is denial. In our medical culture, our collective medical denial of the effects of over prescribing has proven to be harmful to our patients.
As a physician trained in the science and art of Family Practice, patient-centred care was at the heart of our training. Yes, diagnostics was important, the physical examination and laboratory investigations, knowing the pharmacopeia of the day, being facile in a number of in-office procedures, managing hospital care, doing house calls and for many of us, training in obstetrics; but what was of upmost import was the patient that we were caring for. Knowing who the person is, who is sick. Supervision by experienced family physicians, as well as social workers, pharmacists, nurses and psychotherapists was routine. A team approach to health care was exemplified in our residency programmes. Participating in consciousness raising Balint groups was encouraged. And it was drummed into us that the doctor should think twice, and then again, before picking up the prescription pad and writing a script. How was this drug going to help? And what were the potential side effects and interactions of the proposed drug therapy. Was there really more benefit to the proposed treatment, than harm. Primum non nocere, doctor. Are you living up to that very basic dictum? To aid us in this, we were taught not to rely on the literature produced by the drug companies, and in fact to be sceptical of their studies and to look for independent study data. I recall one of my family physician supervisors saying to us that he would consider it close to malpractice, and certainly a medical disgrace, to see drug reps in our offices once we started into our own practices. (I recall him using much more colourful language saying he would ‘kick our ass’ if he ever found out we did such a thing. He got away with such language, likely because he was Irish, and so obviously lavished love and caring on his student doctor charges.)
Now, I have a confession to make. Over the three decades of practicing medicine, I have delved into what has variously been called “holistic”,“alternative”, “complementary” and most recently “integrative” medicine. Some of our colleagues consider these simply, the ‘dark arts’. Okay, now breathe, after that collective gasp of horror, let me explain. It starts small. As a young physician you look for ways to help relieve suffering that obviously has no serious organ pathology, without resorting to the prescription pad and the route of benzodiazepines and other sedatives, so you look at the literature on the mind-body connection and you become comfortable with prescribing breathing and mindfulness exercises and other cognitive behavioural therapy . And you start practicing meditation and yoga yourself, to help with the pressures of an expanding, busy practice. You deepen your skills in hypnosis and guided imagery for labour and childbirth pain. You spend weekends taking courses in acupuncture. And because you are a new physician in town, you tend to attract patients who have either not had success with other physicians or are the difficult cases that get lost between the cracks of ‘usual’ medical care, to these patients you apply some of the basic principals of family practice, almost invariably including streamlining the often confusing pharmacological cocktails these people tend to accumulate, and lo and behold, they start feeling better. And most importantly you listen to them. And word spreads, “He doesn’t prescribe medicines for every little ailment, in fact he takes you off them.” In order to receive more training, you start attending conferences with other like minded physicians and find a community of practitioners who, not only do not have two heads, but are genuinely caring individuals and are more than willing to share their experiences and expertise. And you get introduced to such concepts as biochemical individuality, functional medicine and orthomolecular medicine. And in most cases, rather than less science you find that, here, your medical school nemesis, the snoozer of all sciences with all those pathways and cycles and factoids you thought you could forget, taught by the bow-tied prof with the incredible ability to put you into a somnolent state, Biochemistry, was necessary to understand what these promulgators of the dark arts had to say. And it made sense. And it helped you understand disease and health states of the body at a much deeper level. And you started (horror of horrors) actually prescribing vitamins and relying less on drugs. And thus started the slippery slope into the land of what your colleagues called ‘simply placebo dear fellow’. Well, maybe not so kindly put, because this is where you became thankful that as a society we no longer burn people at the stake for being heretics.
Yet, is there not room in our collective professional heart to look again at these areas we have shunned, look at the science and if the case studies and the small trials don’t satisfy, then have the collective integrity to design unbiased science based trials which will further our understanding. (In some of these areas, RCT’s cannot be the ‘gold standard’ of analysis. Think of the challenges in designing a trial to prove the value of H20 in the functioning of the human organism. And who would stand in line for a RCT to answer the question ‘Do parachutes save lives when jumping out of an aeroplane?’)
If not collectively then individually, physicians are washing their hands of their pharmacological addiction and daring to look into these areas and finding great benefit. For any physician starting to question this area, there could be no better place to start than some of the professional organizations providing continuing medical education events. Your professional horizons will be expanded and your patients will be grateful to you for many, many of them will benefit from ‘another way’.
‘Care more particularly for the individual patient than for the special features of the disease.’
Sir William Osler
Old Gladys died at home at 101 1/2 years of age, with her younger sister of 97 years and her family physician in attendance. She was predeceased by her beloved husband by a decade and a half and her son who succumbed to leukaemia at the brink of adulthood in the early 1960’s. Such might be the obituary that give the bare bone facts of her life and death, but would give nothing of the portrait of the proud woman with an iron will, an impish smile complete with sparkling eyes and stories galore from childhood in the Depression; when she and her sibs would chew on roadway tar pretending it was gum; when she left school and with money from her police constable father, bought a pair of roller skates so she could skate 10 miles, to and from her first job at a local fabric mill, which later morphed into a busy, successful seamstress business, the results of which could still be seen in the dresses and the housecoats she and her sister wore daily.
In the last 10 years of her life, Gladys did not step foot outside the front door of her wartime bungalow, too crippled with arthritis to negotiate the 3 small steps to her front walkway and neurotically fearful that someone would somehow snatch her off the street and lock her away in a Nursing Home. She would take my hand, look me in the eye with her piercing laser look, to draw out of me the promise that would put her mind at ease, “Now Doctor” she would begin her voice raising a few tones and decibels with each passing word, “I want you to promise me that you will never, ever put me in one of those homes. I would rather die than be one of those poor, forgotten old people”. Over the many years of getting to know Gladys I could hit upon the right tone and massaging words to relax her hidden fears. “Now Gladys, why would I ever put a young lady, such as yourself, in one of those places. And Gladys, I would never, ever go against your wishes.” She would then nudge me on the shoulder, give one of her lilting laughs and we could get on to the business of my visit, the care of her aging body which slowly was failing her.
Gladys was amongst my very first family practice patients, that 30 years ago, I opened in the residential area of the old town, a few blocks away from her house. She would come in with her husband to have me check his blood pressure, which was always fine and then with some cajoling I would be allowed to check her blood pressure which was always 20 points higher than his. I had my first row with Gladys the day that I suggested that her blood pressure was getting to the point where a medication might be warranted to keep it in check. She immediately stiffened, pulled her 75 year old self up out of the chair, took her husbands arm and said, “Well, I never took you to be one of those doctors” and left a stunned younger me wondering, what had just transpired. In grand Gladys style, she came back the next day, with a single rose from her garden and apologized for her behaviour. Luckily for me, her blood pressure was still borderline and I used our visits to give her suggestions about lifestyle factors that could help bring it down. Luckily for Gladys, I had had the privilege of being educated by Dr. MacWhinney and his team in patient-centred family practice and was taught to have a more critical relationship with pharmaceuticals in contradistinction to the pharmaceutically ‘evidence-based’ model of care which seems to be ‘au rigeur’ today.
As Gladys was nearing her 90th birthday, still full of vim and vigor, over a cup of tea during a home visit, I asked her what she thought the secret was to living to a healthy old age. She looked at me with the twinkle in her eye that was usually a harbinger of a story, whereupon she recounted a story her mother told her about some poor sod back in England who going to a physician in the days prior to antibiotics was subjected to repeated treatments of what sounded like a mercurial ‘remedy’ until he died a horribly painful death. She then looked me in the eye and said, “So my mother always told us kids that the secret to a long life was to stay away from doctors” at which point she laughed, “now that would be impossible for you doctor” and then dead serious she continued, “but I don’t want to be poked and prodded and experimented upon, and plied with drugs, it does the body no good…”
Gladys had never been in hospital and had a deathly fear of them. As life would have it, during one of my vacations away from the office, in her 96th year, Gladys developed palpitations and chest pain and her sister, who was visiting her at the time, called 911. From Glady’s point of view this is what happened. She was taken to the Emergency of the local hospital in an ambulance with its sirens screaming that in her deafened state was all she could hear. She was then hooked up to gadgets and lines and poked and prodded in the CCU and was shocked, (she had developed Atrial Fibrillation and was electro-cardioverted). She was in a state of confusion and “panicked out of her wits”, as she put it and would sign anything put in front of her as long as the answer to her question “will this get me back home” was affirmative. She was given “pill after pill, all day long” and someone asked her if she would be willing to be part of an experimental study to which again she agreed to “as long as this will get me back home”. She was home by the time I got back from vacation and sitting with her on her couch in her living room, she recounted her experience with modern medicine. This 96 year old woman who went into hospital on two medications, an older beta blocker for hypertension and aspirin for arthritis, left hospital on 7 pharmaceuticals; the usual cocktail of cardiac drugs including a statin which caused extensive muscle pain, drugs to bring her BP to the ‘gold standard’ which left her dizzy whenever she got up from a sitting position, a newer NSAID for her arthritis, all of which brought her in line with ‘evidence based medicine’ but compromised her ability to care for herself. She brought out an unlabelled bottle of pills and shrilly said, “and this is the drug they are doing their experiments on me with…” at which point she started sobbing. I took her off all the drugs, de-enrolled her from the study and got her back to her previous beta blocker and aspirin; no, her numbers were not perfect, but she was able to take care of herself again, as she continued to do for the next 5 years, in her dignified, unique Gladys way. The last words she said to me was to bless me on her death bed. And I thanked her for the privilege of knowing her, from deep within my physician heart.