Dr Barry White

Consultant Haematologist, St James’s Hospital and former National Director for National Clinical

Programmes

Ancient system of medicine

• Blood and other bodily fluid were regarded as “humors” that had to remain in balance to maintain health.

• Bloodletting was based on this ancient system and was the most common medical practice for over 2000 years

• The purpose was to correct the imbalances of the bodily fluids

• No real change in life expectancy over this period of time

Locations for bloodletting Field book of Medicine, Hand von Gersdoff, 1571

In 1799 George Washington (aged 65), the first U.S. president, died after having 3.75 liters of blood removed from his body within a 10 hour period as treatment for a throat infection

Reductionism - “world is like a machine composed of many smaller parts and that it could be understood by taking it apart

and studying the part..” Descartes

Holism

• A contrast to the reductionist approach is holism or emergentism. Holism is the idea that things can have properties (emergent properties) as a whole that are not explainable from the sum of their parts.

• “The whole is more than the sum of its parts” - Aristole

Reductionism leads to dramatic improvements in medicine in 20th century

• Antibiotics• Vaccinations• Pharamceutical breakthrough across full

spectrum of illness (aspirin, statins, analgesia, antihypertensives, immunosuppressants, chemotherapy)

• Transfusion medicine• Surgery, anaesthesia, ITU

Major improvements in health from 17th to 21st Century

• Life expectance 25 yrs to 80 yrs age• Infant mortality 30-40% to 0.3% • Child mortality before the age of 5 went from

70% to 0.4%• Maternal mortality 3%to 0.03%

Has it all been good?

• Safety– 100,000 deaths/yr in USA, 4% of hospital admissions

• Effectiveness– 50% of patients with chronic diseases are on the right

treatment (thereafter 50-70% adherence)• Patient experience• Access• Equity• Cost• Clinician health

(i) Endemic reductionism• Society driving endemic reductionism in healthcare – “super specialitis”

– Hospital doctors– Nurses– AHPs– GPSI

• Patient care is being reduced not just to systems but the actual disease• On average 17 consultants are managing the multi co-morbidity

patients that account for the majority of health spend• While there are benefits probably driven by standardisation overall it

drives cost, risk, poor patient experience “I don’t want to be the ball anymore”

(ii) Have we learnt the lessons of improvement science?

• Focus is on science of discover• Improvement science requires totally different

philosophy and methods

Improvement science

• “Every system is perfectly designed to get the result it achieves” Batleson

(iii) Definition of health and healing

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”

Preamble to the Constitution of the World Health Organization which entered into force on 7 April 1948. The Definition has not been amended since 1948

Medicalisation of life

• If I am bereaved, does that mean I am unhealthy? • 25% of teenagers suffering from mental health

problems! Is this a medical condition or part of adolesence?

• Advances in technology have resulted in investigation +/- treatment of many “illnesses” e.g. early prostate cancer, non malignant breast disease, imaging “incidentalomas”, coronary heart disease

Expectations!“I need something to make me feel better”

(iv) Failure to address behavioural factors

• The commonest condition in most specialties is “functional”

• In addition biopsy provable diseases are primarily driven by diet, exercise, alcohol and cigarettes

• Despite this, self management and self efficacy training is peripheral activity

• The roof is leaking and we only seem to be able to respond by debating whether we need more people to to empty the water or whether they need to worker faster

Solutions• Generalist provides care; specialist role is to support generalist with

smaller amount of direct patient care with exceptions of proceedures – Standardise with specialty support – For rare diseases or rare complication of common diseases either direct care

by specialist or specialist supports generalist delivering care e.g Project Echo• Implement science of improvement into healthcare• Redefine health and healing – as integration of Descartes and Aristotle • Redefine the role of the patient and clinician; switch expectations to

patient and support self care – you are what you choose • Create new business model, metrics and incentives to support the above• Improve awareness to achieve technical competence, deep insight and

compassion (doctors and patients)

Awareness

Patient• Recognise and respond to

the psychological and social factors at play

• Develop the skills needed to self care and to understand the meaning of health and healing

• Understand their own limitations and distractions

• Self compassion

Clinician• Recognise and respond to the

physical, psychological and social factors at play and how variaitons will impact patient

• Understand their own limitations and distractions

• Act with technical competence and insight

• Deeper meaning to their work and life

• Compassionate to self and others

Thank you

Health and healing

• Healing and health is the ability to reconcile all aspects of the self (physical, psychological and social) – “to be in balance” - even in the setting of aging, incurable illness (social, psychological or physical) and pending death.

• To understand- we our what we choose

“I need something to make me feel better”

Expectations

Awareness

• The central pillar is the self aware clinician and the self aware patient

• Awareness in patient and clinician• Insight and prediction regarding physiological, psychological

and social dimensions as well as deeper issues relating to who we are and meaning to life for self and the patient

• Taken far enough awareness will strike the spring of compassion

• Ultimate goal of a Full aware clinician and patient will find their true nature which is compassion (for self and others)

Health and healing

• What is the difference between healing and curing?• Healing – transcending suffering, illness and

ultimately death beyond cure alone• The patient needs to, in the majority of cases, take

responsibility for being the primary treater. As such the clinician becomes as much teacher as treater.

• We are what we choose?• We need to prescribe training in self care and self

efficacy

• Domains of healthcare• Why problems– Reductionism vol and standardisation– Definition of health generating demand, and

unrealistic expectation on doctor and projection– QI and systems of healthcare– Holistic arpproacj

• Most criticism of the WHO definition concerns the absoluteness of the word “complete” in relation to wellbeing. The first problem is that it unintentionally contributes to the medicalisation of society. The requirement for complete health “would leave most of us unhealthy most of the time.”4 It therefore supports the tendencies of the medical technology and drug industries, in association with professional organisations, to redefine diseases, expanding the scope of the healthcare system. New screening technologies detect abnormalities at levels that might never cause illness and pharmaceutical companies produce drugs for “conditions” not previously defined as health problems. Thresholds for intervention tend to be lowered—for example, with blood pressure, lipids, and sugar. The persistent emphasis on complete physical wellbeing …

Bloodletting didn’t work!

• In the 1830s, Pierre Charles Alexandre Louis convincingly argued against the perceived effectiveness of phlebotomy for the treatment of pneumonia and fever. Ironically, with the gradual decline of bloodletting there was an increase of other dangerous and ineffective treatments, such as the use of electricity, elixirs and potions. These medications gained popularity for the same reason that bloodletting had in earlier times: it sometimes worked as a placebo. Because the patients believed that receiving electric shock therapy would heal their illness, the psychological factor may have been enough to actually make them feel better.

Health and healing

• Expectation that “healthcare providers” job is to make you “healthy” i.e. complete physical, mental and social well-being

• This is unachievable and is not consistent with our experience of human existence which is one of suffering (even the suffering of emptiness if nothing is wrong), aging, illness and death

• Leads to projection (doctors fault not mine) , litigation and burnout

Reductionism

• Though the idea of reductionism has existed since the ancient Greeks, René Descartes, a 17th century French philosopher and scientist and father of modern philosophy was the first to formally state the concept.

• He stated that the world was like a machine composed of many smaller parts and that it could be understood by taking is apart and studying the part before learning how they all fit into the whole.

Evidence based medicine finally identifies bloodletting as harmful

• However not without a fight• Sir William Osler still recommended it in 1923,

Principles and Practice of Medicine• “Many of those who have practiced blood letting were

careful and shrewd mean….it seems scarcely possible that such men should have been utterly mistaken in assigning advantages to this powerful means of modifying vital actions. Imprimis non nicere, like all proverbial morality is a maxim oftener used to justify the coward than to guide the conscientious”, A fair trial for bloodletting, BMJ 1871

Increase in lve

Current problem

• Definition of health• Awareness as to the respective roles of the

clinician and the patient

“I need something to make me feel better”

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study DoThe Improvement Guide, API

Aims

Measures

Ideas