Tuesday, 31 July 2012

An Olympic Legacy?

The ambition for the Olympics has been to create 'a legacy.' No one that I have heard has actually spelled out what that legacy might actually be, but I assume that it relates to participation in sport. That seems fair enough - not enough people do enough exercise. But I wonder whether the titanic effort that we see all these sports men and women put in to having the fleeting chance to win a medal can actually be more suffocating than inspiring.

The three factors that seem to be ubiquitous to success in elite sport are time (lots of it), personal sacrifice, and pain. Natural talent comes in to it somewhere, but this is not something you can work on -you either have it or you don't. These people put themselves through physical discomfort that you and I usually take as a cue to stop. I actually heard one swimmer talk about how she had got back in to the habit of enjoying the pain.

Crikey. Not many of us have that kind of gumption. And here's a bit of the rub: for lots of people, the sport they play is their relaxation, a way of unwinding; and yet the example laid out in front of us, by all these Olympians, is that sport is about total commitment. These are totally different approaches to sport, and while I often get emotional watching others try, succeed or fail in their own heroic efforts, I do wonder how many people it inspires, and how many people it makes wallow deeper in to physical apathy, weighed down by the increasing understanding that these sports people are not just fitter than they are, they are almost a different species.

And yet, inspiration can come from strange places in sport. Let me share with you what I have seen.

I was inspired by Mark Cavendish failing to win the road race - not because it was a heroic failure, but because of the way that the team spoke about it afterwards. What rang through loud and clear, was that this group of men had sat down and decided what their best tactics for winning were, had committed to the plan completely, and given it their best go. They knew that it might not work, but were happy with their choices, each understood what their own individual role was, and put their hearts into making it happen. It didn't, and that frankly is sport. It doesn't mean that they didn't train hard enough, or that their plan was wrong, but that other factors conspired against them.

I guess the first rule of winning well is learning to lose well. This is not the same as being OK with losing. We have seen this mistake made by countless British athletes over the years, who have spoken about the good experience they have had at the big competitions, about learning lots, about doing better than they expected and so on. This misses the point a little: losing well means that you have done every thing that you can do to maximise your chances, from training to mental preparation to nutrition and so on, so that by the time you arrive at race day, there is nothing more that you could have done. Losing when you have done every thing is sport. Losing when you haven't is simply bad preparation.

At the time of writing, there have been no British Gold medals, but there have been some stellar examples of losing well. The British mens gymnasts didn't win gold, but they did win bronze, and in doing so, they improved on where they had been before, and they did this not through good luck, but through performing well, on the back of good preparation.

This is an important difference. Historically, it has seemed that a lot of British athletes have turned up in hope, but with no expectation that they would do well. This makes all the more heartening when they do succeed, but also provides an endless litany of shrugged shoulders, and 'oh wells, maybe next time.'

I imagine lots of us have been hoping that our athletes would turn up and win, but that just isn't the way that the world works. What, however, is refreshing is to see that a great many of them have clearly committed as much as they can to the cause, even though this does not mean that they win, and even though lots of them know that they won't.

What this shows us is that it is still worth while to give something your best go. That there is intrinsic value in being prepared to try, and being prepared to fail. This is something that we can all learn from.

An Oympic Legacy?

Tuesday, 24 July 2012

How I learned to stop worrying

The sub heading of Dr Strangelove is ‘How I learned to stop worrying and love the bomb.’

I recently stole part of that phrase to make a point to a friend of mine. The only problem was that I didn’t explain myself very well. I think I was secretly too chuffed with myself for having come up with the idea, to spend enough intellectual capital on actually sharing what I meant. I suppose that deep down I wanted it to be a point that made itself. It didn’t, and here is my attempt to  make up for the shortfall.

We all have situations that push our buttons. Sometimes by learning what it is that either makes you perform well or poorly, you can learn to either encourage or mitigate these situations to ensure their propagation, or their containment.

However, particularly with things that wind you up, learning what they are is merely an exercise in observation. There is often little that you can do to prevent the circumstance, or to pre-empt your response to it. The best that you can hope for is that the insight into the relationship between situation A and its impact on your performance or behaviour is to to warn other people (If A happens, then I am liable to do B) or to remove yourself from the active arena.

I have grown up wanting to believe that we are the products of our own deepest desires, and that wanting something about yourself to be true is all you really needed to actually make it true. Experience has taught me that this isn’t the way life works, but that doesn’t stop many of us trying. If you don’t believe me, ask yourself honestly (and in private if necessary) whether you have tried to be different in anyway when you have moved somewhere new? Did you try to be different when you started your last job, or did you reinvent yourself when you went to University? If you can genuinely answer no to those questions, then you might as well stop reading. You can go to the pub early, or move on to whatever it is that you were going to do next.

If, however, you had to answer yes, don’t worry -  there is nothing wrong with you, there is nothing different you need to do. You only need to learn to love the bomb.

And what follows now is the explanation I never gave my friend, but I really wish I had.

The atomic bomb exists - lots of people do not like the fact that it exists, and wish that they could get rid of it. In fact, a great many people have spent a long time campaigning for that exact result. They haven’t yet succeeded, and indeed it is not an imminent outcome.

How then can we reconcile the reality of the bomb to the reality that we really would prefer to live in a world where we are not constantly at risk of mutually assured destruction? Well, the answer would seem to lie in the understanding that the one thing that the proliferation of atomic bombs achieved was the realisation that one country could not use the bomb, without guaranteeing that others would retaliate, and ensure that everyone was destroyed. The one good thing, therefore, about the bomb is that it ensures that we will not destroy each other.

The bomb ensures that we limit the extent to which we inflict violence on each other. That is the way to love the bomb.

Therefore, when I remind people that they are in ‘a love the bomb’ moment, what I am in fact telling them is that the thing about themselves that they are moaning about is actually an opportunity to find something good in someone or something else. Learning to love the bomb in yourself means you have gained insight into the way you work, which suggests a good level of reflective practice. It also means that you have to find ways around your own perceived limitations, which might involve working in news ways with new people, or developing new skills. It could lead to a thousand other things that you would never have learned, developed or experienced without your own sense of inadequacy.

Loving the bomb doesn’t mean giving up, it just means working within the constraints of the real world.

You may not think that it is a particularly good point, but that is the explanation that I should have given a couple of weeks ago.

Sunday, 22 July 2012

Managing expectations - not just the patients', but also the doctors'

N Engl J Med 2012; 367:99-101 | 10.1056/NEJMp1205634

All patients are different. But as a geriatrician, the presentation of my patients is often fairly standard: they either fall over, or become more confused. The challenge for any doctor dealing with such patients is to decide what particular factor has changed to lead to the deterioration. Most of my patients have multiple medical problems, many of them have dementia, and a proportion are instantly recognisable as being frail.

Any number of factors can be to blame, from acute medical problems, through breakdown of social support networks to psychological issues. And more often than not, when you first meet a patient, you can identify a whole range of issues that aren't quite right.

This kind of reality leads to a divergence in how doctors approach elderly and complex patients in hospital: on the one hand you have doctors who try to investigate and treat all of the issues that have gone wrong, and correct them all back to normal. And on the other hand you have doctors that work on the assumption that although there are many things that need correcting, some of these will have deteriorated as the result of another more significant issue, and some of these are beyond correction at all. These doctors, therefore, try to identify the main issue problem that has changed, correct that, and then see how the other problems respond to improvement in what you have guessed is the primary problem. .

The latter approach is the one that I have tended towards over the course of my training, not only because it is the approach that fits best with my style, but also because I have grown weary of watching patients patients experience complications and side effects from investigations and treatments..

It is impossible to tell exactly which patients will experience the pitfalls of iatrogenesis, but you can be certain that of all the patients who are offered treatments, it is my elderly, frail and confused patients who will experience the least benefit and the most inconvenience.

So why the long preamble?

Although my training and insights into geriatric medicine have encouraged me towards a more parsimonious form of practice, the truth of modern medical practice is that doctors are often rewarded for taking a more interventional or active approach.

I have often taken an expectant approach with my patients, only for other physicians to intervene and do something extra. At this point, one of two things happens: either the patient gets better, and the other doctors congratulates themselves for intervening, or the patient deteriorates, and the other doctor chastises me for not acting sooner. Sometimes they are right, but sometimes, the patients that got better were going to get better anyway, and did so in spite of the extra interventions; and sometimes the patients got worse, and did so because what we did precipitated a deterioration. not an improvement.
We know that a great deal of what we do to elderly patients causes harm. We are often flying blind when recommending therapies for the elderly, as there is very little evidence base: many of the big trials exclude the elderly from participation.

What modern medicine therefore adopts is a more is better approach, that while well-meant, is often not well-supported.

As doctors we are often overly influenced by our own personal experiences: for example, we know that doctors who have patients who suffer bleeding complications on warfarin tend to offer warfarin less often to their patients than the evidence-base suggests they should.

But the issue of over-treatment of patients raises some other issues in the care of patients: as the people who deal with sickness every day, patients look to their doctors for guidance on what they can expect to happen. Patients do not know how to best to approach their sickness, as they have never had to deal with it before. The doctor is both their technical expert and their measure of social norms: what do other people do when they are in the same situation? The tendency, therefore has developed for doctors to over-treat. Afterall, treatment is what doctors are trained to do, and if patients looks to doctors for guidance as to what they should do, then it should be no surprise that a tendency has developed to approach disease and illnesses with curative (and often aggressive) intent.

At the severe end of the spectrum, when a patient asks you how long they have left, I have to answer them honestly and say that I do not know: it is very difficult to take the overall percentages, and apply them to particular individuals, as we cannot know where in the normal distribution that particular patient lies.

The issue here is that patients are socialised to ask the wrong question: what they mean to ask, I think, is 'Doctor, what can I expect?' and instead of answering this question for them, which would be useful and informative, we fob off the question they did ask, and move on to areas where we are comfortable, which is the process of diagnosis and treatment options.

But by not answering the question about expectations, we are not giving the patients the appropriate opportunity to discuss with us what their style of dealing with sickness really is. Instead, they find themselves in a new situation of sickness, and understandably look to the people who deal with the sickness every day to guide their choices.

And here's the rub: we have got in to the habit as doctors, of just doing stuff to patients, rather than emphasising to them that sometimes not doing very much at all can be the best option.

It is particularly true of cancer diagnoses, but also of other chronic conditions, that if we acknowledge sooner that the illness cannot be cured,then patients can enjoy a longer and better quality of life, than if we dive in and try to cure them.

Doing nothing is not always the wrong choice, because it doesn’t actually mean doing nothing. What it means is that your doctor has admitted to you that the condition you have is one that you cannot be cured of. This of course covers a range of ills, from diabetes to metastatic cancer. But the realisation that this is something that will always have to be managed, rather than purged is an important intellectual milestone for patients to reach. Establishing the natural history of the particular disease for a particular patient involves careful, and honest, communication. .

It is only afterwards that a conversation can be held about what the best course of action is.

I suspect, although I don't actually know, that if we were better at having these kinds of conversations, our patients would have a better experience, and in many cases a better death. And with the particular group of patients that I deal with, that means a lot.

Friday, 20 July 2012

Winning clean - a lesson for everyone

In the Tour de France on Sunday, some lunatic threw carpet tacks on to the road at the top of one of the big climbs, causing 30 riders to suffer punctures, and one rider to fall and break his collar bone. It was an action of crass stupidity, that not only threatened the safety of riders who already take plenty of their own risks haring down the mountain, but also threatened to affect the result. One of the riders affected by the tacks was Cadel Evans, the reigning champion, who at that time was lying in third place.

That it didn't have any real impact on the leader board was down to the decision by Bradley Wiggins to call a truce, and suspend racing until those affected had the chance to catch up.

There are many traditions in the Tour de France - they are often whimsical, and to some seem incongruous, particularly when compared against the legacy of doping that exists within cycling. It may surprise you to know that within professional cycling there is a heritage of fair play, and an honour in the way that one conducts oneself.

When Bradley called a truce, he was acting as the patron of the peloton. The patron is often the yellow jersey wearer, but may also be one of the big names - someone who has won the race before, for example. And it is their responsibility to act as opinion former and moral guardian, when unexpected things happen. The need to end hostilities was instantly recognisable to Bradley, but not everyone agreed. One French cyclist buggered off into the distance, and only slowed down when his team told him that he looked like a bit of a pratt racing ahead when everyone else had decided that would be unfair..

Reconciling this attitude of fair play, with the legion of dopers that have previously dominated the sport can be difficult. Many people still need some reassurance that riders are cycling clean, and I think that Bradley has given us a lead on this with the way that he has behaved.

I thought back to other times when riders have either stopped or failed to stop when their competitors have suffered a misfortune.

In the early 2000s, Lance Armstrong gwas knocked off his bike when his handle bars got hooked in the strap of a spectators bag. His main rival, Jan Ulrich, waited for him to recover, only for Lance Armstrong to attack as soon as he had caught up. Lance Armstrong has never been caught doping, but it is indicative of something that he still remains embroiled in charges against him, years after he was the main force in cycling.

In 2010, Andy Schleck's chain came of his bike while he was attacking Alberto Contador. Contador rode on, and beat Schleck for the title by the amount of time that he gained that day. He later had this title removed from him, after he returned a positive test from a urine sample taken the day after this incident.

There are many examples that I could give, but the theme that I am trying to outline is one of ruthlessness. These examples display, I think, a single mindedness in these people, that is perhaps emblematic of dopers. Exploiting the misfortune of others on the way to victory is a surrogate of the same attitude that applies to doping. It is the obsessive need to win, at any price, that obviates other important themes, like fair play, level playing fields, and the realisation that it is just sport.

Bradley displayed the exact reverse: he was embodiment of the idea that winning means nothing, if you win either by cheating, or taking advantage of the bad luck of others. There are many people who doubt that Bradley has been riding clean. They clearly haven't been following his career very closely: he is not some rider who came from nowhere. He is a triple Olympic Gold medal winner who has adapted and trained for a different challenge.

Bradley races clean because winning dirty means nothing to him, and represents the basest betrayal of his sporting ideals. It is for the same reasons that he waited for Cadel Evans. Win clean, win fair, or don't win at all might be his motto.

In a world that often seems to celebrate the victor regardless of how they got there, it is refreshing to see someone risk their chances of success because of their sense of honour.

At the investigation of Ben Johnson's doping in 100m at the Seoul Olympics, the doctor who supplied his drugs told the enquiry that in 1984, 20 medals were won by athletes that he knew were doping.

How much honest athletic endeavour has gone unrewarded because of the cheating that has gone on in the past? In our emphasis of success, we have forgotten some central tenets of fair play.

That is a shame but at least we have Bradley Wiggins to remind us what it is all about. There are undoubtedly riders doping this year, but this year, they are losing to someone who has done it the right way. And that in itself is something worth celebrating.

Monday, 9 July 2012

Exploiting the placebo effect, or exploiting patients?

At a wedding this weekend, an old school friend of mine, whom I had not seen for a few years, delivered to me a monologue on the virtues of the placebo effect.

His argument was thus - the illusion of intervention delivers a clinical benefit: patients who think they have been given a treatment often behave as if they have been given a treatment. The more invasive or involved the illusion is, the bigger the impact of the phoney treatment. An injection of saline is more effective than a sugar pill, and a surgical scar is more effective than an injection.

The rub comes that the placebo effect requires the person administering the phoney treatment to collude, and not let the patient know that they are being given an inactive treatment.

In the case of the alternative therapies, for which no evidence of impact has been demonstrated, we are given a demonstration of how elaborate successful delivery of the placebo effect can be: in these circumstances it is not just the patients who are being duped - the therapists have also signed up for the illusion. And perhaps this is what it takes for the placebo effect to be its most effective: for the therapist to also think that they are delivering effective treatment.

The current tradition within evidence based medicine is to cancel out the placebo effect, and this is achieved through the use of double-blind studies. We seek to give treatments that have benefit beyond placebo, and reject those that offer nothing more.

So far, I have not told you anything you don't know (perhaps I rarely do). But my friend was arguing that if the placebo effect has a measurable and reliable clinical benefit, are we not beholden as doctors, to exploit all techniques available to us in the name of best clinical outcomes? There are many conditions for which we have no effective (as measured by RCTs) treatments, and in such circumstances, our approach currently is to offer an explanation to our patients, and offer them the best symptom control that we can. My friend would have us behave differently.

And he makes an interesting point: our choice not to take advantage of the placebo effect is compounded by some other aspects of the phenomenon: the fact that we have no understanding of the mechanisms by which the effect is exerted should make it an important line for research, and yet it remains on the fringes of clinical investigation. The reality of the placebo effect in every treatment we use should mean that it should be taught and discussed on medical school courses in great detail. Medicine often treats the placebo effect like an embarrassing relative: we simply pretend it doesn't exist.

And yet it offers us opportunity where our medical sciences have so far failed to deliver, and it perhaps offers us an insight into health and healing, and how to influence them positively. We know that we can exert a positive clinical benefit by doing something as minor as giving a sugar pill, and we know that we can exert bigger impacts by giving more invasive placebos, like intravenous injections of saline, or surgical scars, underneath which there has been no actual surgery.

At the moment, we throw away explanation of this process, simply by saying it is the placebo effect, and giving it no further explanation or enquiry. The fact that it does not conform to our scientific models of enquiry and explanation has meant that we do not give it due consideration. The term 'placebo effect' has become a short hand for the sentiment that we cannot understand or explain this phenomenon, therefore, there is not further reason to mention it.

However, perhaps medicine could open new avenues to whole new forms of treatment by gaining a handle on the mechanisms underlying the placebo effect, and exploiting them to gain greater clinical benefits.

Perhaps if this were to happen, if harnessing the placebo effect were to become an evidence based practice, informed by high quality clinical research, the action of doctors in using it for the benefit of the patient could move from being the action of the deceitful to well-informed clinical intervention.

But until this time, in the context of modern clinical practice, most doctors should be uncomfortable with the idea of engaging in regular and institutionalised deception of their patients.

We know that there are few certainties in medical practice, and the positive movement we have made in the last few decades has been a greater degree of transparency and involvement of our patients in the health choices that directly affect them.

Any move to deceive patients in the name of better health would need to be done with the broad agreement that it is appropriate to do so. It is not the role of doctors to decide the morality of health care by themselves - it is the role of doctors to deliver healthcare that is ethical with reference to the standards of the communities they serve.

Wednesday, 4 July 2012

Risk, precision and aesthetics

My brother directed me towards a programme on the iPlayer last night called 'Madness on Wheels: Rallying's Craziest Years', and I'm glad he did - it made for compelling viewing. If nothing else, it reminded me of where my taste in cars was formed. These flared and angular machines of the 1980s are still my benchmarked ideal for what a car should look like today. It is no surprise that of the cars I have owned, my favourite was my Volvo 480, with pop up head lights, no curved lines in sight, it conformed to my ideal so completely that I was prepared to forgive the fact that I never knew how much petrol was in it, and had to fill it up with a litre of oil every week.
But apart from my own person reminiscence, the programme was fascinating for the footage of the rallies in Corsica and Portugal, when drivers would race at a million miles an hour down these dusty tracks, trying not to be distracted by the hoards of people lined up by the sides of the road, often only jumping out of the way of the car at the last minute, and often trying to touch them as they went past. To have one's leg broken by a passing rally car was considered by some to be a medal of honour.
This was of course a morality tale, of the risks of unfettered technological advance in the absence of modernisation of other features of racing. Rallying is always going to be a risky, but the footage of a Ford RS200 ploughing its way through a crowd of spectators makes its own argument for the level of risk that spectators should be exposed to when they are watching others risk their own lives in the name of sport.
In rallying, there used to be a big problem with what I will call 'risk interface' - a rally driver and his co-pilot step in to their car knowing that what they do is risky. The rally driver has control over what happens, and is therefore to a greater extent, in command of his fate. The co-pilot exists in a middle ground: his instructions help the driver drive quickly and safely, but he doesn't have his hands or feet on any controls. One has to wonder how often co-pilots find themselves pressing a phantom brake peddle when they find themselves hurtling towards tree, cliff or other form of mortal danger.
The fans, however, come to see these cars race, but how many of them think that this in itself is, or should have, attached to it risk of harm. There are of course, some plonkers who run across the track, try to touch the car, or stand at the side of the track on the apex of a corner, but do they see it is as risky, and should it be allowed to be risky?
There is an inherent subjectivity to such a discussion, but one's approach is no doubt influenced by how one frames the issue.
There was a magic moment in the programme, when the director juxtaposed the views of two of the top drivers of the time, about the risks that they took as drivers. Ari Vatanen, a Finnish driver, who raced the legendary Peugeot 205 spoke about rallying by using allusions to music. He spoke about how when he listens to music, he closes his eyes, and lets the sound wash over him, feeling his way through the composition. For Walter Rohrl, the German Lancia driver, rallying was about precision, and that was reflected in his language - he talked about the calculation of risk, and the fear the fans at the side of the road caused him, because he wasn't in control of what they would do.
Polarising racing drivers between the robot on one one side and the artist on the other has been done many times before, but perhaps most famously between Ayrton Senna and Alain Prost. Prost used to be called the Professor. Senna was the man who said that 'if you do not go for a gap, you are no longer a racing driver' and was guilty of some spectacularly misjudged over-taking attempts. He was also responsible for some of the most glorious examples of racing that you will ever see.
Given what you know about Senna, it will probably cause you no surprise at all to discover that it was Vatanen had a big shunt, from which it took him 18 months to recover, while Rohrl raced safely and competitively until he retired in 1987.
So what does this mean? To hear Vatanen talk about rallying is rather inspirational: he looks into the middle distance, and he mimes driving with his hands, as if he is conducting the car. To him, driving has a real aesthetic quality, and is an outlet for his creative forces. He is the kind of person to inspire you to become a rally driver.  
For Rohrl on the other hand, driving is no less thrilling, but for slightly different reasons: he revels in the precision of it. Where Vatanen no doubt thrives on the beautiful arcs he can create while putting the tail of his car out going round a bend, for Rohrl, the pleasure of exactly the same corner is expressed more in terms of the fine balance of the accelerator and brakes, and holding the car in exactly the right position. Where Vatanen feeds off the music of driving, Rohrl enjoys the physics of it.
I suspect Vatanen was more popular than Rohrl - he can obviously command the imagination of others. But who would you rather be co-pilot for?
The calculation of risk, and the chances you take are informed by the possible benefits, and also by the potential fall out. It is one thing to take a punt when the only potential victim is you, but quite another to subject others to the prospect of harm.
The way we process risk is influenced by all sorts of factors, such as the way information is presented, and the manner in which it is processed. Do you put your faith in the person for whom the risky activity is a thing of beauty, or do you place it with the person who makes it a calculation?