Introduction to the Profession UnitIntegration Session, week 2

“Teasing out the Threads”:

Humanities & the Art of Medicine

Health & Wholeness

Culture & our Perceptions

Weaving a Tangle of Threads...

Understanding:

Into a Patterned Cloth

Often while feeling you’re hanging

by a thread!

Some Themes of the Week

• Medicine: Slices vs. Wholes

• Your Roles: Narrow vs. Broad

• = Treatment vs. Healing

• Culture: West and East; North and South

• Science: Reductionism versus Holism

• Explanation: How? versus Why?

(Dr Hall’s diagramof componentsthat lie beneathclinical presentation)

PH

YS

ICA

L

EM

OT

ION

AL

SO

CIA

L

SP

IRIT

UA

L

Case Study: Adherence to treatment• Most medicines work very well, so obviously patients should

take them as recommended by their physician (based on drug trials).

• “Adherence to treatment” (aka ‘compliance’) is widely studied. For example:

• British Medical Journal, July 1, 2006, page 15. “A meta-analysis of the association between adherence to drug therapy and mortality.”

• Aggregated 19 studies into a meta-analysis. There were 26,436 participants in all.

• Those with good adherence to therapy had roughly half the likelihood of mortality during the study period (odds ratio 0.55, 95% CI 0.49 to 0.62).

• Any comments?

Adherence, continued • Good. But then they did a really interesting

thing:• Aggregation of 8 studies of placebo

(=19,633 participants).• Those with good adherence to placebo

also had almost half the likelihood of mortality during the following year (odds ratio 0.56, 95% CI 0.43 to 0.74).

• So, is it the drugs, or something about compliance, that protects patients?

Some threads arising...

• Modern medicine based on biological science• But there is much more; there are complex interactions

between psyche and soma; there are mysteries & surprises.

• There are many ways people heal. • Dr. Gelfand mentioned the transition from religious and

spiritual healing towards allopathic medicine. • The placebo suggests that the physician herself or

himself is a crucial in the equation. • How do you see the clinical role: the active ingredient?

Sometimes metaphor is useful: a catalyst? An enzyme? • The professionalism theme alluded to humility and

respect in approaching these broader processes. “Illusions of control”.

Healing & health

• Hale – whole; soundness of body• Balance of parts; illness as getting out of balance. • But many chronic illnesses cannot be cured and healing

does not necessarily entail eliminating disease. • Many cultural variants; Western medicine under-

emphasizes the balance, the healing, the wellness. • From the Town Hall session: as physicians, your caring

& curing roles are intertwined in trying to restore balance at cellular, organ, individual & social levels.

• This week has emphasized communication; taking your time with the patient; much illness is self-limiting and your role is to support healing

Dr. Cook’s Ways of Healing

• Talking

• Crying

• Laughing

• Dancing

• Sweating

• Yawning

• Yelling

• Walking in nature

This links to discussions over the placebo effect. This has been called “contextual healing” – healing that is enhanced by the context in which

it is given. Cf. RCTs of patient expectations.

Science Art

• So, we are blending science & art.• Medicine concerns the whole

and many layers of its parts; these interact• The physician balances these perspectives in

her or his approach. Your science will interact with your art.

• This is hard to achieve and is an ongoing, lifelong challenge.

• What is the science of the art; the art in the science?

Ways of knowing

• Induction Deduction in medicine

• Lenses: gender, culture, poverty

• Causes & determinants

• Understanding & explanation; the “How?” and the “Why?”

• Learning how to learn

• Different in different sciences:

So, what of the social level?

• All of the above occurs at the social level, as well as the individual.

• The story of Roseto, Pennsylvania• The layers of health

determinants interact:

• The big questionremains the Why?

Cultures

• Culture has been introduced as one way to gain insight into your patients’ ways.

• But you must be careful: we are all influenced by commitment to many cultures at once, so you must not prejudge a person on the basis of their culture (prejudge = prejudice).

• This is the theme of cultural safety.

• However, insight into culture is often useful in making sense of behaviors after they occur.

Culture & styles of parentingA circumplex model (after Bowlby, 1969)

Warmth

Remote, Distant

Control Autonomy

Detac

hed

Affectionate

constraint

Harshcontrol

Nurturance

Discipline

Laissezfaire

China UK

JapanTraditionalcentral Asiancultures(?)

Note: cultures migrate over time: none of these placements is static!

Why is it so Hard to Predict Health?The cone of variability in influences on health

Broad social determinants ultimately drive patterns of health. However, as we move from cell to organ, to person, to group, the variability in responses increases, so the precision of causal statements declines.

Precision of predictions

Variance of estimates

CulturesSociety

CommunityPerson

Biologicalprocesses

Social sciences can offer general guides and insights, rather than precise laws. But they do offer neat ways of conceptualizing issues. For example, parenting styles: