Alcoholism: heartsink or microcosm?

ImageFew GPs get excited by seeing known alcoholics walk into their surgery; they are the classic ‘heartsink’ patients, with a host of problems, often insoluble. They range from the physical (you really do destroy your body with long term drinking), through the underlying psychology (there are often personality disorders and depression), to the day to day consequences, such as social isolation, unemployment, and homelessness.

Dealing with all these issues is difficult, as it entails the interaction of many different people, each with their own rules, cultures, and bureaucracies: alcoholism is perceived in very different ways by say, policemen, social workers, and nurses. Moreover, the patients themselves are often unwilling or unable to take control of their own destinies, and this makes the oversight and management of alcoholism all the more difficult.

However, with patience, experience, and the ability to work across many professions and disciplines, progress can usually be made. It may not be possible to overcome the problem completely, but at least one may be able to reach some form of stable balance between alcohol and the external world, a modus vivendi that allows life to continue in a relatively sustainable way.

In that sense, there may be lessons to be learned from alcoholism as an example of modern medicine’s new Big Issue: the treatment of all long term conditions.

The first half century of the British NHS were dedicated to the creation of super-specialists, able to diagnose and treat ever more precise conditions, thus defining their patients not as people, but by their illnesses (‘the leg in Bed 4’, ‘the appendicitis in A&E’). This approach may be useful when everything is running smoothly apart from one small problem, but such a ‘Kwik Fit’ approach to medicine fails utterly when there are several major issues to be addressed at the same time, especially when they include social and psychological determinants as well as physical ones.

Increasingly, health services around the developed world are finding that it is these complex cases that are exercising their services (and increasing their expenditure) rather than simple mechanical failures. Managing a sixty year old lady who has diabetes, breast cancer, and has recently been widowed is very different from mending a broken leg, or even treating a straightforward heart attack, and it is here that there may be useful lessons from the enlightened management of alcoholism. The key messages in both instances are:

  • Take an holistic, person based approach to the problem, don’t try to fragment it into reductive components to be treated in separate silos.
  • Be prepared to work with other teams, disciplines, professions, and organisations, without assuming that only you have the answers
  • Care is at least as important as cure: many of these conditions will last a lifetime, so we have to move away from the idea that absence of cure is failure.
  • Work with the patient, and not at them; in the end, it is their illness, and their involvement and expertise are key to its management.

I wrote this piece for the blog site of the Health Services Management Centre (HSMC), where it was posted last week.

Kissing it better: beliefs in modern medicine

ImageI’m trying out a new medium today, using the University of Birmingham’s Ideas Lab, on which they’ve just posted a podcast from me about health beliefs. You can find it at:

I think the issues are as pertinent to health care professionals as they are to patients and the public, and it’d be really helpful to start a proper discussion about ways of harnessing and influencing people’s health beliefs, rather than always trying to discount them.  Even the term ‘placebo’ now has negative connotations, rather than being seen as a useful tool in the clinician’s bag.

What do you think? Should we be sticking to the narrow and reductive route of evidence based medicine to the exclusion of all else, or is there benefit in looking at a more holistic view of healthcare that uses all the levers it can find, even (perhaps especially) the ones that reside inside our own heads?

The issues obviously matter in the determination and implementation of ‘best care’, but it may also be relevant when we consider professional knowledge transfer; how and why do professionals change their practice, and how can we influence that? Can it be done scientifically, by assuming that this week’s articles in the Lancet will translate into next week’s clinics, or is there something deeper that influences how clinicians think, how their beliefs affect their behaviour? If the latter is true, we may need to augment those scientific journals with ‘softer’, more fuzzy approaches, the kind of tools used in social marketing.

I’d be very interested in your views…