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LETTERS: Caroline White If it doesn't work, stop it: Summary of rapid responses BMJ 2004; 328: 1016-a [Full text]

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If it doesn't work, stop it. Do something else!

Søren Ventegodt, Mohammed Morad, and Joav Merrick   (26 April 2004)

If it doesn't work, stop it. Do something else! 26 April 2004
Søren Ventegodt, Director The Quality of Life Research Center, Teglgårdstræde 4-8, DK-1452 Copenhagen K, Denmark, Mohammed Morad, and Joav Merrick Send response to journal: Re: If it doesn't work, stop it. Do something else!	EDITOR—Many letters to the editor have followed each other in the BMJ debate on the extremely important theme of stopping doing what we usually do, when it does not work. This seemingly being the most difficult thing a physician can do! May we suggest that we expand the range of the physician’s activities with other toolboxes than the biomedical, so that we can find something new to do, when what we usually do does not work? If the NNT (number needed to treat) of the best working drug or operation is say 5, 10 or even higher, rendering only a small fraction of our patients helped by our medical intervention? Remembering the old definition of insanity and its treatment: “to continue doing what we always have done, expecting new results”, we on the other hand suggest that the physician should be open-minded to other kinds of treatment and perspectives on health and disease. In fact we actually want the modern physician to be multi-paradigmatic. All medical work is based on the intention of doing good, either improving the health, the quality of life or the ability of functioning – or a combination. Independently of the good intention coming from the physician, the medical work is always bound to some medical theory or a frame of interpretation. Hence the different paradigms1 - giving a number of different perceptions, hypothesis, diagnoses, actions and reactions. Just compare how we construct our consciousness in general and in our reality.2,3 The process of healing is – as life itself - often fairly complicated. The course of the disease, the healing process, personal development, learning and coping in connection with a disease is highly individual. The modern physician is often multi-paradigmatic as he serves many different types of people in many different existential circumstances. He basically has the three, very different sets of technologies or “toolboxes” at his disposal, derived from three different medical paradigms: 1. Classical, manual medicine, where the hands – used with the best and most humane intentions – constitute the main tools. It dates back to Hippocrates and Greek antiquity.4,5 2. Biomedicine, which came into widespread use around 1950, born paradigmatically along with the discovery of penicillin, where biomedicine has a focus on body chemistry and physiology.5 3. Holistic medicine or consciousness-oriented medicine, which is a new and increasingly popular trend with many family physicians in the western world. It draws on a variety of healing processes, philosophies and systems, taken in the original or modified form from the pre-modern cultures. The most important thinkers influencing holistic medicine in Europe today is great physicians and philosophers like Jung6,7, Maslow8, Antonovsky9,10, Frankl11, Fromm12, Goleman13,14, Sartre15, Kiekegaard16 and Allart17. The holistic approach focus on the person as a whole, where this wholeness, soul or total existence is thought to be able to heal from its very totality – becoming “whole again”, when the wholeness is partly or completely lost.18-27 Depending on the perspective, or paradigm, very different things might happen to the patient, when treated by the physician, where the signs and symptoms of development or progress of health and disease is interpreted very differently. If you go to a homeopathic doctor, which for example is fairly common in Germany, it is seen as a good sign, if the treatment makes you feel worse for a while28-31, but if you consult a biomedical doctor, then medicine is expected to make you feel better almost at once. If you consult a holistic doctor working according to the holistic process theory and the life mission theory5,26,27, you would normally expect a very different path, even when occasionally confronting painful old traumas. The reason for this is that the earliest existential wounds normally are the toughest to overcome, but the more resources you have, the more severe wounds on your soul, you will manage to confront and heal. In lack of a better term we have called the extended medical science, integrating these three different paradigms and their three strands of tools and methods, the “new medicine”. CLINICAL HOLISTIC MEDICINE The life mission theory18-23 state that everybody has a purpose of life, or a huge talent. Happiness comes from living this purpose and succeeding in expressing the core talent in your life. To do this, it is important to develop as a person into what is known as the natural condition, a condition where you know yourself and use all your efforts to achieve what is most important for you. The holistic process theory of healing26,27 and the related quality of life (QOL) theories32-34 states that the return to the natural state of being is possible, whenever the person gets the resources needed for the existential healing. The resources needed are, according to the theory: “holding” in the dimensions of awareness, respect, care, acknowledgment and acceptance with support and processing in the dimensions of feeling, understanding and letting go of negative attitudes and beliefs. The precondition for the holistic healing to take place, is trust with the intention that healing takes place. Existential healing is not a local healing of any kind, but a healing of the wholeness of the person, making him much more resourceful, loving, and knowledgeable of himself, his own needs and wishes. In letting go of negative attitudes and beliefs, the person returns to a more responsible existential position and an improved quality of life. The philosophical change of the person healing, is often a change towards preferring difficult problems and challenges, instead of avoiding difficulties in life.35-43 The person who becomes happier and more resourceful is often also becoming more healthy, more talented and more able of functioning.44-46 CONSCIOUSNESS-BASED MEDICINE In the search for the best way to make a new medical clinical practice to serve the new type of patients we now see in our western society (the critical and knowledgeable patient or the patient focused on personal or spiritual development), we have worked with three different approaches to the new medicine: 1. Quality of life as medicine: Focusing on human feelings and emotions, we have combined bio-medicine with a number of complementary therapies, like Rosen body work, classical Chinese acupuncture and gestalt psychotherapy. We have called this holistic approach ”quality of life as medicine”.44-46 The combined treatment have the intention of inducing existential healing26,27 and encompasses three phases, which is popularly described as: “Feel, understand, and let go”: Feel the blockages in body and mind, behind your health problems and symptoms, understand the life- denying conclusions you reached then which created them, and let go of these decisions once you are ready to assume responsibility and be your true, responsible self again. The team of physician and alternative therapist complementing each other working under medical supervision, could be the most efficient way to induce existential healing, in spite of the differences in professional language, culture and paradigm. 2. Meaning of life as medicine: focusing on the purpose of life, meaning of life, life mission and talent.18-23 Focusing on the hidden potentials, on the beauty and magnificence of the soul and on the power of our existential choices, gives many patients faith and a fast healing progress. When the existential theories, the QOL philosophy and theories, and the QOL concepts are explained to the patients and internalised, patients gradually find themselves, and return to a natural state of being, comparable in some aspects to the state in which they were born with a certain purpose of life, and certain great talents to be used. The life mission theory simply states, that denying your meaning in life leads you to illness, unhappiness and poor performance, while recovering your purpose of life depends on finding and working for your purpose of life. 3. Love as medicine: Based on the concept of genuine human relationships and the power of unconditional love and acceptance, we have worked with the spiritual gift of love and the healing power of this in what we have designated an experimental, social utopia.46,47 When patients belong to a small community with true companionship, contact and emotional surplus, their way to recovery seems to be much shorter. The problem with social utopia is, that it is very difficult to create and even more difficult to control. One of the preconditions seems to be that the participants do not have sex with each other, as this disturbs the possibility of intimacy in the group setting. Although consciousness-based medicine supports individuals in their personal development; therapy and the patient-physician relationship can never replace a vibrant reality lived with those most important to them. It is the conquest of a good personal world to live in, which can bring wholeness and healing. Quite simply, an individual can only realize the meaning and purpose of life in a social context. This purpose is what we are meant to be and with this gift we will be able to give to others. This can only happen most fully in intimate relationships, full of trust and love. A huge body of evidence has been collected on the connection between health and survival, and love and intimacy.48 Many medical doctors seem to be unable to work with therapists not scientifically trained, and many therapists do not like to be directed by a medical doctor, which makes the approach very difficult. Problems of this kind in the treatment team do not help the patients, as we have painfully experienced in our own clinical practice. As human beings we are limited to loving only a few percentages of our fellow men. This is an issue that often naturally grow to a larger fraction, as we grow older, more wise, spacious and containing, as we understand that love might be a leading concept in medicine. Maybe even the strongest of the three concepts for inducing existential healing. Since such an approach for many seems unnatural, we are for all practical purposes left with the second approach in order for the modern physician to use the “new medicine”. Interestingly, the three approaches mentioned above express to what degree the physician is willing to come close with the patient. This mirrors the intention of the physician towards his patient. In a) the physician has the intent of helping the patient to heal, in b) he has the intent of personally giving a gift to the patient from the bottom of his heart and in c) the physician has the intention to let the patient be a part of his life, in true appreciation of the magnificence of this unique soul in front of him. We believe that most physicians of our time, who search their soul will find that the intentions of b) is an appropriate ambition for their work. The physician, who truly can give the holding8,9 and processing in order to come close to his patients needs, will always be loved and respected by his patients. WHAT MAKES A PHYSICIAN EXCELLENT? What will make a physician excellent are his good intentions, his deep knowledge and developed skills. In order to assist his patient to a successful treatment and help his patient, the physician is only excellent, when the good intentions result in the patient being adequately helped. The patient is helped when one of the following two conditions is fulfilled: 1. The patient gets what he wants: quality of life in some aspect or globally, health in some aspect or globally, or ability of functioning in some aspect or globally – or a combination of these. 2. The physician gets what he wants: the broken leg healed or the disease treated or prevented. So the situation is fairly complex, and much is depending on the physician choosing the right medical paradigm or toolbox. It is not easy to tell, what a good medical treatment is, unless: 1. you understand the paradigm chosen, and look at the patient from inside it. 2. you keep track of all the subjective, objective factors and events involved in the process of healing through time. 3. you have a valid way of testing the end result of the treatment. All this is more or less complicated depending on the paradigm with the subjective paradigm the easiest to demonstrate.25 This makes it surprisingly easy to make research and quality improvement in the holistic medical clinic, introducing existential healing according to the holistic process theory, and surprisingly difficult to document effect of the bio- medical treatments, because of the objective approach. This later approach needs a difficult set-up with control groups in the Cochrane design to be valid. AN EXAMPLE OF THE THREE MEDICAL PARADIGMS AT WORK: LOW BACK PAIN49 A patient comes to the physician with low back pain. If the physician uses manual medicine, he will examine the patient carefully to exclude the need of surgery; he works with his hands on the patient, helping the patient to be more relaxed, less tense and less in pain. Most fine body workers or chiropractors can remove a normal low back pain within an hour. When the cause in the body is understood and removed, the job is done. If the pain returns, so must the patient. If he gets a bad discus (a slipped disc) and a severe problem later with compression of the spinal nerves it is not related to this treatment. If the physician is working according to biomedicine, he will examine the patient carefully to exclude the need of surgery, and if the problem is not serious he will mobilise the patient, and use the painkillers necessary for this. He will talk about prevention, avoiding heavy lifting or poor working postures. If the cause of the pain is understood this is fine, but mostly the low back pain has no objective cause and this is no obstacle for giving the treatment. When the patient is well again after the mobilisation – it normally takes a couple of days – the job is done. If the physician is working with conscious-based medicine he will examine the patient carefully to exclude the need of surgery. He will look for the cause of the illness in the patient’s consciousness – difficult feelings repressed and placed in the longissimus thoraces muscles and other muscles. He will talk to the patient, give “holding” and processing, and inspire him to a more honest and joyful living. When the cause in the consciousness is understood and removed, and the pain is gone, the job is done. It is not that any of these medical paradigms are better or worse that the other. The excellent physician mastering what we call the “new medicine” uses the most efficient way to help every patient, giving him or her exactly what is needed under the circumstances. So, if it does not work, stop the treatment and try something else. Søren Ventegodt, MD, is a general practitioner and the director of the Quality of Life Research Center in Copenhagen, Denmark. E-mail: ventegodt@livskvalitet.org Website: www.livskvalitet.org/ Mohammed Morad, MD, is a family physician the medical director of a large area clinic in the city of Beer-Sheva, Israel. E-mail: morad62@barak-online.net Joav Merrick, MD, DMSc is professor of child health and human development, director of the National Institute of Child Health and Human Development and the medical director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel. E-mail: jmerrick@internet-zahav.net. 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