lundi 16 janvier 2017

SUBURBAN SHAMAN WHY DOCTORS SHOULD REGAIN THE HUMAN ASPECT OF MEDICINE FROM THEIR PAPERS AND PODS

Oliver Sacks wrote in the Introduction to this book:
Cecil Helman is many things: old-fashioned General (Family) Practitioner, psychiatrist, cultural anthropologist, storyteller, poet and artist-and all this comes together in Suburban Shaman, a beautifully written, devastatingly honest (and often very funny) account of an audacious and adventurous life.
Cecil, a South African Jew, was my teacher where I studied Medical Anthropology in London, later he became a a good friend and was instrumental in helping me offer the first ever course in Medical Anthropology in Havana, Cuba.
He passed away in 2009, I miss him and a homage to that is his appearance in my eyes and his words in my heart, when looking at the Medical Practice with an Anthropological Eye.

It happened when American Diabetes Association published their recent recommendations regarding care of patients with this chronic illness.
First I give you a summary published by a writer who is not a medical doctor but who has concerns of the society and the patient in mind; to be followed by a summary by a "diabetes Expert" who has only drugs and body as a machine metaphor in his mind. What a pity..

First I will quote from Cecil's book, in his words:
It took me some time in practice to realise that a fundamental aspect of Family Medicine was its attitude to uncertainty. After literally tens of thousands of consultations with patients, and many hundreds of house-calls, clinnical practice eventually taught me one big, and rather soberinng lesson: It's that the more you know about doctorinng and why it works (or does'nt work), the more you realise how much you don't know. For despite its patina of science at its core medicine -and not just Family Practice-is not really about certainties, nor ever has been. To the disappointment of some of the new breed of "techno-doctors" as I've called them, it's also about doubt and ambiguity, and ethical dilemma that are sometimes difficult or evven impossible to solve. It's also about the limits of human expertise, especially with serious, chronic or incurable diseases.

When I began working with American Indians, one of the first lessons they taught me was the acceptance of ambiguity, and chaos present in one's life, over which may be superimposed some form of suffering from an illness.

Here is the same recommendations of American Diabetes Association presented from a patient's or the societal point of view and those of an Techno-Doctor who is more interested in numbers and paper print outs.

New recommendations for 2017 include:
·        Assess patients for psychological problems, including diabetes distress, depression, anxiety, and disordered eating.
·        Determine patients' social context, including potential financial barriers, food insecurity, and housing stability.
·        Perform autoantibody testing in first-degree relatives of people with type 1 diabetes to assess risk.
·        Consider periodic vitamin B12 measurements in metformin-treated patients, with supplementation as needed.
·        Consider empagliflozin and liraglutide in patients with type 2 diabetes and established cardiovascular disease.
·        Assess sleep pattern and duration as part of diabetes management.
·        Prolonged sitting should be interrupted every 30 min with short bouts of physical activity.
·        Clinically significant hypoglycemia now defined as ≤54 mg/dL, with “alert value” for taking action at ≤70 mg/dL.
·        Include fat and protein counting in addition to carbohydrates for patients who use premeal insulin.  
·        Bariatric surgery is re-named metabolic surgery, with threshold for considering it in patients with type 2 diabetes lowered down to BMI 30 kg/m2 (27.5 in Asian-Americans).  
COMPARE THE ABOVE WRITTEN BY AN INTERESTED OUTSIDER RATHER THAN A PHARMA PEON “EXPERT”, WELL KNOWN FOR HIS HONORARIA FROM DRUG COMPANIES

The American Diabetes Association (ADA) recently issued its revised Standards of Care for 2017 (
summarized here). There are several changes to these guidelines this year. Therefore, it is important that anyone involved in the care of a patient with diabetes read them. The overall standards are long and detailed, but are summarized in one of the articles in the supplement. Here, I highlight and summarize are few of the most important changes.
·        Screening for diabetes is emphasized again, but with some clarification on whom to screen and an example of a validated tool to use for screening.
·        The evaluation of a patient highlights the importance of comorbidities, including assessing sleep pattern, HIV, and various psychiatric disorders.  
Several changes were made to pharmacological therapy:
·        The recognition of vitamin B12 deficiency with metformin use is new but important, as it may contribute to neurological problems.
·        The costs/affordability of medication have been highlighted, including the high cost of insulin (which was previously considered inexpensive).
·        Recent cardiovascular outcome trials are discussed to support a recommendation to use empagliflozin or liraglutide in high-risk patients with cardiovascular disease.
Although these may be the most important/novel updates, the standards have been updated and clarified in several areas and will probably affect clinical practice significantly. 
You can see the doctor had neglected to mention the psychosocial aspects of a disease which is very socially oriented whereas the other writer had included all the recommendations including the psychosocial ones.
This is not an isolated example. The bio medically oriented doctors whether in private practice or at the university think of themselves as experts of a narrow spectrum of paper outputs and printed laboratory tests and neglect the person who is suffering from the disease and reduce that person to a collection of papers and results and part of the Evidence based Medicine.
DR CECIL HELMAN WAS A PHYSICIAN ANTHROPOLOGIST WHO PRACTICED FAMILY MEDICINE FOR NEARLY 30 YEARS WHILE BEING ON THE FACULTY WHERE THE BEST COURSE IN MEDICAL ANTHROPOLOGY WAS  TAUGHT IN LONDON.
He was a good friend and I miss him.