Cold water swimming

Inspired by Floating, Joe Minihane’s memoir about swimming in seas, rivers and lidos around the UK, I plan to do more outdoor swimming this year. I have ample opportunity here in New Zealand, being lucky enough to live in a house with a pool in the garden and ten minutes walk from the sea. I already swim most days during the hot summer months but intend to try extending the season.

Swimming, especially in cold water and sea water, seems to confer mental and physical health benefits over and above those to be gained from exercise in general. Mechanisms for this include the physiological stimulation of being in cold water, the meditative state induced by rhythmic movement and deep breathing, being surrounded by nature, and absorption of the minerals present in the sea. Many people feel an immediate uplift of mood and energy when they go for a swim. Regular swimming over a period of several months appears to reduce stress, helps to regulate the immune and endocrine systems, and reduces inflammation. Regular swimmers catch fewer colds, and there is preliminary evidence that swimming can help in the management of numerous medical disorders including anxiety and depression, eczema and psoriasis, hypertension and diabetes. However it takes time for the body to adapt to the demands of cold water swimming and reap these health benefits. So it is important to build up the practice gradually, and to be aware of the potential hazards as outlined below.

The shock of getting into cold water can throw all body systems out of balance, causing the sudden onset of breathing difficulties, muscle spasms, raised blood pressure and disordered heart rhythm. Cold water shock can be fatal due to a heart attack, stroke or inhalation of water. Hypothermia can ensue after more prolonged immersion and is manifest by shaking, weakness and confusion. To avoid hypothermia it is important to wrap up and warm up after the swim. Individual tolerance to cold varies but my understanding from various websites is that water temperatures below 15C are always dangerous, and that beginners should probably not start below 20C. Wild swimming in rivers or seas carries the risks of infections, injuries, and drownings due to powerful currents or tides.

Being a person who gets cold easily I considered buying a wetsuit, but after a trial fitting decided against it. I found the suit so cumbersome to take on and off, and so constricting to wear, that I felt it would detract from the pleasure and benefit of swimming. I got leggings and a neoprene jacket instead and am proud to report that yesterday, the last day of winter, managed to swim one length of the pool …

J contemplating water

Taking tablets

“Healthy living” – good diet, regular exercise, enough sleep, stress reduction, positive outlook – and natural therapies can achieve a lot, but in many cases of medical illness they are not enough on their own. I am thankful to have found effective drugs to control my own episodes of high blood pressure and cardiac arrhythmia. At the same time I can well understand why around 50% of people with chronic disease fail to take some or all of the medication prescribed for them.

There are many reasons for non-compliance (or non-adherence). Side-effects: the experience of unpleasant symptoms in the present, or concern about possible permanent damage in the future. Reluctance to accept a need for ongoing treatment: especially if the benefits cannot be felt immediately, if healthcare professionals have not explained them clearly, or if there is genuine uncertainty about the pros and cons of longterm medication. A desire to avoid artificial chemicals. The financial cost of the drugs.

All these are valid points and there is no doubt that some prescriptions are unnecessary or harmful. But assuming that taking the drugs is indeed the right thing to do, here are some personal observations about how the physical form of the tablets (or pills or capsules) might affect compliance. These aspects may not be considered by the prescribing doctors, though I expect nurses and pharmacists appreciate them more.

Size: while this is partly determined by the chemical makeup of the drug, big tablets are hard to swallow, and small ones can get lost.

Colour and shape: many generic drugs are presented as small round white pills which are hard to tell apart, and this can lead to mistakes in dosage. Coloured tablets of different shapes are much easier to identify. Incidentally, there are some interesting studies showing that the colour of a tablet affects patients’ reports of its effects.

Strength: having to break tablets into halves or quarters is tedious and often inaccurate. Tablet-cutters can help, but it is better if low-dose versions are available.

Frequency of dosage: again this is partly dependent on the properties of the drug, but if it is possible to get a controlled-release preparation to be taken once daily this is preferable to divided dosing.

Such practicalities were not mentioned in my pharmacology course at medical school, as far as I recall. Perhaps they seemed too simple and obvious to be considered in an academic context. I certainly paid them little attention when I practiced as a doctor, not always being aware what the tablets I was prescribing would look like when dispensed. I now realise that size, colour, strength and frequency of dosage can be quite important to patients, especially those who have problems with eyesight or memory. Here in New Zealand it is impossible to get some of the low-strength and controlled release preparations that are available in the UK and elsewhere, and make patients’ lives easier.

 

Bach flowers: medicine or magic

After taking a few years out from my Bach flower remedy practice due to illness in the family I am now available to see clients again, so it seems timely to revisit the topic on this blog.

The remedies are intended to restore emotional balance. Common presenting problems include anxiety, grief, relationship difficulties, lack of direction in life, and the hardships of physical disease. I am continually impressed with how well the system works: 80 of my first 100 clients reported an improvement, and this figure is in line with the experience of other practitioners. But it is not always easy to reconcile my background in orthodox medicine with my interest in holistic therapies like the Bach flowers. I have to acknowledge there is no accepted scientific explanation for their mode of action, and that when tested in the artificial context of clinical trials they usually perform no better than placebo.

Leaving aside the question of whether the remedies have direct effects, a consultation with a Bach practitioner can be therapeutic because it empowers the client – as the jargon goes – “to take responsibility for their own healing”.  The interview does not follow a set structure, and it is up to the client to decide what they want to talk about and how much detail to reveal. The practitioner listens, and asks questions for clarification, but does not probe for extra information or offer unsolicited advice. The selection of remedies is a cooperative process, with the practitioner making suggestions but the client helping to choose what flowers they need, and sometimes seeing their problems in a new light as a result. The combination of up to six flowers is tailored to the unique individual’s state of mind rather than a symptom or diagnosis.

This is very different from the assessment process used in orthodox medicine and psychiatry. Traditionally, in the orthodox system, the doctor is in charge while the patient takes a passive role. The consultation follows a standard format, with a series of questions followed by examination and investigations, aimed towards establishing a diagnosis. The drugs, surgery or radiation prescribed will usually have evidence-based benefit for the disease concerned, but inevitably carry some risk of side effects. The orthodox approach often works very well, especially for acute conditions and those that are clearly defined, and is sometimes life-saving (as was clearly brought home to me in 2015 when my husband required heart surgery, described in my short memoir Across a Sea of Troubles).

The orthodox approach with its armamentarium of marvellous medical and surgical technology, and the holistic approach which draws on the universal principles of healing and self-help, are truly complementary to each other and can be used together – I think of them as representing the “yin” and “yang” of healthcare. Unfortunately there is considerable antipathy and misunderstanding between practitioners of the two schools and the concept of integrative medicine, which combines the best of both, has not been widely accepted.

While Bach flowers can be used on their own for minor mental or physical imbalances, they are not sufficient as a sole treatment for anything more serious. I often advise clients to seek a medical assessment if they have not done so already because physical diseases, for example over- or under-activity of the thyroid gland which is common especially in women, can present with psychological symptoms.

Clients are attracted to therapies like the Bach flowers because they are natural and safe, treat them as a “whole person” rather than just a case of a particular disease, and provide them with a sense of choice and control.  More information about Bach flowers can be found on this page.

Complementary therapies in cancer care

This short overview is based on a talk I recently gave to the members of Sweet Louise, a New Zealand charity for the support of people with incurable breast cancer.

Complementary therapies can be loosely defined as those not included in orthodox medical training or practice, though this can change, for example acupuncture has been used in pain clinics for many years. Some therapies involve physically touching the body – examples include massage, reflexology, acupuncture. Others involve taking substances by mouth – herbal remedies, homeopathy, flower essences, special diets. Then the mind body therapies such as relaxation, meditation, yoga, visualisation and guided imagery, energy healing. And creative therapies with art, music, writing and dance. Several types can be combined.

They are often known as “natural” therapies, and the same ones may be called “complementary” when used alongside orthodox medical treatments, and “alternative” when used instead. The “integrative” approach combines them both but has been slow to get established, perhaps because of prejudice and misunderstanding on both sides. All these therapies are grounded in the “holistic” approach, which aims to balance the whole person in body, emotions, mind and spirit, and mobilise the potential for self-healing. This is in contrast to the approach of conventional medicine, which uses powerful drugs, surgery or radiation to suppress symptoms and destroy disease, and in which patients have a passive role. Both approaches have their place and can often be used alongside each other.

Surveys show that as many of two thirds of women with breast cancer are using one or more natural therapies, and there is good evidence that they can improve quality of life – helping to relieve physical symptoms such as pain and nausea, mental symptoms such as anxiety and depression, reducing the side-effects of radiotherapy and chemotherapy. They appeal because, in general, they are safe and natural and many of them are pleasant to receive. When I was practising with the Bach flower remedies, many of my clients told me they wanted a therapy that treated them as a unique person, rather than just one more case of a diseased body part.

While all the modalities have specific effects, their benefit is partly due to their positive influence on mind-body relationships. The self-help element, especially with therapies that require some active user participation, enhances a sense of choice and control. Spending time with an understanding therapist in a relaxed setting is comforting. Expectation of improvement can help to bring it about. Such general factors are important, and it is a mistake to devalue them as “just placebo”.

A key question is whether using these therapies can lead to a longer life expectancy or even to remission of the cancer. Many individual cases of remarkable recovery have been reported. But there are few formal research studies on this aspect, and it is a difficult thing to investigate for many reasons – for example treatments are used in individual combinations rather than standard protocols, and patients’ beliefs and motivation affect the outcome.

Some of the therapies carry risks, for example herbal remedies can have adverse interactions with prescribed drugs; massage and acupuncture occasionally cause physical injury. They can be expensive. The field is not tightly regulated and, while most therapists are skilled and honest, there are a few self-styled practitioners who cause more harm than good by making unrealistic promises of curing cancer while advising clients to refuse conventional treatment that would have been effective.

More detail about these topics, with case histories, can be found in some of my non-fiction books.

Fitbit and Zumba Gold

Having read a lot lately about the health benefits of exercise, and the health dangers of sitting down too long, I resolved to spend less time at my desk and more time on the move.

I replaced my wristwatch with a Fitbit Alta HR, in order to track my level of activity. I have always liked walking – though since getting a car I no longer do all the supermarket shopping on foot – so there has been no difficulty in meeting my goal of 12,000 steps per day. Sometimes I do more than that, and get a message on my iPhone about being an over-achiever. The Fitbit also provides heart rate data, and I was pleasantly surprised to be told that my cardiovascular fitness is “excellent”. Another pleasant surprise was that, assuming the reports are accurate, I sleep better than I thought I did and usually meet my target of seven hours per night. Fitbit also measures other physiological variables, and displays text messages, as well as telling the time. Whether wearing this sophisticated technological device does any harm to the body is not known.

So far well and good, but I know my physical coordination could be improved, so I have joined a Zumba Gold class. According to Wikipedia, Zumba draws on diverse traditions including cambia, salsa, merengue, mambo, flamenco, chachacha, reggaeton, soca, samba, hip hop, axe and tango. The “Gold” version is less strenuous than the others, being designed for older people and beginners. Along with about 15 other ladies of a certain age, and the occasional lone male, I spend an hour a week trying to follow the teacher as she dances along with the upbeat music. Hopefully, if I keep practising, the moves will become easier to follow and the class will be more fun.

I already quite enjoy Zumba, certainly much more than I ever enjoyed sports and gym at school. But, apart from walking and swimming in the summer, I have never been very keen on taking exercise for its own sake and am in no danger of getting obsessive about it. Besides, too much exercise can be bad for the joints and the heart. There are other ways to keep well, and a research finding that especially appeals to me is that proximity to a purring cat not only reduces stress, but can improve cardiovascular function and even help to prevent osteoporosis.

Wounded healers

During my medical career I met several doctors and nurses who had achieved excellence in their work despite – or maybe because of – health  difficulties of their own. I am sure I could not have coped so well as they did, but my recent experiences of the patient’s role have made me wonder what it would have been like if I was still in practice.

The term “wounded healer” is usually attributed to Carl Jung, who used it in a psychological context. Many of those who choose psychotherapy or counselling as a career are seeking, consciously or not, to cure problems of their own. If they have insight into these and have taken steps to resolve them, it may make their work more effective. If not, they risk causing further damage to their clients.

The term is also associated with Chiron, a figure from Greek mythology, who suffered from a chronic physical wound as the result of a poisoned arrow. He was able to heal other people but could never cure himself. I don’t know how Chiron felt about this, but many of today’s clinicians would be embarrassed by such a scenario – in line with the mantra “physician heal thyself”, there is a widespread assumption that healthcare professionals should not be ill themselves. Some patients do lack confidence in staff who have something evidently wrong with them. Others feel comforted to know that their attendants are vulnerable to the same ills as the rest of humanity, and encouraged to see them overcoming their limitations and carrying on their careers.

Compared to those in robust health, clinicians with personal experience of ill-health tend to be more sensitive and empathic, which within limits is a good thing but if taken too far can lead to over-involvement, excessive self-disclosure, loss of objectivity, and emotional exhaustion.

There is also the question of fitness to practise. There are both legal and ethical imperatives to give equal opportunities to those with illness or disability, and not discriminate against them. At the same time it must be acknowledged that they may be less capable of work than their healthy peers. Every case is different depending on the skills required in the specialty concerned, the nature of the physical and/or mental symptoms, and the time course of the condition – whether there is a chronic but stable handicap, or an episodic illness with recovery in between attacks. Whatever the diagnosis, it is likely that stamina will be impaired.

The main points that stand out from my own experience of the patient’s role relate to communication. I realised first-hand what a big impact the words of a healthcare professional can make; a casual or clumsily phrased statement regarding diagnosis or prognosis can stick in the patient’s mind, whether instilling fears that may prove unfounded, or providing reassurance that turns out to be false. Also, that the position of the patient’s relatives needs to be acknowledged, and considered in management of the case. Of course I knew about these things before, though I don’t recall being taught anything about them in my medical school days, and did not fully appreciate them till later in my career. Today’s students get more training in “soft” topics like communication skills, and hopefully do not need to wait till they or their loved ones are seriously ill to understand their importance.

Medical murder in fact and fiction

Having one of my medically themed crime novels entered for this year’s Ngaio Marsh Award has led me to reflect on the topic of murder in healthcare settings.

Deliberate killings by doctors or nurses, though rare, are probably more common than can ever be known. Clinical staff are better placed than most people to get away with murder. They have ready access to drugs, anaesthetic gases and surgical instruments, and deaths due to these agents can easily be passed off as natural or accidental. They are privileged to know intimate details of their patients’ lives. And as members of trusted professions they are not readily suspected.

Among the most notorious murderers of modern times was Dr Harold Shipman, who incidentally trained in the class ahead of me at medical school in Leeds in the 1960s. He was found guilty in a court of law of murdering 15 patients in his single-handed general practice and it is likely that he killed many more over his long career, usually by injecting large doses of diamorphine. The estimated number of his victims was 250, most of them being elderly women who were in good health although he fabricated a diagnosis of serious illness on their records. The nature of the mental aberration that led him to commit all these crimes is unknown, because he continued to deny them up until the time he hanged himself in his prison cell. As a result of Shipman’s case, much stricter controls were imposed on medical practice in the UK.

Other convicted serial murderers from medical settings have been nurses, popularly dubbed “angels of death”, working in hospitals or care homes. Their crimes usually masqueraded as mercy killings, but rather than arising from any genuine sense of compassion for someone whose incurable illness was causing unbearable suffering, they were committed for the perpetrators’ own satisfaction and without the knowledge or consent of the victims or their relatives.

Psychiatric evaluation of medical murderers would usually lead to a label of psychopathy, or personality disorder: the lack of moral sense, the inability to feel empathy, the enjoyment of killing, the grandiose belief of having a right to decide that certain persons are not fit to live. These are the extremes of the arrogance, cynicism and wielding of power that are occupational risks in medicine and related professions. Hallucinations and delusions secondary to psychosis or drug abuse are sometimes implicated.

Most if not all murderers are found to have a psychiatric diagnosis of some kind, and this may be sufficient to explain their crimes. In the context of fiction, however, using mental disorder as the sole reason for killing would usually be seen as a cop-out. Readers of crime novels expect a murder mystery to have a more complex solution,  perhaps involving money, sex, revenge, or concealment of discreditable secrets. These motives may of course account for real-life cases too.

Some would say there is a fine line between deliberate criminal killings and the various other forms of unnatural death that can occur through the actions of medical personnel. Some result from malpractice, others are sanctioned by law in certain jurisdictions. They include euthanasia, abortion, execution, experiments such as those carried out in Nazi Germany, drugs or surgery used inappropriately for commercial gain, and simple carelessness or incompetence.

My novel Unfaithful unto Death is intended as a light read with elements of black comedy, but touches on some of these serious themes.