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.

A writer’s purpose

My writing career has been at a standstill lately, perhaps due to being distracted by various health concerns and family events, and discouraged by a couple of negative reviews. Looking back at my own advice about dealing with writer’s block, taken from my short ebook Wellbeing for Writers:

“Inspiration tends to come in waves. There are times when writers are full of ideas. At other times they may have none, which is always frustrating, and presents a major problem for those who earn their living from writing or have publishing deadlines to meet.

There may be an obvious reason for feeling blocked. I always find myself unable to engage with a new book immediately after finishing the last one, even though I am only really satisfied and happy when I have a writing project underway. I make use of such fallow periods to organise and de-clutter the paperwork in my office and the files on my computer, and to market the book I have just completed.

Some of the other causes for writer’s block, for example striving too hard for perfection, feeling upset about rejection or criticism, adverse experiences in another sphere of life, having too many other things to do, or suffering from a depressive mood swing, are discussed in other chapters.

Besides dealing with any remediable underlying causes, there are various strategies for overcoming writer’s block. If circumstances permit it can be a good idea to take a complete break from writing, and do something else for a day or two or even much longer. Preferably this will involve activities, people and places completely different from those encountered in your usual routine, which may provide new ideas. Other forms of creativity, such as painting or dancing, can help.

The opposite approach is to discipline yourself to keep on writing for a set period each day, but again try doing it with a new approach. Clear the clutter from your desk to encourage a fresh start. Write a short and simple piece instead of attempting the major work on which you feel stuck. Some authorities suggest inducing a relaxed state with deep breathing or slow music and then using your non-dominant hand to write something – anything – which even if it turns out to be nonsense may still stimulate the creative flow. Or try writing late at night or early in the morning, when you are half-asleep and more able to access the reservoir of images and memories in the subconscious mind.

Getting started again often presents the biggest barrier, and if you can get past that it will usually be much easier to continue.”

Fair enough, but I also find myself asking what is the point of writing at all? This is what I said in Wellbeing for Writers:

“The most fundamental and compelling motive for writing is for the sheer love of it. Some people feel they were born to write, in the same way that others know from early childhood that they were born to climb mountains, to heal the sick, to do scientific research or to make music. Writing is their vocation, destiny or soul’s purpose; the one activity which brings them ‘into the flow’ and if they are prevented from doing it they will feel frustrated and unfulfilled.

Even if you do not feel quite such a passionate commitment, you may find that writing brings other personal benefits. These could include making sense of your life experiences and challenges, expressing emotion, exploring new subjects, exercising your intellect, or feeling that you are creating something original to form a lasting legacy of your time on Earth.

These inner rewards of writing can be seen as doubly important when you consider that it takes long hours of solitary work to complete a book, and that the fate of the eventual product is unpredictable. Finishing your book, getting it published, receiving positive responses from readers, and receiving royalty payments are all worthwhile outcomes and not to be devalued. But not all writers will achieve these goals. Some books are never finished; others do get finished but are never published; many of those that do get published are seldom read or reviewed; and few authors make a good living from their royalties. The market is currently supersaturated with self-published books many of which, however good they are, will be overlooked. So it is highly desirable for the actual process of writing to be perceived as satisfying and worthwhile. In other words it is just as important to enjoy the journey as to reach the destination.”

I hope my inspiration for writing will return again soon. Meanwhile, remembering what I put in the section on writers’ health, it is better to spend time walking outdoors in the bright sunshine of the New Zealand winter than sitting down at the computer.

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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.

Homer: rest in peace

clare & homer

Sad news for the many friends of Homer the cat.  He had developed an untreatable abdominal lymphoma, and yesterday the heartbreaking decision to euthanise him was made.

Being officially my cat, he has been buried in our back garden, though he never really regarded our property as his home.  After many wanderings he settled with my mother Clare (pictured) and they spent several happy years together until she died in 2015. After that he chose to live in turn with two younger couples, both of whom cared for him lovingly and are devastated by his loss.

To read more about Homer’s remarkable life, search for his name on this blog.

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.