Minimally invasive medicine

As a medical student in the early 90’s I was witness to a new era of medicine, some of which was pioneered at my university, in the North East of Scotland.

Professor Alfred Cuschieri was a quiet, almost humble Maltese surgeon who was amongst the first people in the world to perform laparoscopic, keyhole surgery.

This form of operation, made with a few holes in the patient’s abdomen which was then inflated with nitrogen gas, illuminated with fibreoptic lights and seen through filamentous cameras was a breakthrough, reducing the numbers of days recovery following surgery to remove a gall bladder from weeks to days.

The rest of the surgical world followed-suit and today tiny cameras finagle their way into every human orifice or cavity. You can even buy your own endoscope on Amazon and look inside your ears or nose if you are particularly interested.

OK.

Most people know about this, some of you might have undergone the scope.

The subject of this blog is medicine rather than surgery and the idea comes from a Peruvian endocrinologist now living in the US called Victor Montori.

Rather than findings efficiency in ways to investigate and treat the human body, Montori has focused on the disruption, with which modern medicine invades, and takes-over the lives of patients.

It is an amazingly simple idea.

I have once or twice run a thought experiment as to my developing cancer. In these scenarios, it is not the cancer so much that scares me, rather the disruption to my life that would follow – the blood tests, clinic appointments, biopsies, scans, the side effects of radio or chemotherapy. All that. It seems overwhelming and perhaps explains why some people, particularly my older patients prefer to wait and watch.

You don’t need to have cancer for your life to be turned upside down in this way. Most of us, that is people over the age of say, 45 are living with at least one long-term condition – asthma, diabetes, arthritis, hypertension. As we age diseases and conditions accrue along the lines of my favourite image, barnacles; adhering, coalescing, merging with our person, our self.

At some point, people make the switch from being people to patients. They acquire NHS and hospital numbers, they learn the level of their haemoglobin, creatinine or cholesterol. They become data points on a normogram.

And with this shift, we take medicines.

A multi-trillion dollar industry is dependent upon our dependence.

Our need for inhalers, cholesterol, blood pressure and blood sugar lowering drugs, anti-coagulants and anti-platelets, pain killers and disease modulators, the industry is, well, an industry and we are, like cogs part of the mechanism.

And this is the tension that Montori seeks first to define then to disentangle.

Montori, who has his own TED talk, speaks about the experience in America which is undoubtedly many times worse than the UK (read, the monetised, future Tory vision of the NHS).

Even in the UK, where I don’t have to necessarily worry about the cost of my medicine or treatment, the systems built around health and care are equivalent, they operate along lines of my being one of many who needs to comply, to fit into a diagnostic category, box or pathway or risk major disruption.

It is not uncommon for me to meet patients and, when arranging a follow-up appointment, they leaf through diaries that are filled not with social commitments but outpatient clinics, blood test dates and therapy sessions.

How do we achieve this state of minimally invasive medicine?

I remember, back in the early days of endoscopic surgery it was claimed that the manual dexterity required was beyond certain surgeons – probably the older guys (they were almost always men) and for a patient’s benefit it would be better if Mr X was your surgeon for you to undergo traditional surgery (with the weeks recovery) rather than risking the minimally invasive type (days recovery) which might turn traditional when Mr X cuts the wrong tube or blood vessel and the little holes are converted into a massive incision with fumbling rubber-gloved hands where they shouldn’t be.

The same I suspect applies to, let’s call it MIM.

Doctors and, of course, by implication I am talking about all clinicians, as well as social workers work within a framework of person-centredness.

For some, the patient is one of many, their disease is what is the matter and they should take the tablet, and come back in 12 months for follow-up.

For others, I’d like to think, the more enlightened, it is what matters to the patient that is important, the impact of the disease on the person, not the disease on the patient or the physiology. (A person being made-up of the patient, the disease, physiology, pathology, mentis and soma, the good and the bad).

Some people get this approach intuitively, they see a person and rather than lines of Matrix-like code, see the individual before them, the finite and the infinite squeezed into a human frame. They perceive the wonder of human spontaneity, the fragility of hope and fear, the layers of anxiety, of prejudice, hope, joy and deprivation spinning atomic around the patient’s sense of self.

They see that just as they (the doctor/nurse/social worker) is not approaching the patient/person/client as a robot (all that complexity, mess and beauty is within us too), they need to engage with a commensurate level of sensitivity.

For others, it is all, data points, flow, waiting lists and the machine.

Balancing a tautology.

MIM is finding a way through all of this. Understanding the significance of a throwaway statement, the subtlety of words and gestures and their impact on patient, carer, friends or family.

Sure, life doesn’t have to be lived at this level of complexity, at this depth, yet we can all be victims of the system. Like sandcastles, we can be washed away by one sweep of the waves.

And, just as the pre-scope dinosaurs are now either dead, retired or have moved on to other pursuits, this is the world of healthcare we need to build.

One in which each person is central to the narrative.

Where the level of disruption caused by health or social care must be minimised, where the side effects of the medicine are not just the rash or upset stomach, but the restrictions imposed by the regime, that is too easily prescribed by a doctor with a tap of the keyboard and follows with a lifetime of adherence by the patient. (Take this tablet four times a day on an empty stomach, for life.)

Sure, medicine is not endlessly adaptable, sometimes the patient has to change, alter their behaviour, give-up the cigarettes and fatty sausage, or start to exercise, yet, until we start to think about the two sides of the equation we will fall-short, we contribute to the growth of something that none of us want.