Ancestral Health and General Practice – Art, Science or Quackery? Part I

After the success of the first AHSNZ conference in Christchurch we had many people who were unable to make it contact us hungry for more information. In response we have requested that our speakers write a post on their presentation. Reading it on your computer screen pales in comparison to hearing it in person, in a room full of like-minded passionate people, but we felt that these talks were too important. So, without further ado, allow us to present the AHSNZ Conference series of posts. Let us know what you think, which presentations sparked your interest, and what topics you would like to see addressed at our next conference in Wanaka on October 25.

Ancestral Health and General Practice: Art, Science or Quackery

Dr Pam Olver

We often hear of Medicine (being a doctor) being called both an art and a science. This is very true in general practice. Why or what then, is the ‘art of general practice’? Once we understand General Practice as an art it is easy to see why we can (and I believe should) incorporate Ancestral Health principles into the everyday health care that we are providing.

So, what is the art of general practice? I look at the art of medicine as the ‘touchy- feely’ part of medicine. It is difficult to define. It is quite unique and specific to each doctor–patient interaction. It concerns the ability of the doctor to connect with the patient and understand the context in which the patient seeks care. It is a dynamic two way process. It is not textbook medicine. Just as we don’t all enjoy or appreciate the same music, hobbies, paintings or clothes we should not expect every patient to like every doctor. Find someone you get along with even if it takes a few tries. I know there are patients who love being my patient (they have told me that) and others who would only see me if they really had to. It really is ‘different strokes for different folks’.

Your consultation with a GP doesn’t have a script or a recipe. Once the door is shut, anything can happen. There is no rehearsal or practice run. The GP has to improvise. The patient takes the lead. It’s a bit like theatre sports with ‘The Improvisers” – the patient takes the leading role, there is a start, a finish and a ‘theme’ but there is no script.

The issues and concerns that patients bring today are likely much the same as they were 30 or 40 years ago or even before I was born. So, what has changed then?

What has changed (among other things) is :

  • the intrusion of advances in technology
  • the advent of evidence based medicine and its consequences – guideline focused medicine

Tui

So, how have these changes impacted the doctor-patient relationship? The most obvious change in today’s Doctor’s office is the intrusion of the computer screen: no more paper files. We cannot do our work without a computer: our notes, labs, X-rays, ACC. Everything we are required to do revolves around technology. It is not all bad (ask anyone who has tried to read a doctor’s handwriting!).

But, with all the advances and requirements of a modern health system we risk letting the noise of modern medicine drown out the real signals from the patient.

We can’t hear or we don’t listen.

So, what happens when we don’t hear or listen?

  • Over diagnosis
  • Over treatment
  • Health anxiety
  • Fear
  • Uncertainty

So what is a GP to do? There’s no textbook to look up an answer. We have to work it out on the fly (often). How?

The skilful execution of the GP’s art requires that GPs know what biases or beliefs they have and the influence of these on their behaviour.

The skilful execution of the GP’s art requires that GPs know what biases or beliefs they have and the influence of these on their behaviour. We need to know how to deal with those biases and beliefs in order to say the right words at the right time. We need to understand the beliefs of our patients too.

There is little evidence that those GPs whose practice is based on an understanding of evidence directly obtained from research (known as ‘expert guidelines’) will provide superior patient care, compared with GP’s who rely on an understanding of basic mechanisms and their own clinical experiences. So maybe that biochemistry and n=1 is important after all! It means that I didn’t waste my time studying and that I value your personal experience.

But here we now have colliding cultures:

  • one that thinks in statistical and population based models (expert guidelines)
  • and one where thinking in anecdotal terms is considered valuable (experienced GP’s?).

How do we get the best of both so that our patients benefit?

In our modern world one of the big challenges to the GP is the art of mastering the evidence. GP’s needs to be able to assess the validity of evidence but to be fair most just do not have the time.

In our modern world one of the big challenges to the GP is the art of mastering the evidence. GP’s needs to be able to assess the validity of evidence but to be fair most just do not have the time. They rely on experts and their guidelines. At the very least I believe GP’s should be honest where uncertainty exists or they do not know the answers. There are no cut and dry answers for everything and we shouldn’t pretend that there are. When the consulting door closes we still have to inform the patient honestly and allay their uncertainty.

The ability to reduce uncertainty for the patient is and always will be an art.

Many times I feel that I am expected know everything about everything. But there just is not time and many of the answers are unclear or they don’t exist. We live in a society that loves to rush. We want answers to everything – yesterday. As your doctor I want to give you an answer to your question. Perhaps if we all slowed down, listened and were patient the answers would come because we have the time to find them.

So does an Ancestral Health paradigm fit with general practice? For me the answer is undoubtedly yes.

So does an Ancestral Health paradigm fit with general practice? For me the answer is undoubtedly yes.

If you had asked me this question a couple of years ago I would have thought the notion of anything other than classic textbook based, guideline directed medicine was a bit fringe/hippie/alternative. (Another way of saying I blindly believed that guidelines are the rule book and to be followed closely, ‘or else’).

So, what changed? My experiences as real life GP with real life people and a bit of serendipity, I guess. But probably the essential catalyst for change was that I was able to change my belief system in the face of evidence challenging what I had been taught.

I chose to embrace a new paradigm

I chose to embrace a new paradigm (I could have just denied it and plodded a long in the same old way, seeing the same old problems and providing the same predetermined plans).

For me application of Ancestral Health Principles is simple. It’s common sense really.

Eat, sleep, and play. We’ve just forgotten how.

The difficult part of applying principles in ancestral health in GP is making an assessment of an individual’s readiness (or not) to hear a new approach to managing their wellness and health. That is the art of day-to-day GP work.

Doug’s story:

He is a 39 yr old bloke who I hadn’t seen for some time. We chatted briefly and he started to tell me his story:

“Pam, remember when I had that accident 10 years ago and broke my back?”

I listened, waiting for more…

“They thought I had injured my duodenum and went in, then I got adhesions and they went in again. You know, from time to time, maybe once or twice a year I get terrible pain in my upper stomach, it bulges and a can’t eat for a week and then it goes. The surgeon doesn’t want to go in again because I’m prone to adhesions. So I have just lived with it. But then about 10 days ago after lots of reading Linda and I decided to go gluten free and dairy free and, you know, suddenly I’m not having 3-4 loose bowel motions a day, my brain fog has gone, and I’ve got energy.”

I just kept listening. He then recounted how that as a child he suffered with tummy ailments too. He then hesitated and asked whether I thought these improvements could be diet related? So I then dared to mention the P-word (Paleo). He laughed and relaxed – he realised that I ‘got it’ and that I understood what he was telling me. That I respected his experience.

And another thing, he added –

“I don’t know if this is related but I’ve been feeling pretty anxious over the last few months and it has just gone. Am I just imagining things? “

As he left (40 minutes later) he smiled, thanked me and told me how glad he was to have come in but also how afraid he had been to tell this story as he had no idea what my reaction or response was going to be. Would the story have the same ending if he had gone to most other doctors? I hope that in the future it will be.

That is the art and science of Ancestral Health and General Practice in action.