Supergeneralism – the new model for patient care.
Having just read the Evolution of Medicine I wanted to share my synopsis on this new model of thinking about health and where this could take us in terms of patient care.
Globally there are pockets of the world that seem to coexist in a different way in terms of health and longevity. California, Italy, Greece, Japan and Costa Rica have communities that oddly are not well connected to hospitals or technology but have some of the highest number of centenarians. Their longevity seems to be largely down to a holistic approach of community support, nutrition and prevention of disease. Recent studies at the UCLA’s Stress Lab show that targeted rejection (i.e. if a person is fired on their own rather than as a team) has a monumental effect on their health, increasing inflammatory markers. It would appear support is key to health. Wouldn’t it be wonderful if we could replicate holistic supportive communities in more areas and make it the norm rather than the unusual? To do this we have to assess where we are in patient care, what is lacking and what we might do to improve the current situation.
The problem with symptoms
Let’s say you are really sick, something that we all dread, and you have several frightening symptoms that suddenly invade your body for no apparent reason; for example chest pains, heart palpitations migraines and diarrhoea. If these symptoms cannot be contained or treated within a surgery or A&E setting you will be referred to a specialist. It’s pretty obvious with this example that you will see a cardiologist first for more investigations, but what about the bowel and the headaches, as they don’t come under the cardiology banner? You may well end up seeing a gastroenterologist and a neurologist as well. Why? Because this is the way it’s done, this is the accepted format. What this way of looking at health exposes is that the consultants are not talking to one another, so your body is being looked at in boxes separate from one another. Just supposing these symptoms turned out to be caused by a food allergy (I’m stretching it a bit with this example, but bear with me). If that is so you might eventually get sent to a specialist that deals with allergies. Let’s say it was all due to a bad reaction to food but the patient hadn’t put two and two together. The patient may end up seeing three specialists when only one was needed. The amount of money to see those specialists whether privately or on the NHS is significant as is the time frame. To separate symptoms like this has kept us in specialist boxes that although to a degree have served their purpose, certainly leaves something to be desired. I’m not in any way saying that consultants are not necessary, their skills are superb and the surgical specialists we have now are second to none. I’m talking more about chronic conditions than the acute. Most people going to their GP have more than one symptom; these day to day symptoms (headaches, fatigue, bloating, skin conditions etc) are often lifestyle related and take up most of the GP practice time. Someone needs to start joining the dots. Understanding the body as an integrated system rather than a series of separate boxes enables you to see the connections more easily. This in essence is supergeneralism. Dr Ranjan Chatterjee from Doctor in the House who describes himself as a super generalist talks about medicine being about aetiology not symptomology. This is certainly a good place to start.
Treating symptoms is difficult because one symptom can be so many disease states and caused by so many different things. Our overstretched overworked GP’s have a lot to sort out in an insane amount of time – the ten minute appointment leaves no time for a nice little chat. Certainly patients feel, whether rightly or wrongly, that the service has become more about writing prescriptions than patient care. Patients want more time and to be seen as a whole person but in the framework we have at the moment that is virtually impossible. The GP does not have time to ask about your stress levels, nutrition intake and exercise regime. Could we not look at this in a different way without reinventing the wheel? Could we perhaps treat ‘a person’ as a whole person? Can “holistic” medicine ever become good standard practice within a scientific framework? Can we even use the word “holistic” without sharp intakes of breath?! The short answer is of course yes we can. This new way of treating people although it has been happening for a very long time alongside mainstream medicine is starting to make breakthroughs in new and exciting ways of treating patients. It’s called supergeneralism and there’s not a quack in sight. You see to be a super generalist and in order to do this kind of work you will need to have trained as a GP or as a minimum be trained in functional medicine and often need additional strings to your bow like Immunology or Microbiology.
A new approach
The arrival of the super generalist is great news not only for patients but for doctors as well, who may certainly gain more patient satisfaction and patients do prefer a one to one individualised approach as the outcomes are far better. Not only can it be good for the patient, but good behavioural changes can be carried on through second and third generations allowing a solid framework for a healthier lifestyle not only in individuals but their families.
Dr Daniel Kraft founder of Intellimedicine has devised a model of working like this called P4 medicine – the P stands for predictive, personalised, participatory and preventative. Doctors are often as sick as their patients and many have become highly disillusioned about a system they might not be entirely invested in anymore. We certainly need a new way to engage patients and modern medicine needs to work out how to treat patients individually, spending more time with them to stimulate and support these behavioural changes that can hopefully lead to better outcomes, a system that treats the root cause of disease and not simply treat the symptoms. Root cause resolution has been labelled quacky, I think unfairly. It‘s just common sense and looks at the patient‘s past. It’s saying this is how you got to where you are now. Obviously not 100% of disease states start like this, but for the most this works.
The importance of the timeline.
People rarely just suddenly get ill. Don‘t get me wrong, their symptoms can be sudden and lethal. However it didn’t happen just at that moment your heart “attacks” you, you have to go back, sometimes way back. Is a dose of dysentery in India twenty years ago relevant to the IBS symptoms of the patient now ? The root cause of your IBS might be undiagnosed gut issues caused by that incident. Were you born by C section and have more infections than is normal? The root cause of this might be your gut microbiome. Have you lived on a high sugar, highly refined diet and are now suffering type two diabetes? There is a high likelihood that this high sugar diet has caused the disease state of which you now suffer. It’s these clues from the past that put together the story of why someone got ill in the first place. I see a lot of veterinary nurses in my clinics with IBS. Many of these nurses unwittingly pick up parasitic infections from the animals. No big deal, but their environment is key, if you didn‘t know they were a veterinary nurse you couldn’t make that connection. What people do job wise, their stress levels, their travel history, their antibiotic history, their birth, it all gives you clues as to how to help them and where they need the support.
The rise of the microbiome
Running alongside the rise of the super generalist approach is our dear friend the microbiome who has done more in the last ten years of joining up the dots than any other discovery in the history of medicine. The speed and rate of the research in this field is staggering. The rise in autoimmune disease can be put straight at the door of the microbiome and environment. How the gut effects our health is the most important discovery and changes how we approach symptoms and treat them. How we are bought into this world can have a marked effect on our overall health. We know C section births omit the important natural spread of good bacteria’s from the mother. Additionally we now know that our microbes have an impact on chronic inflammation and how the gut brain axis impacts each other through the vagus nerve.
So we could ask why don’t our GP’s know about the microbiome and why aren’t they practising this form of treatment. It takes 17 years on average for research to trickle down to general practice. The irony is that most lay people know a little about gut flora but to my utter surprise a consultant friend of mine had never heard of the gut microbiome. No doubt their busy diaries and stressful lives means there is not time for anything extra on their plate but it’s still a large gap in their knowledge base.
One of the reasons why I specialise in the microbiome is that it makes me a generalist of sorts, not a super GP type generalist as I don’t have the knowledge base but a generalist none the less. I follow the functional medicine matrix of looking at the body in terms of systems. One of the largest issues we have in this country are diseases of inflammation, and obesity comes into that bracket. My obese patients often have raised inflammatory markers (ESR and CRP) and one of the fundamental points I try to teach people is that most of their symptoms are due to inflammation and that can include depression, obesity, heart disease, and the more obvious conditions like arthritis etc. The microbiome means we are an eco system and should be treated that way – as one whole person. It is this new information we have now which is forcing us to look at our bodies in different ways.
It is a tragedy that personalised medicine has been around for a while but is only accessibly by those who can afford it. If I could work in the NHS like this, trust me I would, and I do where and when I can. It is clear that no two humans are the same and there is no “average” human. Our environments, genetics and microbiomes are so unique that we need unique personalised healthcare. Patients also need to be participating in their care, and empowering patients to do this leads to better outcomes. Patients don’t just need prescriptions handed out to them they need to fully engage with their lifestyles and nutrition.
This new way of treating patients is not about slamming pharmaceutical companies and taking up homeopathy. It is finding a common language to engage and motivate people, forming a bridge between old and new models of working. I am hoping in the next twenty years there will more practices going in this direction with a super generalist in every surgery. It may well be that the patient will have to pay for this themselves for a long time to come, but like most things demand can bring radical changes. It is in our hands as well to ask for this and to participate in our own healthcare and take responsibility for our health.