Making medicines safer for all of us

To be read in conjunction with Little Red Riding Hood.

Once a newly qualified doctor, wearing her red stethoscope, set out to treat an older woman, bringing medicines and the milk of human kindness. As the doctor was walking through the hospital, the medical director came up to her and asked where she was going.

“To Mrs Clinton’s bedside”, she replied.

“Which path are you taking, the path of clinical experience or the path of the guidelines?” “The path of the guidelines”.

So the medical director took the path of clinical experience and arrived first at the bedside. Mrs Clinton was dead. She had been taking warfarin and a device the hospital had been supplied for free as part of a Xarelto clinical trial had malfunctioned and she had had a stroke.

The medical director drained her blood and poured it into a bottle, sliced her flesh onto a platter, and stored it in the fridge. Then he called an inquiry. Little Red Stethoscope was summoned.

“Knock, knock.”

“Come in, my dear”.

“Hello, I’ve brought with me the medicines and milk I was bringing to Mrs Clinton as you asked.”

“Have something yourself, my dear. The lunch on the table in front of you is free”.

Little Red ate what she was offered. As she did, an app on her phone said: “Slut to eat the flesh and drink the blood of Mrs Clinton!”

“Then the medical director said, “While waiting for a report on Mrs Clinton’s death, you will have to be suspended”.

“Where shall I put my white coat?”

“Throw it in the sluice room; you won’t need it any more”.

“For each item ‑ pager, ophthalmoscope, radiation badge ‑ Little Red asked the same question; and each time the medical director answered, “Throw it in the sluice room; you won’t need it anymore.”

When she was finished Little Red said to the medical director, “Oh!  How hairy you are!”

“Yes its the testosterone – power does this to you, my dear.”

“Oh!  What big shoulders you have !”

“All the better to carry my laptop, my dear”.

“Oh!  What manicured hands and nails you have ?”

“Its for writing reports better, my dear !”

“Oh!  What big teeth you have !”

“Its for eating you better, my dear.”

And he sank his teeth into her with a report that made her solely responsible for Mrs Clinton’s death.

Little Red Riding Hood and Little Red Stethoscope are both cautionary tales about risks and their management. When I began training, no-one ever heard the words Risk Management even though medicine was obviously about managing risks.

Several decades later, Risk Management was everywhere with most nurses and doctors spending their time managing any risks there might be to the organization that employs them.

When I began training medical directors were in the business of guiding junior doctors down the path of clinical experience as they recognized that the best way to manage risks was to have the best possible people in place. Whatever about surgical procedures, the idea that risks could be managed by ticking boxes was famously met with a response – we’re not running a Chinese take-away here.

Medical directors now are more concerned about the brand value of the organization they work for and their own brand within it than they are for any patients or staff.

When I began training everyone bought their own stethoscope and they were all grey. Then somewhere toward the end of training red stethoscopes appeared. They initially came as gifts from drug companies. Where could the problem come from having a red stethoscope? Surely the more stethoscopes around the place, whatever their color, the better.

Some day a Coby and Mina Grimm may update the Red Stethoscope story – giving it an alternate ending, in which someone, could be Little Red herself, strangles the medical director with a red stethoscope. As long as no-one offers an “interpretation” that this feature reveals that the true meaning of the story lies in a latent lust for power, the essential meaning will not have been perverted.

This is the first of a two part piece. Little Red Stethoscope follows. More on the current post can be found in Images of Trauma.

A grimm tale

The development of psychoanalysis depended heavily on Freud’s approach to the interpretation of dreams and myths. Key to these interpretations were his claims about the symbolic nature of certain elements of dreams, myths or conversations. Interpreting the symbol revealed what the dreamer, myth-maker or patient really meant.

Following Freud a number of prominent psychoanalysts analyzed various fairy tales and claimed to offer their timeless and true meaning. Chief among these analysts were Bruno Bettleheim and Erich Fromm.

At the centerpiece of most of these interpretive efforts was Little Red Riding Hood.

In recent years Angela Carter’s short story made into a marvelous movie by Neil Jordan, The Company of Wolves, hinged on this true meaning revealed by the analysts.

Briefly, the Red Riding Hood indicates a young girl on the verge of puberty. The Bottle she carries in her basket symbolizes her virginity. Her mother’s Warning not to stray from the path is an injunction against sexual intercourse. Visiting her grandmother is an Oedipal abolition of her mother. The Wolf represents her Id and her Father. The saving huntsman is her rational ego.

A grimmer tale

The analytic claim that interpreting this fairy story in these terms reveals the correct and timeless significance of the story offers a wonderful and beautiful tale in its own right. But it’s a fiction. These interpretations cannot be correct. They are based on a fundamental inaccuracy, which is that the text used for these interpretations comes from Jacob and Wilhelm Grimm, which is a corruption of the version that came down through the oral traditions of French peasants.

The origi­nal version is as follows:

Once a little girl was told by her mother to bring some bread and milk to her grandmother. As the girl was walking through the forest, a wolf came up to her and asked where she was going.

“To grandmother’s house“, she replied.

“Which path are you taking, the path of the pins or the path of the needles?”

“The path of the needles“.

So the wolf took the path of the pins and arrived first at the house. He killed grandmother, poured her blood into a bottle and sliced her flesh onto a platter. Then he got into her night­ clothes and waited in bed.

“Knock, knock.”

“Come in, my dear”.

“Hello, grandmother. I’ve brought you some bread and milk.”

“Have something yourself, my dear. There is meat and wine in the pantry”.

So the little girl ate what was offered. As she did, a little cat said:

“Slut to eat the flesh and drink the blood or your grandmother !”

Then the wolf said,

“Undress and get into bed with me”.

“Where shall I put my apron ?”

“Throw it on the fire; you won’t need it any more“.

For each garment ‑ bodice, skirt, petticoat and stockings ‑ the girl asked the same question; and each time the wolf answered,

“Throw it on the fire; you won’t need it anymore.”

When the girl got into bed, she said,

“Oh, grandmother !  How hairy you are!”

“Its to keep me warmer, my dear.”

“Oh, grandmother !  What big shoulders you have !”

“Its for better carrying firewood, my dear“.

“Oh grandmother !  What long nails you have ?“

“Its for scratching myself better, my dear !“

“Oh grandmother !  What big teeth you have !“

“Its for eating you better, my dear.“

And he ate her.

There are no red hoods, bottles, admonitions to stay on the narrow path or saving hunters in the original. The interpretation of elements of a story in terms of its symbolic qualities may be justified but if this is to be undertaken it would seem necessary to establish beforehand the correct version of the story to be interpreted – or you can make up what you want.

This is the Sixteenth Modern Myth featuring Crusoe. The Persecution series resumes next week with Brand Fascism.

The clinics were different now to what they had been.

Hands on fire

The woman walked in, glancing at her hands as she came. Crusoe already knew what she would say. In days gone by peripheral neuropathies were rare. You saw one a year, perhaps in older people – more often women than men. The books talked of stocking and glove problems – the person with a burning or other odd sensation in their hands or feet. The books linked the problems to alcohol which was odd as it seemed to happen more in women than men.

But now it was becoming common and seemed to affect any age – often quite young women – who presented with burning feet. These weren’t peripheral neuropathies strictly speaking but if the person was referred to a neurologist that was the diagnosis they would end up with.

Nobody knew what was going on or how to treat it. People on triptans for migraine came in with strange sensations across their upper body. Those on antidepressants or benzodiazepines had burning feet.

Those on antibiotics like Cipro and Levaquin had the worst problem – especially it seemed to her, the men who had prostatism. If the treatment was stopped quickly, they might be left with no more than tingling sensations in their hands or feet. This wasn’t trivial – nothing that lasts for years is trivial. But if the treatment went on for longer, the problems could be anywhere round the body and were often much worse than tingling. Sometimes the person was left in constant disabling pain.

Worse again, if really badly affected, the neurologist might run tests on their nerves and the test reports would say working normally. She had seen lots of people told it was all in their mind and they were given a prescription for antidepressants.

Is he alright doctor?

The next woman brought her baby in. He was eighteen months old. He seemed slower than her first child had been she said. Was there anything she should be worried about? A quick check on the computer showed she had been on antidepressant during pregnancy.

Here was a dilemma. Crusoe was trained was to see variation in children as normal – in her generation there were boys who were tiny till late adolescence who later became the tallest people in the class, girls who at first seemed slow in school who later got first place in class exams. Some babies seemed to live on nothing while others were just voracious but they all ended up the same size.

So did she just advise the mother to do nothing that everything would be okay or did she tell her there was a possibility that the antidepressant might have caused a problem? She was seeing more and more of these children and still hadn’t worked out what the right thing to say was.

She’d heard a Ministry official on the evening news the previous day, asked about some drug and its problems, say that the Benefit-Risk ratio was still favourable. As long as a drug was still on the market, this is what they always said but what did it mean? It seemed to mean that it was more than the bureaucrat’s life was worth to start asking questions.

Where art thou Romeo?

What bothered her as much as anything was a new problem that was linked to the disappearance of old one – there were fewer Romeos and Juliettes. There used to be a string of broken hearted adolescents looking for antidepressants. She tried her best to keep them off medications – you’re eighteen and in love – how do you expect to be feeling?

There still were some Romeos, but there was an increasing number of teenagers who seemed to have no interest in romance.  At first she thought that it was one of those swings of the pendulum to Puritanism. Perhaps some new Just Say No campaign in schools was having an impact.

But when she fished, the kids knew what she was talking about but told her that she was a sexual and they weren’t. They just accepted it. Didn’t bother them. They’d never known any different.

What didn’t bother them bothered her. It bothered her that the same few drugs came up in their mother’s pregnancy records or in the kids records before they hit puberty.

Years ago she had met a a man who desperately wanted a limb removed. I’ll feel more like me without my right leg, doctor. This was in the early days of the Internet, and using Google before the word googling came into use, she found communities of “apotemnophiliacs”. Some people had probably always had feelings like this but others looked more vulnerable, uncertain of their own identities, and at risk of getting sucked in by a group like this. What would happen when they had a leg removed?

She could believe there might have always been some Asexuals around waiting for the Internet to shine a light on them. But lots of the kids she was now seeing had never accessed any Asexual websites. And there just seemed to be too many of them.

Drifting out to sea

More and more she felt that if she voiced her suspicions to any of her colleagues, or even her friends, she would start feeling like an island unconnected to their mainland. Might be time to find a real island.

The woman with burning hands, the mother with the autistic baby or the asexual son, were in the same place as her – no-one wanted to know them. Was there any way to unite all these people, each marooned on their own island, this new Archipelago of the Shipwrecked?

The shortest novel in the English language, complete with its post-modernist twist, came to mind.

“Crusoe, we say, was rescued”.

Rescued?

Illustration: The Sea of Medicine, © 2014 created by Billiam James

This is the Fifteenth Modern Myth, featuring Crusoe. The rest can be accessed under the modern myth tag. There will be another next week. The Pharma Sub-Series of the Persecution Murder Mystery will resume in the first week of the New Year.

A strange man

It was a time when Crusoe managed to be in Europe in Septembers. In 1957, interested in the fuss surrounding the new tranquilizers, she dropped in to a World Congress of Psychiatry Meeting being held that year in Zurich. There was an extraordinary buzz – the excitement surrounding the discovery of chlorpromazine was growing not fading. It really did seem like a cure for schizophrenia or the harbinger of a cure that would arrive any day now.

The meeting was full of chatter about the next wonder drug about to appear and what it all meant. As one of the delegates put it, this was the only thing in the world besides football that would get the French and the Germans into the same room.

Needing a break from the razzmatazz, she slipped into a side room that looked quieter. There was a presentation just starting from an unusual man – older than the rest. He looked awkward and eccentric. Spindly, waving his arms around, insisting on his points she felt when no-one was arguing. There was an unprecedented number of delegates at the meeting – well over a thousand, but there was almost no-one in this room. She counted twelve aside from the speaker. Not even company people were there.

But if you could get past the combination of country accent and school-master style what he was saying was surprising. This pill, G22355, was different. Starting in January 1956, he had given it to agitated and psychotically depressed patients, the kind that nothing else except Shock Treatment touched. They mostly recovered in a week. The first was Paula JF – difficult not to wonder if JF meant Jewish Female. She recovered after six days. He didn’t have a name for his drug – it wasn’t a tranquilizer he said, it wasn’t a stimulant. He emphasized that it was for severe depression but then seemed almost to contradict himself by saying he had had a homosexual patient change orientation on it.

In the train station when she was leaving Zurich that evening, she spotted a number of the delegates she had seen at the meeting heading into the Banquet Room. She stopped one of them – almost a White Rabbit she thought – and asked what was up. He winked conspiratorially and said they were on their way to found a new Church. One dedicated to psychopharmacology. It was going to come into being over a meal in the Banquet Room.

A strange scene

Maybe it was the reception a year later on September 9th at the Pope’s summer residence in Castel Gandolfo that did it, Crusoe mused.

Once it had been agreed that the first meeting of the New College would be in Rome, one of those in the train station had used his influence to get Pius to address the delegates on the moral framework of the new field – and to bless them.

The Pope stressed that it was observance of the moral order that conferred value and dignity on human activities. Hardly profound. Difficult to take seriously, given his silence in the shadow of the death camps. But even though psychopharmacology was a Jewish thing. and the single largest section of the group listening to him were Jews, no-one questioned him.

Pius pointed to the risks that drugs like the new tranquilizers could be over-used. No hint here that the driver to over-use might come from industry.

People couldn’t be trusted. They had to be led. It was clear Pius saw himself as speaking to the leaders in the new field.

He said nothing about the visions, the spirituality, linked to Sandoz’s most famous drug – LSD – that along with chlorpromazine had created the New World.

This just didn’t feel like a message for the times, she thought.

It was openly accepted that the new College had been created by Sandoz, who had convened the Supper in Zurich. One delegate even joked that Sandoz’s boss, Rothlin, the President of the College, was the head of a new religion – a Pope. Rothlin though was a businessman – well maybe that’s what Pope’s were. Not someone anyone thought was likely to have had LSD himself.

Sandoz and other companies bankrolled the meeting, paid for the delegates to be there, and put on the coaches that took them from Rome to Castel Gandolfo. On other days, there were trips to Mussolini’s villa where the tour guides worked their way through the dictator’s mistresses.

She spotted the strange man from Zurich at the reception but when she looked for him later on the program he was nowhere to be found. There were others talking about his drug and calling it an antidepressant.

A few weeks later the front pages featured the death of Pius. The editorial writers wondered where the Church might go from there. None mentioned the fact that his brush with the new church of psychopharmacology had been one of his last engagements.

Going viral

Fifty years later the talk was all about how to get things to go viral. Was it the Supper with a select few that was key, or was it delivering a message few understood to an audience of Twelve that did it, she wondered.

Illustration: The Miracle of the Chemical Cure, © 2014 created by Billiam James

Crusoe and Hans grew up together. Crusoe’s father encouraged her to believe she could do anything she put her mind to. Han’s father, Peter, was a story-teller who delighted both children with his stories, especially during the long evenings at the onset of Winter. He told them about the Microbe Hunters who discovered the causes of diseases and laid the basis for new cures.

But their favourite was the story of the Snow Queen. So scarily did Peter tell this that both children were certain that some Winter, the Snow Queen would sweep down and take one of them away leaving the other behind with a Mission to save whichever of them now had a sliver of ice in their heart.

Fairy tales

But fairy tales are just that after all. Both went to University, and became doctors.

Medicine had just passed through a glorious Summer that had led to the greatest harvesting of the benefits of new treatments ever recorded in human history. Life expectancies increased dramatically. Where once almost every family was blighted by the death of a child, now almost no family had a child who died. In some countries the treatments conferred such obvious benefits that governments made them available for free. A tyranny of fear had been lifted.

After qualifying their paths diverged. Crusoe immersed herself in the problems patients brought to her. For her every patient was different.

Evidence based medicine

Hans gravitated toward the most exciting new discipline – evidence based medicine. What could be better than ensuring doctors stuck to treatments that had been proven to work and stopped doing things for which there was no evidence. Patients’ stories might be interesting, but the evidence allowed you to pull back the veil of stories and glimpse reality. Patient improvement might be only a placebo response. They and their doctors might think they knew what was happening but be wrong.

Even when there seemed to be cast iron proof that a drug did something useful in a laboratory or at a bedside, Hans insisted on the need to test it out in hundreds of patients. He was adept at reeling off instances when laboratory breakthroughs have proven to be a mirage. Hard-hearted though it might seem to dying patients, he insisted on a proper demonstration that treatments worked.

The snow queen

Unlike some of his colleagues, Hans was not a fundamentalist. There was a passion behind his approach born of a recognition that Medicine was up against the wiliest of adversaries – the pharmaceutical industry – who thought nothing of the deaths of children in pursuit of profits unless those deaths compromised a profit line.

Industry was truly villainous, and in an effort to contain its capacity to injure people Hans was to the forefront of ensuring that the latest evidence was built into guidelines to which doctors would have to adhere. Frustrated at the slow rate of progress, he was of the view this could only be explained by the fact that some doctors even those who were involved in writing the guidelines were on the take. He became a crusader for Sunlight – bringing all and any payments to doctors from industry into the chilly light of day.

His career took off. He moved to Boston. He hadn’t seen or heard from Crusoe for years. There was an ocean between them. He became dimly aware that she had become critical of guidelines. She seemed to have drifted into a position close to homeopathy quoting obscurantist nineteenth century philosophy about there being an Art to medicine in knowing when to give a drug but an even greater Art in knowing when not to treat.

Medicine clearly had to be one thing or the other – an Art or a Science. The idea that modern medicine could be an art he thought belonged to an era that believed in fairy tales.

The clinic

Not having heard from Hans for over a decade, when she found a trip took her through Boston, Crusoe decided to surprise him. She found from his secretary that he had a clinic on Tuesday afternoons and joined the queue in the waiting room planning to walk in as his last patient.

She was early but had her iPad. The string of patients ahead of her after their appointments came back to the room to pick up waiting relatives, friends and belongings. She registered the low muttering of these returns. She could only catch snatches of the stories but there was no missing the disappointment.

“He told me there is no evidence that there is a dependence on these drugs – that my difficulties must just be the illness coming back”.

“He said I should stop worrying about the drugs. If I stopped the treatment and the illness came back that would be much more likely to cause harm to any baby we might have. If he had his way, pills would come stamped with an image of a pregnant mother precisely to stop people like me from misinterpreting what we find on the internet”.

“He told me that my hunch that my pills were causing me to drink were typical alcoholic denial and unless I got to grips with my alcoholism there was nothing he could do for me”.

“He told me that my idea that the medication he put me on to stop me smoking had caused me to have epilepsy was bizarre. Epilepsy is genetic not drug induced”.

“He told me that my conviction that the drugs had caused Shane to commit suicide was becoming close to delusional. I think we should leave before he detains me in a psychiatric unit”.

Crusoe walked in less jauntily than she had planned. Had she not known it was Hans she might not have recognized him. Flinty was the word that came to mind.

A drink?

For a moment he had no idea who she was. Once he recognized her, he greeted her teasingly:

“What’s this I hear about you having gone over to the Dark Side?”

“Come out for a drink and a meal and I’ll tell you all about it”, she said.

He had a series of committee meetings he said but he could skip one and give her an hour – it was so good to see her. She really should have told him she was coming.

To win some, you have to lose some

Quizzing him over a drink on how his patients responded to him, he told her that he suspected that time would show he was wrong in some cases but even on cases that once worried him he’d stopped feeling a long time ago. If the patients had been injured by treatment they would suffer less if he denied a link to treatment.

If someone who had been injured came to doubt the system and think that their injury could have been avoided, or that the system was going to acknowledge the injustice, it might lead to despair and who knows even suicide.

If patients on treatment or still to enter treatment came to doubt the system it would be too appalling a vista to contemplate.

Better leave it to people like him to negotiate with regulators and drug companies dispassionately. He was now in a position to do just this – a position he would never have been appointed to had he been too outspoken. And the companies were slowly coming round – they are registering their trials and making more data than ever before available.

Through the looking glass

There was even talk of nominating Andrew Witty for a special award – Nobel Prize might be a step too far for some people to take but even that artificial barrier would have to fall sometime.

 “You do know that you’re killing more people than you’re saving”, she said.

“Don’t be silly”, he responded.

“Well life expectancies are falling, and drug induced death might even the leading cause of death now. That’s not because of the chemicals – the chemicals have always been risky. It’s because the information that makes it possible to use a chemical as a medicine has never been so toxic.

“Sorry”, she said, “that I didn’t get to Peter’s funeral. He was so pleased when you brought him over here to Boston.

“He got the best possible treatment,” he said.

“Oh I’m sure, given the treating team knew who you are, that he was being treated perfectly according to every guideline for diabetes and hypertension. But you know if you wrote a guideline for treating a Peter the first thing you’d have to put in is to half the number of whatever medicines he is on.  I hear he was on twenty-one when he died”.

“So what do we do – do we go back to the day when some doctor arbitrarily decides what to keep in and what to leave out?”, he asked.

“Well  when it all comes down to dust, you believe in placebos. You call them RCTs but they are really placebos – mumbo-jumbo. You force people to believe in a system rather than to question it and make it better”.

“And”?

said Crusoe’s partner afterwards.

“The Snow Queen is far more formidable and wilier than I ever suspected”, she said. “Maybe I should have dropped some anti-freeze in his glass of wine”.

Illustration: The Heart of Medicine, © 2013 created by Billiam James