Chronic Illness and Suicide: Looking after patient and practitioner with Dr Mark Donohoe

Chronic Illness and Suicide: Looking after patient and practitioner with Dr Mark Donohoe

Those patients for which medicine has no answers or solutions are very often the ones ending up in front of an integrative medicine practitioner. The time spent with patients is often longer, the investigations, sometimes deeper and in that process comes a mutual connection between patient and practitioner as they attempt together, to piece that person's health and wellbeing back together. The darker side of this kind of health care are the patients we were unable to help. Those who's health challenges are so insurmountable that they feel like taking their life is the answer.

Today we are joined by Dr Mark Donohoe, who has been faced with these circumstances more than once in his decades-long career. Following his most recent loss he felt it was time to share this conversation with a wider audience with the hope that in doing so, it might help others who are grappling with similar circumstances.
**Warning: you may need tissues for this one.**

Covered in this episode

[00:35] Welcoming back Dr Mark Donohoe
[01:26] The complexities of chronic diseases
[11:00] Mood disorders: a feature of most chronic illnesses
[16:44] There's opportunities in adjunctive therapies
[22:50] Professional limitations aren't a weakness
[31:31] The polypharmacy conundrum
[40:06] Care for the health professional/ carer
[48:08] Resources: Organisations for assistance

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us in the studio again today is Dr. Mark Donohoe. Who earned his medical degree from Sydney Uni in 1980. And he worked around the central coast honing his medical skills, and this is where his interest in integrative medicine sparked because his patients just weren't fitting into those boxes of diagnoses and treatments which were drummed into him in medical school. Mark is considered one of the fathers of integrative medicine in Australia and he's been a vanguard for patient health throughout his whole career.

Today, we're going to discuss the long term impacts of chronic illness. Welcome back to FX Medicine, Mark, how are you?

Mark: I'm good, and it's great to be back.

Andrew: Mark, we're going to be talking about some serious aspects of treatment and responsibility, I guess?

Mark: Yeah.

Andrew: And indeed self-care. But take us through, first, what you have specialised in for decades. And that is the hallmarks of chronic illness, both on a physical level, but also on an emotional level.

Mark: Yeah, it's something that, you know, comes home to one every so often, and the trigger for this was two suicides at my practice recently. It's happened over the years, and it brings you to a moment in your medical practice, no matter where you are, where it affects me, as a practitioner, and me as a person, very deeply. People that I know who I've cared for suffering illnesses that don't have any clear ending that just drag on and on, they have their ups and downs. And I, like the other practitioners that they see, work to relieve suffering, work to improve function, and the acceptance sometimes that these people are not going to get better, is really, really difficult for a doctor, for any kind of a practitioner, we have to take the hope of recovery, we have to keep that alive in a person, keep working with them to improve what we can. And then accept on occasions that we can not do magic, that we are not the responsible person for another person's choices in life.

And that sounds morbid, but it is a story of how do we separate while still caring? While still giving that emotional support, that care, that contact with another person that's so special to being a professional in healthcare? How do you maintain both of those without disintegrating when the choices are, or the outcomes are everything that we hoped it wouldn't be?

And so I thought it was a good opportunity just to have that discussion. Because having visited on a number of occasions through my medical career, which goes back a decade or two, shall we say...

Andrew: Scores.

Mark: Yes, having visited on many occasions, every time the pain is the same, and it doesn't change. When there's loss, and we know the person, and we've involved ourselves deeply enough to want to be with the person in their journey, then to have them disappear, dying from cancer, everybody dies. And the strangest thing is medicine is always thought that the enemy is death. The enemy is not death, everyone's outcome is death eventually. The enemy is suffering. And the doing that alone, a lot of the patients that we see with chronic illness, their biggest fear is not dying, their biggest fear is living and being isolated, and having no one who will be there to support them.

And so that work as a practitioner to be one of that group of people who are there to support them without becoming too entangled to the point that we don't function in the way that we are meant to. That we make decisions with them that help guide them to the best outcomes we can. And that we are then prepared to be able to separate from them should outcomes be like this. Separate from them, allow them to make their choices and go on still healing, still helping, and still involving ourselves with other patients.

And I thought it was a good time just for reflection because every practitioner who's in this business for more than five years will face it.

Andrew: There's obviously going to be more groups than this, but just three that are sparking in my mind are; people who have cancer, a diagnosis of cancer, and they get the initial call it relief of the surgery, the chemotherapy, where they have a better prognosis, the survival time. And then eventually, more than likely, they will re-present with a cancer.

Mark: Many.

Andrew: Many of them, a secondary. And it will be that secondary that if not well treated, will lead to their demise.

Then you've got people with chronic illness. You know, we're well aware of people with chronic rheumatoid arthritis, for instance. Or other autoimmune diseases we've all…

Mark: Relentlessness progressive kind of...

Andrew: Cardiovascular diseases. And indeed, the mitochondrial diseases, the muscular diseases.

Mark: Yes.

Andrew: This other group of patient would be those with psychiatric illness who have a mood disorder, who have suicidal ideations. Do you see any commonalities amongst these groups of patients?

Mark: I’d add a few other groups though. I mean, I still have to think of… there's loss without the person dying in Alzheimer's and in the degenerative disorders. And so...

Andrew: Neurological diseases, of course.

Mark: I think of them as neurological degenerative diseases, cardiovascular degenerative diseases, some with autoimmune degenerative diseases. That there is a process going on in the body that we understand too poorly to be able to really do something to change the direction of that illness.

What we can often do, say with lifestyle, is diet and lifestyle, quality of life, sunshine, nutrition. We do a lot to stop the progression of it, but there are still some where you can tell from the family history that no matter how much you intervene, what you're doing is delaying…

Andrew: Yep.

Mark: That you are not curing or reversing. What we in medicine love, is when a person gets to a disease state that we know the cure for. And we know that they come into hospital, they have their steroids, antibiotics, they're in emergency, in intensive care, and in two weeks time, they're going to walk out and go back to work. That's the perfect kind of disease for doctors because we feel powerful, we know what we're doing, the illness submits to our interventions. And the hospital system...when I graduated, the hospital system is the Cathedral of those kinds of outcomes where everything is thrown at the individual to stop them from dying.

And the salvage there sees a very impressive outcome that they're back out in the community. The cost of that treatment is often that in 5 years, or 10 years or 15 years time, things are falling apart in a way that medicine doesn't handle very well. Or that we as practitioners generally can't handle well where the person's degenerating, going down a hill and we don't know what's driving that downhill course, and we do our best and we live with hope. And a lot of what we do see in the best outcomes of most of those degenerative diseases is that support and mobilisation of the person's internal ability to manage that, is far more powerful than the drug therapies which can do something in the short term but then have a cost. And then another medication, on the medication, on the medication.

And so that ability to step back and say, well, firstly, what do we understand honestly? Not, "Oh, I've got a magic vitamin that is going to cure your degenerative disease." But what do we understand honestly, and what can we implement from our knowledge and experience? And where our knowledge and experience is poor, seek other practitioners who have that ability or that understanding, or that research, or the publications to go with it.

That's a good example of where specialist medical practitioners are a great resource. What they can do is answer the question, is this problem solvable with the best medical information we have available right at the moment? And if so, what is that solution? But what specialists are not is they're not primary carers. By definition, they're there for the ability to deal with the extraordinary to provide the best advice. And then the person comes back to the practitioner who has the discussion with the patient and a decision is made about the directions that are compatible with that patient's needs and wants and desires.

And so we still, at the primary care level, have the responsibility of integrating the best evidence available and allowing it to inform our discussion with our own patients or clients. And I think if we bring it back to the basics of the consultation, we seek the best knowledge we can have to present to a person, then we go on a journey with them for their way of emerging from their own illness. And many times that will be successful, and sometimes it will not be.

And we have to have a strategy not just for success. We have to have an understanding of limitations that we can say, "I can't help you with this anymore, but other people can. I can hand you over to someone's care." And in the case of psychiatric disease, that's a very good area. Where to know what people go through with psychoactive medications, there are some good salvages around the place. And there are also times where polypharmacy really just sees the person disintegrate right in front of you.

There is a time for a GP, especially, this is not so much for naturopaths, for a GP to say, "This is going nowhere good," even though the psychiatrists say, "But I can fix that, but I can fix that, but I can fix that." And bring it back to the discussion who knows this person the best? The practitioner that spends the time with them to understand what their needs are.

And that, I think, gives us a good framework for understanding where our limitations are, what can we help you with that we know ourselves? How can we aggregate enough information to help you in the best way we can with chronic disease? And where there are limitations to that knowledge, we can put stuff in place, we can go back to the basics of diet, sleep, nutrition, sunlight, we can do all of that, and the outcomes may still be bad. And we need to be able to accept that limitation.

Andrew: Do you think it prudent that we should all be assessing patients in the early days of visitations, assessing all patients for, if nothing else, they're positivity to see how they're going to handle a chronic disease, or indeed to uncover maybe a simmering mood disorder that nobody's looked at properly?

Mark: Yeah, every disease has a mood disorder. So I'm not a big fan of the psychic versus the physical self. So I see people with chronic fatigue syndrome, are they depressed? Yes. Would I be depressed in those circumstances? Yes.

There are reactions and moods which are absolutely appropriate to the illness, which we may still do something to relieve the suffering of. So it's not either/or, it's not mood, emotion, or physical. People are people. And when we try and deal with a person as a whole and unwillingness to say there is a mood and emotional component to this is as bad as saying there is no physical component to this.

If we're unwilling to explore areas of the whole person, then that's our deficiency and our limitations as a practitioner ourself. And I've been through this right? I've been through this because I saw chronic fatigue syndrome at the time it was thought to be purely psychological.

Andrew: I remember. I remember you on television. I'll always remember you then.

Mark: I remember that, too. But what did I do? I drew away with my patients to say, look, everybody who is sick and incapable of leaving their home for years at a time will be depressed. Depression is a symptom, it is not the origin.

How do we know? There's history when they were getting sick, what happened? Were they depressed before? Had there been any trajectory? Is there a family history? So it's worth exploring.

For years, I made the mistake of wanting to withdraw from that questioning, so as not to even go into that category. I wanted it to be physical, and I would not listen to an alternative view. I have patients like everybody else who've seen the psychologists, psychiatrists who've ended up on medications that I think “Oh, really, should you be on that?” Who get magical help from that medication.

But I've seen people with terrible headaches get benefit from Panadol and I don't stop just to say, "Oh, you're a Panadol deficiency syndrome."

Andrew: Yep, yeah, yeah.

Mark: So the going further, the ability to immerse, not just to say, "What symptomatic care can I give you?" Most of those medications...a good example being antidepressants, many of them have anticholinergic effects, predisposes ultimately, to an increased risk of Alzheimer's.

Do we just take symptomatic treatment and say that'll do? Or do we go a little bit further with the skills that we have as practitioners? And I think naturopaths are uniquely...well, not just naturopaths but non-medical practitioners have a great skill and this ability to reconstruct life, and hope, and be personable with people. And give them that hope and the stirring up of internal healing processes, which doctors ignore when we just give drugs. We are ignoring the capacity of the person to do their own job by giving a pill which covers the symptoms, and then that'll do for five years. And then that person says, "Well, this drug is making me not sleep, and now I'm getting anxious. And now, I can't..." "Oh, I've got another pill for that.

And so I think they're exploring deeply on chronic illnesses, this isn't going to be a three week or six-month thing. This is something where you've got to prepare for the journey and have sustainable management, and sustainable skills. And not be reliant on medications with a short half-life. Best example I can think of, we called Prednisone vitamin P when I was in hospital.

Andrew: I remember, yeah.

Mark: It fixed everything. It didn't matter what the person came with.

Andrew: Well, it certainly fixed the symptoms of everything.

Mark: It fixed everything from a doctor's perspective, in casualty, in hospital. You see a person and inflammation is out of control, and the person risks dying, you load them up with Prednisone and it all stops.

And the reason I'm saying that is every doctor recognises now that that's not a cure of any type. What you do is you erode the bones, you change the brain, you change the ability of the immune system to respond, and it's uniformly a terrible outcome.

And in the long term doesn't mean we don't use Prednisone, not at all. When you're up shit creek, as they say, you take your Prednisone, you get out of that creek, and then you say, "How do I not end up in there again?"

Andrew: Crisis creek.

Mark: Yes, we call it a different one, crisis creek is much better.

So again, the battle often rages with chronic illness of practitioners wanting a patient or a client to choose philosophically which path they're going to have, as though they have to make a choice of their practitioner. What often happens is patients who have been in that state have seen doctor after doctor after doctor, and eventually get loaded onto the psychiatrists, and get thoroughly disillusioned with it and run away from medicine.

And sometimes we've got to say, well, I understand why you're running from it, but there are still useful things over here that you do not need to run from. Integrative medicine purports to do that, but if you look at most of us as integrative doctors, we tend on the let's not do drug therapy, let's go over here and do something the next five years will be sustainable. And often what the patient saying is, "Can you help now, and have a long-term plan, both? Do I need to go and see my rheumatologist and have him load me up with Methotrexate, Prednisone and everything, every time I feel sick? And pretend that you're not there when I see you, and he's not there when I see him." And so you do get that division, which never, ever helps the patient.

Andrew: See, I'm a great fan of adjunctive therapy, I really am. And I really think that this is where the magic lies. Because you have, you know, the crisis creek. You have the acute pharmacological medication and intervention. But there are certain side effects, and particularly with chronic or the chronicity of treatment, that you can allay or reduce or retard using, call them, natural medicines.

And this is where I feel them the magic is. Is either helping the pharmaceutical to work more effectively…

Mark: Yes.

Andrew: Reducing the side effects, in the main outcome of which is that the long term outcome of the patient is improved.

Mark: Yeah.

Andrew: And in some cases, they actually are an alternative. They have a better...natural medicines have a better use in the long term.

Mark: What they also often have is a sustainable advantage over the medications. And so medicine...I say this many times, I still think it's true. Medicine is the identification and treatment of disease. Primarily, what we are best at is when a person has reached a disease state that we can nominate, and we know the drug or the intervention that is going to change that. Sometimes, a good example, antibiotics, would you ignore them? No, you would never ignore them because sometimes, many times they are life-saving. Did we use them appropriately in medicine? No, we gave it for every cough, cold, flu, middle ear infection, every tonsillitis. We treated the world with antibiotics as though it was the new magic. And the magic runs out after a couple of generations. And the people who've had it have the chronic illnesses.

And a great example here is I see people with depression, anxiety-depression especially, with lots of gastrointestinal symptoms, poor sleep, the whole lot. And the story is, "Oh, yeah, I was on years of antibiotics for acne," or, "I was on years of the oral contraceptive pill." There's a story about before which I was fine, medical intervention for something worked well. And then on the other side of it, not only did it not work well, but something weird happened. And the typical one there is my acne cleared up, but a couple of years later, my gastrointestinal tract is a mess. And I've got diarrhea the whole time. And now I feel anxious, depressed, and fearful the whole time.

Remarkable number of those people with the magic formula, the stewed apple, and the probiotics. But you go for the gut without even mentioning that there could be an impact on mood, emotional ability, or depression. And the first thing that happens is the gut. And the second thing is, I'm not waking up feeling depressed anymore, I'm waking up with energy in the morning. So you see, without even hinting to the person, there can be an improvement in mood that they pick up the improvement mood just by doing something very, very replenishing in the probiotic world. Food and probiotics tend to work well, in that way, and sometimes it doesn't.

I claim that, you know, the probiotics work so well. Now, I have a problem in my practice. Because many people listen to this podcast, most of the patients have come in, and they've already tried the probiotic program, and it didn't work for them. And that's the only reason they pay the money to see me is, what's next? So initially, it was like magic, all the people that I had not managed the guts of properly, I was starting to manage better and better. And I was getting really good results, high consistency in the 70%, 75% range.

Now, when everyone's tried that, I'm seeing the leftovers. And so this means that my waiting list is not as long as it was before because now it's out there. People do the gut program and those that get better unbook. And once they've, unbooked, I don't need to see them, I'm thrilled about that. But what it does mean is I now see a group of people who have already done what I would have suggested for the simple gut program, and they have something which is, you know, another level away from that. So I am seeing sicker patients with more resistance, they are more resistant to lifestyle interventions now.

Andrew: Unfortunately, we'll need to wait a few years before the analysis of the microbiota/biome, what is supposedly a ‘normal’ one, which they have failed at achieving, or isolating. We'll have to wait a few more years before we get more data on what is "normal."

Mark: Well, I'm convinced here...I'm going to just do this parenthetically. I'm convinced that for Caucasians, seasonality and foods-in-season and high variability of the variability of the microbiome is going to be the hallmark of health and success.

Andrew: That's really interesting.

Mark: Yeah, and so the ability to change...

Andrew: So you’ve got 20 years, 30 years?

Mark: Yes, I'm thinking of that. I've been talking to a few people about just doing that kind of research. But the ability to vary almost our resilience, one level of resilience, is the resilience of the microbes to reinvent themselves every few months with new food, with...and not poisoning them. I'm really convinced about this now that the organic, pesticide-free food that the impact was never on humans. I thought it was. Because I have all my chemically-sensitive patients, the chemically-injured patients whose one big thing is that they will always keep with organic food.

But the other thing they do is they keep it organic, fresh food in season. And I was paying all the attention to the organic side of it without recognising that the natural variability, you can stir it up by starving it of protein every so often, reinitiating the protein. The fats have to be there, and then they can be out.

And so I do now see a group of people whose health is maintained by varying their diet by keeping everything local, growing their own foods. And so I'm learning things about chronic illness from patients that I should have actually known just on the theory of it.

Andrew: You mentioned a word a couple of times, limitations. How can we recognise these in ourselves? Because it seems to me that we all want to be experts, and we all want to project this aura of confidence. But there are certain things that we cannot be expert in. How do we recognise these responsibly, even in the very outset of the first visit with a patient, or at least in the early stages, or as the patient's chronic illness progresses and changes their needs?

Mark: Boy, that, in your words, that touches on 30 things that I would like to talk about prior to the...it is complicated.

Andrew: Parter.

Mark: Each practitioner has a worldview which is influenced by the patients who see them, the successes they have, the failures that they have. And what happens with a practice over time, like mine, was I interested in chronic fatigue syndrome? Not initially. I was interested in people with chronic illnesses from pesticides in an agricultural area in Gosford. And they're common thing was this unrelenting fatigue. And it didn't have a name of chronic fatigue syndrome. When I started practice, it was 1983...

Andrew: ME.

Mark: Well, it was called Neurasthenia…

Andrew: Oh.

Mark: It had all lots and lots of different names…

Andrew: Oh, this is before ME?

Mark: Yeah, this was right...

Andrew: Was it myalgic myloencephalitis, is that right?

Mark: Yeah, encephalomyelitis, myalgic encephalomyelitis. And it’s back in as terminology again now.

But there was a time where it was just people with chronic illnesses. And what I'd learned to do, oddly, in my career in the hospital was...it was Lidcomb hospital, lots of old people there. I was learning to safely take people off their drugs. There was a very good registrar, who's currently still practicing in Sydney. And his expertise was these people are over medicated, if you take people off their meds, a lot of the times the person emerges.

And this was never more true than, you know, 60 or 70-year-olds on 5 medications. And one would be Valium, one would be Serepax and another one would be Mogadon. And people were just adding and adding until the person was submerged below the drugs.

Andrew: So we're talking Diazepam.

Mark: Benzodiazepine.

Andrew: Oxazepam.

Mark: That's right.

Andrew: And what's Moggies?

Mark: Nitrazepam.

Andrew: Nitrazepam. Thank you.

Mark: And so all of them, they were just being added one after another until the old person shut up. And then the next thing was, I think they have dementia? And so the obvious thing for bringing them into hospital was, oh, guess what, if you take them off those medications and even take them off digitalis, so take them off antihypertensives, the original person emerged. And what the registrar was very good at understanding was these people have survived to 72 years of age despite all the drugs, not because of them. You take them off, there's an opportunity for the original person to emerge again. And they would come through and they'd be narky, nasty, nasty old people, but they were the normal old people. What doctors and the families wanted was submissive old people that weren't like the people that they were seeing. And we were using medication, say, as straitjackets at that time.

So the expertise that I had was how do you safely remove people from medications? Most of these people with these chronic illnesses had similarly ended up on lots of drug therapies. And as we took them off them, many of those people, their fatigue syndrome disappeared. It wasn't fatigue syndrome, it was benzodiazepines in high doses. And too much of them too often. Uppers and downers, so that they are on things to put them to sleep and wake them up in the morning.

It was the days when amphetamines were still able to be used in the early days in my career, at least for weight loss. And so the uppers/downers was very, very common. Taking people off their medications was what I did. It built a very big practice very quickly, it got a bit of annoyance from all the doctors around the area there because they’d put them on the drugs. And it's a challenge for every doctor to say, "Well, maybe I was wrong, maybe this person could have done without it."

What that transferred to was people with chronic illness coming to see me because the drugs hadn't worked, that's why they were on so many drugs. Saying, well, what will work? And me having to discover that, and me going and doing the ACNEM course and doing the environmental medicine courses to try and build expertise. So the managing of chronic illness was just what can we do environmentally, nutritionally, what can you do in lifestyle that would make a difference?

After that, I'd self-selected, and the answer in medicine is you don't specialise in something, something specialises in you. And I was seeing patients who would say, "I felt like you and this doctor helped me," and so more of those kinds of people will come. So it was never a choice to go and focus on chronic fatigue syndrome. But by '95, we were running conferences on it, it was a challenge to find out how you got people to emerge from this kind of an illness. And how you manage that thing of yep, some of them do great on antidepressants. And they really emerged. Did they get rid of their chronic fatigue? No, but they're not depressed about their chronic fatigue.

You can do stuff with mitochondrial support, as I think Christabelle just talked about. You can do the mitochondrial support, and some people emerge. Magic cases, where just Ubiquinol 300 to 600 milligrams, and some magnesium. And it's like you put the fuel back in the system, and six weeks later, that person is back to normal life again.

But they're the exceptions. The rest of the time, the chronicity of the illness means that the person has gone downhill 5, 10, 15 years before has entered a kind of hibernating adaptive state. It's low energy, low voltage, low ability to withstand anything, but it's survival.

Andrew: Yep.

Mark: And they're surviving, they're not dying from something that could otherwise have had a very bad outcome. Now, what we learn in that is if you override those adaptive mechanisms, you take a real chance with a patient. They've adapted for a reason. And if you don't understand why their body ended up in that state, when you push them, the infections burst to life, or their psychiatric illnesses really take off.

So if you get a person feeling brighter and more energetic, and there's an underlying severe depression, there is definitely a risk of suicide. Which many of the drug manufacturers are fair with their drugs, that you up the ability of the body to function, you better have the ability to stop the depression at the same time, otherwise suicide risk is very real.

So we have these kind of problems with chronic illness, that there's one thing that we know and that is there is death at the end of many diseases. Heart disease, heart attacks, alive or dead, you know, 48, 72 hours later, there's a real risk that you're going to die. You do anything, you move heaven and earth to do that. What do you do with the person at the other end of it? Do you put them on, you know, the life-saving drugs? No, you come off those ones, move them back to a cardiologist, try and understand why. And now the cardiologists are getting into lifestyle medicine. There's a sustainable outcome.

And so I'm seeing it, as you do, that when medicine and complementary or integrative medicine do their best, the crisis is managed by medicine. Because it's got rapid onset of highly powerful drugs, surgical and other interventions that can do a job. Shrink a tumor, bring it under control, excise the tumor, do the job. And then plan B, is usually on the other side of a divide that those doctors who do the acute work are not all that good at.

And our job is often to pick up that person and then say, "And I will be with you for the rest of your days here," effectively, if you're a young doctor. There may be 20 years of seeing that person. There may be 25 years. I've got two-generation families of people with chronic fatigue syndrome. And the ability to be there, sustain the loss that that person has with them, and support them unrelentingly is a gift that you have to almost earn. And if you go too far onto that and you put your whole self into it as a practitioner, you risk going down the same gurgler that the patient is going down as well.

So the finest of lines is to care deeply, to do our best, to recognise our limitations, and to hand over when those limitations are reached. And not to fight as though we are the patient themselves. But to negotiate, talk, cajole, bring them around so that they make the best possible decisions for themselves. And that is, the life of a practitioner is spent learning that I think. It's no easier or harder now than it was two decades ago for me.

Andrew: I want to talk about who cares for the carer in a second. But before we do that, you were mentioning about, you know, putting them on the psychoactive medication more often than not. So the benzodiazepines was the group that you mentioned. And I wonder, you know, when I've seen these chronic diseases and they're being managed by nothing less than polypharmacy, and the polypharmacy I'm alluding to is a side effect of one drug is managed by a knockout of that symptom, that pesky symptom, by a subsequent drug.

Mark: Yes.

Andrew: And then that subsequent drug causes another pesky side effect, which is knocked out or mitigated by a further drug, and so on and so forth.

I'll always remember this one lady who had a Tupperware container full of drugs, I think she was on 26 medications per month. And so in Australia, she was on the free list by March.

Mark: Right.

Andrew: She'd gone through her 50...

Mark: Okay.

Andrew: Was it 54? Forgive me, 52 prescriptions.

Mark: And there's no inhibition to having any more because they cost nothing.

Andrew: And it was...like, it was heartbreaking. I remember delivering her medications and eventually I'd had it. I just said, "I can't do this. As a nurse, I can't do this." So I got her assessed. She was put in the hospital by a physician and she came out on four medicines.

Now here's my point, both...forget ‘pesky integrative medicine.’ I wonder if any, every patient on four or more medicines should be automatically reviewed every year to reduce cost. Let's be really...

Mark: Blunt.

Andrew: ...brutal about it. To reduce cost to the health care system, to maintain the vibrancy of life for the patient, to adequately control and treat their disease statements, which needs pharmaceutical medications. I would extend this now, to all people that are on an extensive list of supplements. That they should be automatically reviewed as to do they need that medicine anymore and can they get away with either fully ceasing that medicine or at least decreasing that medicine?

And I think this goes back to assessment of; are we giving benefit to the patient? Because if it's not working, and they're just taking it, then we're just peeing it down the toilet anyway, it's not helping them.

Mark: Often there is a failure to remember to take a person off a medication. So there is what I call ‘medical inertia.’ Medical inertia is once a drug has been given and works, what's to stop it?

Andrew: It must always work, yeah.

Mark: And we keep getting...you know, the National Prescribing Service keeps coming back and saying, "Please don't leave people on those antidepressants, right? Please don't do that." But they're so effective, and they're so seductive. We have one kind of a typical thing with polypharmacy is sometimes we get drug combinations that go together. We give Celecoxib or we give one of the nonsteroidals. We know it's going irritate the gut...

Andrew: So we give a…

Mark: ...so we use a proton pump inhibitor. The proton pump inhibitor now induces a potential for increased infection in the lungs and the gastrointestinal tract, so now there's an antibiotic. And it's not unthoughtful to go through that. What's the unthinking part is why don't we review the medications, as you said? Getting people who are on proton pump inhibitors, acid suppressants, every so often the doctor comes back and says, "Well, A, do you still need it, and B, would there be a better way of doing that?"

And so I see this as all the way on one end from high intervention medicine with very powerful drugs that may be life-saving, down to a transfer of power to the patient themselves with lifestyle advice, exercise...

Andrew: Self-care.

Mark: ...diet, managing their sleep in ways that they probably should.

Andrew: Being empowered.

Mark: Yeah. And this even goes with pain management. A lot of arthritis, autoimmunity, a lot of what happens in cancer is pain, not just pain, but the fear of pain and the awareness of those limitations. And so our skills as practitioners, one of the skills that we need to learn to hone should be part of our education in medicine, is how to stop pills just as much as how to prescribe pills. The pills that we prescribe that remain dangling around are going to be a problem in the future.

That number four was what we finally came to. Four medications was what a 65-year-old could take, where you can be confident that if there were 4 pills in different areas, that you could cope with that complexity, and the patient could. By 75, it was 2. And so our tendency in medicine is the older you are, the more pills you get, not the less pill you get.

As metabolism of those medications decreases over time, as vulnerability of the brain and other organs increases just by a little wear and tear through life, we should always be on the lookout for what can we transfer back to what the person can do for themselves, what exercise does has been transformative. When I talk about stewed apple and the like, it's not the only thing, the reviving of exercise, moving of the body, qi gong, yoga...

Andrew: And not just walking, but movement of joints, movement of axis on our body.

Mark: Yeah, the ability to be flexible...

Andrew: Dancing.

Mark: Dancing...dancing or dancing? The ability to joyfully move has such powerful effects, the signaling effects that come back to the brain to say, "Hey, I'm still alive, we're moving out here. There is life to be lived." And we often forget that. We think there's death to be avoided, but having avoidance of death, my patients will say it all the time, there's no point avoiding death if you haven't got something to live for. The ability to provide the other side of life, which is you can move and be out in the sun and walk with your kids, or your dog, or you can dance.

Andrew: And what about insight, what about healthcare institutions playing music? I mean, how many people out there have visited an elderly relative and walked into these silent corridors with distant murmurs of people in the cafeteria eating their stewed peas?

Mark: Not stewed apples?

Andrew: Yes, no, stewed peas, eating their mush in all but solemnant states.

Mark: I've gotta say...

Andrew: You know, medicated to the outhouse. So I think this is a real deficiency in our healthcare system. It's easier, it's simpler, it's less confronting to medicate the hell out of our elderly patients, and to "take their pain away," than to get them moving. I'm going to say this, I'm going to say even give them medical cannabis to take some of their pain away, and get them moving and enjoying their time in their twilight years. Rather than in a chair or..

Mark: Well, somewhat from being twilight by the years as well. This idea of twilight years is always someone who's 20 years older than me. So someone 20 years older than me, clearly, they're old. I have a movable feast of what I now consider. And so from a perspective of a 60-something person...

Andrew: So are you in your dusk years?

Mark: No, I'm not there, I'm not even a grandfather of integrative medicine. I'm simply a parenty kind of thing.

But that ability to mobilise a person, to have them understand not that there's a cure to their disease or their illness, or that there's a magic drug that may come. But that there's life to be lived at whatever level that is. To share with them that, is the joyful side of being a practitioner. As we increase our skill set, lifestyle, exercise, the dietary part, people find meaning in food again. They eat with their families.

Andrew: Yeah.

Mark: They prepare food from their own garden.

Andrew: Yeah.

Mark: They become gardeners. This is something which always was seen as, "Oh, well, that's not medicine." But that is more medicine, that's the origins about Hippocratic medicine, our food be our medicine, our exercise, our ability to be outside. We can say, "Oh, you're vitamin D deficient. Oh, you have sarcopenia." They’re medical diagnoses of, "You're not living that life that is going to keep you the healthiest that you can be." And the ability to not have to go down the line of, "We will save your life no matter what the cost," I think is from the past noe.

Andrew: We spoke about music. You just mentioned things like flowers.

Mark: Yes.

Andrew: And we all think about flowers in an institution as being in a bunch, in a very clean vase, in the corner of the room that will be thrown out in two days because there's an infection risk.

Now what I'm thinking about is okay, how many patients look out a window? What are they looking at out that window, a brick wall? Could they look at flowers? This indeed was done for my father in his last days by two of my sisters who visited him and thought he's looking at a barren garden bed at eye level there, why don't we just plant some flowers? If nothing else they'll last a season, which they did. Now, let's move that over. You talk about seasonality. Why can't they grow some vegetables? Why can't they have some enjoyment about picking beans or radishes?

We need to move on though because we haven't got that much time. And I do want to talk about self-care for the practitioner a little bit. We spoke about limitations, we need to know our own limitations. When do we need to ring alarm bells for us? When do we need to go, "I can't help you, the patient, because if I try, I'm going to sink?"

Mark: I think that there's a prior question of what alliances do we have, our touchstones for ourselves and when we're doing well, and when we're not doing well?

In other words, in my view, other practitioners who can keep an eye on each other, people from similar fields and similar areas. That having colleagues is, in fact, one way of maintaining positivity for patients. Why? Placebo effects are not the patient's belief in what you give them, they're the patient's belief in the practitioner. And when a practitioner fails, their ability to feel positive and provide that support that the patient needs to hang their future on disappears very, very quickly.

It can happen, as happened to me the first time that I had any patient suicides. For months afterwards, I was useless because I took it on very personally, kept it all internal. There was no discussion with anybody. And as time has gone by, I have more colleagues, more people that I can discuss it with without a sense of shame because it is part of a practitioner's journey, I think every practitioner's journey, that they immerse themselves in another person's life and feel the loss of that person dying, suiciding, however much that happens.

Even feeling the loss of Alzheimer's patients that you see the person disappear in front of you, there's a body, but there's no person there where they used to be. And the ability to deal with that I think, has a frank discussion with other practitioners who also feel the same things that you share the load, but you also share the future. You share okay, here's new ideas, here's another way. Had I never become part of lifestyle medicine, I think I'd think of exercise as kind of ancillary thing that you do, now I see it as a core of recovery. When I see patient care, good outcomes versus bad outcomes depend on the diet that they're on and the exercise that they do afterwards.

So in learning that, that requires colleagues, education, the BioCeuticals Symposia, are a good example of things that I love to go to each year because you hear the novelty, you hear, "Here's what you could try." Sometimes it works, sometimes it doesn't. But when it does, it's a whole new spark that goes not just to the practitioner, but to the patient. It's a new tool that allows you to expand your knowledge base. And it's a new way of thinking when it's in lifestyle areas that mean you're not challenging anybody else. You're not fighting an oncologist for the use of marijuana versus the use of oxycodone, for example. You are giving a person something that everybody can step back and say, "I can sign up for that myself."

That has a powerful effect when oncologist, surgeon, GP, naturopath can agree about lifestyle, a patient becomes enrolled in it. If they have every medical person go, "Bullshit, that's not going to work, how could that possibly work?" Which has happened for the last 40 years…

Andrew: Yep.

Mark: When that's done, the patient is left in confusion. I have a naturopath who I trust, a nutritionist who I trust, they're telling me that this will work. And what's happening over here is you will depend on my drugs, you will depend on this.

So as medicine is finding that lifestyle has such a powerful influence, we are opening new gates across all the healing professions to involve new practitioners, dietitians, nutritionists, naturopaths, chiropractors, osteopaths, that if we can get bodies moving, if we can get that done with our patients then we're good.

And here's the final paradox, what's good for the practitioner is good for the patient, the client as well. So in healing ourselves, in having groups that we can go and look to of colleagues, we do ourselves a favour and we become more potent as practitioners, we become more useful to our patients in that way. And we have a level of protection. That it's the kind of safety net that when things do fall apart with patients, and we feel at our lowest points, that we could go to our colleagues and say, "This is how I feel." That replenishing is so critical to the longevity of any healthcare practitioner.

And I think that’s, you know, that's something that I'm finding this time, the discussion, the ability to say, "I wonder if I failed," and own up to that. And have others say, "Well, here's my perspective on it." That replenishing of a practitioner is a lifelong path all by itself.

Andrew: So I think for all of our practitioner listeners out there as a part of responsibility for your own survival throughout your career, you need to be investigating collegiate institutions, collegiate events where you can not just network on a social scale, but on a deeper level where you can actually talk the real talk.

Mark: And the real talk needs to be, "Here are my current failings, as I see them, how can I do something about that?"

Andrew: We never like to talk about those, do we?

Mark: I know, and I think it takes a long time. For me, I lived 25 years of my practitioner life in a fear that I was wrong, or that I would miss something, or that...without really paying attention to where I lack someone else has a strength. And the job is not for me to have their strengths, the job is for me to know the person who has that strength and say to my patient, "You should see this person, they are better at this than I am." We all want to think that we cover everything, but we don't, no practitioner, no matter how long they live, can ever cover everything.

And so that ability to be in the environment, to expose ourselves to be vulnerable, and say where we feel we've lacked, I think is critical to patient care, but it's also critical to our care. To have practitioners, to watch many of my colleagues go down that hill. I have to say, one of the patients who's taken their life was a doctor. Who was injured, who was isolated and who, in the end, had colleagues turn against him saying, "Oh, no, you couldn't possibly be sick with that kind of..." there was an odd medical story. In the end, he was disabled and all he needed was care. And what did the medical profession..."There's no evidence that that could have made you that sick, therefore, you're not sick."

The ability of medicine to do harm is really, really potent. When we define illness, where we define disability, we define compensation. And so we have to be aware of all of those limitations. We have the glorious opportunity to share the lives of people who come to us vulnerable, sick, and share their vulnerabilities with us. And a lot of us, me included, don't share our vulnerabilities with somebody else. And that's a weakness that I think that we can compensate for.

Andrew: I want to just lastly give a call out, if you like, to a few institutions that help save people.

Mark: Yeah.

Andrew: Both in an acute and chronic situation. And in Australia, we have some amazing support networks, people like Lifeline, The Black Dog Institute, Beyond Blue. I also just want to give a personal call out to a mate of mine who works with an organisation do an incredible job in the construction industry, Mates in Construction, do an incredible job.

But also overseas, you've got suicidepreventionlifeline.org in America. Even if you look at Wikipedia for those people that might need help, you can look up a list of suicide crisis lines internationally. Now, that will more often than not give you the emergency number, but there are some resources there at least that you can access. Anything else, Mark?

Mark: I have a new view of the social network. And that is my own daughter's involved in this, lots of patients are involved in this, support across the internet. What looked like oh, it's all about cats and dogs doing, you know, somersaults. Tumblr, and Facebook groups, there are groups that are mutual support. Not trying to take the role away from doctors, but you need a conversation, you're in your own home in the dark, you can be online. And I've listened to my daughter on phone calls and in Tumblr sessions providing that support. Not expert advice, but there is a community around you.

And for a lot of people who are at this point with chronic illness, the feeling of loneliness is, in fact, the most horrifying thing for them. And the ability to provide that community support, to be the next door neighbour, even though you're in another country, even though you are far away, and to build those relationships, that often does the job.

And I'm not promoting it as an alternative to medical care or to referral where things are urgent, desperate, where a person is at risk of suicide, never try and hold onto that yourself. You hand over to health and mental health professionals, you save a life and then you work out how to rebuild that life on the other side.

Andrew: You support, yeah.

Mark: So it's not an alternative to it, but for people to not feel alone. My own patients, where did you get your support? I have people all over the world, colleagues and friends, and people over the world that they have never met and never will meet, but who at those times of crisis become support people, people who can stand up for them.

Andrew: We've ended on a sadder note this week, Mark.

Mark: We have.

Andrew: But I hope that our listeners can gain some strength in, as we said before, being collegiate and being supportive for themselves and gaining strength from that. So that they can best support their patients. Thanks so much for joining us on FX Medicine.

Mark: It's been my pleasure again, thank you.

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook

Additional Resources

Mates in Construction

Other podcasts with Mark include:

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