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PROMOTING EMOTIONAL HEALTH AND CLEAR THINKING
Editorial: Volume 13, No. 2 — 2006
Learning by heart
A FINDING about cardiologists' prescribing of warfarin to patients with
atrial fibrillation seems unlikely material for coverage in this
journal.(1) Yet what it tells us about human behaviour goes far beyond
the field of heart disease. It serves to remind us just how strong a
part a single personal experience can play in directing future
behaviours — as therapists who work with phobia and panic attack
sufferers will well know.
Atrial fibrillation is the most common abnormal rhythm of the heart,
the prevalence (or diagnosis) of which is apparently increasing. It can
lead, among other things, to the formation of blood clots and, as a
result, stroke. Although there is strong evidence that warfarin, which
inhibits clot formation, can prevent stroke, it is prescribed in only
half of ‘suitable’ cases, and Dr Niteesh Choudry, together with colleagues at Harvard Medical School and the University of Toronto, are
troubled as to why. So they identified a raft
of patients with atrial fibrillation who had been prescribed warfarin
and had to be re-admitted to hospital within four months of starting
treatment because of sudden serious brain or upper gastro-intestinal haemorrhage. They also tracked down patients with atrial
fibrillation who had not been prescribed warfarin and who experienced a
thromboembolic stroke within the next four months.
Now comes the interesting bit. The researchers analysed the prescribing decisions of the hundreds of cardiologists involved in these cases and found that those who had treated a patient who had a major haemorrhage while taking warfarin were far less likely to prescribe warfarin for atrial fibrillation thereafter, whereas those who treated patients who had strokes while not on warfarin carried on prescribing exactly as they had before. For reasons connected with trial design, the researchers suggest their findings may be an underestimate of the impact of one adverse event — and are surprised that specialists could be so influenced by experiences with individual patients.
However, as Dr Kieran Sweeny, honorary clinical senior lecturer in general practice at the Peninsula Medical School in Exeter, comments in an editorial in the journal that published the findings, “Doctors are neither passive recipients of, nor simple conduits for, clinical evidence. All of us … have our own ‘view from somewhere’. … At stake here is something quite profound, and poorly accepted within the medical community: the personal participation of the knower in all acts of understanding.”(2)
What we understand from our experiences is not a variable that
researchers have much control over, as was discovered in an experiment
described by Cordelia Fine in her book A Mind of its Own (reviewed on
page 38). When two groups of school students were asked to solve a
difficult maths problem, after seeing either a helpful instructional
video or a deliberately hopelessly confusing one, those who saw the latter and
did poorly remained convinced that they were rubbish at maths, even
when all was revealed and they were shown the helpful video. Indeed, it
took a great deal of effort and ingenuity on the part of the
experimenters to persuade them otherwise. It is, as reviewer Ian Thomson points out, “a salutary lesson for all those involved in educational and caring activities”.
For, much personal knowing can be negative — limiting and misleading, albeit powerful and ‘real’. It is fuelled by the fear of getting it wrong, of being wrong. (See Pat Williams, page 10, on the most fundamental of fears.) At its most dangerous, it can be a killer. “Got to be thin”, starting on page 24, is a searing account of how deadly‘personal knowing’ can be when anorexia is imparting the information. See, too, how ‘personal knowing’, derived from an explosive cocktail of mixed up yearnings for identity, meaning and security, can lead to the deaths of thousands (“Common ground: diplomacy and the human givens”, on page 11).
The most common symptom of atrial fibrillation is heart palpitations. Because delivery of blood around the body is impaired, there are other symptoms, including dizziness, fainting, weakness and shortness of breath, along with chest pain, caused by reduced blood flow to the heart muscles: the very symptoms of panic attacks, of course, so commonly misinterpreted as a heart attack. Fortunately, there is incontrovertible proof that, once taught, people can abort panics quickly and successfully, enabling a negative knowing to be transformed into a positive one. Where the evidence is less compelling (and that may have little to do with statistical significance), we can only try to remain aware that personal knowing inevitably colours what we think, feel and pay attention to; sometimes it is extremely helpful and sometimes it is not.
The Editors
1. Choudry, N K et al (2006). Impact of adverse events on prescribing
warfarin in patients with atrial fibrillation: matched pair analysis. BMJ, 332, 141–3.
2. Sweeney, K (2006). Personal knowledge. BMJ, 332, 129.
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