Medical

The Hand of Comfort

Hand

I am a man. Really I am. And men don’t cry-correct?

Well this one does-not very often, but when I do it is usually a good moment to pause and reflect on the circumstances. Just to check, you know, that I’m still a real man.

Shortly after the birth of our first child, I stayed up one evening to watch Life Is Beautiful, the wonderful Oscar winning film starring Roberto Benigni (1). This film should carry a health warning-beautiful yet haunting as it shifts from delight to horror over two glorious hours. The following morning I tried to describe the film to my wife as we sat in bed over a cup of tea, enjoying a rare moment of peace from our newborn daughter. I didn’t quite manage to get the words out as I choked on the raw emotion of the film I had sat through the previous evening, and tears flowed unexpectedly. My wife looked puzzled, but comforted me as I tried in vain to describe the movie, my emotions associated with it and the new responsibilities I now carried as a father. My wife is still yet to see the film 11 years on-I think the time will come.

Over my medical career I have been reduced to real tears on three, sadly memorable, occasions. These episodes were all slightly different, two involving the death of children and the third an unexpected finding of advancing cancer in a young patient. Each situation remains fresh in my memory but especially the first, despite occurring over 20 years ago-the emergency bleep, a collapsed child, manually ventilating for several hours in our small paediatric unit, the evolving fear of those involved, and the baptism at the bedside by the hospital priest. That day I, and others, will never forget.

On each occasion the tears came suddenly, uncontrollably after the events-that is to say, I managed to hold my emotions whilst I was with the patient or their family, and support them in their most difficult hour, but their trauma entangled me, and abruptly hit me, as I later tried to explain the case to colleagues or my wife (also a doctor). They looked on, reaching out to me, feeling my vicarious pain, and most importantly, they comforted me. A touching hand, a small embrace, a hand on the shoulder from a receptionist, doctor colleague, nurse or my wife was recognition enough-recognition that it was alright to be like this, to be human and upset. Somehow the touching helped-bodily contact soothing the wound.

As doctors we touch people frequently. The handshake as a patient enters the room, the blood pressure check or a physical examination. Mostly this is with implied patient consent-we will seek specific consent for a more intimate examination, but what about the comforting hand? We are doctors, but also we are humans. I would have no difficulty in physically comforting a distressed child, loved one, colleague or even a stranger as a fellow human being-but what about a patient? The human part of me says “don’t be silly, it’s OK” but the doctor part of me says “do be careful”. Our relationship with patients is like no other, and needs to be carefully observed.  I read this account (2) and it resonated with me. There is very little worthwhile work on how patients feel about touch that I could find, although there are many discussion forums that have covered the subject. This was a nice, small, primary care based study that is worth reading (3).

So can I be a real man, a doctor, and a human all at the same time?

I think that understanding your “weaknesses” can be your greatest strength. In my case, one of these is an acceptance of the effect that dealing with difficult cases can have-protecting patients from this but seeking support from those around me when needed.

On several occasions I have found this difficult- I have reached out a hand and withdrawn it, unsure of my role for a moment, leaving patients untouched. This problem can be amplified with female patients. A male doctor, a female patient, a human touch. I have several times been comforted by my (female) GP partner, and I know that in my hour of need I will look for the Hand of Comfort.

References:

  1. http://m.youtube.com/watch?v=64ZoO7oiN0s&desktop_uri=%2Fwatch%3Fv%3D64ZoO7oiN0s
  2. http://articles.latimes.com/2011/oct/24/health/la-he-practice-touch-20111024
  3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289810/
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qof-a conflict of interest?

8:30 Monday evening and Mr Jones walks in to the consulting room. He and the doctor are new to each other. What could possibly go wrong.

“Good evening Mr Jones”.

Silence is the answer. No verbal response, downcast eyes and a flickering of the lip.

The doctor watches and his diagnostic feelers start to quiver-albeit slowly as it has been rather a long day. Mr Jones has arrived halfway through his third surgery of the day, 12 hours after the start of the first. Gordon Brown has certainly left his mark on primary care-extended hours surgeries a boon for patients?

So what next-the doctor starts to think, what goes through his mind? What should go through his mind? He tries to focus-on the patient in front of him, not on the distracting forces around him. What are those forces-what can distract him from the single most important aspect of his work?

To understand how best to help the patient, we may first need to understand how best to help ourselves as doctors. To clear the mind, to remain alert, psychologically well, and concentrate our efforts during those sacred 10 minutes. This is not easy, especially when some factors are out of our control. We find ourselves making working, lifestyle and financial choices which can all affect patient care if not handled carefully. We work within a practice, and have obligations to our partners as well as our patients. We may be part of a family and must also fulfil our role at home. We have bills to pay, maybe a mortgage, as do our partners at work and this also hovers in the back of our minds during the working day. How do we ensure that we separate the patient’s needs from our own? There has been much published over the years about the doctor/patient relationship-much of it very good at the time, and many aspects of it still relevant today. I would argue that this relationship is under threat by external factors-particularly QOF, and we will have to concentrate our efforts to preserve it in its natural form.

I can’t say that QOF has had no beneficial effects for patients-I think that it has and has probably helped to improve some aspects of our care, and highlight some deficiencies as well. However, it is a blunt tool, and it was never designed with the consultation in mind.

I don’t like QOF now. In fact I resent it. Moving goalposts and adjustments year on year soak up efforts and resources from the practice that should be focussed on patient care. I dread to think how many hours we put aside to discuss QOF targets/exemptions and how many staff we have working on this. The practice machine works away slowly at this over the year-but the focus is never really on good outcomes for the patient, it is on the financial implications for the practice.

Let’s go back to Mr Jones. Our first thoughts are to try to engage with him and untangle his problems. Depression? Migraine? Bereavement? In to which domain, if any, will he be categorised by QOF?  When I am trying to help a patient with possible depression, I don’t want to be trying to remember which template to complete, or whether I have remembered every component of said template. I want to be listening, watching. I was glad to see the passing of PHQ9-some found it helpful but I cannot remember it ever helping in a treatment decision. Why did we do PHQs? Why do we spend time completing templates? For patient care? I’m not convinced. If our primary interest is patients, then QOF=finance= possible conflict of interest.

So where to next? Are we, as physicians, able to manage and treat patients without being contaminated by financial or practice affairs, and is this a reasonable expectation? I hope that we are, but I don’t think that QOF helps us. We should look for alternatives, and pursue these in any future “negotiations” with DOH. I am not naïve enough to believe we can ignore the financial constraints within the NHS. I do believe, however, that we need to minimise the impact of this during the consultation.

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Medical

1984

1984 was a great year-not just for George Orwell lovers, or for me as I embarked on my medical education. Daley Thompson won his second Olympic gold medal in the decathlon event, and in securing his place in athletics history also broke the world record. Picture the scene afterwards if you can, as journalists jostled to talk to the great man draped in Union flags and his gold medal. “Daley-well done on your double Olympic success. Are you now going to consider specialising?”

Daley-Thompson_2308638b

How will you respond next time you are faced with that question? As a GP, I have been asked many times about my lack of specialisation-the implication perhaps being that I have failed in my profession. How do I live with the daily thought that, in some circles, I am viewed as a sub-species, a “not quite made it” doctor?

I think we should celebrate our generalisation, our ability to see all comers and usually generate some sort of management plan. We often bemoan the lack of a generalist in secondary care and have recently welcomed with open arms the rapid access to a clinic for those patients who just “aren’t really that well”-this has filled the gap of an urgent outpatient appointment which seems to have died a death.  We can’t all specialise, and we certainly don’t all want to, a bit like Tesco really-come to us and we’ll do our best to sort you out, try not to miss anything important and refer on to a proper doctor when needed.

To paraphrase Fletcher in the great Porridge TV comedy, my specialty is “the statement of the bleeding obvious”. By this I mean that our day to day work is a combination of sharing our medical knowledge, common sense, and our own life experiences with patients. All these three can be helpful at certain times and in different situations but I often wonder if my own experiences of life’s tricky situations, and learning from how patients deal with these are the most helpful for me as a doctor, and also for some of my patients.

When dealing with parents struggling with behavioural issues, people grappling with trying to give something up, or suffering from stress in the workplace, it is frequently not my medical knowledge that I draw on. It is very often my own or learned experiences, combined with common sense that can be most helpful to patients. Of course, the medical knowledge helps-knowing a little bit about lots of things won’t win me a gold medal, but it might just get me on the podium for those patients presenting without a barcode on their forehead.

Barcode

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Medical

The decline.

I was out cycling with a friend recently when he told me about the comments of an ex professional cyclist. When asked about how he enjoyed cycling after his retirement, his reply was, “it’s all about managing the decline”. We chatted about how difficult this must be, to reach the peak of a sport, and realise that your time is up and how to deal with that recognition. As I watched my friend disappear in to the distance, I mused over my own peak-had I reached it yet?

Decline

It was later in the day, on recovering my breath, that I began to draw an association with our role as primary care physicians and the “management of decline”. We see many patients every day, of all ages, some ill and some not so ill. With the ever increasing age of the population, we are of course seeing larger  numbers of  patients who are past “their peak”, whose health is declining, and many of them also struggle to come to terms with this, and will frequently seek help in how to manage it. More specifically, it got me thinking about those patients whose health is deteriorating, for whom there is no prospect of improvement, and coming to the realisation that we perhaps should be focusing our efforts jointly with patients on “managing decline” rather than cure. One difficulty is accepting this, or understanding when that point is close to being reached, or has already been passed.

I am not talking about the patients on a clear cut pathway of treatment and transition into palliation. The oncologists and palliative care teams will be seeing a lot of these patients, and of course usually manage this transition well. I am talking about those suffering a gradual decline and being managed mainly in primary care-perhaps living with dementia, heart failure or simply old age.

A few years ago I heard of a patient living with alcoholic liver disease. His GP advised him during a consultation-“look, we’ve discussed this before, if you don’t stop drinking then you are going to kill yourself”.
The patient paused before answering-“I know that doctor. You have told me before, but you didn’t tell me it would take this long”.
The penny dropped, the doctor realised at this point that the patient understood his predicament. He was not going to stop drinking-he wanted help and support in “managing his decline”. The relationship changed, the doctor stopped looking for a cure, and they worked together with a shared understanding of the management plan.

plan

So what can we learn from this? As a doctor, I have learnt to keep listening, asking questions and to constantly revisit the management plan to ensure that wherever possible patients, carers, families and doctors are all singing from the same hymn sheet. We perhaps should consider this more readily, even in those patients without an obvious “terminal illness”, helping patients accept illness and to manage their ill health. We should not be afraid or surprised of what patients might tell us-offer them opportunities to discuss their fears and expectations, encourage them, allow them to voice their darkest thoughts . Above all, support them in that difficult journey from health, through their peak, down the inevitable decline towards death.
Patients may have formed their own conclusions about their health well before we realise, and discovering this sooner rather than later will help them and doctors alike.

Richard Cook
August 2013

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Medical

Twitter,doctors and rules.

This blog first appeared in the BMJ online version, in August 2013.

http://blogs.bmj.com/bmj/2013/08/28/richard-cook-twitter-doctors-and-rules/

Ever get frustrated during a consultation? How should doctors deal with that? The patient comes first of course—we, as doctors, know that and have that mantra at the centre of how we work. What if, just if, the doctor came first? How would a consultation look? If you could draw up a list of how to make the perfect consultation, for a doctor, not a patient, what would it look like? Could it be helpful to do this?

We all live by certain rules.

As a keen, but slow, cyclist I have been intrigued by “The Rules” as laid out on the cycling enthusiasts website Velominati. These have clearly been developed for cyclists who have a lot of time on their hands and either take themselves too seriously, or are able to incorporate some of “The Rules” into the enjoyment of their sport, while appreciating that there is no legal obligation to adhere to every last point. In summary, they are there for fun, to be interpreted however the reader wishes.

I am also a doctor. A GP. I have to live by certain rules to carry out my role responsibly. I try to adhere to the GMC guidance on duties of a doctor (http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp). I work in a partnership, I have regular appraisals, and I am working towards revalidation. I enjoy my job, respect my patients and colleagues, and, I like to think that I will always try to help people to the best of my ability.

Sometimes, however, I get frustrated. Who doesn’t? Patients are why we are here; they are who we are here to help; they are our source of work; they test our knowledge, our patience, our skills. They can also be our biggest source of frustration—so how do we deal with that? The first step is recognising our frustrations—what is it specifically each day that can be a source of difficulties for us as doctors? Are there everyday issues, relating to the consultation and things patients say to us, that we might need to recognise? I think there are.

I decided to develop a set of “Rules” to help patients maximise their experience of consulting a GP, and give GPs a chance to vent their frustration. They were inspired by discussion with colleagues after years of work and thousands of consultations with patients. They were helped in their development by the rules of cycling (http://www.velominati.com/the-rules/ ) and were intended as a guide only—one with which I hope doctors could identify, and patients could perhaps use to help them understand the physician’s perspective. “The Rules” are meant to provide an alternative view to the patient centred consultation—some doctors have found them amusing.

I have discovered, the hard way, that it is very difficult to present deadpan tongue in cheek views or humour over the internet. In fact, it is best not to try it. At all. This is particularly important when you are dealing with an area as sacrosanct as the doctor-patient relationship. If you feel it is appropriate to try to apply humour to ease your frustrations, then please keep it behind closed doors, away from patients and certainly away from the public arena or internet and all social media sites.

I published my rules on a public website, and associated them with a new Twitter account @drmoderate. I had never used a social media outlet before and I quickly came to appreciate that it is a very public domain; people have strong views and are not afraid to post them. I also quickly realised that my “Rules,” whatever their intention had been, were not appropriate to be shared in public. I had a lot of feedback and much of it was very positive, from doctors sharing frustrations to patients also supporting the need to let off steam. I also received very negative feedback from doctors and patients with very opposite views—eventually these led to me removing my “Rules” from the public domain and engaging in interesting dialogue via Twitter with educationalists, doctors, and patients of all different backgrounds. I learnt a lot, reflected, apologised for any offence and tried to glean some positives from the whole experience.

What have I learnt about Twitter, medical matters, and how can this help others?

1. Do use Twitter—it’s an excellent resource for information and debate on all matters, including medical. Create an account, observe, follow and post when you are ready.

2. Know your audience. Share your humour only with appropriate groups. Social media may well not be the place for this.

3. Don’t get too disheartened by negative feedback. Everyone is entitled to an opinion—be polite, respect the opinions of others, and try to learn from them.

4. Some people take matters very seriously. It is difficult to judge who does, and who doesn’t, over the internet. Remember this, err on the side of caution and be nice.

5. I still quite like “The Rules.” They make me chuckle. I think this is possible without losing the focus on patients.

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