How do you describe your illness?

Does they way people describe their illness affect the eventual outcome? I think that is probably true as I had a woman in surgery this morning that was doing just that.
She had started a degree course in nursing but was now thinking of giving it up because she had a bad back. She was 32 years old and 18 months previously had been shunted from behind in a car accident. Her back hurt ever since. True it may still be hurting, but x-rays and an MRI scan were reassuring normal. ‘I have a chronic backache and it is only going to get worse.’ Well that is only true if she believes it to be. She went onto to say her mother had something similar and she never got over it, so she would be the same. Definitely not true as back injuries or weak backs are not hereditary. What made it worse is that the physiotherapist said that her discs between her vertebrae were dehydrated and that was difficult to treat. May be true but never heard of ‘dehydrated discs’ in 30 years of practice.
So here we have a woman with a story about her illness that tells of hopelessness and a lifetime of suffering in front of her, and her mother and physiotherapist support that story. The words she uses are negative and tend to reinforce the despair. It made me think does she really want to become a nurse and what are her motives of being sick. Well we did discuss that and she seemed genuine enough. Time to change the story and language. ‘Yes, you did have an injury 18 months ago but all the bruising and injury will have fully healed by now. Your muscles have become oversensitive as a result and that is why you are still in some discomfort. You will make a complete recovery provided you do regular exercise and stretches. Massage is useful. Walking and swimming is good. Use positive language to describe your progress to yourself and others, and imagine your back with tough flexible discs between the vertebrae.’
She came into the surgery with a frown on her face and left with a smile. Lets hope that it lasts.

A holistic birth

2 weeks ago my eldest daughter gave birth to a boy, Benjamin. It was a good holistic birth.

She had had a straightforward pregnancy and was working as a practice nurse up to 37 weeks. She had read all the books, been to antenatal classes with the National childbirth trust and attended yoga regularly. I felt being prepared helps but you never know how you may cope until the big day.

She was over at our house having lunch, and while on the phone to her husband her waters broke. No panic but plenty of excitement. We drove her back to her house and had afternoon tea, and as Wimbledon tennis was on the television that helped as a distraction. The midwife came and confirmed that she was in early labour and to call back when the contractions, or should I say ‘surges’, were coming every 4 minutes. As the contractions became more regular she walked around the house finding the most comfortable place and position. Her husband was being a great support and we sat calmly creating an atmosphere of peace and joyful expectation. Her husband made some pasta and she remembered to keep drinking as all the effort was going to be using up energy.

We timed her contractions and by 11pm she was now quite regular. She had no painkillers and the breathing was helping her manage. Back massage helped too. The midwife came and said she was 9cm dilated and doing well. She was now in the zone and quite focused. My wife and I felt she and her husband needed that special space to themselves so we left for home with encouraging words. Three hours later Ben was born on the stairs (best position) with her husband holding her up. He cut the cord and the placenta passed naturally 2 hours later.

Born 4th July, it was their first wedding anniversary- a special golden child. Very happy parents and very proud grandparents.

Continuity or access in patient care?

Patients often complain in general practice that they cannot see their own doctor. There is no problem with access but it is continuity of care that is lacking.

GP’s used to pride themselves knowing their patients and families well. In our practice we have 12,000 patients. We used to have six fulltime partners- that is 2,000 patients each. Now for the same number of patients there are 3 full time partners, 2 part time partners, 1 full time salaried doctor, 2 part time salaried doctors, a GP registrar, an F1 doctor and innumerable locums.

I saw a 12year old boy last week that had recurrent severe abdominal pains over 3 months. He had seen consulted ten doctors. He had seen two out of hours doctors, visited casualty twice, seen a specialist, and had consulted five doctors at our practice. He had lost lots of time at school and was on regular painkillers. The parents had no complaints about the doctors attention but they felt nothing had been achieved to relief his suffering or find the cause. I tended to agree, as the symptoms seemed genuine although difficult to explain. No professional had stood back at look at the whole story.

A call to the paediatric consultant was needed to get him admitted and sorted. I felt if he had one doctor who could have seen the pattern and knew the family well he could have been sorted out quicker. That is the job of a good family physician

I have tried everything

‘I have spent over a thousand pounds on my neck and I want it sorted,’ was Mrs Harrington’s opening statement. Indeed she had tried lots of treatments; acupuncture, physiotherapy, osteopathy and a variety of medications. She had seen a specialist and had an mri scan which did show some wear and tear of the vertebrae. He offered to inject her neck but she did not fancy that.
She is lady that has her own business and cannot afford anymore time off. Her husband sent her to get it sorted.
It is not easy to deal with a personality that has a mechanistic view of their body and a high achiever that is used to getting rsults.
Well listening and empathy always helps. Going a bit deeper with some quaestions can open things up. When did it start? What makes it better? What does she think is the cause? What is really important in her life? There was some resistance, but I think she began to reflect on her situation from a different perspective.
The consulatation ended with me suggesting to her to view ‘painful neck’ as a chronic condition that she needed to adapt to rather than look for a cure. Maybe some seeds were sown for her to begin to change her attitude.

Spiritual care

Spiritual care, what is it? How do we give spiritual care in our day-to-day consultations with patients? For holistic practitioners it is challenging because for them the question is, ‘Can spiritual care be separated from mental and physical care, or is it essentially part of everything?’

The answer has to be yes and no, and both. How we are in ourselves, and how we are with patients determines the space that allows a caring spiritual atmosphere to be present. With the intention of bringing benefit to the patient, whatever is meant to happen, will happen. A spiritual relationship in a consultation is when we are fully attentive and yet are detached from the outcome. I mean attentive mentally and detached emotionally.

However there are some prompt questions that are helpful in directing the conversation towards the spiritual dimension:

What is really important to you?
How do you find inner peace?
What do you think is happening to you- concerning your illness, etc?
What and who gives you support?

I like the picture of a visitor playing her guitar and singing to residents at a nursing home. Simply anything that can lift your spirits, is spiritual care.

Holism versus reductionism.

Sometimes I despair. Where are we going with this reductionist, target driven medical care?

Mary was referred to my morning surgery by the nurse. She was 83 years old. Her blood pressure was 160/90. For goodness sake she is 83!

Protocol guidelines say that her blood pressure should be 140/90. Mary had been taking tablets for her blood pressure for 15 years and her blood pressure had not altered over the last 4 years. But guidelines are guidelines.

She asked me if it was her nerves that maybe had put her blood pressure up. I asked what she meant and of course what she really wanted to do was tell her story. She had been a widow for 20 years and she was finding it increasingly difficult to look after her elder brother that lived nearby. She was getting more and more tired having to cope with him as well as her own house. She did all the shopping and looking after the bills. A cleaner came in once a week. Her family lived by and helped out when they could but she did not want to bother them too much with her troubles.

We as doctors want to check her blood pressure presumably to lower her risk of a stroke. Or is to reach our targets and get paid? She wants someone to listen to her story and offer a bit of support and advise. I hope she left feeling she had shared her troubles. After she left I contacted social services to see if they could offer some help for her brother.

My mother's death

Last week my mother died. She was 94years old and had been in a nursing home for 3 years. However up until the last 6 weeks she was alert and interested in everything around her. Despite her difficulty with speech when visiting her, she was first to ask how you were. She took a keen interest in everyone’s life. She always looked on the bright side. She was a happy, generous caring soul and that is how I will remember her, not the frail body of the last 6 months.

As a holistic practitioner we need to acknowledge that things happen to us and affect us too. We often deal with others grief and distress but how do we deal with our own? Who do we look for support? Doctors generally are not good at this and tend to deny many of the feelings and carry on at work regardless. If it happens to you, have time off to reflect and learn from the experience. It will help you develop and be a better doctor.

What did I learn? The most important thing when sitting with a dying person is the state of your own mind. I focused on creating a peaceful atmosphere for my mother. I ensured that she was physically comfortable then spent time meditating in her presence. I focused on love, light and peace. I felt calm and a comfortable feeling was created in the room. When the nurses came to attend her they commented on it.

One evening I went through all her own photograph albums, which gave me a perspective on her life. I felt many of the special people in her life were close and ready to welcome her. Although she was not responding for the last three days I spoke to her softly and reassuringly of how much she had given to life and how much she had been appreciated. It was now OK for her to go when she was ready and that everything was in order.

In the end it was very gentle and peaceful passing. Of course we will miss her, but I feel good that it was a good death.