HolisticGP

How do you describe your illness?

2009-11-04T08:27:00.000-08:00

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

2009-07-21T08:41:00.000-07:00

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?

2009-05-10T11:52:00.000-07:00

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

2009-04-13T13:06:00.000-07:00

‘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

2009-03-21T03:21:00.001-07:00

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.

2009-02-28T04:45:00.000-08:00

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

2009-02-17T11:53:00.000-08:00

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.

Robert Burns and Holism

2009-01-31T09:54:00.000-08:00

Jan Smuts coined the phrase ‘holism’ at the beginning of the last century. Robert Burns was a great example of holism a 150 years before that.

Rabbie died at the age of 37yrs from complications of Rheumatic fever (sub acute bacterial endocarditis). His physician at the time advised that he bathed every day in the cold River Nith. We are not told if this was an alternative therapy or a common prescription for his condition. However like any good patient he followed instructions despite his deteriorating health.

He had an acute sensitivity to the fine balance in nature and his environmental awareness was centuries ahead of its time Just read these verses of ‘To a mouse’ to really appreciated his simple genius.

Wee, sleekit, cowran, tim'rous beastie,

O, what panic's in thy breastie!

Thou need na start awa sae hasty,

Wi' bickering brattle!

I wad be laith to rin an' chase thee,

Wi' murd'ring pattle!

I'm truly sorry Man's dominion

Has broken Nature's social union,

An' justifies that ill opinion,

Which makes thee startle,

At me, thy poor, earth-born companion,

An' fellow-mortal!

But Mousie, thou are no thy-lane,

In proving foresight may be vain:

The best laid schemes o' Mice an' Men,

Gang aft agley,

An' lea'e us nought but grief an' pain,

For promis'd joy!

Still, thou art blest, compar'd wi' me!

The present only toucheth thee:

But Och! I backward cast my e'e,

On prospects drear!

An' forward, tho' I canna see,

I guess an' fear!

Check out that last verse again of his mindfulness of being in the present and not looking back or forward. He must have studied Zen practices.

As Scotland’s national bard he promoted a brotherhood of all men through his poem ‘A Man’s a man for a that.’ He was a liberal in his thinking and a socialist in action.

Robert Burns is truly an international figure as I learnt when teaching a group of doctors in Beijing last year. I asked them what was their favourite song and one participant said ‘Auld Lang Syne,’ as it gave him a feeling of friendship and good memories.

Many of his poems were love poems such as ‘A red red rose,’ yet he showed his feminine side by writing from a woman’s perspective with the beautiful song ‘Ye Banks and Braes of Bonny Doon.’

The holistic consultation

2009-01-17T12:18:00.000-08:00

A holistic consultation is like sitting on a beach talking to a friend.

People often ask me, ‘How can you practice holistically in general practice when you have so little time?’ I think they mean attend to all the physical ailments and include their mental and emotional well being, while also taking into account the social and environmental factors.

Firstly, it is good to be in the mind-set that 10 minutes is plenty of time. It helps me feel relaxed and comfortable.

For patients it is important they feel that they have time to tell their story. So an opening question like, ‘Tell me what can I do for you?’ allows them to go through things in their own way. I listen, attentively without interrupting. Curiously most patients will complete what they want to say within 3 minutes.

I will then ask some specific questions about their condition so I can begin to formulate what the problems are. They may need examining to help with a diagnosis.

I will have already checked on the computer their past medical conditions and drug medication before the consultation. In most cases I will know something of their family and social situation as I have been in the practice for 30 years.

I can now think how to manage their issues and give information and advise.

When all this is done I may ask how they feel about what is happening, or why they feel this may be happening to them now?

And perhaps some time for social conversation, the weather and news.

All done in 10 minutes. Well it is possible, but if not I can ask them to come back for another appointment.

Often for difficult emotional consultations I say nothing and just listen. Often when leaving they will say, ‘Thanks very much doctor for all your advise.’ -a very satisfying consultation for both of us.

Asthma and Hyperventilation

2009-01-10T03:55:00.000-08:00

The last patient in the morning surgery was a lady with asthma who said she was not any better despite the treatment she was given last week.

She had been an asthmatic for 12 years and took her inhalers regularly. She had a recent chest infection and had completed a course of steroids and antibiotics and was worried she was still short of breath.

An acute attack of asthma can be terrifying and as breathing becomes more difficult- it can feel like drowning. No wonder people panic when it happens and are fearful it can recur. If you wish to view click

When I examined her chest was clear and her lung function had not deteriorated-I checked it on her peak flow meter. However I saw that her breathing was rapid and shallow, and when I pointed this out to her she said it was worse when she was anxious and sometimes her lips and arms started to tingle. This was not a worsening of her asthma but she was hyperventilating. These are classical symptoms of hyperventilation.

The remedy for hyperventilation is to slow the breathing and take deeper breathes from the belly. It sounds simple- and it is when you are calm. But it needs practice.

Lie flat on your bed with the palms of your hands resting on your belly. Try and relax, then watch your breathing. Breathe through your nose slowly and find your own natural rhythm to your breathing. Concentrate on your breath. Your hands should rise up when you breathe in, and fall when you breath out.

I do this if I find it difficult getting to sleep at night. It is like counting sheep-you rarely get beyond 10 before you are asleep.

I showed this lady how to do this and referred her to a physiotherapist to encourage her to practice. This will not only help her when she is hyperventilating, but the deep breathing will directly help her asthma.

Back from hols.

2008-12-28T11:04:00.000-08:00

Just back from skiing holiday over Christmas. Lots of snow, blue skies, fresh air, exercise and relaxation. No TV or internet, and quality time with the family.

When I was a full time GP I took 8 weeks holiday a year, plus bank holidays and had a half day off a week with no nights or week-ends on call.

However, my first job as a surgical houseman was 108 hours a week with no days off and 2 weeks holiday each six months.

My early years in general practice we had eleven hour days, worked Saturday mornings and did a night and a week-end rota of 1 in 5. It was hard, yet rewarding. However looking back we all suffered various degrees of burnout, and in some instances depression and stress related illness. So I would not go back to those days.

As a holistic doctor I feel it is important to take time out to enjoy yourself and pursue other interests. And to have time for friends and family. But more importantly time for yourself-to relax and reflect -to have space to think, ponder and process feelings.

This needs planning. Book holidays and on days off do something you enjoy that is not work related. Also during your working day have breaks, even short ones. I play a short tracks from a CD on relaxation which is on my practice computer called Just-a-minute. These are one minute relaxation and meditation tracks. I find really helpful to keep up my energy and enthusiasm. You can download all 21 tracks for free.

Burnout in teachers

2008-12-20T01:52:00.000-08:00

End of the school term just before Christmas- guarantees several teachers will make an appointment at the surgery. Common symptoms are excessive tiredness, poor sleep, general aches, and respiratory infections. In teachers hoarseness is a frequent feature. This is called laryngitis and the treatment is simple; rest, paracetamol and no talking-or singing for that matter in the school choir.

However it is worth enquiring a bit deeper as the symptoms may be a sign of stress.

Jane consulted me this week with hoarseness. She had been a primary school teacher for 10 years. Routine questioning confirmed a viral laryngitis. But when I added a simple additional question, ‘How are you coping?’ it resulted in floods of tears. The truth was she had not been coping for a long time. She was stressed and exhausted. She is worried about her job, is lacking in self confidence and sleeping poorly. When she started her job as a teacher she loved it. However recent changes has altered the job beyond recognition. There is more paperwork, target setting and expectations of her are much higher. Many children seemed out of control.

This made her angry, depressed, and frustrated all at the same time. But most of all she was mentally and physically exhausted and now did not really care anymore.

This sounded like burnout and it is quite common in the medical profession too.

So what advise to give her? She needs to begin first to care for herself. Do the things she enjoys doing, and do more of it- walking, meeting friends, listening to music, relaxing. The Christmas holdiday may not be long enough. She needs help and support at work and at home.

I have asked Jane to come back and see me before she goes back to school to discuss what else we can do, and decide if she is fit to return to work. It my experience she will need counselling, support and perhaps anti-depressants over the next few months. It would be sad to see her leave the teaching profession -I hope it does not come to that.

An article in the BMJ in November showed how counselling helped doctors with burnout.

Migraine headaches

2008-12-18T09:48:00.000-08:00

Migraines can ruin your life. But Mary (not her real name) is determined the attacks will not ruin hers. She is thirty, has four children, works part time and migraines have plagued her for 12 years.

She had eliminated all the common trigger factors, such as cheese, chocolate and alcohol searched the internet for a remedy tied most of them but without lasting benefit.

She has been to the neurologist at the hospital. He was sympathetic and suggested several drugs but none suited her because of the side affects.

The last time I saw her I suggested she tried meditation and she said it certainly helped reduce the intensity of attacks. However they still affected her about eight days every month. Now she did admit she is a high achiever and tends to be obsessional- typical migraine sufferer personality traits. But it made her who she is-a successful mother and management consultant. Anyway personality can be difficult to change!

I suggested she might like to try cranio-sacral therapy. This is like gentle osteopathy to the head and spine with some hands on healing. If you follow this blog I will let you know how she gets on the next time she consults.

My First Blog

2008-12-18T03:52:00.000-08:00

My daughter is training to be a journalist. She blogs. She says if you want to communicate to anyone under 30 years old you need to blog. Blogging is the verb. A blog is what you write.

I think the holistic approach to general practice is important. So I am going to write a blog on my experience as a general practitioner and how a holistic approach is practical and useful to patients and doctors.

She also says that blogs should have links to other sources. Not references as we use when writing an article for a journal. But something that you can click on and get instantly connected to.

Have you heard of the 5th Estate?
‘Witnessing the rapid rise of wikis, blogs, and many other online social networks (such as FaceBook, YouTube, and MySpace), we wonder if we are ready for what has been called the Fifth Estate,- a new form of civil society participation, enabled by the growing use of the Internet, mobile phones, and related information and communication technologies.'

This came from the BMJ 13th December 2008. ‘How should health be defined?' Vol 337 p1364. That is an old style reference. Clicking on the above will take you instantly there.

My blog will be mainly case histories and may include podcasts and other such new communication developments. I hope you will connect to my adventure.