Confessions

Ara Darzi (Saturday Interview, December 29) gives an example of a patient who develops abdominal pain and, like all patients in Darzi’s isolated surgical world, is merely a scan away from a diagnosis and a cut away from a cure.

Giving Darzi the job of reorganising London’s primary care services is like asking Lewis Hamilton to sort out public transport. He may be a brilliant surgeon, but he has a naively medicalised view of health in which patients suffer from a single pathology. The art of medicine lies in the challenge of trying to understand patients and their symptoms holistically in the context of their complex social and cultural history. The kind of medicine he proposes is designed to suit private insurance companies who pay for scanning and cutting.

Good, scientific, evidenced-based healthcare which is needed to diagnose the cause of suffering and avoid unnecessary procedures depends on expert clinician time. At the core is the doctor-patient relationship. We agree that continuity of care is vital, but anyone with an interest in primary care should be extremely wary of his proposals.
Dr Jonathon Tomlinson, Dr Helen Andrewes, Dr Mel Sayer, Dr Ruth Silverman, Dr Alison Gibb, Dr Jens Ruhbach
London Guardian Letters: Health is about a lot more than scans and scalpels

The Guardian, Wednesday 2 January 2008 Article history

Meryl had come to say that she hadn’t received her hospital gynaecology appointment. She wanted me to find out what was going on. The last clinic letter sent by the nurse specialist said, ‘your patient was unable to cooperate with the exercises and so I have referred her for surgery’. She was complaining of urinary incontinence thought to be a consequence of a difficult delivery almost 20 years ago. I could have explained that the hospital was going to write and send her an appointment, ended the consultation early and moved on to the next patient. She wasn’t one of my usual patients, but she said she was very worried about the hospital appointment and couldn’t wait until the end of the week to see her usual doctor, so the receptionists had fitted her in to my surgery.

Just then I remembered when I had last seen her. She had been standing at the reception screaming and swearing at the receptionists when they tried to explain that her doctor was running late because she had been called out on a urgent home visit. Our patients are exceptionally anxious due to a toxic mix of social insecurity, deprivation, lack of education and so on, so we are used to abuse, but this was beyond the usual degree.  I had come out at that time and tried to reassure her that her doctor would be back soon, but she screamed at me that she was too sick to wait and if somebody didn’t do something soon she would call an ambulance. I couldn’t calm her down in the waiting room and so I had to see her myself, keeping my own patients waiting, who then complained to the receptionists that if they started screaming would they be seen sooner?

With this in mind, I asked her how badly the her health was affecting her. She burst into tears, and I handed over the tissues, always on my desk between myself and my patients because this happens at least once a day. It was almost 2 minutes before she could speak. Her life was ruined she said. Her husband was beating her because she didn’t want to have sex with him, she sat at home all day crying, she had no friends, no family apart from her children, and without them she had no reason to live, if she could she would kill herself. I asked how long she had felt like this, as I handed over some fresh tissues.

Since 1997 she said.

Why then, I asked, what happened?

In 1997 she gave birth to her second child. She had just separated from her violent partner and was suffering from depression. Because of her depression she hadn’t had any antenatal care and she gave birth alone at home. She had a severe tear and a haemorrhage during delivery that almost killed her. After that she developed septicaemia and was in hospital for 3 weeks unable to care for her baby. Exhausted, alone and vulnerable she let her partner move back in with her. She could not, did not want to have sex with him. After the traumatic delivery her vagina had changed, it was bigger, uglier and numb. She cried for years at what had happened to her body, but could tell nobody what was wrong.

She had seen psychiatrists and psychologists, been prescribed antidepressent and antipsychotic drugs. She had been addicted to sleeping tablets and referred to a pain clinic for chronic back pain. They prescribed opiates and anti-epileptic drugs for her pain. She had suffered years of beatings from her husband and her children were on the child protection register.

But she had never talked about what happened when she gave birth. Until now. We talked about what in the world might make her feel better. “I just want to be normal, I want them (the gynaecologists) to make me normal again. It’s not the urine (the incontinence), it’s how it looks, it how I can’t feel anything. I want my husband to love me again, I want to be able to make love to him. I just want to be normal”

The gynaecologists run a highly efficient urinary incontince service. The nurse specialist was following protocol and so would the surgeons. They would treat her incontinence professionally and efficiently with a standard surgical procedure. If she explained her problem to them, an unnecessary procedure might be avoided, but she would still be far from having the care she really needs to deal with the psychological trauma of that lonely birth 15 years ago.

Confessions like this are an almost daily occurence in general practice. Straightforward requests from patients can be accepted at face value or explored in depth. I think few people realise how often a diagnosis is made or a treatment carried out which fails to deal with the underlying problem. In general practice the patients keep coming back.

The idea that skilled clinicians should be replaced by protocol-competent nurses or technicians is popular amongst the health policy fraternity. Objections are usually met with predictable cliches about ‘vested interests’ or ‘professionalism is a conspiracy against the laity’ (Bernard Shaw, Doctor’s dilemma)

The art of medicine relies on our empathy and communication, in the trust we share with our patients, in the cooperative endeavour to find out what is going on. How different it is from the scan to diagnosis, cut and cure model of protocol-led industrial medicine.

I have condensed the conversation and changed many details to protect the identity of the patient.

See also:

The Myth of the trivial consultation

Iona Heath: Harvian Oration, Divided we Fall

Trisha Greenhalgh: Why do we always end up here?

Association between low functional health literacy and mortality in older adults: longitudinal cohort study BMJ Important article because over 30% of older adults have low health literacy, which explains why the emphasis on ‘patient choice’ threatens to increase health inequalities

The economics of choice. Lessons from the US healthcare market. The risks to patients with low health literacy.

Patients need a doctor, not someone whose primary consideration is to satisfy them. Nuanced look at the difference between the care we want & the care we need. Science based medicine.

Old blog posts:

Patients and individual responsibility

What’s the point of patient choice?

5 responses to “Confessions

  1. You are absolutely right about Darzi. When he was the “Czar” I was invited to a meeting at Richmond House along with a couple of dozen doctors, nurses and other healthcare professionals. We listened to a long tedious delivery explaining the DoH stance on healthcare. He did not have enough time to answer questions because of other “engagements”!
    He is, I am afraid to say, the archetypal surgeon – the gold and glory doctor – who is very good at performing complicated procedures which require great manual dexterity but expect to be rewarded like a professional footballer. These are the wealthy advisers who help to craft healthcare policy. Fortunately there are still some surgeons left who do not belong to that exalted clique but they are not on the list of the government’s best friends.
    Although I spent my career in hospital medicine I can well remember patients like yours whom no one had any time for and who was passed around like a bag of dirty laundry.
    With the current obsession about length of hospital stay, more and more of these sort of problems will be manufactured and no clever surgeon will have the solution or the time to devote to the root cause of such problems.

  2. I am old enough to remember being ill before the NHS and I have told my doctor in the presence of my wife that I will in no circumstances accept private medicine. Fortunately, there is little prospect that I or those who care for me will ever be faced with the choice, for I do not currently live in England.

    At 72, I am a diabetic who had a triple heart bypass six weeks ago, an injury leading to bowel complications five years ago and a minor CVA 20+ years ago. I am on the continuing caseload of ten NHS staff or departments in a health centre and three hospitals up to over 50 miles apart, two of which involve a sea crossing and one of these normally requires an overnight stay (provided free, as are transport costs, in an on-site four-star hotel if required and requested).

    In America, the treatment I have received in the last three months would cost more than the equity in my house.

    I can fairly claim to be able to recognise a bad hospital when I see one, for I was in 1974 part of the management team responsible for what was then officially recognised to be the worst hospital in the country.

    You may concede then, that I may well be able to recognise a good hospital when I see one. So can my wife (a former midwife) who has experienced both dangerous and high quality care when injured on holiday.

    That the services which I benefit from are almost beyond improvement is not only because of an 18% higher funding than in England, but because the root cause of that higher funding is that from the mid 19thC, support for publicly funded services (Health, Water, and much much earlier, Education) has been, for identifiable historical reasons, a consensus of left and right. This was because the once overwhelmingly popular party of the right was Christian Democrat, albeit strongly protestant. It was inspired more by Matthew 25 than the Church of Adam Smith.

    In rural areas “Choice” is a foreign concept in much of life. Recent choices for parents and primary schools were whether your five-year old safely walks to school, (as I did) or has a 50 minute commute each way, and whether or not a state school is re-opened for a single pupil or not. (It was.)

    Patients do want to see a doctor rather than be processed by a target driven Outpatient Appointments Manager. It is many years since I heard the once commonly used expression “You’ve got to do what the doctor ordered” but it was once widely used metaphorically to refer to non-medical sapiental authority of any kind. Such was the respect in which the medical profession was held that at one time, to combat overcrowding, random unannounced night-time inspections followed by fines for exceeding the limit were accepted as a price worth paying for public health. No expense was spared to achieve speedy and high quality engineering to provide water and sewage systems the quality of which is still admired today.

    My wife, as a nineteen year old trainee community midwife in the 1950′s, was told that, so long as she was in uniform, and carrying her distinctive midwife’s bag she need have no concerns about going into streets where the police only went in pairs.

    Have you worked out yet which country I am living in?

    Where it is that the public health systems are going in the opposite direction to England, more generously funded, and publicly supported? Where public health issues like the smoking ban are accepted more readily and sooner than they are in England? Where vestigial elements of marketisation are being dismantled? Where professional opinion is respected? Where Nottingham University found that the healthcare system’s “groundbreaking” approach to the art of industrial relations was “arguably the most ambitious labour-management partnership so far attempted” in the public sector and made it work?

    Where the number of pandas exceeds the number of Conservative MP’s and the disparity is set to increase in both directions?

    Some people think Scotland is so different from England that it should be a separate country.

  3. Jonathan, thankyou for sharing this.
    It’s an incredibly moving story, but also does not surprise me.
    I think there is so little understanding of what roles entail,
    or the complexity of people’s health needs- which involve
    the whole person; not just ticking boxes or rushing them through the door.
    I’m glad for her that she found the right person and doctor to speak to;
    but what a tragedy it took this long- and so much suffering.
    If I may be honest- not all GP’s have the skills or give the time
    to people with more complex needs; perhaps it comes down to their medical training? Eg- lack of emphasis on personal skills or counselling/
    self awareness training, even at a basic level. TBC.

  4. (Continued- as box limited.)
    Just to explain-my background was as a health professional,
    as RGN, RMN, and HV in primary care setting more recently.
    I’ve worked with many different people in various roles,
    in hospitals and community.When I specialized in mental health
    back in the 80′s, I became very aware how useful it would be
    for merging areas of practice and skills; eg breaking away
    from a medicalized model, and viewing people has whole beings;
    treating patients holistically, and training staff in basic communication
    skills; for me, that was especially doctors; but also general trained
    nurses.Considering GP caseloads have very high percentage of people with mental health problems and complex chronic health conditions,I’d envisage professionals need the grounded training and understanding to be able to respond; also they themselves need support.I totally agree that the current reforms may add unbearable pressure on already hard pressed GP’s and create far less time to listen and respond effectively; it could even be dangerous.I hope it is possible that many of us as a health professional community can share experience and support in the future now the pressure is so much greater; at the very least for the purpose of supporting patients and providing the very best quality care that any of us are capable of,with limited resources and under great strain.There is a lot of wisdom and experience to be shared. Thankyou, Jo F.

  5. I had a problem after something suddenly hurt while I was doing circuit training and I found I couldn’t get a tampon in any more (much less anything else). My GP referred me to a gynaecologist who told him I was just a bit tense and had severe mental illness. My GP’s response to the mental illness bit was “we knew that, but that wasn’t why I referred you”.

    Subsequent examinations for other things by both doctors and nurses for other reasons (post-menopausal bleeding and smear tests) have shown that things aren’t lying in their normal place.

    I can’t make things go back to how they were and the gynaecologists aren’t interested in fixing them, so I’ve abandoned all hope of a sex life, but I could have hugged my GP for what he said. At least someone wasn’t simply writing me off because I also have severe and enduring mental illness. Sometimes a doctor doesn’t have to fix you, they just have to believe you.

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