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
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.
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.
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