New kinds of heroes


Half a league, half a league,

Half a league onward,

All in the valley of Death

Rode the six hundred.

“Forward, the Light Brigade!

Charge for the guns!” he said.

Into the valley of Death

Rode the six hundred.

“Forward, the Light Brigade!”

Was there a man dismayed?

Not though the soldier knew

Someone had blundered.

Theirs not to make reply,

Theirs not to reason why,

Theirs but to do and die.

Into the valley of Death

Rode the six hundred.

The Charge of the Light Brigade

The generals repeated the old lie, “Dulce et decorum est, propatria mori!” Sweet and becoming it is, to die for one’s country

Hippocrates and Galen, are still renowned for their wise and innovative advice on medical matters. When it came to plague, they offered guidance, rendered in Latin as ‘Cito, Longe, Tarde,’ which translates as ‘Leave quickly, go far away and come back slowly.’ When the Black Death swept over much of Asia, Europe and parts of Africa in the mid-1300s, such advice was about as good as it got.” Bought to Life

Some did stay, out of Christian duty, desire for fame or because they got ‘hazard pay’ from local communities. The idea of a social contract didn’t come around until the 19th century.

At the start of the 20th century the American medical code of ethics stated, “when pestilence prevails it’s the physician’s duty to continue ministering to the sick even in peril of their own lives”

In 1912 the language was strengthened to say there was, “an obligation to continue taking care of people who posed a contagious threat even if you were not being paid to do so.” Ethics Talk podcast

But how far should this duty reasonably extend? Doctors are already dying from Coronavirus infections contracted in the course of caring for infected patients. Many, if not the majority, lack the recommended protective equipment.

Doctors have always placed themselves at risk in the course of their work. In 2003-4 I joined Medecins Sans Frontieres (Doctors without Borders) and I accepted a job in North West Afghanistan knowing that there were risks including death, because of ongoing conflict. While I was there some of my colleagues were assassinated very close to where I was working. Since then I have chosen not to go back to work in conflict zones, but other doctors continue to do so. Doctors’ attitudes to personal risk in the line of duty vary considerably.

At one end of the spectrum are those, like David Nott, the war surgeon, who wrote, “I have travelled the world for 25 years in search of trouble. It is a kind of addiction, a pull I find hard to resist. It stems partly from the desire to use my knowledge as a surgeon to help people who are experiencing the worst that humanity can throw at them, and partly from the thrill of just being in those terrible places, of living in a liminal zone where most people have neither been, nor want to go.” Others are risk averse and under the current circumstances are avoiding all clinical contact while their colleagues continue to work in intensive care units with patients who have coronavirus infections.

I find myself somewhere in the middle of the spectrum. In 2003 I was single and in search of adventure and I felt invincible. In 2020 have young children and I feel more mortal.

We all have reasons for where we might find ourselves on the risk-taking spectrum. One is what motivates us. Not all doctors are primarily motivated to take risks by the desire to save lives or help people less fortunate than themselves. The motivation may be extrinsic rewards like money or fame. Other motivations include intrinsic values like caring, social justice or self-sacrifice which may derive from upbringing, life experiences or religion. Caring can be viewed as a positive motivation; for example, someone bought up in a caring environment with positive experiences of care and caring, for whom caring is an integral part of their identity.

The need to care for others and sacrifice oneself may also come from a need to repair something flawed, damaged or shameful about oneself, to compensate for low self-esteem. Growing up in a relationship with parents who made someone feel inadequate may result in these feelings persisting into adulthood. The adult tries to compensate by self-sacrifice and risk taking. The sense of being flawed or ‘bad’ drives the need to ‘do good’ while the risk-taking is driven by a sense of ‘just deserts’.

There is a strong sense of this when listening to the war surgeon David Nott who places himself not just in high risk, but unnecessarily high-risk situations. Risk for him is both euphoric and addictive. He is the archetype of a heroic doctor, putting the lives of his patients above concerns for his own life. We might hope for him to be our surgeon in a life or death situation, but we might feel differently if we worked with him.

Doctors work in teams; with other doctors, nurses and health professionals as well as admin staff. It’s easier and perhaps more comforting to imagine that the patient is their only, or at least primary concern, particularly in relation to a war surgeon. A GP has to care for individual patients as well as their practice population. We have to support widows who are grieving and be sure that all the children registered are fully immunized. As a senior partner in my practice I am responsible for over 26000 patients and 40 members of staff. The more I sacrifice myself in the services on one person the less I am available for others.

Brain surgeon Henry Marsh is another heroic doctor whose concern for his patients described in his book First Do No Harm runs to commandeering hospital beds and over-riding clinical colleagues and an open contempt for hospital managers whose concern is the smooth running of the hospital. From an individual patient perspective, you’d want him on your side, but if you happened to need a hospital bed for something other than neurosurgery you might feel differently.

Obligations to individuals and populations come into conflict all the time in medical practice and the extent to which our sphere of responsibility diminishes with distance varies considerably between doctors and between individualistic and communitarian cultures. We live in an individualistic culture that valorizes heroes. We are conservative; suspicious of foreigners and socialism having voted for Brexit and 10 years of Tory rule. We are looking for heroes to save us from Coronavirus.

For the last week I have been self-isolating – with what feels like a typical cough and cold. I don’t have breathlessness or a fever. There’s no way of knowing if it is a mild case of coronavirus. Under other circumstances I would be at work. Presenteeism – the phenomenon whereby healthcare professionals come to work in a state of ill-health that they would advise their patients to stay at home, is rife. But this might be Coronavirus. As the pandemic unfolds we might reach a situation where medical professionals are more likely to be infected than their patients. Dr Gordon Caldwell a consultant physician in Oban, has written about what should happen if he requires ventilation because of coronavirus infection.

If I survive to be weaned off the ventilator (1 in 5 chance) it would be at the expense of 1 staff member with severe Covid 19 and 3 others infected, who in turn could infect other staff, patients, and their own family and friends. Until someone can counter this argument with a convincing statistical, not emotional, case, I have stated that I am “Do Not Attempt Cardiopulmonary Resuscitation (DNACPR” and “Do Not Intubate and Ventilate (DNIV)”


Hospitals as well as doctors might soon become the hubs for transmission of coronavirus in the UK if we continue to follow Italy’s lead. The hero who remains on deck after all the passengers and crew have left the sinking ship is not suited to the present epidemic. Our present-day heroes will have to relinquish the helm while they isolate themselves to protect their colleagues and their patients. They will have to trust their colleagues to take over. They will have to show that we can carry on without them.

Michael West – an organizational psychologist who leads on compassionate leadership for the NHS recommends that the priorities should be listening to staff, removing obstacles to safe and effective work, and providing for their basic needs: safety, rest, nourishment and connection. The lesson from this is that during this crisis every single one of us, will at some point have to be a new kind of hero.


Trauma informed care in General Practice

“In the mid 1990s the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for 7 out of 10 of the leading causes of death in the United States. In high doses it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed. Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy. And yet, doctors today are not trained in routine screening or treatment. The exposure I’m talking about is not a pesticide or packaging material it’s childhood trauma”.

Nadine Burke Harris


In this blog, I’d like to suggest what routine screening and treatment might look like in primary care/ general practice. In previous blogs I’ve focused on care for individuals, but here I want to describe a population approach.

Childhood trauma (also called ACEs Adverse Childhood Experiences,  is a risk factor for disease, and like other risk factors, for example smoking, the greater the exposure, the greater the risks. Maltreatment that begins earlier in life, is more severe and continues for a longer duration is associated with the worst outcomes. The harm is a result of physiological and behavioural changes; what I have recently described as the ‘Trauma World’  also called ‘Toxic stress’. The word ‘trauma’ is often used to refer to this response, rather than the traumatic events. This is what makes trauma traumatic. For example, PTSD often develops after a supportive partner dies, because their partner provided them with enough resilience to cope with the trauma of their past experiences. Trauma is a legacy of emotional hypersensitivity (or the opposite, alexithymia/ numbness), toxic shame, dissociation and harmful coping strategies. Survivors present to GPs with chronic anxiety, recurrent panic attacks, chronic pain and chronic fatigue. They are more likely to suffer from multiple long-term conditions like diabetes, vascular and lung diseases, autoimmune diseases and cancer at younger ages. As well as being at risk of ill-health they are at risk of violence, abuse, homelessness and destitution. They are less likely to have attended for vaccinations or screening for cancer and they are more likely to smoke, drink alcohol excessively and use drugs including potentially hazardous combinations of prescribed drugs.

A GP practice would want to identify people suffering from trauma in order to diagnose diseases early, to prevent them from developing and to provide appropriate social and psychological support.

A GP practice has a list of registered patients (a denominator) and they will know the numbers of people with long-term conditions such as diabetes, hypertension and depression (the numerators), and they will be invited in for regular reviews. It is easy to identify these people because they have a diagnosis. Because ‘trauma’ is not a diagnosis, it is not tested for or documented like other long-term-conditions so we do not yet have a reliable way of identifying patients who have been affected. A recent study found that trying to identify patients by searching their records for evidence of Adverse Childhood Experiences found only about 1% of those they expected to find.

There is a code for ‘History of complex trauma in childhood’ which has only recently been introduced, but despite my interest in the subject, I am yet to use it because I’m not sure that many people would want it in their medical records. They might rightly fear that other clinicians would bring it up uninvited or worry that whatever symptom they sought help for would be blamed on ‘trauma’. A history of trauma may be hidden in the text of a consultation or a hospital letter, but we cannot search the electronic records in this much detail as we can for diagnostic or problem titles. In any case, it is the presence of trauma, rather than a history of adversity that we are trying to identify. So instead of searching for a diagnosis we could include people with symptoms that are suggestive, if not diagnostic of a past history of trauma; problems like chronic anxiety, chronic pain, irritable bowel syndrome, chronic depression, OCD, self-harm, personality disorders, alcoholism, opiate/ benzodiazepine addiction – and I would include anyone on long-term anti-depressant or antipsychotic medication, regular opiate or benzodiazepine prescriptions.

Patients identified this way might represent 10-50% of a GP practice population depending on issues like deprivation and immigration. Having identified patients, they should be invited in for an initial review and if suitable (more on ‘suitability’ below) added to an ‘at risk’ register for continued annual reviews. Many of these patients will be known to be suffering trauma, and some will not. At the initial review both doctor and patient need to agree whether a regular review would be useful. If there is a disagreement, then the patient’s preference is what matters, after all it’s for their benefit. I would caution against assuming that non-attendance is a sign of disagreement, since people whose lives are insecure and full of anxiety often struggle to attend appointments

The review:


An annual review should be comprehensive so that all the patient’s long-term conditions are reviewed at the same time, so as not to overburden them with appointments. Their lives are usually filled with bureaucracy as it is. I would include:

  1. A co-created problem list.

It’s been enormously helpful for me to look at patient’s records with them and agree on what to call their different conditions and which are active and significant. It’s an opportunity to think about what the prefix ‘chronic’ means when applied to pain, anxiety or depression. I quite often discover that embarrassing problems like incontinence, mentioned years ago have not been bought up since and are not ‘minor, past problems’ but are definitely ‘significant and active’. In my experience, the process of agreeing on this list together helps both patient and clinician to join-the-dots and see how different conditions relate to one another. At this point it is not unusual for childhood trauma to be bought up and discussed in detail or at least acknowledged. This is a good opportunity to explain the purpose of the review.

An important point here is to recognise that significant childhood trauma is a risk factor for a wide range of diseases and the point of the review is to treat them early or prevent them so far as possible. This can help to reassure patients that far from attributing all their symptoms to trauma, we are staying vigilant for the biological consequences of a lifetime of stress in a way that is safe, structured and planned.

  1. Disease identification and prevention

For many people the experience of past trauma leaves them in a state of tension and hyperarousal, so assessing for hypertension, cardiovascular disease and inflammatory diseases such as arthritis and colitis should be included. Screening for cancer, vaccinations for HPV, childhood viruses, hepatitis and flu, sexual and reproductive health are all especially relevant for people with a history of trauma who may, as a result of insecure, chaotic lives have missed out. Because trauma increases the risks of developing disease, they have more to gain from screening than people more fortunate.

  1. Risk factors relating to coping

People who have experienced significant past trauma often resort to coping strategies that in themselves can be harmful: smoking, excessive drinking, illicit drug use, eating disorders, unsafe sex and so on. We should ask about coping strategies and offer support with smoking cessation and alcohol services, sexual and reproductive health and whatever else is required. We should help them find other, less harmful ways of coping.

  1. Social security

One of the most traumatic events that effects my patients who have already experienced trauma is having their benefits stopped after assessment by DWP. Over 90% of them succeed on appeal but have nothing to live on for 6 months or so while waiting for the process. We need benefits advisers to be available to help people when they need it, within GP surgeries. Social security also includes personal safety and many women that I look after with a history of childhood trauma also have ongoing trauma from domestic violence, so we should ask about this – the HARK questionnaire is a useful aid. We can then refer to specialist supportive services. Young people are at risk of gang violence and exploitation and should be offered support.

  1. Mental health

Many patients will already be suffering from diagnosed mental illnesses, but others will have undiagnosed problems like anxiety, panic disorder, OCD and autistic spectrum disorders. Including mental health as part of a general healthcare review helps to create a culture in which a healthy mind and body are considered together.

  1. Medication review

People with a history of significant trauma are often prescribed a lot of drugs to help alleviate their symptoms and treat their various long-term conditions. A medication review is an opportunity to talk about which drugs are helping and which ones are no longer useful and which ones are harmful; to check for side-effects, interactions and risks including dependence and accidental overdose. We have a clinical pharmacist in our practice who can help with medication reviews including tapering regimes for people who want to come off harmful drugs.

  1. Social prescribing and social isolation

One of the consequences of trauma is that survivors are more likely than others to be isolated and lonely. Annual reviews could take the form of ‘group consultations’ already being used successfully for diabetic annual reviews. There could be a social space in the practice, in the waiting room if it is big enough, where people can get a cup of tea and sit around tables where they can chat while waiting to see a clinician. Some people much prefer to be in their own space, so they need to be made to feel safe and comfortable as well. Most practices can refer patients to social prescribing to help patients find safe places to be doing things with other people in the community.

  1. Physical wellbeing

Bottom up therapies are things that you can do to feel more in control of your body. It can be anything from knitting to yoga, from gardening to parkrun. Nerve fibres from the body travel up to the brain, so that things that make our bodies feel capable, controlled and strong also help our minds to feel the same way. For many people this is much more effective (and acceptable) than psychological therapies. Most practices can refer for exercise programmes and some are even introducing other activities like tai chi and therapeutic gardening.

  1. Nutrition

It is hard to be feel well if you are unable to afford to eat well, if your diet is unhealthy or food is associated with shame. Programmes like Food For Life run by Shoreditch trust can help people learn to change their relationship with food


This is an idea and not something that I have implemented, yet. From a GP perspective it might seem like a lot of additional work, but I suspect that most people identified will already be coming in for a review because they have previously been diagnosed with other long-term conditions. It will identify new patients by including a new set of long-term conditions like chronic pain and addiction. I hope that it upsets the Bio-psycho-social hierarchy by making social security, mental health and physical health equally important. I hope too, that it helps to reduce the risks of diagnostic overshadowing by taking a proactive approach to the early identification of disease in people at high risk. Most of all I hope that it helps doctors and patients to come to a better shared understanding of one another by co-creating a problem list and thinking about why it looks that way and what the implications are. And from this I hope to shine a light on hope and salutogenesis.

What is toxic stress and what can we do about it?

*Felicity De Zulueta





The Trauma World and The Healing World

John sat next to his mum, an elderly, anxious looking woman who did most of the talking. He rubbed his palms hard together, as if trying to rub out a stain while she talked. He was sweating and his right leg kept trembling. He clamped his hands between his thighs to keep his leg and hands still. Mostly he looked down, without focusing, at the floor in front of him. He wore a black jacket over a grey tracksuit with white trainers that had seen better days. He was new to the practice, though I had met his mum a few times before. He wasn’t long out of prison and Janet, his mum, had told me a while ago that she wanted to bring him to see me when he got out. Fortunately the recent spell inside had been short and we had a pretty decent set of notes from his previous GP.

Before he came in I looked at his ‘problem’ list. The electronic patient (medical) record (EMR) has a list of Active and Past Problems, sub-categorised into Significant and Minor. A patient’s problem becomes a Problem in the EMR when it is picked up by the EMR and ascribed a code. A Problem can be a diagnosis, a symptom, or anything else a patient reports that a doctor or a medical summariser adds to the record, so long as it is picked up by the EMR (it comes up in blue text as you type it in). Problem codes aren’t (though I would like them to be) a definitive list of a patient’s problems, but they can be useful. John’s problem list ran to about 160 entries over 4 pages. There were Problems that weren’t problems like, ‘Telephone call to patient’ and ‘results discussed’ as well as Past Problems that I suspected should have been Active Problems like, ‘Anxiety’ and ‘Depression’. Some Minor Problems like ‘Alcohol Problem Drinking’ and ‘Overdose of opiates’ I thought were probably Significant. Problem lists accrue over years and if they are not ‘tidied up’ it becomes impossible to see what problems are ‘Active and Significant’ because they are mixed up with everything else. Another issue is that different problem codes are used to refer to the same problem, for example:

Anxiety states (Significant Past)

O/E anxious (Minor Past)

Generalised Anxiety Disorder (Significant Past)

Anxiety NOS (Minor Past)

Anxiety with depression (Significant Active)

Panic attack (Significant Past)

Agoraphobia (Minor Past)

Social Anxiety (Minor Past)

Irritability and anger (Minor Past)

Often the same Problem code is there repeatedly; there were 5 Anxiety States, 4 O/E anxious and 3 Anxiety NOS. as if anxiety is something new each time, rather than a chronic, enduring state.

Problems relating to anxiety were a feature of his problem list from the age of 11 up to his present 41 years.

Other Problems referred to physical symptoms and conditions that frequently accompany anxiety:

Irritable bowel syndrome (4 times, Significant Past)

Dyspepsia (8 times, Significant Past, 3 times, Minor Past)

Bloating symptom (5 times, Minor Past)

Abdominal pain (5 times, Minor Past)

Chest pain (4 times, Significant Past


Feels Faint


Urinary symptoms (3 times, Minor Past)

Burning symptom

Going through a problem list is like examining a crime scene for evidence in order to make sense of what has gone on. A problem list is limited by culture, assumptions, omissions, misunderstandings and mistakes. It serves as a tool for audit and finance – we need to know how many patients we have with depression/ diabetes/ cancer/ heart disease and so on so that we know can make sure that we call them in at regular intervals for proactive, preventive care and get paid for it. Because of this, certain problems like these are more reliably coded than others. The presence of multiple problem codes referring to anxiety over a lifetime suggest that anxiety isn’t just situational, but has something to do with what happened in childhood or perhaps a genetic/ familial trait. Taken in conjunction with multiple related physical symptoms, the issue looks more like a lifetime of hyper-arousal – a state of chronic fight of flight than of anxiety alone.

One consequence of being stuck in a state of ‘fight of flight’ is exhaustion. This hyper-vigilance is unsustainable. In childhood it comes across as hyperactivity or ADHD, but with increasing age this gives way to exhaustion with chronic fatigue, depression and chronic pain, or cycles that swing from mania or hyperactivity to depression and numbness. I note that John has ‘Emotionally Unstable Personality disorder [replaced Bipolar disorder]’ among his Active Significant Problems. For some people, this chronic stress causes autoimmune diseases like inflammatory bowel disease, connective-tissue disease or inflammatory arthritis.

There were Problems relating to pain:

Abdominal Pain

Generalised pain

Back pain

Low Back Pain

Chronic Low Back Pain

Lumbar Disc Degeneration


Pain in leg

Radiculopathy NOS

Neck pain


I looked for Problems that suggested ways of trying to cope with chronic anxiety, depression, exhaustion and pain.

Opiate misuse

Diazepam dependence

Alcohol problem drinking

Self harm

Accidental overdose

Suicide attempt

The problems suggested something that Daniela Seiff wrote about in Understanding and Healing Emotional Trauma called The Trauma World. I’ve adapted it to use in practice – as shown in the slide below. The Fight or Flight response which may include psychological symptoms of anxiety and hyperactivity as well as physical symptoms like irritable bowel syndrome and palpitations comes under hyper-arousal. These are usually the most obvious or visible symptoms. The flip-side, the ‘freeze or flop response’ includes fatigue, alexithymia (numbness) and chronic pain and comes under hypo-arousal. Toxic Shame refers to pervasive self-blame and may include suicidal behaviour and self-neglect. Symptoms like depersonalisation, derealisation, and functional neurological symptoms like non-epileptic seizures are examples of Dissociation. The use of stimulant or sedative drugs – prescribed or illicit, comes under ‘Coping’. According to this model, addiction is a symptom of The Trauma World, not something separate, or even the primary problem. In red I have written words that refer to the experiences that people who live with The Trauma World suffered when their trauma was committed and frequently continue to suffer in their interactions with medical (and other) professionals; cruelty, disbelief, blame and rejection/ chaos.

The Trauma World

There are no simple answers to Trauma World, but there is a mirror image that I have found to be useful, which I call The Healing World.

Where there has been cruelty we can be kind, where there has been disbelief, validation, where there has been blame and shame, vindication and where there has been chaos (and rejection) commitment and consistency, demonstrated by continuity of care. The fingers and thumb don’t mirror the Trauma World, but do serve as a guide for what’s needed. Mind refers to feelings, memories and thoughts which can be helped by therapy. Body refers to physical activity which might be yoga, Tai Chi or knitting, singing, dancing or baking. Something where the focus of attention is on doing things controlled and creative and ideally rhythmical with the body. Biology refers to everything that goes in the body – food and drink, even fresh air. It is a reminder that medicines are only a small part of The Healing World and that what you put in your body affects every part of your body. Positive human relationships have been proven to be the most important factor in recovery from trauma. People are often isolated, lonely and frightened of human interaction, afraid of what other people might think of them or say about them. Feelings of shame, anxiety and depression colour interactions with pessimistic expectations; ambiguous social cues are interpreted negatively. This can be so hard to overcome, and may take years and long-term relationships and unconditional love. A friend and survivor of trauma who runs groups for men who were abused reminds me that, “there are too many of us for you [GPs] but you can help us to help ourselves by providing space for us to meet and run peer support groups'”

Social security is absolutely vital. It is why there is The Trauma World has a social gradient; people who are deprived have fewer resources to buffer the effects of trauma and may live with the threats of violence and destitution. Social security wraps around everything else; make a fist and your thumb wraps around your fingers.

With John beside me, we look at his problem list together. One significant and profoundly useful act, is to agree about what Problems are Active and Significant and what labels accurately describe his symptoms. There no Problem codes for “The Trauma World’ or ‘Complex Trauma’ or even ‘Complex PTSD’. There is ‘Other PTSD’ and ‘Chronic Anxiety’, ‘Chronic Depression’ and ‘Chronic Pain’. We add ‘Irritable Bowel Syndrome’ and ‘Irritable Bladder’. After ‘Other PTSD’ I add a note – ‘discussed with patient, see consult 20.01.2020’ If patients are to receive the benefits to which they are entitled, then at the very least they need a medical report that is accurate and has a list of mental health conditions – in John’s case, Generalised Anxiety Disorder, Panic Disorder, Agoraphobia, Complex PTSD, Depression, History of Self Harm and Suicide Attempts. Emotionally Unstable Personalty Disorder may be unacceptably pejorative, but it’s might be of use in a benefits claim.

I don’t know what happened when John was growing up. I’m not at all sure that it’s necessary for me to know. Probably only if and when John wants to bring it up. There’s enough in his Problem list to know that ‘stuff happened’. Usually though, once we’ve worked through the list and seen the pattern, we’ve laid down a foundation for trust and the past comes out. In that case I document it and leave a reference next to the problem title, so that in future another doctor can look it up without John having to go through it all again.

The Trauma World and the Healing World are grounded in patient experiences and clinical practice. They are a call to action. They demand that we take notice of the bigger picture, that we stop making distinctions between mind and body, that we pay attention to shame and injustice and do something to make a difference.

For more on Social Security and mental health see this special edition of Asylum Magazine (with thanks to on Twitter)

For more on The Trauma World see Daniella Seiff’s website

For more on The Healing World see

For more on dissociation see

For more on Trauma see

For more on Chronic Pain see

My psychology of pain

Three and a half weeks ago I crashed my mountain bike riding downhill over a jump in Epping Forest, trying to keep up with my 9 year old who is perfectly comfortable being airbourne. I somersaulted in mid air landing on my back, then bounced onto my head and back onto my back (or something that felt like that). The small backpack I was carrying with tools, snacks and spare tubes, dug into my back on the right side of my chest and I was winded, speechless and in a lot of pain. My ride home was exquisitely painful. I diagnosed myself with 2 fractured ribs at the back of my chest and one at the front on the right side and one at the front on the left – I could feel a small step and some movement where they hurt, and still, sleep is almost impossible, sneezing agony and I cannot find any painkillers that do much (apart from 100mg diclofenac suppositories which give me about 5 hours relative relief)

I went back to work the day after the crash – GP partners have a ‘shadow contract’ which stipulates that we shall continue working up until the point of death and for a minimum of another month after that.

It’s still painful, but I can ride to work (10km) so long as I don’t stand up or change speed too quickly.

I’ve begun to notice small signs of improvement and changes to the nature of the pain. More and more it seems to hurt deep inside – where my liver is. I’ve been telling my (non-medical) wife that my liver feels bruised.

Yesterday a partner came back to work after maternity leave, noticed my discomfort and asked what happened. “How do you know you haven’t got a liver haemorrhage?!” she asked, aghast. I let this sink in while my attention drifted into and around my ache.

Ever since then it’s been impossible to shift the focus of my concern. Now it’s my liver that hurts more than my ribs and the nature has become more of a tense, dull, livery kind of pain and less of a sharp, crunchy ribby kind of pain. I’ve given up alcohol for a month and paracetamol and have started being more cautious with how I move.

Simply being more focused on ‘a bleeding liver’ has changed my pain perception and my pain behaviour. It definitely ‘feels like’ my liver is swollen and engorged with a big blood clot. If I have a scan and can see how much or how little damage there is (as represented by the scan) how will I feel then? If it’s ok, will the pain resolve, will I celebrate with a drink? If not, will I worry more and if it looks bad, will the pain get worse and more ‘livery’?

I don’t know.

The iatrogenic harm (harm done by the things doctors say and do) that comes from a suggestion is significant, but largely overlooked – by doctors at least, except perhaps by GPs who are constantly picking up the pieces after their patients have attended A&E with unexplained symptoms onto which an enthusiastic junior doctor has attached a list of possible diagnoses that their daft old GP couldn’t possible have thought of. Our patients come back to see us saying – “the hospital told me you have to refer me / arrange a scan …” Furthermore the more tests we do, scans/blood tests etc. the more abnormalities will show up that are unrelated to any disease or adverse prognosis, but are a reminder that our bodies are flawed and imperfect. A reminder that may make us actually feel unwell.

By not presenting myself to hospital, but avoiding a scan, I’m avoiding a diagnosis, a label and a cascade of interventions. I’m also evading the potential indignity of poor care and invalidation. I’ve had a lot of A&E and follow up hospital visits in the last year of cycling related trauma and the petty humiliations: being ignored, nobody introducing themselves, being patronised and condescended to, upset me. But also it’s upsetting because I / we are all representatives of the NHS and these petty humiliations are symbolic of a service that is failing. And this is another kind of pain I’m keen to avoid.


The Exceptional Potential of General Practice



If your impression of NHS general practice is one of terminal decline and despair, you’re looking in the wrong places. The wonderful paradox that is General Practice at the Deep End has proven yet again that if you want to be inspired by examples of clinical excellence, educational innovation, and passion for practice then you need to be talking to people delivering primary healthcare to the most vulnerable people in the most challenging places.

  1. Relationship-based care – connecting people and places
  2. Generalist, multidisciplinary primary care
  3. Proactive, anticipatory and planned care
  4. Education, research and advocacy for patients and providers
  5. Hope: focus on what is possible
  6. Solidarity: we’re part of a movement

The six points above are my summary of two days of presentations and conversations in Glasgow at a celebration of the life and work of Julian Tudor Hart and the launch of Professor Graham Watt’s book, The Exceptional Potential of General Practice.

  1. Relationship based care

Biology is bound up with biography. The doctors, nurses, social workers, health-visitors, district nurses and Focused Care Practitioners who work with vulnerable people bear witness to their lives and their stories. Adverse childhood experiences aren’t an abstract notion for professionals who visit their homes, stitch up their wounds and drink tea with people whose lives are beset with trauma we can barely imagine. We make human bonds over time, and develop trust, respect and affection that flows both ways. Our surgeries are safe havens, ‘palaces for the people’ where people who have power and privilege listen and are kind to those who do not, and are capable and use their power to heal and enable. Trusted people and places build connections and create formal and informal networks. People discover that they are worthy of care and attention. There are places where one need not feel ashamed.

  1. Generalist, multidisciplinary primary care

The most vulnerable people – those with learning difficulties, serious mental illnesses, the homeless, abused and addicted – die two or three decades younger than the most fortunate. They die from the complications of under-treated long-term conditions like hypertension, heart-disease, diabetes, asthma and COPD. Treating these conditions can narrow the gap in life-expectancy. But these conditions are ‘silent killers’ because they are usually symptomless. Suffering comes from anxiety and depression and the stress and distress of poverty, hunger, violence and neglect. Where we cannot offer a cure, we provide relief. Holistic, generalist primary care is concerned with the relief of any suffering, no matter what its cause.

  1. Proactive, anticipatory and planned care

Far from the ‘worried well’ that most GPs complain about, and the worried unwell that worry us, the unworried unwell are the ones we are most concerned about. These are the patients who attend when they are in crisis but whose arteries are about to catastrophically thrombose under the stress of uncontrolled hypertension and diabetes. Planned care with routine appointments in pre-arranged clinics doesn’t work well for people whose lives are filled with crises or whose mental health is precarious or who don’t know or don’t care or have other, more pressing concerns. They need anticipatory care – attention to what might kill them, whenever they on attend with what ails them. They need proactive care- delivered at home, in the night shelter, on the streets even, wherever we can track them down. We need to know who our patients are whose health-care needs have been neglected and make sure nobody is omitted.

  1. Education, research and advocacy for patients and providers

We need professionals with the skills suited to the problems that they are expected to deal with; complex multimorbidity with social insecurity, chronic pain, addiction and adverse childhood experiences are highly prevalent and can be distressing for professionals who are not prepared or well supported. We should use research to advocate for political action on the political and economic drivers of inequity, the poor housing, poverty and insecurity that results and the high prevalence of diseases that we have to treat. Failure to act upstream means we need more resources to treat the consequences downstream.

  1. Hope: focus on what is possible

Those of us who work in the Deep End know how bleak the situation is. We don’t go to conferences to be reminded of our daily grind. We go to discover what is possible, to hear from people who are succeeding and thriving despite austerity. Professionals who work in areas of deprivation frequently talk about how much they learn about resilience, survival and recovery from their patients. Just because it’s possible to overcome adverse childhood experiences doesn’t mean that we won’t fight for children’s rights. Just because some poor people can eat well from food banks doesn’t mean that we think that food banks aren’t the result of a profoundly unjust set of policy decisions in the wake of the global financial crisis. Focusing on the possible protects us from nihilism and despair, keeps us open to learning, helps us to seize opportunities, keeps lines of dialogue open. The hopelessness that so often accompanies poverty can be contagious, but so is the hope and optimism that goes with Deep End general practice.

  1. Solidarity: we’re part of a movement

Shared values, a shared mission and an infections optimism bind us together. Contributors at the conference from England, Ireland, Scotland, Wales, the US, Lebanon and Belgium showed us that at the same time as it is possible to be an expert in the health needs and behaviours of people in a specific place it is also possible to be kindred spirits with doctors from all over the world. Doctors in deprived practices are often professionally isolated and heavily burdened by the complexity and emotional labour of care. To bond with peers with whom you are morally and intellectually aligned is empowering and energising.

Thanks to GPs at the Deep End all over the world.

Deep End logo

The Exceptional Potential of General Practice – Conference Programme


The filming of the speakers can be found here:

The speakers’ presentations (PowerPoints) can be found here:


University of Strathclyde Technology and Innovation Centre, 99 George Street, Glasgow G1 1RD.



Day One: Thursday, 14 February 2019


13.00               Arrival and registration



SESSION ONE: Dr Julian Tudor Hart and The Inverse Care Law


Chair: Dr Carey Lunan, Chair of RCGP Scotland


14.00               Welcome and introduction: Dr Carey Lunan


14.10               The example of Dr Julian Tudor Hart: Professor Graham Watt


14.30               The Inverse Care Law – market forces: Professor Allyson Pollock


14.50               The Inverse Care Law – research evidence: Professor Stewart Mercer


15.10               Discussion


15.25               Break



SESSION TWO: The Exceptional Potential of General Practice


Chair: Dr Carey Lunan, Chair of RCGP Scotland


15.55               Serial encounters: Dr Iona Heath


16.15               Community practice: Dr Peter Cawston


16.35               Big data: Dr John Robson


16.55               Discussion


17.10               Close










Day Two: Friday 15 February 2019, Morning Session



From 08:45     Registration


SESSION THREE: General Practitioners at the Deep End


Chair: Professor Graham Watt, University of Glasgow


09.15               Welcome and introduction





09.20               General Practitioners at the Deep End: Dr Anne Mullin


09.30               Govan SHIP: Dr John Montgomery


09.45               The Pioneer Scheme: Dr Petra Sambale


10.00               Discussion





10.15               The Irish Deep End Project: Dr Patrick O’Donnell


10.30               GP training and recruitment: Dr Austin O’Carroll


10.45               Discussion


11.00               Break





Chair: Dr Helen Stokes-Lampard, Chair of RCGP Council


11.30               Yorkshire/Humber: Dr Elizabeth Walton


11.45               Greater Manchester: Dr John Patterson


12.00               Discussion





12.15               Where next for the Deep End Projects?


13.00               Lunch




Day Two: Friday 15 February 2019, Afternoon Session


SESSION FOUR: Future Challenges


Chair: Dr Khairat Al-Habbal, Lebanese American University, Beirut


14.00               Welcome and introduction


14.05               Social Medicine: Professor Jan De Maeseneer


14.25               The Wider World: Professor Sir Andy Haines


14.45               The Educational Challenge: Dr David Blane


15.05               Break  




SESSION FIVE: What Does the Future Look Like for General Practice?


Moderator: Dr Richard Horton, Editor, The Lancet


15.30               Plenary discussion with panel


16.30               Close





The Exceptional Potential of General Practice


Speaker Biographies


David Blane is an academic General Practitioner at the University of Glasgow and has been involved in the Deep End group since 2010, combining clinical work as a part-time GP with teaching and research commitments. He was awarded a Master of Public Health degree with distinction in 2012 and his PhD in 2018. He has authored several Deep End reports and manage the group’s social media presence. He is Academic Co-ordinator of the Deep End GP Pioneer Scheme.


Peter Cawston is a full-time GP Principal in a Deep End practice and was GP Cluster Quality Lead for seven Deep End GP practices in Drumchapel, Glasgow, Scotland. He qualified in Glasgow in 1993 and after working in France for two years completed GP training and a GP higher professional fellowship in Glasgow, where he has now served as a Deep End GP since 1999. Other roles have included: clinical lecturer, working with several patient groups and leading the Scottish Government’s pilot Link Worker Programme. “The mainstay of my working life, however, have been the long term relationships with colleagues in my practice team and with our patients on whose trust, forgiveness, good humour and resilience we rely every day.”


Jan De Maeseneer chaired the Department of Family Medicine and Primary Health Care at Ghent University from 1991-2017. He contributed to the development of inter-professional Community Health Centres in Belgium, with integrated needs-based capitation financing. His research focused on equity in health, strengthening PHC and improving social accountability. He chaired the European Forum for Primary Care from 2005-2017 and was Secretary General of The Network: Towards Unity For Health from 2007-2015. He chairs the Expert Panel on Effective Ways of Investing in Health, advising the European Commission.


John Frey qualified in medicine in 1970 from North Western University, Chicago. When he worked with Julian Tudor Hart in South Wales in the early 1970s he was the first family medicine-trained US doctor to work in the British NHS. He was head of the Department of Family Medicine at the University of Wisconsin, Madison for 13 years. Now retired, he remains active and is a regular contributor to the BJGP on US health care issues.


Andy Haines was Dean (subsequently Director) of the London School of Hygiene & Tropical Medicine for nearly 10 years until October 2010 and is currently Professor of Environmental Change and Public Health. He was a family doctor in inner London for many years and formerly Professor of Primary Health Care at UCL. He has been a member of many national and international committees, including the UN IPCC, and was chair of the Rockefeller Foundation /Lancet Commission on Planetary Health. His research interests focus on the linkages between health and environmental change including sustainable healthy cities and food systems.


Iona Heath, General Practitioner at Kentish Town, London for 35 years, and Past-President of the RCGP, has written regularly for the British Medical Journal and has contributed essays to many other medical journals across the world.  She has been particularly interested to explore the nature of general practice, the importance of medical generalism, issues of justice and liberty in relation to health care, the corrosive influence of the medical


industrial complex and the commercialisation of medicine, and the challenges posed by disease-mongering, the care of the dying and violence within families.


Stewart Mercer is an academic General Practitioner, having worked clinically in a range of settings including the Deep End. He was a researcher at Glasgow University for 20 years studying inequalities in health and health care and the importance of empathic, patient-centred care. Since 2008 he has led a programme of research on the needs of patients with multiple complex problems (multimorbidity). He has expertise in the development and evaluation of complex interventions and has been the Director of the Scottish School of Primary Care since 2014. In 2019 he is moving to a chair at the University of Edinburgh.


John Montgomery has worked in the David Elder Medical Practice, Govan Health Centre since 1987, initially as a registrar, as a partner since 1989 and now as senior partner. He became a GP trainer, developed an interest in diabetes with the SCI Diabetes Group, had a spell in medical broadcasting with BBC Radio Scotland, was elected chair of the South Glasgow GP Committee and now has the Lead Clinician role in the development of the Govan SHIP project.


Anne Mullin has worked in Govan for 24 years as a GP and “I am exactly where I want to be in my career”. She chairs the Steering Group of General Practitioners at the Deep End.


Austin O’Carroll, General Practitioner in Dublin, founded several initiatives addressing health inequities: Safetynet primary-care service for over 6000 marginalized patients annually; GMQ, primary-care service for homeless people; Partnership for Health Equity, a research, education, policy and service delivery collaboration; Curam Healthnet, creating new GP practices in areas of deprivation; and the North Dublin City GP Training programme. He completed a Doctorate in ethnographic research into the health service usage behaviours of homeless people. He received the Irish Health Professional of the Year Award in 2015.


Patrick O’Donnell graduated from a rural vocational training scheme in 2012, competed a master’s degree in global health and now works as a GP and Clinical Fellow in Social Inclusion at the University of Limerick. He is currently doing a PhD on social exclusion and primary healthcare. As well as working as a GP in a disadvantaged area of Limerick city, he runs clinics for marginalised groups who do not have access to mainstream medical care.


John Patterson is a General Practitioner and Medical Director of Hope Citadel Healthcare, a NHS Social Enterprise running nine practices covering 31,000 patients in hard-pressed neighbourhoods around Greater Manchester. Their response to the demands of the ‘Deep End’ was to design a ‘Focused Care’ model to bias healthcare access to the most vulnerable and needy households. Three of their practices have been rated ‘Outstanding’ by CQC. From 2018 he was appointed CCO of Oldham CCG.


Allyson Pollock is Professor and Director of the Institute of Health & Society at Newcastle University. A public health physician, she is a leading authority on the fundamental principles of universal health systems, marketisation and public private partnerships, and international trade law and health. Her current research is around access to medicines, pharmaceutical regulation, and public health; and child and sports injury. Her book NHS plc: the privatisation of our health care was published by Verso, and she is currently working on a book An Anthem for the NHS.



John Robson has been a GP in Tower Hamlets, East London for 37 years, has a longstanding interest in cardiovascular disease, chaired the NICE guideline 2008 on lipids and CVD risk estimation and was a co-author of the QRisk and QDiabetes scores. He is CV lead for University College London Partners and Tower Hamlets CCG and Clinical Effectiveness Group lead at Queen Margaret University London (QMUL). He has carried out a range of research studies on the evaluation of quality improvement in equitable health service delivery.


Petra Sambale has worked in both the UK and her native country Germany. She qualified as a GP in Glasgow and has been a partner in Keppoch Medical Practice since 2000. She values the principles of the NHS and enjoys being a GP trainer in an area of concentrated deprivation. She believes GPs have an important part in addressing health inequalities.  Her involvement in the Deep End Steering Group led to her current role as Lead GP of the Deep End Pioneer Project.


Elizabeth Walton is a Clinical Lecturer in primary care medicine and a GP in the most deprived area of Sheffield at the Whitehouse Surgery. Her NIHR funding is to develop research and teaching skills with a focus on health inequalities. Her passion to work towards health equity for communities and to support professionals working with vulnerable groups was inspired through witnessing the contrasts in the social determinants of health for patients throughout her career.


Graham Watt is an Aberdeen medical graduate and after hospital jobs in Shetland, Leicester, Aberdeen and Nottingham worked as MRC Research Registrar at Glyncorrrwg in South Wales with Julian Tudor Hart. After GP training at Ladywell Medical Centre in Edinburgh and Townhead Health Centre in Glasgow, he completed public health training with posts in epidemiology, health services research management and academic public health. Despite this circuitous route, he had the great good fortune in 1994 to become Norie Miller Professor of General Practice at the University of Glasgow. He retired in 2016 and is now Emeritus Professor.


Chair Biographies


Khairat Al Habbal is a family medicine specialist in Beirut and Clinical Instructor of Family Medicine and Social Medicine at the Lebanese American University, Beirut .


Richard Horton graduated in medicine from the University of Birmingham in 1986. Since 1995 he has been Editor-in-Chief of The Lancet.


Mayur Lakhani is President of the Royal College of General Practitioners and a General Practitioner in Sileby, Leicestershire.


Carey Lunan is a GP at Craigmillar Health Centre in Edinburgh and is Chair of RCGP Scotland.


Andrew Lyon, after working in shops and factories, studied Sociology and Economics at Edinburgh University.  With the International Futures Forum, he worked to restore effectiveness in times of rapid change. He chaired the Deep End Steering group from 2009-16.


Helen Stokes-Lampard is Chair of the Royal College of General Practitioners and a General Practitioner in Lichfield, Staffordshire.


Hope and salutogensis


Four patients in my afternoon surgery were suffering from chronic pain and had spent years being treated by pain specialists, spinal surgeons, psychologists, physiotherapists and complementary therapists. None of this specialist attention had alleviated their pain to any significant degree or provided a satisfactory explanation for their suffering. I have long-since stopped trying to ‘explain pain’, but for people who want explanations there are excellent resources online like ‘Pain is Weird’ by Paul Ingraham on and Tame The Beast by Professor of pain science, Lorimer Moseley.

Two of these patients with chronic pain had suffered child sexual abuse and one had also been a child slave. One had been tortured by the police in his home country and one had been traumatised by having to kill people when he was an army conscript. One of the women who had been abused had been seeing me with her back pain for 13 years and yet I only learned a few weeks ago about how she was sold into child slavery and some of what happened after that.

In nearly 20 years of working as a GP, I have very rarely come across patients with chronic intractable pain, who do not have a history of trauma. It may not be necessary to talk about what has happened, but it is necessary to acknowledge that what has happened long ago can have lasting physical effects,

For patients who have suffered with chronic pain for years, discovering the links between past trauma and present suffering may very often be re-traumatising and bring on symptoms of PTSD, like nightmares and flashbacks, also worsening the pain and fatigue and other symptoms like IBS (irritable bowel syndrome). Even where we are aware of the links, there is a fear that confessing to a history of abuse will mean that fellow pain sufferers – who by this time may make up an important social/ supportive network, along with professionals who have been treating them – will reject them because their pain is somehow less ‘real’. The shame that is inherent with trauma, comes into sharp relief; shame goes with self-blame “I am to blame for the way I feel – emotionally and physically, it’s up to me to fix myself, no-one can help me now”.

Talking about the past may also be overwhelming for clinicians. Doctors exposed to stories of rape and incest, torture, domestic violence, neglect and loss, can suffer from secondary trauma. There are days when I am completely, emotionally overwhelmed. And like most GPs I don’t have a therapist of my own.

My patients and I need to be able to find hope amidst past trauma and present-day suffering, and we are discovering this together by changing our focus of attention away from ‘pathogenesis’ – the science of what makes us ill and the subject of medical education – to ‘salutogenesis’, the science of what makes us well.

At this point I would recommend you watch “What causes wellness?” an amazing talk by Harry Burns, recently chief medical officer for Scotland, in which he gives a brief history of salutogenesis grounded in the reality of trying to improve outcomes for Scotland’s most deprived citizens.

I wanted to be able to share these ideas with my patients, but 20 minutes was too long to spend watching Youtube during my consultations, so I had to find something that summed it up, that people could easily remember. The picture at the start of this piece is on the wall of my consulting room. If you hold out your left hand in front of you, fingers outstretched, looking at the palm and then look at the picture you’ll be able to imagine our conversations. Each area requires care and attention if we are to be well. Salutogenesis requires a balance; neglect one or two areas and you’ll need the others to be robust to compensate, but that’s not sustainable for long.

Beginning with the little finger, ‘Mind’ refers to feelings/ emotions/ memories, thoughts, and interpretations. Shame and anger, depression and fearfulness, heart-ache and grief, confusion, hope and despair. Taking care of your mind depends on how overwhelming (or numbed) your feelings are. For some people a good therapist is essential and the quality of the therapeutic relationship is more important than the type of therapy, but in general, the further back the problems go, the longer the therapy needs to be, and CBT probably won’t delve deep enough for long enough.

Taking care of your body definitely doesn’t require gym-membership or marathon running, many people who have experienced trauma or who suffer with pain, irritable bowels or other chronic physical symptoms have very difficult relationships with their bodies. Taking care of your body means changing those relationships, so that your body isn’t a cause of shame or dread, but something that belongs to you and does what you want it to. Yoga, dance, singing, painting, making music, arranging flowers, or baking bread can be as therapeutic as fell-running or mountain-biking. You and your body are working together, you’re enjoying what you are able to do. And you don’t need to go over painful memories.

Taking care of your biology refers to everything that you consume; food, drink, medication, supplements, alcohol and drugs, even the air that you breathe. I talk about this with patients to put medication into a holistic context – it’s one part of biology which is one finger on the hand of salutogenesis. It’s something, but it’s not, by a long way, the only thing. With a sceptical eye always open to the science of nutrition, I’m pretty confident that so far as diet is concerned, Michael Pollen is right: “Eat [real] food, not too much, mostly plants”. Most people who come to be discussing salutogenesis with me have really strained relationships with food – it’s either a punishment or a reward. Their appetite comes and goes, their weight goes up and down. They’ve been on and off diets and supplements half their lives. Helping vulnerable to stop smoking, cut down on alcohol and reduce their intake of drugs and prescribed medications can always do more to improve their wellbeing than anything new that I can prescribe.

‘Human Relationships’ is usually the most painful area. “Do you have anyone in your life who knows you well, how you love and trust, who loves and trusts you back?” is usually how I phrase the question. Loneliness is one of the worst things that anyone can suffer from. It so frequently accompanies chronic pain and chronic mental illness. Sometimes the people I ask this question say, “Apart from you?” For too many people, the GP is the ‘only normal person they know’. Helping people connect compassionately with themselves and others is almost certainly the most important thing that can be done for salutogenesis according to the Harvard Cohort Study and other research.

Human connection also requires spaces for people to meet and connect with one another. In the next video, Eric Kleinberg explains how death rates in very similar neighbourhoods varied ten-fold during a drought because some places had a lot more places where people would gather, do things together, get to know one another, and in a time of crisis, look after each other.

People for whom the dark shadow of trauma lasts into adulthood were very frequently betrayed by an adult who they trusted, who they expected to care for them. The adult may have abandoned them or abused them, and they may find it very hard to trust other people from then on out of fear of being abandoned or abused. They may blame themselves for what was done to them leading to a sense of shame. To understand shame, a sense of being profoundly un-deserving of love, kindness and respect – I have written a series of blogs – beginning here.

I really like Dr Phil Hammond’s CLANGERS – the first, and most important point is ‘Connect’ – each day I will try to like myself and reach out to others.

The thumb refers to social security, by which I mean security of housing, finance, employment, and safety from violence, intimidation and all forms of abuse. The tip of the thumb touches every other finger, with adequate social security it is so much easier to access therapy, to join a gym or go to classes, to eat healthily and to socialise. Doctors have a duty to act as social advocates and help people access the benefits they are entitled to and draw attention to the health effects of poverty. A decade of austerity and failed welfare reform means that social security has hardly been worse in living memory.

Social prescribing, derided my some GPs but greatly appreciated by others like myself, helps people to connect with other people and to access social security. With awareness of salutogenesis Social Prescribing makes a lot of sense.

Crisis management is written across the wrist because that is where so often I seen cuts that have been inflicted in a time of crisis. When the pain gets too much, self-harm and suicide are ways to bring it to an end. A crisis plan should be written, shared with others, referred to in a crisis and reviewed afterwards. It should include warning signs that a crisis is coming, people to speak to, places to go, things to do. Even if self-harm is not part of what happens in a crisis, people with chronic pain will still have days when it’s too much, when the usual strategies are insufficient. They need a crisis plan or a ‘rescue pack’ for these days. can help.

A few months ago, I faced a woman whose daughter had recently died by suicide. The woman I faced, a patient I knew well, had suffered her own terrible traumatic past and suffered with chronic pain related to connective tissue disease, trauma and grief. She wanted me to prescribe more painkillers. “What kind of pain are we treating?” I asked her, “Is it physical, emotional or grief?” She stared back at me, confrontational, “What. Is. The. Difference?” She demanded. “How can you even tell?”

I can remember the confrontation vividly. She was right. All pain affects, and is affected by physical, biological, emotional, biographical and social systems. You cannot neglect any of these areas if you want to manage pain, but when pain is overwhelming, sometimes it is easier for patients and doctors to go for a prescription, and I gave her some more Oxycodone, “We know it works”, she said, “we both know, it numbs every kind of pain.” But we also know that it’s not enough, it’s not safe and it will soon stop working. Whenever we meet we check in on all the areas on the hand together, MInd, Body, Biology, Relationships, Social Security, crisis plan. In every aspect there is room for improvement, something to be done – and in there lies hope.

“How do you cope with seeing people like me every day?” asked another patient this week. He knows what I know, that the waiting room is full of people who are full of pain and trauma. He has lived around here for 30 years. I had to think before answering and I answered carefully. “It’s true, at the end of the day I am drained. But I’ve been here long enough to have seen people through the worst of times and out the other side. Sometimes that takes weeks and sometimes it takes months or years. So I share in the suffering, but I also get to see people go through the most appalling circumstances and then recover. And that’s priceless and that’s why I’m still here and why I’m going to stay here and stick with you for as long as it takes.”

Dr Austin O’Carroll, a GP who works with homeless patients in Dublin describes this commitment and continuity to patients as ‘high fidelity’.

And in a time of professional burnout, it is important for doctors and other health professionals to think about their own salutogenesis. We are prone to burying the bits of our past that we are ashamed of, we neglect our emotional health, eat badly (especially when on call), drink too much alcohol and lose touch with our non-medical friends and family, even though we are fortunate enough to be more socially secure than most people. We are prone to over-compensate when feeling stressed, by putting all our efforts into exercise, dieting or therapy, when what we need is a balance.

I hope that the image of the hand will help me, my patients and my colleagues to focus on what we need to be well, and will give us reasons for optimism, especially for those of us working in areas of deprivation. We can always find areas where positive changes, no matter how small, are possible.

Reflections on medical culture and the Bawa Garba case

For a background to the case – see this excellent BBC report by Dr Deborah Cohen

I have been a doctor for over 20 years, 5 in hospital and 15 in general practice. I have been on the receiving end of medical errors and have made complaints about my own care, and the care of family members, who are not doctors and have lacked the confidence to complain, even when complaints are clearly justified. I have also been on the receiving end of serious complaints from patients, I have been successfully sued and had cases against me investigated by the Parliamentary Health Ombudsman.

Any doctor who has practised more than a few years will know that the vast majority of medical errors are not noticed, ignored or covered up – and though the majority of these don’t cause any serious harm, a minority do. Any doctor who has practiced as long as I have, will, like me, have personally contributed to a patient’s death. Doctors are aware that most patients and their families do not complain even when they are aware that there has been an error and when they have had very reasonable grounds to complain. I have had to make complaints on my patients’ behalf because they were afraid or insufficiently literate/ articulate to do so themselves. I know that most of the time, complaints are dismissed. When patients do complain, clinicians know that the majority of complaints are not about issues involving patient harm or clinical decisions, but about problems where patients and their families feel more confident, for example; lost dentures or professional attitudes, cancelled clinics, lost results or other organisational issues. Doctors know that the worst of their colleagues seem to be immune to the complaints they deserve, while the most conscientious are prone to the most vexatious.

Dr Bawa Garba was forced, under stress to write down everything she could think of that she personally had done wrong. The person who forced her to do this wasn’t a prosecuting lawyer, but her clinical supervisor, the consultant who should have been supporting her on the day that Jack Adcock died. He did not help her think through what had happened in a place and at a time suited for reflective thinking. He made her write a list of everything that she had done wrong in a hospital canteen. He then made her upload the list as a ‘reflection’ in her educational eportfolio. This is not medical education as I or any other medical educator would practice it, but too many doctors’ experience of ‘reflection’ in medical education is shallow, critical, unsupportive and frankly, unreflective. If anyone in this case was ‘truly, exceptionally bad’ it was this doctor, Dr Stephen O’Riordan.

To make matters even worse, the media is a menace – fanning the flames of fear, pitting doctors and families against one-another and baying for vengeance and then moving on to the next story before the dust has settled.

In very little time at all doctors learn from experience that complaints are no measure of a doctor’s moral character or clinical competence. Doctors and patients learn that justice is rarely achieved.

Consequently, many doctors grow cynical, hateful of the GMC and the tabloid media and suspicious of patients. And a growing number of patients are losing trust in medical professionals.

These are problems of culture and psychology far more than they are technical and legal.

The solution must therefore involve an honest acknowledgement of the cultural milieu that doctors and patients inhabit. Doctors live in fear of patients discovering the mistakes they make and patients live in fear of being harmed. Both have good reason to think that the system is unjust. The solution must bring patients and clinicians together to have honest conversations that bring about what Richard Lehman has described as the ‘shared understanding of medicine’. It must include much greater transparency including shared medical records, patient safety reports, transparency about organisational pressures and what the NHS can afford. Patients and clinicians do need safe spaces where they can learn from mistakes apart from one another, but this should not and need not reduce the requirement to have shared learning as well. Only by making alliances with patients (contra pharma/ commercial healthcare) and by treating patients as expert partners in care (and part of the solution) rather than a burden / problem, can we change. Medical educators and supervisors must take reflection seriously and learn how to use it as a force to challenge and change medical culture for the better. Finally – as Dr JulianTudor Hart has argued, ‘Accountability must require that doctors insist that they have time to do their work properly’.

Relationship centred care Dr Jonathon Tomlinson blog

Defining Patient Centred care New England Journal of Medicine

A New Kind of Doctor: Professional Accountability. Dr Julian Tudor Hart

Managing the threat to reflective writing. Dr John Launer