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

EPGP

 

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:

https://www.youtube.com/playlist?list=PL53OebaxnaDUmBu7mgP5eY1-V5YvQaYvv

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

https://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/deepend/events/exceptionalpotential/

 

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

 

 

SCOTLAND

 

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

 

 

IRELAND

 

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

 

 

ENGLAND

 

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

 

 

PANEL AND PLENARY 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

Salutogenesis

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 Painscience.com 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. https://stayingsafe.net/ 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

Book list

A list of books about medicine, society and more – posted here from one of my medical education wikispaces. Please send other suggestions! My intention is to keep adding to it.
Most of these books i’ve read. Many of them are old. Although I’ve linked them to Amazon for your convenience, i’d recommend you try your library (if you still have one), your local independent bookshop or second-hand from abebooks

General:
Henry E. Sigerist: Medical Historian and Social Visionary

  • All of his books are very highly recommended, especially Medicine and Human Welfare
  • His book ‘Man and Medicine’ was written for medical students.

Medicine and society:

Medicine and science in the media:

The media:

Hoxton history:

General practice:

Doctors and patients:

Medicine and politics:

Markets

Pregnancy and childbirth:

An examination of who controls childbirth and who controls doctors

Food, politics and health:

Health promotion

Poverty and medicine:

Pain: history and culture:

Pharma

Medicalisation

Dying

Mental health:

Medical ethics

Medicine and History

Misc

Dr Jonathan Tomlinson Law And Justice Interview – SoundCloud

An interview with Jane Mulcahy about the ways childhood trauma manifests in adults who present to healthcare and criminal justice

Listen to Dr Jonathan Tomlinson Law And Justice Interview by Jane Mulcahy #np on #SoundCloud

The Adverse Childhood Experiences evidence base–a wake up call to radically redesign Children’s Mental Health Services.

For any readers based in Hackney where I work, I’m reposting this in response to Saturday’s SAFAPLACE conference at Stoke Newington Secondary School. What was an excellent conference was notable for there being no discussion about the impact of adverse childhood experiences. I’m very grateful to discover Elizabeth’s work

We need to talk about Children's Mental Health

Throughout my twenty year career as a psychologist working in Specialist Children’s Mental Health Services (SCAMHS) two frequently repeated mantras have been amongst the biggest sources of  frustration for me:

“It’s a social problem, not a mental disorder” and  “the child needs to be stable to access therapy”; the latter often responded to with the helpless reply  “but the child need’s therapy in order to be stable”. Indeed, much of the tension between Health and Social Care can be boiled down to these two themes.

I understand, of course, that service design and a splitting of health and social care lies at the root of this; along with a scarcity of resources and a need to carve the work up somehow. However, as  a psychologist employed by health, I see a child’s context and life experiences as fundamental to their mental health and emotional wellbeing. Ironically, when it comes down to individual…

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