Time is the basis of human experience, it is the foundation of narrative, the vehicle of observation and the thread of trust. Its linear and physical path draws our attention away from the cyclical daily routine we inevitably follow at times. Understanding the importance of the future is health itself. Building and discovering a past that nourishes us is what provides our peace, contentment and a framework for generosity. As a healing profession, we must work with time, give our time and help people regain or maintain their desire for health and well-being.
Many people we see as general practitioners need our time more than our tests or our treatments. Just spending time with someone on a few occasions can have a significant impact on their lives. This is not well understood but does depend on our care and reputation. We do know that science has not been able to determine which components of many effective ‘talking therapies’ (such as cognitive behavioural therapy) actually make a difference over and above the engagement of a significant person with shared goals for a period of time. Spending time in conversation with someone in difficulty is inherently worthwhile. It must involve listening, should involve challenging the key determinants of the person’s situation and may involve sharing some insights gained elsewhere. Doing so builds two narratives; the narrative of the person’s life and their difficulties as well as the narrative of the time shared with us. Insights inevitably arise and as a consequence a changed view of the past and future. These narratives, now shared, allow trust to grow with a mutual understanding, and can be drawn on in the future when further difficulties intervene.
This approach also has a role in acute care. If we think of ‘monitoring’ a person’s condition as limited to taking measurements and making observations, it reduces our impact to the singular (and sometimes very important) biological dimension. However, we can also use time when someone is acutely ill in much the same way as when the person is distressed, building trust and a shared narrative. That way we can work with the ill person not only to make sure they are safe, but also to learn how we should work together effectively in the future. Such an approach allows a mother to take her sick child home for a short period (perhaps 4 hours or overnight) and return to discuss any changes, what social support they have been able to muster and how they are both coping. What we learn together can be used to ensure a good outcome and also to determine appropriate care when similar situations arise in the future. This provides a much greater gain than a prolonged trip to the emergency department to be tested and scanned unless, of course, there are signs of major illness. The shared narrative is valuable to all concerned regardless of the next decision.
And what of protracted physical symptoms such as back pain or headaches. Although tests seem most likely to provide benefit, it is rare that they do. We know, for instance, that most changes seen on CT or MRI scans of backs do not correlate with symptoms. But doctors tend to make these spurious correlations, leading to ongoing concern and even an unwarranted deterioration in perceived health. Using time, as part of a naturalistic approach, is far more helpful, leading to observation, trust and a shared narrative. If the person will not take time to get stronger and more active or take time out to relax and nourish themselves or other simple measures to address the problem, then this can be challenged, but only from a position of trust. Arthroscopies may damage knees (especially in the elderly) while time often heals them. It takes a practitioner’s time to gain the trust of a person that allows them to give their bodies time to recover.
No one is time poor, for we all have the same day-to-day allocation. Horizons shrink with age and illness but time marches constantly. Even when our patients die, the once shared narrative remains as illustration or, in its public form, to share with relatives and friends and provide a new basis for trust. Time has one demand. We must be realistic. As Camus said, “Live life resolutely without hope for there is no consolation.” This is not a call to hopelessness but a call to being realistic and it is a very helpful stake in the ground for people who have a grave diagnosis and much uncertainty.
A growing personal narrative, more valuable if shared, is at the heart of our humanity. When thin or missing it is a mortal wound. People create this story with parents and kin, often rejigging and changing the colour of bits and pieces. It becomes who we are, the gaps , the inconsistencies. It is far harder to fill gaps retrospectively when they emerge later in life. The stolen generation and secretly adopted children testify to this. The value of memory with anchoring narratives is probably paramount to a happy life, no matter the distress that may have been part of the experiences that generated it. Working with our patients to put together the narrative of their lives, despite their focus on the woes of the present, is a wonderful experience and can make a difference for generations.
Medicine at the Deep End 