Time Share

Time traveller
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 regigging 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.

Why bother?

Hong Kong Hang OutIt is easy to get the feeling that we could all do a good job in general practice if it wasn’t for the crazies, the difficult ones, the slower types and the worried well. It is a bit like John Cleese in Fawlty Towers – who made the same mistake.

Today I saw a woman that I met a decade ago. She looked dreadful, much as she had done then. At that time she had been banned from our local emergency department. Now she is unable to get care from the psychiatrists. A decade ago she was complaining of pain and was relentless in trying to get medication and something done. In fact she had an abscess in her neck, no doubt due in some part to her lifestyle. She was sent away to a tertiary center and put through the mill. Spinal surgery, intensive care, rehabilitation.

She recovered in terms of her abscess but remains as out of control now as she was when all this started. Today, 10 years later, she is again begging me not to see her as a drug seeker, a doctor shopper, a write off. It was difficult not to do so all that time ago despite her neurological signs, just as it is now.

I have never prescribed her painkillers or benzodiazepines despite massive protestation: the sort that makes you bleed. It is heart felt, theatrical and even a little endearing before it becomes somewhat intimidating, quickly tedious for those measuring their own responses in terms of best practice or guidelines. There is absolutely no vaguely visible road to success. It is so compelling only because she genuinely suffers so much; wailing, pleading as tissues amass in or near the bin.

She sees her future only in terms of medications provided by doctors; me and my colleagues only in terms of degrees of rejection. She is “The Hulk” of medication users – she even looks a little green. There is no end of medical and social labels that apply, made all the more compelling due to her lack of insight. She is stark naked in her intoxicated disguises.

How to help? Her life is always on a thread. Efforts to help from a myriad of agencies lead nowhere noticeable. The pain is felt by all.

I shook her hand today and we parted peacefully enough. She might take me up on my offer to help her be a little healthier without feeding her hunger for intoxication. Some I have known like her have died younger, some have stumbled into middle age where they sparkle like drunk adolescents in a bowls club. I really wonder at her will to live and be fed. I feel for her family.

Do I have room for hope?

I’ve had my first complaint

DSC00763Yesterday I received the first complaint of my 35 year career through the Health Services Comp
laints Commission. It was submitted on behalf of a patient by my local MP’s office. I spent a few hours yesterday coming to terms with it and again today responding. It has made me realise that we have a problem. I have written to my local MP requesting the chance to spend some time with him to explain the implications of formal complaints through the HSCC after determination of my complaint. I am experienced enough to take this on the chin, but a less experienced doctor will undoubtedly find such a process daunting and is likely to see the community as hostile.

There is no doubt that there is a very great need for a clear and powerful pathway to complain as a citizen about the health care we receive. It is also fundamentally important that this process is geared to deal with complaints at different levels. If the person has been harmed or suffered in a major way, it is important that this goes to APHRA and into a legal process where appropriate. If the person has been harmed in a temporary way, caused to suffer unnecessarily or does not feel that they received adequate care or information, this should lead to a local and careful process. Any claim of offense should be taken very seriously.

However, if the person has been inconvenienced or communication has been poor but has had reasonable care, or the complaint is vexatious, then the professional should not be required to respond in a lengthy manner and should not suffer unduly. If this happens frequently the community will receive more and more defensive care of dubious value. There are already many GPs who largely do what patients request for fear of complaint. Interestingly, a US study has shown that doctors who have very high levels of patient satisfaction have poor outcomes, even in terms of mortality. Patients don’t always know best.

We also need to acknowledge that there are the normal checks and balances that operate in terms of patient experience were no harm results. Patients are free in Australia to seek health care elsewhere or complain to the provider, even publicise the problem (now common on social media). I believe this should be the accepted pathway when no harm has been caused. Accredited general practices have to demonstrate that they act reasonably in such situations and keep a register of complaints.

Such unsatisfactory experiences are universal in all service settings including healthcare settings and some providers and some patients find it difficult at times to understand the situation of the other person. Regulation and heavy handed approaches will not solve this very human situation.

How can we ensure that these increasingly common formal complaint processes do not cause more harm than good? First, a professional who has received a complaint should be able to discuss the complaint with a qualified professional within the complaints environment. This could resolve situations where there are clearly no grounds for complaint and where a conciliatory process is inappropriate. While this might appear to be more costly it would forego the costs to many professionals of the hours spent dealing with a complaint, the demoralising effect of receiving notice from a statutory body and the loss of face with colleagues.

 Second, there needs to be some formal redress for vexatious complaints or minor complaints that have used this heavy handed approach to be heard rather than seeking conciliation through the provider. This requires responsibility of those managing the process to ensure maximum general good and not just meeting the complainant’s wishes. It also requires an apology from the statutory body to professionals when processed complaints are found to be inappropriate or vexatious. Again, while there is no professional input within the complaints environment prior to passing the complaint to the professional this is likely to be frequent.

I fear formal complaints will become all the rage, encouraged by social media and politicians standing up for a fair go. At present the professional has to respond according to legislation – no doubt for our own good. Don’t mistake me, I do believe conciliation is the best approach and practice this avidly in our setting. However, at times it is not helpful to seek conciliation and it is most appropriate to separate and for the patient to seek health care elsewhere. I think a practitioner should have the right to ignore the complaint with the understanding that legal approaches may costly and perhaps not covered by medical defense insurance. Sometimes we know there is absolutely no cause for complaint and absolutely no chance that reconciliation will change anything. What should we do?

Facing complexity

DSC00747

The wonderful Jan Radford (you should follow her on twitter)  drew my attention to Garth et al’s excellent study on repeat prescription management in general practice. I enjoyed the approach, a  feel good experience. On reflection I think this paper is avoiding complexity and seeing it as a problem for the consumer. Is that fair?

Why do people take medications that are of marginal benefit or doing them harm? Why do so many patients attend and ask for their scripts without any concern for their health and the continuing relevance of these medicines?

My introduction to the study of repeat prescribing was Michael Balint’s excellent research work with a group of GPs entitled “Treatment or Diagnosis: research into repeat prescribing in general practice” published in the 1970s. Although this predates many pharmaceutical treatments for chronic disease, it raises critical issues with regard to human behaviour and receiving medications as a surrogate for care. These are perhaps more relevant today. What does taking the medication mean for that person? Did it start when their mother died, perhaps their child or spouse? Is it the one remaining legacy of a doctor that helped them a great deal and is missed terribly? Does it avoid conversation and inquiry and keep the doctor happy?

A friend told me how he turned up for a script for his epileptic medicine for years after he stopped taking it, just to keep the doctor happy – he was too scared to say he had stopped it. Many people are afraid to stop taking something that affects them negatively for fear of something worse – the wrath of relatives or doctor? The fear of withdrawal effects?

We are the source of repeat prescribing and if we expect people to be organised 99% of the time, then a few people will run short unexpectedly every day. Should we blame them? The amounts vary – 28 or 30 tablets for some things – 25 or 50 tablets for others – 5 or 2 repeats. How do they manage at all? Is the list of medications in their file an “all time list” or an up-to-date managed list. Do you actually know what they are taking?

Then we have the narcotic repeat prescriptions – perhaps 100,000 medical addicts who cannot be late or they feel sick. When will we doctors learn that narcotics do not work for chronic pain, in fact they clearly exacerbate the problem. And Endone should be banned (along with its long acting preparations). What are we doing to people? A pain clinic referral is unlikely to help as the return letters  only seems to justify the damage or at least ease the conscience of the GP.

Finally, we can insist on people waiting for an appointment if they urgently need a script but have been reviewed recently, as a punishment and monetary tactic. This enables the doctor to be seen and the fee to be subsidised or bulk billed.  Is this a reasonable use of public money and is there any measurable benefit?

Repeat prescribing is truly complicated, involving issues of compliance, funding, safety, quality and motivation. Difficulties cannot be seen solely as a problem patients bring on themselves.  The doctor’s statement “Your lack of organisation doesn’t constitute our emergency” could be reflected as “Your complexity, dependency inducement and chaos causes our emergency”. Whatever your point of view, repeat prescribing illustrates the complexity of modern general practice.