Answers we don’t have

I was going to write on overcoming resistance, stepping out on to a limb. Which is what I have been doing lately.

But something else came up, something all too common. When patients ask us questions we have no idea how to answer, or make statements or choose options we entirely disagree with. “Doctor, I don’t want to accept what you are offering – I would like to go alternate”. “Doctor, how can I beat this (cancer)?” “What do you think of ‘potion x’ for my treatment?” And so on. I was speaking to a colleague who deals in cancer, who was patently at a loss to answer a patient who was just not on the same page – and because they are there, we feel obliged to offer something. They trap us in our own world, in our training, in our beliefs, our own sense that “we have to fix it”, and we can’t wiggle out of it.

My approach would be to open wide into the realm of possibilities. To investigate what would work for the patient, and then negotiate to have some input along the way. Ask questions. And we do have to be aware of all the various therapies out there – that’s the only way IMO we can make sense of anything. The alternative is to declare that you cannot offer anything other than that already offered, and suggest other physicians, which is never satisfactory. Another way would be to have some help – colleagues who have experience in alternative approaches, and who can work in partnership with you, perhaps even in joint consultations. A true integrative approach would be to have joint consultations, or alternative views, with a patient-centred approach. Some patients will say “tell me what to do”. Others want to be in control.

We should be able to deal with any approach, and not let what we believe to be the most important way, to get in the way. And sometimes a patient’s choice will be at complete odds with ours; how do we honour their choice, even if the outcome is a disaster? Are we prepared to walk with them, anyway, regardless.

Physician, heal thyself

I met a colleague in an operating theatre (I was watching an operation on a patient of mine) whom I hadn’t met in a very long while. We spoke about how we had all got on over the years. The subject came around to me being a GP, and he an anaesthetist. And then he asked me for some freebie advice, which I was happy to give. He asked about muscle cramps – I suggested magnesium. Then I asked him: “do you take fish oil?” “No”. “How about Vitamin D?” “No”. “Any other minerals or vitamins?” “no”. “What’s wrong with you?”, I asked, and he laughed. It was the first time he knew of where someone had asked what was wrong with them when they weren’t taking anything.

Isn’t that a sign of the times. That (a) things have changed in terms of what people take now and that it appears that we DO have to take supplements; (b) that as a medical person he wasn’t apparently aware of this, and that he may need to supplement his diet. As a GP I am constantly exposed to this kind of thing. How many specialists operate in the cocoon and never get to know about this. It also means he probably doesn’t have his own GP. How many of us still don’t?

Another blog, another time.

Breast cancer care

A lady with bilateral breast cancer, who was going for removal of both breasts was referred to me. In her early forties, not having had children and so much wanting to, and facing the prospect of never having the opportunity, especially if she accepted the recommendation of post-operative long-term chemotherapy. She had tried to be at peace with this, but she was in a state of conflict and fear.

It is always a wonder to me that we can literally go and “speak” to our bodies, ask questions and get answers. It seems logical in a way to be able to do this – go to the expert!

In a Journey process she was able to go to the cancer sites, and discover a younger self that had brought into her life the belief that she was “not good enough”, causing her to judge herself harshly for 30-odd years. Climbing the unclimbable glass mountain. In the process she was able to get to meet the younger self, resolve the relevant issues, forgive her, and love and accept her. She was able to address the cancer, find out what it represented in her life, and resolve to learn from that and get back to being who she really is, and not who she was trying to make herself into. It is and always was – a nurturing issue.

At the end of the process she was at peace with herself and her decision to go ahead with surgery. The old belief of not being good enough was dropped entirely, and replaced with a new healthy sense of who she really is.

This kind of attention is perhaps what every person facing major surgery should get. How often do we just inform patients, give them all the information we can, and neglect their feelings, their terror? They come from their hearts, we come from our heads. How often do we fast-track people into some kind of intervention because of a perceived medical imperative, and neglect to take care of the whole person? Either because we are unaware, are time-short, or simply don’t have the right tools to do it. We can be kind, empathetic, supportive – is that enough?

I know of surgeons who pray for their patient whilst operating, they talk to the body while they are operating – this is great. Playing music in theatre is a very good idea. What we need is a more systematised total approach to pre-operative care, so that the patient is in optimal condition before surgery.

Being there in tough times

My week seems to have been characterised by this – patients going for major surgery. One man had to go urgently for a laparotomy for an intra-abdominal mass, a carcinoid tumour. I was fortunate enough to be able to be there for the surgery, and say hello beforehand. There was no doubt that he was very pleased to see me there. However, when I asked him how he felt, he said “terrified”; I realised I had not done my job, or served his needs. It would have been so easy to find a few minutes beforehand and help him through the terror into a place of peace. After all, this is what I go on about – this is what I have trained myself for. A missed opportunity indeed. Who knows what hormones, amines were pouring around his system that may have interfered with his anaesthetic, with his recovery, with post-operative pain and its control? I’m sure there are studies on this somewhere.

This is an excerpt from Wikepedia, on serotonin: Serotonin is a neurotransmitter, and in the gut mediates gut movements … and the animal’s perception of resource availability. In advanced animals resources can also mean social dominance. In response to the perceived abundance or scarcity of resources the animal’s growth, reproduction or mood may be elevated or lowered. Studies have demonstrated that serotonin has strong associations with depression in regards to a negative environment. How much food an animal gets not only depends on the abundance of food, but also on the animal’s ability to compete with others. This is especially true for social animals, where the stronger individuals might steal food from the weaker. Thus, serotonin is not only involved in the perception of food availability, but also of social rank. Serotonin inhibits the fleeing reaction in subordinates, but enhances it in socially dominant or isolated individuals.

Food for thought here – to look at his perception of himself in terms of being able to provide, to compete, to dominate. Why would his body have the need to pour out this extra serotonin?

Old dinosaurs

Old dinosaurs – old problems needing new solutions. I have always been able to think “outside the box”, to think laterally, to look for alternative solutions. This must come from growing up in Zimbabwe (then Rhodesia), being the “rebels”, and having to think of creative ways to overcome political restrictions. Medicine is, by nature, a very conservative profession. We are governed by the dictum “first do no harm”. From this, evidence based medicine arises, at least in the Western context. So, it takes a brave soul to want to explore outside the known, and to be part of the solution, rather than part of the problem.

Change has to come from within. It has to come as a result of the tensions between wanting to find better solutions, and needing to remain safe.

One of the ways is to co-opt patient willingness and co-operation. To explain that everything that we normally do has been tried, and that (so far) nothing has worked. Ask them if they would be prepared to look at alternative solutions. Would they try herbs, meditative techniques, lifestyle changes, therapy of some kind. Perhaps a combination of more than one. From my experience, people are usually (a) very interested, (b) have often already started to think along these lines and are quite relieved to be able to share, and not operate in secret.

Does this mean that this is in the province of general practice alone? I don’t believe so. It is the topic of another blog about how to deal with the answers to these questions; here at least we are on common ground in just learning where the patient wants to go. So, are there these intractable problems in your practice? Are there problems which are crying out to be solved in a non-standardised way? This is what I have spent so much time on, learning, practising. There are real rewards here – it just takes a moment to stop, open your thinking, and ask the question. You may be surprised at the answer.

When all else fails ….

Welcome to Spirit of Medicine’s blog. I am really excited about doing this. The aim is to inform and educate and to form working partnerships, to help with better outcomes for all our patients, especially dealing with those difficult problems for which there have been no satisfactory solutions or outcomes up until now. I welcome comments, feedback, any dialogue which will help shine a light into these areas.

It has always intrigued me that what we see as doctors is often the surface presenting issue. We are very rarely given what was driving it. Finding ways to get to core issues has been a passion and driving force for over 25 years. I really started to get insights when I took part in a 2 year Balint program, looking at “difficult patients”. After around 6 months, it was obvious that we weren’t bringing difficult patients, we were all bringing cases that highlighted difficulties we had ourselves. In other words, if I had an issue (don’t we all!), and someone presented with the same issue, then they pressed my “hot button”, and I was no longer objective and in the best place to deal with whatever was presenting.

So began my journey into self-development, and looking for clinical tools that could help elicit what was really going on, and be effective in dealing with it. This in essence, is for me, the Spirit of Medicine – to not only help with the presenting (usually physical) issue, but to find and eliminate what was causing it, so promoting total good health.

What I propose to write on, and share thoughts on, are the many and varied ways in which people with health problems present, how to elicit any underlying meaning, and how to go about accompanying them on their journey until a return to health is achieved – at least that’s the goal. Sometimes it isn’t the outcome that counts, but the journey. Medicine can often look at a “negative outcome” as a “failure”. I would like to explore this notion at another time – is this in fact the case?

I have used as a by-line – “when all else fails”. In other words, when traditional methods fail, where do we go from there?