Archive for the ‘from the consulting room’ Category

When I left rural General Practice in Southwest Scotland to join my friend Sandy in the big city of Edinburgh I swapped villages, farms and fields, for busy streets, blocks of flats and the noise of a city life. Sandy and I had a small Practice initially which was split between two different parts of Edinburgh – Portobello and Mayfield Road. In those early years there were two distinct communities of patients, one in each area, and the ordinary everyday involved a fair bit of doing house visits in both parts of the Practice, as well as driving from the one area to the other to deliver clinics in each of our Practice premises.

There was a link between the two. Well, I know there are always many different roads to choose between any two destinations, but one of my favourite ways to travel between them was a small road looping round the base of Arthur’s Seat in Holyrood Park. It was like a small voyage through the countryside between two webs of city streets.

Arthur’s Seat is a such a presence in Edinburgh. It’s an ancient volcano and dominates the entire city. Holyrood Park, in which it sits, has several small lochs which invite you to sit by the water for a while. General Practice work is, however, busy, busy work, with plenty of demand, lots of patients to see, homes to visit, every single day. Sometimes, often in fact, I’d feel on the edge of being overwhelmed by the long list of visits to make and tasks to perform, all with an ever present pressure of time. I’d drive between the two premises via Holyrood Park and sometimes I’d see an empty park bench.

An empty park bench.

Can you imagine the feelings of longing, the huge surge of desire, the unattainable wish to stop and sit on that bench?

It could become like a life goal. “One day I’ll stop and sit on that bench and just do nothing. Just for a bit. Not forever, of course, but without a deadline, without a need to be somewhere else in a few minutes time.”

I never sat on that bench.

Years later, on holiday in France, I saw this old sign on the wall of a small village house –

“Gently in the morning, not too quickly in the evening”

I thought of that park bench when I saw that and I thought…..”one day!”

Much later an Italian friend of my mine told me about “Dolce far niente” – doing sweet nothing – and I realised it was the same thing.

How life can be so utterly full of busy-ness that there just never feels like there is time to stop, time to pause, and just be. (Ha! Ha! What sprang into my mind there was Bart Simpson saying “I’m a human being, not a human doing!”)

This is such a deep human need. I think we find it in all cultures. Although often we have to justify it to ourselves as a “time of contemplation”, “a few moments of mindfulness meditation”, or “a time to reflect”. Now, I think all those things are great too. I think they all have the power to bring quality to our lives, but they aren’t the same as slowing down to the point of taking a pause, and just….being.

We need to “Mind the Gap” – need to find those spaces between one task and another, the spaces between one breath and another, the spaces which exist between the end of one thought and the beginning of another.

I wish I’d paid more attention to that. I think it would have been good for me. But, hey, it clicked eventually, and even now when in retirement a day can fly by filled with “things to do” and “things which need done”, I remember to stop sometimes, and……


When I stop to enjoy a pause now, I don’t try to “empty my mind”, or “still my thoughts”, or “focus on my breath”, or anything like that. I just start to notice. I hear bird song, like the bird which sounds like a squeaky gate (I’ve never seen that bird but I hear it often!), or the flapping wings of a pigeon flying overhead. I hear the sound of the wind in the vines. I feel the temperature of the air on my skin. I smell the newly cut grass. I see the ever changing shapes of the clouds in the sky.

Then I carry on and do what I was intending to do next. But I’m back.

Back into the present instead of lost in the memories and imaginary futures where I was before the pause.

Back here in the real world from the world of thoughts and concerns which was filling my life before the pause.

I feel re-connected.

Who’d have thought stepping out of the flow for a spell was the best way of being in the flow?

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This strikes me as a shocking graph. Oxycodone is an opiate painkiller, and this graph charts its annual consumption from 1980 to 2015.

The first thing is astonishing explosion of consumption in the USA since around 1996, and the second is the contrast between the USA and Europe.

What are we to make of this? Did Americans suddenly develop many more painful conditions than Europeans? Why did their consumption remain pretty steady from 1980 to 1995, then rapidly go through the roof?

The answers, of course, are complicated. They relate to the marketing of products by drug companies in different countries, the differences between cultures and changes in economic and social conditions….amongst a host of other things.

It’s true that whilst the great health success story of the last century has been the decline of infectious disease, the not so great story is of ever increasing rates of chronic, non-communicable diseases. In 2014 60% of American adults reported having at least one chronic disease, and 12% actually had at least five at the same time. A report from the NHS in England and Wales today states that men are being diagnosed with their first “significant long-term condition” at the age of 56, and women at 55. In the poorest areas, these figures drop down to the ages of 49 and 47. It found that women in the UK are living “in poor health” for 29 years, and men for 23 years.

Not all of these conditions cause pain, but what does?

Kurt Kroenke has published many research studies showing that symptoms, including pain, are not good indicators of underlying disease. In fact, he has shown that the top ten commonest symptoms patients present to doctors are all highly unlikely to be associated with clear underlying diseases –

Notice that four of these top ten symptoms are pain.

One question then is what is the cause of this patient’s pain? If there is a modifiable cause, then the best treatment is to deal with that. For example, if someone’s pain is due to a severely arthritic hip, then a replacement hip joint will most likely solve the problem. Sadly, most underlying causes are not that straightforward to deal with. Painful chronic inflammatory conditions and incurable cancers are not so easily dealt with. But it gets more complicated, because we also know there is no direct, reliable relationship between the amount of pain a person experiences and the size, severity or extent of any pathology in their body.

So what do we do?

I suspect that what we mainly do is treat pain as if it is an entity in its own right.

The answer to pain, we think, is a painkiller. It’s just a matter of finding the one which kills the most pain for this particular patient. The trouble is this approach has two particularly unhelpful downsides. Firstly, painkiller after painkiller has been shown to be ineffective in the longer term. The longer someone uses a particular painkiller, the less benefit they get from it. Worse than that, the longer they use it, the more likely they are to suffer harm from it. Secondly, by treating pain as if it is an entity in its own right, we lose sight of the causes of the pain. We lose sight of its origins and its variable, daily contexts.

At a population level we have to address the causes of chronic ill health, including poverty, inequality, poor housing, environmental and food chain pollutants, and increasing levels of insecurity and fear.

At a personal level, people need understanding, support, and reassurance. They need to have underlying diseases treated as effectively as possible, and they need to be helped to develop both their coping strategies and the life skills which enhance the daily quality of life. None of this is possible without adequate consultation times, good quality relationships between doctors and patients, continuity of care, and the treatment of every patient as a unique human being.

There will always be a place for good painkillers, but they are never going to be THE answer.


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Here they come! The first little crocus flowers.

It’s the middle of January, and here in the Charente we have blue skies and a bitingly cold wind blowing from the North East (the literal opposite direction from the prevailing winds which come from the South West).

Every year in late autumn I poke some more holes in the grass around the mulberry tree and plant some crocus bulbs. Last time I planted about fifty of them. I’ve lost count of how many I’ve planted in the last five years. We have an image in mind of a carpet of yellow, purple and white crocus flowers covering the ground at the foot of the tree, but, so far, it’s never looked remotely like that, so I just keep adding a few more every year.

Did you know that there is no scientific way to tell if a seed is dead or alive? No way to know which have the potential to burst out of their shells and make their way through the soil towards the Sun. Any botanists out there can correct me, but I suspect the same applies to bulbs. There’s no way of knowing which will produce full-blown flowers, and there certainly is no way of knowing which of them will appear first.

That means that every single year the sight of the first crocus is a surprise and a delight. It’s like making a discovery. Even if I know it’s me who planted the bulbs there. That delight doesn’t go away with the appearance of the first flower either. Every single new plant brings an equal measure of delight. It’s the gift that goes on giving!

This is one of the occasions where I am struck by how we humans can welcome and embrace uncertainty. We’d like to think we can control things. We’d like to think we can predict things. And there are certainly cases where we can, but more often than not, we can’t. I worked as a General Practitioner for four decades of my life, and the core skill of a GP is to be able to handle uncertainty.

In the Primary Care setting, a GP (Family Doctor), tends to be one of the first to be consulted when a patient becomes unwell and can’t manage their illness by themselves. In my training I was taught this meant I’d see a lot of patients with “undifferentiated illness” – because in the earliest stages of illness things can be pretty vague. There might be a bit of a fever, or just a symptom or two….feeling tired, or achey, of slightly nauseous. In these early hours or days there might not be much to find amiss on a physical exam, or at least, not much to find which is distinctive of any specific disease. A few days, or even hours, later, it can be glaringly obvious! Which is why GPs learn to assess the severity of a patient’s symptoms, the over all level of their health, and the need for any urgency. We learn to review the situation as quickly and frequently as appropriate. We also learn that the future is not predictable at the level of the individual patient. We can have a good knowledge of the likely progress of certain pathologies, but we can’t predict the future path of an individual’s illness. Same thing goes for any treatment. Whether or not a certain treatment is so-called “evidence based”, only the unfolding story of this particular patient in the days and weeks ahead will reveal the course of the illness and the appropriateness of the treatment.

I can see that you might read that and despair, thinking, surely the doctor can do better than that? Surely they can predict the future with certainty. Well, nope, they can’t. What that means is that the uniqueness of the individual can never be set aside. The particularity of the person can never be replaced by the categorisation of their illness by diagnosis, or by the likely effectiveness of any treatment. At all the times, the GP has to make a judgement, based on knowledge and experience, use that judgement to decide what to do, then, crucially, follow up.

That’s why I don’t think it’s a good idea to chop the delivery of health care into little pieces. Dealing with the whole person has got a time dimension to it. We need to know how things are progressing, and make another judgement, another decision, in the light of the changes.

So, I might have started writing this thinking about a little yellow crocus popping up, by I find my train of thought exploring uncertainty, unpredictably and the Practice of Medicine, (who saw that coming?!)

Where that takes me to is – I think there are at least three crucial elements to good Medical Practice –

  1. Time – sufficient time for the patient and the doctor to get a good understanding of what’s going on
  2. Continuity of care – follow through of every event into an emerging story over hours, days or weeks
  3. Open minds – never closing down the thought processes by ticking a box, or issuing a prescription, knowing that the future, in all individual circumstances is uncertain.

I’ll leave you with one of the “new”, newly emergent, crocus flowers, by which I mean one of the new variety I planted last year which has just popped up to say hello!

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It’s almost the end of the year and a few days I go something caught my eye when I walked out into the garden here in the Charente – daisies!

I don’t know why, but I’ve always associated daisies with the summer, and I don’t remember ever seeing them flower around the time of the winter solstice, but, who knows? Maybe they do! Perhaps if you’ve more botanical knowledge than I have you’ll be able to enlighten me. However, what I’m saying is this is the first time in my life that I’ve been aware of daisies flowering in the winter time.

So what, you might ask?

Well, here’s why this interests me……

I find that when I notice something different, something new to me, that it slows me down, draws me into the here and now, makes me more present. I felt compelled to turn around, get my camera, then go back out and take some photos of these daisies. I enjoy getting down in the grass to take a close up of the small flowers which grow there, and for a few moments, as I frame and focus, I lose myself in this action. Lose myself in the sense of interrupting the almost chaotic nature of the endless flow of thoughts which seem to occupy my busy brain, and focus for a bit, on looking, on discovering, on photographing these little flowers.

So, there’s the first thing. They take me to another place, to another pace.

Second, as is often the case when I slow down, notice, savour and become absorbed by something, I find a sense of wellbeing, of joy, and of transcendence occurring. I feel nurtured by that.

Third, I start to think about what I know about this family of plants – the daisy family – what I know about them is that they have been used by humans, for hundreds of years, to treat injuries. They have a reputation for stimulating and encouraging repair and recovery. Bellis perennis (this common lawn daisy), Chamomilla, Calendula, Echinacea, Millefolium, Arnica, are all members of what we now call the Asteraceae (the daisy family). And they are all members of Nature’s Pharmacy of healing plants, used particularly in the treatment of injuries. There’s an interesting quality which many of the flowers share which relates to this repair-ability they seem to have – when you walk across the grass, standing on daisies as you go, if you stop and look back, it’s hard to see which ones you stepped on – they have great resilience, great ability to withstand and recover from trauma. Isn’t that interesting?

Fourth, and this is because of what I’ve learned over the years about these little plants, as I wander around the garden, crouching down to take the photos, I start to wonder about resilience. How resilience, which incorporates both an ability to withstand trauma, and an ability to recover from it, is much neglected in Medicine. Even in the treatment of injuries, I wasn’t taught much at Medical School about resilience or how to stimulate and nurture it. But isn’t this an essential part of all healing? This poorly understood phenomenon of self-defence, self-regulation and self-repair. I know now it’s a common feature of all “complex adaptive systems“. But that’s not something taught at Medical School either…..

Fifthly, and, if you are familiar with my thought from other posts on this site you’ll see this one coming, I feel humbled. I feel humbled by the astonishing phenomenon of the lives of these pretty flowers. I feel humbled by the realisation of the limits and partial nature of all human knowledge, and, certainly my own! I feel humbled to be in touch with the natural phenomenon of resilience, and ponder what I can do, what we can do together, to stimulate and support the resilience of ourselves, our loved ones, of other living creatures, of ecosystems, of Nature, of our planet Earth.

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A few days ago I was in Copenhagen and visited the Glyptoteket. I don’t think I’ve ever seen a better presentation of sculpture. It’s a beautiful building with a winter garden in an inner courtyard and it has a permanent exhibition of the most astonishing, gorgeous marble sculptures. Like most museums, it puts on temporary exhibitions, and while I was there, they had one called “The Road to Palmyra”. It is astonishing!

This is new ground for me. I don’t know much at all about that part of the world, or about its history and culture. I was quite blown away by room after room. It still amazes me to read about great cities of the past which have either disappeared, or shrunk down to a tiny fraction of their size in their heyday. Palmyra is one of those cities. At one time it was a meeting place of cultures and peoples, with all kinds of beliefs, values and artistic preferences. That’s all long gone. One of the world’s great cities invaded and destroyed, never to recover. (In fact, you’re probably aware of the destruction of parts of the city by ISIS fighters in recent years. Yet another blow to a once great culture). I still can’t get my head around the fact that today’s great cities might one day be forgotten. That doesn’t seem possible, but history tells us it’s not only possible, it’s pretty inevitable.

I could write a lot about this museum but I wanted to share this one photo with you. I took it in a room dedicated to how the people of Palmyra remembered their dead. Around the walls, each in his or her own little cubby hole, there is a bust or a carving representing someone who died. My first thought was, how wonderful to be able to look at these likenesses, to be able to see the faces of these people who once lived on this planet. How much more is added to the commemoration of their lives by these sculptures? I’m used to seeing gravestones with simple inscriptions – the person’s name, their dates of birth and death, maybe their age at death, and maybe, just sometimes a reference to their work, or their position in a family. But imagine seeing their likeness too? I know in some traditions, a photograph of the loved one is framed and fitted to the gravestone, and that, too, is probably powerful. But, I was left feeling……something is missing.

Yes, it’s great to see these sculptures and you can see how different they all appeared from each other. But I realised what I really wanted, and what I couldn’t get (in the vast majority of cases) were their stories.

I love the unique stories that we have to tell each other. I’ve said this before, but I really did look forward to each Monday of my working week because I knew someone would walk into my consulting room and tell me a story I’d never heard in my life before. Of course, that didn’t just happen on Mondays, and it didn’t just happen occasionally, it happened again and again, every day of my working life.

My life has been filled with stories. I delight in them. I am moved by them. I am amazed by them. I am honoured to have had the opportunities to listen to so many of them. How else could I get to know a person? How else could I get to understand a person? How else could I help a person to cope, perhaps to heal, and even to grow?

What else do we have to give each other in this world?

How wonderful to be able to tell our unique and personal stories. To share them with each other. To enable each other to tell them.

How poor would my life have been without these stories?

I feel that’s more important now than ever. We are in danger of replacing stories with data, of replacing stories with labels. Data which de-humanises us and replaces our stories with algorithms. Labels which de-humanise us and which are used to demonise “the other”.

Our personal stories connect us. I’ve always found I feel more compassion and empathy for the people I get to know and understand when I hear their stories. Stories help us make sense of people, of ourselves, and of our world.

Here’s my intention for 2020 – to tell my story, to share it with others, and to savour the opportunities to hear the stories of others.

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I came across a Royal College of General Practitioners document recently – “Fit for the Future” – It is a vision of General Practice in the UK for 2030. There is a lot in it that I’d support but one of the statements is this –

An overhaul of the GP-patient record into a personalised ‘data dashboard’, accessible by healthcare professionals across the NHS, and that will draw on data from the patient’s genomic profile and wearable monitoring devices.
Now, maybe you read this and it excites you, but it made me stop and think “Hang on a minute! A ‘data dashboard’?”
I remember a line from the English philosopher, Mary Midgely, in her book, ‘Wisdom, Information and Wonder’.
One cannot claim to know somebody merely because one has collected a pile of printed information about them.
She wrote that back in 1989, and it’s clear that, since then, we have, to some extent, replaced the piles of printed information with hard drives full of data. But the point remains the same – you won’t know somebody just by looking at data.
One of my roles when I worked at the ‘NHS Centre for Integrative Care’ in Glasgow was to train young doctors in holistic practice. They’d be allowed to spend as long a consultation as they wanted with a patient then they would come to “present the case” to me. In other words, they’d consult their notes (often several A4 pages of notes) and tell me what they’d learned about the patient. At times what they actually communicated to me were detailed descriptions of the patient’s symptoms. Sometimes so many symptoms in such detail that the amount of information was quite overwhelming. By the time they’d finished I would find myself saying “Well, you’ve told me a lot but I don’t know who this person is'” I had no picture of the patient, their life, how illness came into it, how they’d coped, or the effects the illness had had on them, their family and their friends. A holistic case history is not a “pile of printed information”.
Data, or information, as Midgley pointed out, makes “much better sense when [it has] a context”. The context is revealed by the story. I don’t see how you fully understand a person without hearing their story.
Yet, one junior doctor told me she was being taught elsewhere “Never believe patients. They lie all the time. You can only believe the data” (meaning the results of investigations). That appalled me. What kind of Medicine can we practise if we think “patients lie all the time”? What kind of Medicine can we practise if we distrust their personal, unique stories, but trust only in “data”?
Now, I’m not saying that data isn’t useful. It can be. It would be daft to ignore that. But putting data up front and centre to the point where it replaces the relationship and the story? That’s my fear. That someone will think, “all we need is good algorithms and they will deliver all the right answers once we feed the data in.”
I’m sceptical. It doesn’t seem rational to me. It doesn’t seem realistic to me. And it risks shoving aside human values and the crucial importance of relationships.
Then, just yesterday the UK Health Secretary, Matt Hancock, put forward an aspiration for every newborn child in the UK to have their genome sequenced.  Interestingly, a poll of doctors revealed – “>2000 responses. Only around 10% of doctors would find genetic data more useful than postcode in planning the care for a newborn baby.”
I think we have to claim the ground for the importance of the unique human story. If, as doctors, we fail to consider the environments and circumstances of an individual life, we will fail our patients.
Data without contexts has some use, but it is not a full understanding of, or even a “knowledge of”, a patient.

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I came across a discussion about identity recently, and as identity politics and populism seems to be to the fore in many countries these days, it got me thinking – who am I, really?

A few years ago I was in Marseille and these incredible sculptures were installed around the “Vieux Port”. They really grabbed my attention. Here’s just one of them (see the photo at the start of this post) showing what I immediately perceived as a person. He’s not all there, of course, but we fill in the gaps to make him whole, don’t we? Well, it struck me that that’s what we do all the time.

At least once a week in my consulting room a patient on their first visit, after telling me their story over the course of an hour, would say “I’ve never told anyone what I’ve just told you. Never.” And they’d often add “I feel you know me so well”. It was good feedback, and it reassured me I was on the right track and had established a good therapeutic relationship. But I often thought, “Actually, I only met you an hour ago, and I think it takes a lifetime to get to know someone. I think we can spend most of our lives with a partner but we never really completely know them. I’m still getting to know myself, for heaven’s sake, and I suspect I’ll be doing that for the rest of my life”. Sometimes, I’d say that out loud, but other times, I’d just think it. I think it still.

Here’s me at Primary school –

And here’s me about sixty years later –

Is this the same person?

From my perspective it certainly is! I have the experience of a continuity of Self. I know these are both photos of me, but, boy, have I changed!?

So, who am I, really?

Am I this body?

It’s pretty obvious, even from just those two photos, that this body has changed a lot over the decades. Our bodies are made up of over 30 trillion cells (a number too big for us to imagine, and that’s just an estimate because nobody has been able to count them). Almost all of these cells live much shorter lives than I have done. Some cells live only a few days, other weeks or months, and only a minority last a full lifetime. So, it’s pretty certain that only a minority of the cells in this body I have now are the same ones I had in that earlier photo.

Interesting choice of verb there…..”had” – do I have a body? If so, who is this “I” who has this body? I’m tempted to say, no, I don’t “have” this body, I “am” this body. But there’s the trap, huh? Because if the body is always changing, am “I” always changing too? Where does my sense of continuity of being come from? And I am more than my body aren’t I?

What more am I?

Scientists have discovered and put forward at least three other elements of identity by studying genetics, the “the human microbiome” and epigenetics.

For a while the “Selfish gene” idea gained a lot of traction. “The Human Genome Project” was completed in 2013 and there were great claims for it at the time – a bright new future of “personalised medicine” based on your gene sequences was heralded. Some claimed it would lead to the elimination of a host of diseases. Richard Dawkins, whose book entitled “The Selfish Gene”, popularised the idea that our essence, our core, the “real” “I” wasn’t the body, it wasn’t the mind, it was the double helix spirals of gene sequences….our DNA.

Things haven’t turned out the way the great gene believers imagined however. It seems we can’t be reduced to the level of chains of little molecules. We are more than that. What more?

Well, next up was an exploration of the cells which are part of us but aren’t us – all the bacteria, viruses and other micro-organisms which live on and in our bodies but don’t have the same DNA as we do. It turns out there are at least as many of them as there are “our own” cells. “The Human Microbiome Project” was launched four years after the end of “The Human Genome Project” and by 2016 a lot had been discovered, but it’s still not enough to pin down who we are.

Have these projects helped me to answer the question “Who am I, really?” Not really, but it does make me deeply aware of the fact that I’m not so much an object as some scientific models have suggested. I’m certainly not a fixed entity. Instead, it seems I’m a constant, lively, energetic flow of cells.

It makes me think I’m more like a river than a stone! I’m certainly not like a machine.

But wait, it gets more complicated yet – following on from the discovery of the “genetic codes” researchers discovered that not all the genes are active all the time. In fact they switch on or off all the time. They’re more like music than they are computer code. What presses the keys to play the tunes? What determines which genes are expressed, and when? It seems a whole host of “environmental factors” are involved. You aren’t determined by your genes. They only represent some kind of potential. Whether they become active or not depends on the life your live – the environment you live in and the events and experiences of your life.

We don’t know what all the factors are, or how they work….. “The Human Epigenetic Project” anyone? Well, what do you know? There IS “The Human Epigenome Project“! A consortium exploring at least one of the links between genes and the environment.

So, if my body isn’t all there is to me, if my genes aren’t all there is to me, if my microbiome isn’t all there is to me, then what else is there?

My thoughts? My feelings? My memories, dreams and imaginings? The stories of my life?

Tick “all of the above”. (There are volumes of books which have been, and are still to be, written on each of these)

But there’s a vivid red thread running through all these observations – connections.

Who I am, really, will never be answered by considering myself in isolation. It seems I am a flow. Constantly changing, constantly receiving materials, cells, energies and information from the world in which I exist, constantly sending out materials, cells, energies and information, and constantly changing myself and the world in the process.

My story is not just my story. It’s our story. You and me. Every relationship, every encounter, every exchange, shapes, changes and moulds me, and, you, and the planet we live on.

That excites me.

It’s a new story. It’s the story of evolution, of emergence, of connections, contexts and change.

The answer to “Who am I, really?” won’t be found by looking at smaller and smaller parts. It’ll be found in experiences, in performances, in events, in relationships and interactions. It’ll be found in the unique stories that only I, and only you, can tell. It’ll be found in what we share and how we relate.

Identity is fluid, relative and dynamic.

Maybe we should think of it more as what we share, than what divides us.


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