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It’s 10pm on a Sunday night and all of my family and I are watching and laughing at Gogglebox on Channel 4. Except for my teenage son, who is upstairs in his bedroom. He is studying hard because he has decided that he wants to be a doctor. He’s started his vocation early — he’s only 14.

I reassure him that he is only in second year and there is still plenty of time. But he has already decided that to do well, certain sacrifices (eg, Gogglebox) need to be made to get him over the line.

It is not like those who choose medicine are the only ones studying hard, but I’m already beginning to notice in him something that I hadn’t noticed about my own life in medicine: how a life in medicine marks us out as different from early on and how it can shape and define us from then.

The competitiveness for places in university is high, which demands a degree of focus, obsessiveness and perfectionism early on in those intent on making it. Those sacrifices will serve my son well but will need to continue throughout university training and post-graduate life if he is going to succeed.

After a few years of being surrounded by other over-achievers, he will probably assume that this is the norm.

His medical school training and life as a junior doctor will shape him further.

Like a novice entering a seminary, he will quickly become accustomed to the costumes, props and rituals that define it. He will be exposed to sleepless nights, illness and death in a way that few of his non-medical friends are, but medical training will encourage in him a degree of objective remove from his patients to help him survive. But he won’t notice because most of his friends will also be doctors.

He will also discover early on  that society confers a special value on doctors and aspiring medics. Medical students are celebrated in families and society in a way that novice priests might have been in the past — ‘he’s going to be a doctor, you know’. It is well recognised that even the primitive tribal medicine man (who was also often a priest) was released from the obligation of procuring food for his tribe.

Society needs doctors to be different, and placing us on a pedestal is probably an expression of its need to bestow a kind of magic and infallibility on us. It is part of the way they acquire the necessary trust to surrender themselves to our care. Whereas it might help us get a table in our local restaurant (‘What time would you like to eat, doctor?’), that perceived specialness demands a price.

Doctors are seen by some of their flock, not as the flawed, vulnerable human beings that they are, but as separate, dehumanised, almost God-like versions of themselves. It makes certain people (especially those we have met professionally) behave awkwardly with us socially.

We become a bit like those lonely priests who are greeted exclusively by their title of ‘Father’ — as if they had no name or identity of their own.

Those who embrace their role too seriously (priests and doctors) have to give up part of themselves and will be set up for the inevitable and painful fall from grace when they (and their flock) realise that they’re not as God-like as they thought they were.

Gogglebox is nearly over and I’m tired and want to get to bed early — I have a busy clinic and a couple of important meetings tomorrow. But my wife reminds me that I still have important work to do tonight — tomorrow is bin day.

I call upstairs for my son.

I have been doing some teaching recently.

The final meds have been coming in for some last-minute prep for their exams. They’re a smart bunch and, for the most part, confidant, warm and don’t take themselves too seriously. Much as I’m enjoying the experience, they sure do ask a lot of questions and seem to spend a lot of time on their phones.

This week, while passing on some of my hard-earned pearls of wisdom, I was more than a little annoyed to see that my student for the day was typing away at his mobile phone as I spoke. Whereas I am well used to being ignored in my own home by social media-addicted teenagers glued to their devices, this felt a little different. ‘This bloody generation,’ I thought to myself.  Before I know it, I’ll be asked to pose for a selfie.

“Anything interesting happening on Facebook?” I asked.

“It’s not Facebook,” he remarked, looking completely unfazed, and even a little disappointed in me. “It’s Facebook Messenger. My classmates are messaging me to let me know that I’ve got a tutorial with Prof in an hour. I’ve also been taking notes on the short cases you’ve been showing me on Evernote and sharing them with my friends who are on the wards. I was also checking something you said earlier,” he remarked, without a trace of embarrassment.

“According to this article, the incidence of the HLA B-27 gene in ankylosing spondylitis in Asian populations is a good bit higher than you mentioned. Do you remember where you got that figure?”

My, how things have changed. In my day, no-one but the swottiest, show-offy, and most annoying medical students would take their lives into their own hands by attempting to challenge a consultant’s assertions. No matter how ridiculous or made-up they sounded. To do so would have involved a trip to the library, a manual Index Medicus search, and a two-week wait for the paper to arrive though an interlibrary loan. These days, anyone with access to a phone can do it. It’s a pain in the ass.

Today’s students are of a generation brought up on technology with ‘always on’ access to the Internet. Because they have access to all of the information they need online (ie, they don’t have to memorise everything), they can instantly check facts as they go along and, moreover, they are not afraid to challenge nonsense when they hear it. That has got to be a good thing — even if it means someone like me occasionally being challenged.

Nonetheless, my pride demanded that I have the final word.

“Medicine in the real world,” I announced, in a voice pitched half an octave higher than usual, “is not just about having information, you know. It is about being present, really present with another person, listening, really listening, and doing our best to apply whatever knowledge and technical expertise from that information to human beings.”

Then, after pausing for emphasis: “That takes time, experience, and a degree of humility that you can’t learn from Wikipedia. Now, if you could just put down your phone for a minute and listen, you might learn something.”

The speech, of course, took place in my head as I drove home alone in my car, feeling more than a little dejected and redundant. You wouldn’t dare have an outburst like that in front of a student these days. You might end up on YouTube.

But as it happens, I have some sympathy for the final meds this year. I’m going to be taking part in the exams myself, for the first time since 1989, when I last sat them. I’m more than a little nervous about the whole affair. Not as nervous as them, of course.

At least I’ll be able to bring my phone.

Postscript: The details have been changed to protect the identities of those involved. But I have a good memory for faces.

 

This article was originally published in the The Medical Independent

It is usually at this time of the year — as chatter about the ongoing Leaving Certificate examinations reaches a peak — that the nightmares come back. I arrive late for my Irish exam, unable to recall a word of Irish or a single interesting thing that Peig Sayers might have once said. Or I’m rushing late, down a long corridor, unable to find the exam hall and then having done so (it is empty), unable to find my pen.

As if the nightmares aren’t enough, the masochist in me has been further reliving the Leaving Cert experience by entering my results into one of those online CAO points calculators. I fear (even allowing for some points inflation over time) that my rather modest 487 points (thank goodness for Home Economics) would hardly get me into medicine these days.

Getting into medicine is hard, but it should be. Just gaining the points for entry demands a degree of intelligence, sacrifice, hard work and resilience that will serve those embarking on the gruelling slog that medicine is. But it often comes as a disappointment to those who secured 600 points in the Leaving Cert (and a relief to those who didn’t) to realise that being good at doing exams doesn’t necessarily mark you as someone who will become a great doctor.

Patients in a 2009 Mayo Clinic study identified the best doctors as those who are confident, empathetic, humane, able to see their patients as individuals, forthright, respectful and thorough.

Despite the crudeness of the selection process (and it seems no-one yet knows how much the HPAT adds), most of those starting out in medicine that I have met tick many of these boxes and start with great promise. They are bright, enthusiastic, curious, compassionate and optimistic. Apart from the occasional psychopath or narcissist (a few still make it through), most who start off on a career in medicine do so for the right reasons — a desire to make people better. At least that’s how it starts.

But along the way something happens. The very processes that help us prepare for healthcare can diminish in doctors the very attributes that our patients value most in us. The study of disease tends to break patients down into their component parts and systems, and can make us sometimes forget that the patient with a disease is a person.

Long hours, sleep disturbance and the stress of working in ineffective or overburdened healthcare systems can strip those providing care of their own humanity and ability to empathise. And yet despite this process, so many make it through, a little bruised and shaken, but with some great battle stories and with their humanity intact.

Those who have done so will have developed a degree of self knowledge and awareness of their own vulnerability, an understanding of the importance of work-life balance, of having friends and lives outside medicine, by not taking themselves too seriously, by looking after their own physical health, and even understanding how exposure to the lives of others through literature, art, film and theatre enhances their understanding of their own lives and those of their patients. They will have realised that keeping up with themselves is as important as keeping up with developments within medicine.

If the raw substrate for good doctoring (a degree of intelligence, diligence and compassion) seems to be present in most of those starting out, perhaps the trick is to assist us all to develop skills that help maintain humanity in a system that frequently diminishes it.

Wish me good luck with my Leaving Cert repeats, by the way.

Now, where is my copy of Peig?

This article was originally published in The Medical Independent

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In: Blog, Disease information, Rheumatology, Videos

Comments Off on Diet, supplements and dietary fads in arthritis

One of the questions I’m most frequently asked by patients is whether diet plays any role in the management of arthritis.

If one were to believe what they read in the papers about dietary remedies, or in the number of books promoting diets or supplements claiming to cure arthritis, one would be forgiven for wondering whether they need to take medical treatment at all.

The idea that a simple change to diet might cure, or lessen the symptoms of a disease as potentially devastating as arthritis, is attractive. It it were only that simple….

What I have done is prepare a number of videos which addresses the available evidence for the effectiveness (or otherwise) of commonly used diets and dietary supplements. I hope you find them useful.

 

A word of caution. You should be aware that most of the claims that are made for dietary manipulation in the treatment of arthritis are based, at best, on poor quality research. Claims for the effectiveness of diet are often made in the face of weak (or absent) scientific evidence, or even worse, in the face of scientific information to the contrary.

Any of the scientific evidence that exists for benefits of diet in arthritis relates primarily to symptom improvement. The is no evidence from any of the scientific studies carried out to date, (other than perhaps weight loss diets as a treatment for osteoarthritis of the knee) that diet can slow the damage or other reduced the negative health consequences of a disease like rheumatoid arthritis. Medical treatment will usually still be required.

Where there is evidence for the effectiveness of any given diet, it may not apply to all forms of arthritis. I have done my best to address this where I can.

 

 

Whereas I am long past the point where I have realised I can’t know everything, I like to think I’m good at keeping up to date. I keep abreast of the medical literature, attend conferences and tick all of the necessary CME boxes to keep the Medical Council happy. And yet, as I pass the mid point in my professional career, I have a sense that I may have reached a plateau.

I was reassured to read that I’m in good company. Atul Gawande, surgeon and well-known author of the The Checklist Manifesto, seemed to reach a similar peak in his mid-40s. Writing about it in The New Yorker, he describes a levelling-off of what had been steady improvement in his surgical outcomes for years.

Noting the transformative effect that an hour with a tennis coach had on his tennis game, he began to wonder why doctors didn’t use coaches to ‘up their game’ in a medical setting. Top-class athletes and opera singers don’t assume that they have achieved perfection once they finish their initial training, he observed. They are constantly reassessing, tweaking, and improving with the aid of a second pair of eyes and ears. If a tennis player like Rafael Nadal could benefit from a coach, then why couldn’t a doctor?

So Gawande decided to get himself one. He invited a retired general surgeon under whom he had trained to come and spend a morning observing him and coaching him in theatre. The effect was transformative. The 20-minute feedback discussion they had at the end of his operating list gave Gawande “more to consider and work on” than he’d had in the previous five years.

If it’s good enough for Gawande, I thought…

So last month I persuaded a colleague and long-time mentor to come and coach me. Hoping that he would tell me that I had already reached perfection (but also deep down fearing that I would be exposed as an out-of-date charlatan), I invited him to observe me for a morning in clinic. A full morning load was scheduled and the patients were notified in advance that another doctor would be present. There would be no specific agenda — he would give me feedback on anything he thought worthwhile throughout the course of the day.

He sat, much like a school cigire, at the back of the consulting room and remained largely silent, taking notes, occasionally approaching the examination couch to watch as I examined and performed procedures on my patients. This was the first time I had been observed in this way since I was a medical student. A little daunting, but after a while I largely forgot that he was there.

After lunch, he gave some feedback.

His most interesting observations related to my consultation style and the pace of the interaction. I have become very skilled (like many of us) at ‘keeping things moving’. As a result, I tend to leave almost no time for pause or reflection. Pauses, we agreed, allow us time to step back into ourselves, to try to re-gather a degree of objectivity after periods of more intense engagement during a consultation. Pauses also, of course, allow our patients time to gather their own thoughts and formulate questions. Missed opportunities to do so included the potentially quiet moments while a patient dressed or undressed, during a physical exam, or while washing my hands.

Additionally, whereas I always review patient notes immediately before I see them, this can be a slightly rushed affair when running behind. This results in an air of distractedness as I alternate my attention between my patient and the computerised medical record to double-check information. A suggestion to read through the notes of all patients before the clinic starts was made, allowing a more thorough assessment and freeing-up some time during the consultation.

I also received feedback on my examination technique, on my use of imaging (a tendency to over-rely on imaging findings in making certain diagnoses), my injection technique (“less stabbing, more distraction”), and the language I use to reassure patients (some patients require more of a ‘you will be fine’ approach than a ‘you’ll probably be okay’ one). We also discussed work-life balance, the redemptive powers of hard work, debt, death (ours) and planning for retirement.

It was hugely rewarding and fulfilling, a unique opportunity to get feedback from a peer and I’d be happy to recommend it.

Although at this stage of my career I’m not in this to win any competitions, it is still nice to aspire to an occasional personal best.

Anyone for tennis?

Note: Thanks to the ever-wise Dr Maurice Barry, Consultant Rheumatologist, Connolly Hospital, Blanchardstown, for his time and counsel.

 

This article originally appeared in The Medical Independent

The hedonistic lifestyles of certain musicians will be familiar to many readers, but the unexpected dangers of playing a musical instrument may not.

Aware that I have an interest in musicians’ health, last week a medical colleague alerted my attention on Twitter to an interesting article in the October 2013 edition of Der Hautarzt (German dermatology journal), describing a condition I hadn’t heard before of called ‘fiddler’s neck’.

Fiddler’s neck is a condition where the afflicted violin (or viola) player develops an unsightly mark on the neck — just beneath the angle of the jaw. Although not that well recognised among dermatologists, it is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition (of quite different aetiology) seen in teenagers. The abnormality is due to an area hyperpigmentation and lichenification of the skin due to the rubbing of the instrument on the neck (erythema, scaling, cyst formation, scarring and inflammatory papules or pustules also occur). The article describes the development of a ‘violin hickey’ in (an undoubtedly embarrassed) 72-year-old lady.

Reading about this curious affliction prompted a ‘knight’s move’ wander through the literature on instrument-specific afflictions — and there’s lots to choose from.

Violinists who succumb to violinist’s hickey are also, presumably, susceptible to a condition known as ‘fiddler’s jaw’ (a condition akin to temporomandibular joint disorder, which comes about because of the way the violin is ‘clamped’ between the angle of the jaw and the shoulder), ‘fiddler’s finger’ (Garrod’s pads of the dorsal interphalangeal joints of the left index and middle fingers) and ‘pizzicato paronychia’ (infection in the nail-fold in string players secondary to pizzicato playing). A similar condition can also develop in pianists.

‘Fiddler’s neck’ is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition seen in teenagers
Jazz aficionados will immediately recognise the ballooned-cheeked appearance of ‘Satchmo’s syndrome’ in trumpet player ‘Dizzy’ Gillespie. The condition, originally named after Louis ’satchel mouth’ Armstrong, occurs in trumpet players, trombonists and French horn players comes about as a result of rupture of the orbicularis oris muscle (due to high pressures generated while playing high notes). Pressing the hard metal mouthpiece hard against the soft tissues of the lips without warming up can also cause injury; Freddie Hubbard, the well known jazz trumpeter, allegedly tore his lip during an “ill-advised high-note cutting contest” with another trumpeter, according to the Jazz Times in 2009.

Other hidden dangers of playing wind instruments include ‘flautist’s chin’ — a dermatological condition brought about by irritation from saliva and possibly nickel allergy, and ‘clarinetist’s cheilitis’ (perhaps explaining the ubiquity of the ‘jazz goatee’ in certain musicians). The spread of herpes, HPV and hepatitis have also been described due to the use of instruments that have not been cleaned properly (again, much like ‘violin hickey’, other aetiologies may need to be considered).

Both ‘guitarist groin’ (lower-limb DVT due to the pressure of a guitar held in the classical posture for long periods on the flexed thigh) and ‘guitar nipple’ have also been described. The latter is a form of ‘traumatic mastitis’ and was originally described in a letter to the BMJ in 1973. The case series describes a series of younger female guitarists, who all developed a cystic swelling about the base of the nipple. The cause, it seems, was the playing of full-sized guitars (by younger musicians) and direct trauma to the nipple area by the instrument.

Shortly after the ‘guitar nipple’ report was published, the BMJ published a letter describing an intriguing condition known as ‘cello scrotum’. The eight-line letter, published in 1974, describes the case of a professional cellist who developed an inflamed scrotum which, the author suggested, came about as a result of playing the cello for several hours a day.

Whereas the accuracy of the report was later questioned by other commentators (one suggesting that scrotal friction against the supporting chair was more likely to be responsible than direct cello trauma, per se), it was frequently cited in the literature over the years until the original author finally wrote to the BMJ in 2008, admitting that the case had been fabricated. The original letter had actually been signed and submitted by the Chairman of a brewery in Suffolk (the husband of a doctor) as a practical joke — never expecting that it might be published.

Hopefully there’s no practical jokers among the authors of the reports of the other conditions described.

This article was originally published in The Medical Independent

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In: Blog, Medical Independent, Review, The practice of Medicine

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When’s the last time you read a comic?

As a boy I loved reading The Beano and later, like lots of other adolescent boys, immersed myself in the more violent worlds of Action and 2000AD. As a medical student, I became attracted to the subversive allure of Fat Freddy’s Cat, The Fabulous Furry Freak Brothers and then, in my late 20s, to Viz magazine. Then I stopped. Whatever role comics might have played in my childhood and young adulthood, it was time to move on. So why do I find myself, in my early 50s, back reading comics again?

Because of GP and cartoonist called Ian Williams. Williams is responsible for coining the term ‘Graphic Medicine’ which describes, according to the graphicmedicine.org site that he helps run, “the role that comics can play in study and delivery of healthcare”. Williams has also produced a wonderful new semi-autobiographical graphic novel, entitled The Bad Doctor — “a darkly humorous tale of medicine, cycling, obsessive-compulsive disorder and heavy metal”. The book details the life of the flawed (in his own eyes), yet deeply human, Dr Iwan James. This wonderful meditation on medicine, humanity and healing is a great reason to start reading comics all over again.

As soon as the book starts, we are drawn into Dr Iwan’s world and sympathise with him as he hilariously navigates the daily grind of heartsink patients, difficult colleagues, middle age, baldness and self-doubt. It is particularly touching where it deals with his experience of growing up, trying to maintain relationships and work, all while suffering from OCD.

concentrationIn a scene depicting his childhood, it describes the early development of an exaggerated sense of responsibility for the health of those around him (something many of us will identify with). He even demonstrates how his unique experience of living with an illness can help him to help his patients. In another touching scene in the book, he breaks the usually unspoken boundaries of the doctor-patient relationship by sharing the details of his own illness with a patient struggling to cope with OCD — and in doing so, helps his patient.

 

Writing comics, and bearing witness to his own problems may also have had a cathartic effect for its author. Writing in The Independent, Williams describes how comics gave him a means to talk about an area of his life he hadn’t, as a doctor, felt able to share before.

“In fact, I almost never discussed them with anyone before finding my voice through the medium of comics, in which I found a way to articulate my own earlier struggle with mental illness.”

The book also details the attitude of his professional colleagues to his mental health problems. When he confides with his practice partner that he has fantasised, throughout his life, about killing himself (“Wouldn’t act on it, though… don’t worry. It’s only a mental habit. I don’t own a gun or a guillotine”), his partner’s primary concern is that this might invalidate the practice insurance.

I read the book three times in 24 hours (although it runs to just over 200 pages, it can be read in 30-to-40 minutes). There is something unique about the reading experience of being pulled along by the combination of the framed pictures, the text and the gaps in between. Using cartoons, he manages to describe Dr Iwan’s world in a way that would have been impossible in the form of an essay or through fiction.

With great bravery, wit and technical skill, Williams has managed pull off a number of impressive feats simultaneously. By digging under the surface of a doctor’s working life in the context of his day-to-day existence, he gives an insight into how the theory of medicine is so different from its practice. He also demonstrates what it is like to live life with a mental health illness, while simultaneously showing an excellent doctor practising good medicine, despite it. All the while keeping us laughing and entertained.

This funny, sometimes sad and courageous book will, I hope, go some way to help non-medical readers to understand the challenges of practicing medicine and show that doctors, like them, are human and suffer.

It might even help a few doctors to think a little differently about mental illness amongst their own.

This article was originally published in The Medical Independent

When was the last time you went to the funeral of one of your patients?

Whereas I have had patients with whom I developed strong relationships over the years, whose funerals I might have attended had I known them in any other capacity than as their doctor, I tend not to go. Like many doctors I tell myself I’m too busy.

Although the death of our patients is (in some ways) inevitable, its timing can be difficult to predict. Cancelling or rearranging our working days to attend funeral services is hard to do at short notice, and even though an out-of-hours appearance at a local early evening removal is logistically possible, it is always easier to head on home. It is better to use our time catering to the needs of those above ground, we convince ourselves, than to those below.

But apart from logistics, there may be other reasons why doctors don’t attend the funerals of patients who have died.

Dr Danielle Ofri, writing in The New York Times, suggests that funerals make doctors feel awkward: “Now that the medical care chapter has closed, we’re not quite sure how we fit into the patient’s life. We were so recently actively directing the medical care — doing something — and now we are the awkward bystanders.”

And also, being faced with the reality of the death of a patient hurts. “It hurts to keep seeing the bodies of your patients — bodies with whom you have been intimately familiar — laid out in stone-cold carriage. It hurts to see the face of someone with whom you’ve had deeply personal conversation, now rigid with that oddly blank expression. It just hurts.”

For some of us, turning up at a funeral may also feel like returning to the scene of a crime, with the attendant fear of ‘being lynched’ by angry, grieving relatives. Whereas it is possible that this feeling may occasionally be justified, most of us, on some level, will feel that we have failed our patients in some way when they die. Facing up to this perceived failure can be a difficult part of doctoring in general.

Most of us, on some level, will feel that we have failed our patients in some way when they die
It is not surprising therefore — given the practical and metaphysical realities of attending — that most doctors don’t.

And yet, attending funerals may have unexpected benefits for those who make the effort. Thomas Lynch, a Michigan-based undertaker, poet and essayist, gave some advice to doctors about the benefits of attending. Speaking at a dotMED conference, he told the audience: “As humans, being present at a funeral forces us to look into the abyss. It presses us against the ontological and the existential, and makes us ask the important human questions. Is that all there is? Can this happen to me? Am I all alone? What comes next?” He also suggests that for doctors in particular, facing the human realities of a death among our patients reminds us that not only are we fallible but also that death is an inevitable. “You spend your lives trying to stop the sky falling. But the sky is falling.” Most of those who end up on his embalming table, he points out, are also very likely to have recently attended a doctor.

“Lead with your humanity,” he says to those of us uncertain how to proceed when the time comes. “I encourage you to be among the people of the dead when the time comes — as it always does. You will be improved by it. You can do some really good medicine by just being part of that, when you can, to the extent that time allows — a phone call, a bereavement letter, five minutes at the wake, a cameo appearance at the funeral, a handful of dirt over the grave.”

Whereas our continued involvement and communication with a patient’s family and loved ones after death is not expected, sometimes the smallest sparks of kindness at the darkest times are the ones that illuminate the most. These kindnesses, Lynch says, “are the stuff of good medicine — these ordinary miracles we do for one another”.

Sometimes healing can come about in unexpected ways.

This article was originally published in The Medical Independent

 

Last weekend I was rear ended and my sturdy 2006 Volvo V-70, which I had planned on driving for another few years, was written off. As I got out of the car, I became aware that my neck was painful but naturally declined an onlooker’s offer of calling for an ambulance. The embarrassing prospect of being placed in a cervical collar and being presented to an emergency department colleague on a stretcher did not appeal to me. Besides, I had to drop my daughter to a party.

The fact that I might have injured my neck caused some concern (and some mirth) amongst family members, who could still clearly recall my first whiplash injury — almost 40 years earlier. Having sustained what was, in retrospect, a minor neck strain (following a jump from a wall), I awoke the following day with such severe neck pain that my parents were unable to persuade me to get out of bed. The local GP was called, strong painkillers, muscle relaxants and a neck collar were prescribed and over the next few days my home bedroom was gradually converted, my younger brother recalls, into a temporary intensive care unit.

My physical and considerable emotional needs were carefully attended to by my attentive parents, my fluid balance restored with MiWadi infused through a bendy straw and my nutrition maintained with jelly and ice cream. After a time, and once I felt well enough to lift my head from the pillow, I was transferred to a lower-dependency unit located in the family TV room. After a further, lengthy period of rehabilitation, it was considered safe to allow me to return to school. My neck pain continued and over next few years, I would travel around the country see the best physiotherapists, orthopaedic surgeons and rheumatologists in the land. The advice I received from more than one specialist was that I needed to be very careful with my neck, pay extra attention to my posture and avoid contact sport at all costs.

Despite medical interventions (and perhaps precisely because they had stopped), my neck pain eventually settled. The experience, however, has given me a unique insight into my own low threshold for unpleasantness, some understanding of the non-medical dynamics of chronic pain and how completely unaware most of us are of them as sufferers.

It therefore came as a pleasant surprise that my most recent whiplash injury settled down within a few days. Could I have toughened up?

A quick Google search alerted me to a possible explanation for my speedy recovery: Doctors, it appears, are relatively immune to the long-term effects of neck injuries following rear-end collisions. A study by Ferrari published in 2001 examined the effects of whiplash injury in doctors compared to a control population. Doctors developed acute symptoms less frequently than non-doctors and injured doctors settled down more quickly than controls. They were also quicker to return to work after an injury.

The author’s proposal was that the development of chronic neck pain after a road traffic accident is largely culturally and geographically determined and that these factors are much more important than the mechanism and severity of the initial injury. Where there isn’t an expectation of the development of chronic neck pain after an accident, he argued, then it is much less likely to occur.

In ordinary circumstances, Ferrari detailed in his book The Whiplash Encyclopaedia — The Facts and Myths of Whiplash, the often frightening circumstances surrounding the initial management of a neck injury (paramedics, collars, stretchers and EDs) tend to create the impression than the injury is not benign.

The initial lack of response to treatment by various therapists and specialists (where attention is repeatedly drawn to the symptoms), and subsequent frequent misattribution of symptoms to abnormalities seen on imaging, all tend to further amplify and reinforce the apparent seriousness of the injury. The additional influence of compensation, he argued (the MiWadi, jelly and ice cream of my own experience) can lead to worse outcomes. He pointed out that in countries where ‘no-fault compensation’ has been introduced (and where financial compensation for continued suffering was removed), the incidence and severity of chronic symptoms in this setting has improved.

Most people injured in this setting will be oblivious, as I was, to the influence that all of these factors will have on perpetuation of their symptoms.

It makes sense, though, that doctors are less likely, by the nature of their training and knowledge, to be susceptible to these influences, or to be fortunate enough to avoid exposure to them in the first place. Ferrari has also published similar positive and early recovery outcomes in rodeo riders who have been involved in road traffic accidents — another group with an expectation, based on personal experience, that neck sprains are pretty common and will usually settle down.

As I write, I feel a twinge of pain in my neck. Maybe I should have an MRI scan…

This article was originally published in The Medical Independent

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Comments Off on The Matrix of Healthcare

In the 1999 movie The Matrix, the story’s hero Neo, played by Keanu Reeves, learns how to slow down time. With special training, our hero’s perception and reflexes become so highly attuned to his environment that he is able to anticipate and dodge bullets, blows and kicks — while remaining unflinchingly calm.

There are days in medicine where we all wish we could be like Neo.

Despite the fact that consultation times have increased over the past few decades, our patients are frequently dissatisfied with the amount of time we spend with them. Increasingly complex and sophisticated medical options and rising patient expectation both dictate that we need more time. But decreased funding and increased pressure to see more patients mean that it’s not always available. The race to keep up has resulted in doctors running faster and faster just to stand still — resulting in what Dr Richard Smith, writing in the BMJ, calls ‘Hamster Healthcare’. It is a style of practice that leads to a reduction in professional (and patient) satisfaction and to burnout.

Whereas one possible solution is to allow enough time for every patient by allocating the necessary resources to do so, this will not be seen as an attractive solution to those paying the bills. An alternative solution to ‘Hamster Healthcare’ will come, according to Smith, from “getting off the wheel, not running faster”. He suggests a fundamental redesign of the practice of medicine to meet the patient needs within the economic constraints that exist. This approach will be music to the ears of those in the Department of Health and health insurers, no doubt.

Technology will help

The creative use of technology in medicine is likely to play a significant role in improving the continuity of care, eg, the use of secure email, text messaging, telemedicine and the use of online communities to share relevant healthcare information and support between visits. By using technology to deal with routine tasks and information-related exchanges, it is hoped that more time can be allocated to more meaningful face-to-face visits, when necessary.

Rethinking the consultation

It has also been suggested that rather than focus on the amount of time spent with patients, we should put some thought into changing how that time is spent. A study of patient satisfaction published in 2002 suggested that a patient preference for “more time” in the consultation correlated with patient dissatisfaction about the “emotional aspects of the consultation”. The study concluded that “a doctor who listens and tries to understand their patient may make the patient feel more satisfied with consultation length and subsequently more motivated to follow any recommendations for change”. This can be a hard task to pull off in 12 minutes, the average duration of a GP visit.

Rethinking time

Dr Robin Youngson, founder of the Hearts in Healthcare movement and author of Time to Care, suggests that to understand the consultation properly, we need to look at time differently.

“In our clockwork analogy of the universe, we have an idea of time as something rigid, punctuated and inflexible. This sense of time is reinforced when our care becomes nothing more than a series of tasks.” “But the human experience of time is quite different,” he writes. “In moments of connection, time stands still.”

He also suggests a number of practices which will help us to use our time with patients more effectively; The importance of building a good rapport early in the consultation and of the importance of a good introduction. He advocates the use of mindfulness; the ability to pull our fragmented, distracted selves together to help us pay careful, non-judgemental attention to our patient, and to our reactions to them.

He emphasises the importance of compassion, for ourselves and for our patients, the use of humour and the usefulness of allowing our patients to set their own agenda.

Whereas it is important that we take advantage of whatever technological and metaphysical tricks we can use to maximise the efficiency of our time with our patients, no-one, even Neo, can slow down time.

This article was originally published in The Medical Independent