On listening and time to care

My weekly run with a GP friend has become a breathless litany of the ways in which she feels she and her practice are failing patients.  Last week, she resigned after almost twenty years as a GP partner in a deprived part of London.   She left with regret – still loving the doctor-ing, but no longer feeling she can do it properly.   How to shoehorn the various problems of an asylum seeker with secondary syphilis and compound health problems into a ten minute consultation?  Or a woman with depression and crippling arthritis caring for her husband with advanced dementia?

This has become topical with recent focus on the purpose and future of general practice, from the Kings Fund’s conference last month to words from the outgoing RCGP chair last week.  Similar debates have been had about the need to strengthen the general physician role to provide person-centred care in hospital.

At the risk of sounding like a romantic, there is something special about the general practitioner role and its place in British society.  A seminal work is John Berger’s moving, lyrical (almost mystical) short account, A Fortunate Man, shadowing a country doctor in 1950s rural England, accompanied by haunting photographs http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463119/.  I remember hearing the late, lamented Kieran Sweeney describe a key role of the general practitioner to `bear witness’ to life (and death) events, as well as more technical forms of treatment.  In this vein, Iona Heath’s monograph from nearly twenty years ago is still worth reading for thoughtful reflections on what she calls the mystery of general practice http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/The_Mystery_of_General_Practice.pdf.    I like her description of the GP’s role in helping the patient to make sense of illness – the search for meaning being something which doesn’t fit well with performance metrics. 

Many have been influenced by the great US clinician/writer (and now TEDx speaker), Rita Charon, who helped to develop the field of `narrative medicine’ that honours the stories people (patients) tell and how to listen http://jama.jamanetwork.com/article.aspx?articleid=194300.    A good doctor should have `the capacity for attention and the power of representation’.  In her book, she starts with the great case story of Luz, who she dismisses as a time-waster before understanding the reality of her underlying problems in an act of `clinical imagination’.   

In this country, the torch has been carried by many others, including Trish Greenhalgh’s work on storytelling and its place in the clinical consultation http://www.bmj.com//content/318/7175/48.1.  That many of these leading thinkers are women is perhaps no coincidence.  Evidence this month from Karen Bloor’s team in York shows that women clinicians spend longer on each patient consultation (2.24 minutes to be precise)with a more `relationship-building’ style  http://hsr.sagepub.com/content/18/4/242.abstract

So there is good understanding of the power of narrative and interpretation in clinical encounters.   Medical and nursing education is now more focused on improving communication with patients, using ever more sophisticated role-playing, simulation and interactive teaching of `softer skills'.  But there is often little time to truly `honour the stories of illness’ in a system under strain.

I was thinking of all this as my frail, elderly father goes in and out of hospital (currently over a week waiting in a busy medical care assessment unit until a bed comes free) with a host of complex, overlapping problems.  No one seems to have time to ask him how he is and what has changed.  And it is difficult to understand who, if anyone, is holding the ring.    So how can we bring the best of a female-styled Dr Finlay into the twenty first century? 

Also posted on BMJ blogs 14 October 2013 - http://blogs.bmj.com/bmj/2013/10/15/tara-lamont-a-female-dr-finlay-for-the-21st-century