Unchained Malady

Let me weep

My cruel fate,

And that I

should have freedom.

The duel infringes

within these twisted places,

in my sufferings

I pray for mercy

[Lyrics from Lascia ch’io pianga, an aria from the opera Rinaldo by George Frideric Handel.]

Not so long ago, somewhat disappointingly, I had the very great pleasure of consulting with a patient as part of a Saturday morning surgery. I say disappointed because, to be participating in advanced access arrangements which, in our parts at least, are unnecessary, goes somewhat against the grain. But, for all that, it was a genuine pleasure to see the young lady and her partner and spend some time sharing in their excitement of the pregnancy which promises a little brother or sister for their two year old son. My pleasure was helped significantly by the fact that there was plenty of time to chat since nine of the sixteen appointments offered that Saturday morning weren’t booked and one that was ended as a DNA.

It’s good to have time to connect with patients – to attend to the things that count.

A couple of days later, I also spent time with somebody who was deeply unhappy. Life has dealt her a very poor hand of late and she was understandably bereft. There was little I could say or do that would make much difference. It would have been foolish to imagine that medication held the solution for her wholly appropriate sadness and had even all the counselling in the world been available to her I doubt it would have been any more successful in dissolving her sorrow since the rational cannot be rationalised away. The situation was simply sad. And so I listened and tried to understand whilst endeavouring to share a little of her grief by entering into it with her. Curiously I enjoyed this consultation too – and was left asking myself why that might be.

The answer I came up with was not that I felt some pious sense of self-satisfaction, that in somebody else’s struggles I had somehow proved my worth. Rather my pleasure in the consultation came from a sense that it was good to spend time with someone, connecting with them over things of genuine importance. In a world where too much time is taken up superficially dealing with the trivial, it’s good to go deep with matters of substance.

Whilst there is a place for the trivial, we can over indulge in such sideshows. Too much of what we do in life is superficial and false, undertaken to amuse or distract from what is real. The same can be said for much of what we do at work. We spend far too long worrying about minutiae and passing on our anxieties about things of doubtful significance to patients who, as a consequence, repeatedly pass through the revolving door of a medical system that acts as an anxiety factory perpetually creating work for itself. No wonder we struggle for time. And when something weighty does walk into our consulting rooms, rather than appreciating the heaviness of the burden that is being experienced, we are encouraged to try to lighten the load by reducing it to the manageable by the application of labels and the apportioning of values. In so doing though we simplify the complex, trivialise the important, and diminish the one who has come for help by medicalising them, reducing them to nothing more than their individual clinical parameters.

We tie ourselves up as we try to tie the problem down. What we need to do, what would make a difference is to loosen the chains we are bound by and free ourselves from the constraints of having to deal with a patient’s problem with one eye on QoF, another on the clock and another, as the three eyed mythical beast we are increasing called to be, on national guidelines.

My consultations last week were such an opportunity to practice unchained. The first was a pleasure because of the inherent delight of a planned pregnancy and my having the time to share in the couples joy. Of course a few bits of advice were given, a blood pressure was taken and a referral was made to the midwife, but these were essentially incidentals in the consultation. The second was a pleasure, despite the sadness, because it was similarly a real interaction between two individuals which wasn’t reduced to a dehumanising clinical encounter.

No PHQ-9 was completed.

Imagine the humiliation of having to have the depth of your individual grief scored. Imagine if it wasn’t enough to simply acknowledge the intensity of your sorrow. Imagine if your distress didn’t qualify for compassion.

Worse still, imagine if your distress scored too high for you to be helped. A work based,counsellor, for NHS employees, this week contacted the surgery having rated her client as a ‘3’, out of 10, in terms of self harm risk. This apparently rendered her too disturbed to be supported through her work. As a consequence, rather than being supported there and then, she’d have to wait months for NHS talking therapies instead.

Thankfully PHQ-9 scores are no longer required for QoF purposes. But clinical scores are still very much in favour. Scoring the severity of somebody’s illness by way of a NEWS score may have its place but when, as occurred this week in my practice, a colleague is asked the NEWS score of a patient presenting with unstable angina something has gone wrong – someone isn’t thinking and, perhaps more concerning, someone isn’t feeling either. Reducing an individual to a clinical score serves to distance oneself from the person in need and makes it easier to avoid being affected by the problem being presented. It risks dehumanising both patient and doctor alike. It was bad enough when patients were referred to as ‘the pneumonia in Bed 6’ – how long before patients are not even shown the courtesy of being known even by their diagnosis? How long before they are reduced to being known solely by a number quantifying their clinical condition, the ‘7’ in Bay 2?

And how long before we are categorised similarly. How do you rate as a GP? Are you a ‘7’? You know you ought to be at least a ‘7’. Perhaps you’re an ‘8’, pushing on towards ‘9’. Well done you – but just don’t imagine that you’re you.

We need to keep it real – It’s easy enough to take pleasure in the joy filled experiences of life but there is a kind of joy that can be had in the sadnesses that cross our path if only we can bear to face them as they really are. People are people who need to be cared for, not numbers to be managed – which is as true for us as it is for our patients. We need to remember we are human and that our patients are human too. And since sadness is a normal part of being human, sadness is something we must all feel, something we must all learn to deal with.

The writing of sad songs has been described as more satisfying than the writing of ones that are happy – the writing seeming to sew up a scar in the one who writes. Leonard Cohen said that listening to sad songs helps us feel less isolated as we each form ‘a part of the great human chain which is really involved with the recognition of defeat.’ Though at times messy, being involved in sad consultations can be healing too. Entering into the sadness rather than trying to medicalise it away lessens the loneliness, provides the compassionate touch for which we all hunger, and moulds something capable of holding the tears we all sometimes experience.

There is an authenticity to sorrow,

an exquisiteness to grief,

and beauty in a minor key.

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