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Suffering and hope in the GP surgery

Two of the primary elements in medicine are “acknowledging suffering and offering hope”, but neither comes easy, according to Prof Chris Dowrick, Professor of Primary Medical Care at the University of Liverpool.

Prof Dowrick was recently in Ireland to deliver the Helen Lester Memorial Lecture at the Society for Academic Primary Care (SAPC) 45th Annual Scientific Meeting in Dublin Castle.

His talk on the subject of  ‘suffering and hope’, especially as it exists in the GP-patient relationship, won a standing ovation from the large international audience.

In his lecture, he said that formal training should take into account the most recent research in clinical compassion.

“I think the basis is there. But there is a lot in GP training about thinking communication skills, but that tends to focus on what patients think about stuff, rather than what they feel about stuff. So I think there needs to be a shift in that,” Prof Dowrick told the Medical Independent (MI).

He added that GP training should also look at the role patients can play in their own recovery, and also how those working in primary care can deal with both suffering and hope in their practice.

“The focus on good evidence is there clearly [in GP training],” Prof Dowrick told MI.

“But I think the focus on how people frame positive messages needs much more careful thinking.

“I also think how we look at people as not being passive victims but also looking at how people can play a genuine part in their own treatment needs more [focus] as well.”

The lecture in Dublin was a sort of homecoming for Prof Dowrick, who was born in Dublin, “so this morning I was at St Stephen’s Green, close to our hotel, and I was recalling some of my earliest moments in childhood, feeding the ducks in the Green”. During his lecture, he earned laughs and applause from the audience when he showed his Irish passport, saying that he was one of the lucky people to have one since the recent result in the Brexit referendum.

Challenges

Prof Dowrick acknowledged that mindfulness communication, clinical compassion and an understanding of evidence-based hopefulness can be difficult for a modern GP working under increasing time and work pressures.

He says that many of the challenges faced by increasingly overworked GPs in Ireland are replicated in the NHS in Britain.

“But being open to suffering is getting harder all the time, in the face of huge changes in the delivery of primary care,” he said.

“With consultation rates rising and continuity of care and face-to-face contact declining, an increasing emphasis is on standardised, protocol-driven care and the destructive omnipresence of the computer in consulting. But nonetheless, we can do better.”

But does the increase in workload have a direct impact on the ability of doctors to rustle up the energy to deliver clinical compassion?

“Absolutely yes, the pressures of time, the pressures of achieving targets and all those things,” he told MI.

“It does have a big impact on people’s ability to convey compassion.

“Both GPs and patients can get stuck in little ‘boxes’ or little ruts so the patient should do this, and the GP gets to tick the box and achieve the targets, where all the real important stuff can get lost.”

What constitutes the “real important stuff” was the central focus of his lecture.

“We have a curious ambivalence about acknowledging suffering, and despite our best intentions, we often find it hard to really listen to our patients’ distress,” he told the audience.

“The first thing we need to do is to listen. I don’t know about you, but I often find it exhausting and debilitating to give my full attention to the suffering of others,” he said.

“We often find ways of protecting ourselves, of distancing ourselves from the full emotional impact of what our patients are trying to tell us.”

Depression

Prof Dowrick is an expert on depression and his 2005 book Beyond Depression received very positive reviews. He also contributed to the BMJ ‘Too Much Medicine’ series on the over-medicalisation of depression.

In his Helen Lester Memorial Lecture, Prof Dowrick pointed out how a lack of openness to a patient’s suffering can lead to incorrect diagnosis of depression, for instance.

“We distance ourselves by normalising what the patient is saying, dismissing them, or providing reassurances or providing simplistic explanations,” he said.

“Making a diagnosis of depression, for example, is a particularly attractive option for controlling our uncertainty. [This] will allow [the] option of prescribing antidepressants. GPs tend to over-diagnose and treat depression. [They are] 50 per cent more likely to diagnose depression when it’s not present than to identify a case correctly or miss a case when it is present.”

He cited research that showed that the over-diagnosis of depression can particularly happen in “cross-cultural consultation” situations. Research among Vietnamese and East Timorese patients in Australia has shown how the individual immigrant patients’ experiences of communal dislocation, alienation and cultural difficulties in a new society can often be narrowly diagnosed as individual depression by local GPs.  

“Faced with such structured and communal accounts of suffering, GPs opted to depend and draw on more individualised notions of depression,” he said .

“GPs were in reality distancing themselves from the reality of the suffering presented.”

But this is not just a product of the individual styles of GPs.

“It is not simply a matter of our personal shortcomings,” said Prof Dowrick.

“The systems that we may also operate within may also negate our openness to suffering. Communication training in general practice emphasises cognitive aspects of our patients’ experiences and our dealings. But this focus on what our patients think of their problems can give a false sense that we have covered all the bases. But we might not have asked the crucial question of what they might be feeling.”

Wellbeing

As well as his university work, Prof Dowrick is a GP with Aintree Park Group Practice, an honorary Consultant in Primary Care for Liverpool Primary Care Trust, and a non-executive Director for Mersey Care NHS Trust.

He says that GPs also need to find time for their own wellbeing and to find space to think about issues of suffering and hope.

“For me, what helps me these days are daily meditations, weekly park runs” and “discussing knotty problems’” with family.

But this can be difficult, he acknowledged during his lecture.

“As well as taking the best possible care of our patients, we also need to take good care of ourselves,” he said.

“Whether it’s in the midst of our frantic Friday evening surgery, or being behind targets, or dealing with extra numbers in our busy teaching programme or awareness of our own frailty and mortality in the face of a traumatic accident or a life-threatening disease, we would do well to look at our own suffering sometimes and give ourselves the freedom to hope.”

Hope

Prof Dowrick said that good formal training can increase the ability of GPs to provide empathy and patient-centred care.

Speaking from his own experience with patients, he said that acknowledging suffering and helping facilitate hope for patients means that “my consulting room has become, momentarily, a sanctuary”.

“There is emerging evidence of the clinical benefits of clinical compassion in primary care,” he added, citing a significant number of studies in his lecture.

For example, Prof Dowrick said that evidence has greatly improved knowledge of physical activity and mental health and also the social basis of mental health problems

“We now have a much clearer idea of how GPs can communicate therapeutically with patients presenting with unexplained symptoms.”

He also said there is evidence around the benefits of how to actively push for patients to be part of their own wellbeing,  “emphasise the benefits of exercise and activity or strategies to expand their inner resources”.

“These studies are intriguing and deserve further investigation.”

He also added that the “most speculative” area is in how GPs talk about their work and patients. He cited studies that conclude that GPs often look at diseases as puzzles and problems to solve, using mechanical and physical metaphors when speaking of problems.

“If we change the way we think about ourselves and the patient and [we can] generate a new set of metaphors, dynamic and temporal rather than passive and deterministic, offering concepts like the personal and the self which contain the possibilities of hope, action and purpose,” he said.

“There are some fascinating ideas emerging about this.”

Audience reacts to ‘powerful’ lecture

Prof Dowrick’s lecture was greeted with a standing ovation by the large audience at the SAPC 45th Annual Scientific Meeting in Dublin Castle.

Attendees were also busy on Twitter with their thoughts:

“Masterclass in how to give invited lecture #SAPC2016 challenging and inspiring PC to face patients’ hope and despair.”

Barbara Hanratty, @BarbaraHanratty

“Chris Dowrick, powerful in his images in the Helen Lester Lecture.”

Deborah Sharp, @SharpDebbie

“Chris Dowrick on Suffering and Hope. Wonderful words to end the day: Standing ovation #SAPCASM2016 #onlycriedalittle.”

Catie Nagel, @catiebagel

“The great Chris Dowrick gives the Helen Lester Lecture at SAPC 2016 Dublin. Respect due.”

Carl May, @CarlRMay

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