Transform Healthcare

Medicine - a vocation or just a job?

In 2005 the Royal College of Physicians of England published a milestone document entitled Doctors in Society: Medical Professionalism in a changing world. Of this 69 page document, that has been used extensively round the world to redefine medical professionalism, they make this summary:

 

“Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.”

 

They go on to list the six attributes that count most in professional practice:

integrity, compassion, altruism, continuous improvement, excellence and working in partnership with members of the wider team

 

The summary concludes:

“These values, which underpin the science and practice of medicine, form the basis for a moral contract between the medical profession and society. Each party has a duty to work to strengthen the system of healthcare on which our collective dignity depends.”

 

A few years ago I was having a conversation with a young pre-clinical student in an East European country. She was telling me of her excitement about eventually becoming a doctor, describing how her desire was to help the sick and bring them comfort. I asked her if others in her year felt the same. She replied that most of her friends also felt this way. I told her to try never to lose this idealism. She assured me that she and her friends never would. I then asked her how many of the doctors that she met and worked with appeared to feel this way. She thought a few moments and then she shook her head sadly and said, “Almost none. What happened to them?”

 

What happened indeed? When we ask any group of first-year students, from almost any country, faith or culture, why they have chosen medicine, or indeed any other health care profession, phrases such as wanting “to make a difference”, “to help people” usually occur alongside wanting the excitement of the emergency room (who said a vocation had to be boring?), fascination with the science of the human body and other motives (some more laudable than others). But somewhere along the line, all too often disillusionment and cynicism creep in.

 

I want to draw attention to the use by the College of the word vocation. Search Google for “medicine as a vocation” and you draw down around 40,000 references. Literally it derives from the latin vocare to call and so is a calling, historically having implications of a calling from God.  A couple of years ago, I was privileged to be a guest speaker at the first national conference on mental health arranged by the Nepal Association of Psychiatrists. Prof B K Singh, adviser for the Government of India, addressing the 130 or so doctors, nurses and students there, concluded his opening address with the words, “We must all remember that God has appointed us as his agents to bring healing to the people.” My main presentation was on Therapeutic Relationships – the Healing Power of Compassion. Thereafter, speaker after speaker, Hindu, Buddhist, Christian referred to this divine appointment by God as the source of the compassion needed for such healing.

 

However, not everyone has such belief, but even so the report used this word, rather than ‘job’ or ‘occupation’ to refer to the sense of service that motivates most of us into the caring professions in the first place. Whether you understand the call as coming from God or from the altruism the report refers to in your own heart, it is still a calling – a vocation.

 

Quite some years ago, partway into my professional career in family medicine, I felt burned out. The ‘calling’ had become a job and one in which I was struggling to keep my head above water. I was pretty successful – I had quite rapidly transformed a small practice into one of the biggest in the town, I had an above-average income, a good house, a delightful family, friends. I had become a leader in the local church and was active in affairs of the town. But it was a struggle. I became afraid of making a mistake in case my reputation was damaged, I double checked all my prescriptions, lay in bed at night worrying – even worrying about money although I had no need to.

 

Then one day in a training of trainers event I was involved in, one of the other tutors suggested we all drew a picture of how we saw ourselves that afternoon. I drew myself juggling balls whilst standing on a swaying raft on a sea full of sharks. I looked at the balls I had drawn and saw they represented friends, family, church and money – all good and necessary in themselves – then I realized there was something not there. I drew another one – idealism – the reason I had gone to medical school, the reason I had worked for years as a medical missionary in the Himalayas. Somewhere I had lost it. There and then in the post-graduate centre, I would say I found God again; some might just say I found again my reason for living. Whatever, next day I entered my clinic with new confidence, no longer resented the dozens of patients who wanted to see me, instead of seeing them as “work”, feeling the privilege that people would trust me with their health, even sometimes their lives. I took more joy in my family and friends. I had, as the Bible says, “remembered my first love.”

 

So, whether you felt called by God or just your own inner being, may I say please don’t forget your calling, whatever idealism brought you into the healing professions keep the flame burning bright. Remember the thrill of the first patient who recovered because you were there, the first time someone looked at you and said, “Thank you”. And if it has grown dim, then invite it back into your life.

 

Dr John Geater, MBE.

PRIME International Director.

 

Report of a Working Party of the Royal College of Physicians (RCP) of London. Published by RCP, December 2005. ISBN 9781860162558.

 

The doctor doesn't know what's wrong with me

How often have you heard that cry?

I recently saw a patient with severe back pain. He had previously had surgery for a spinal tumour. He’s now very frustrated because he feels that something is badly wrong but will have to wait for tests to show the diagnosis. 

 

Today I also saw a patient who does not have a diagnosis for her multiple aches and pains.  She is waiting to see a specialist and is angry because we don’t know what’s wrong with her. I feel it is the emotional problems from her past and difficult key relationships that make her as she is, but she doesn’t accept this.

 

The third patient that I saw today has difficulty swallowing and tests to rule out cancer or a stricture have all been negative. She is an anxious lady who is avoiding going out because of the symptoms and I feel she has anxious depression. She does not agree with this. Suggesting that physical symptoms are caused by psychological causes is a sensitive area and often misunderstood as “The doctor said it was all in my mind.”

 

This sort of problem is tricky to manage. I will have to work to win her trust and then gently explore the issues hoping she will come to recognize that it is her nerves that are causing her problems - it may take years.

 

Both patients and doctors find it very difficult to cope with uncertainty of diagnosis and they like to know what is happening and why with their own bodies. But they commonly hear from patients the cry of “The doctor didn't know what was wrong with me…”, This is sometimes expressed as a triumph for the patient rather than a failure in the doctor.  Sometimes it expresses disappointment, confusion and anxiety.

 

Dealing with patients who have unexplained medical symptoms is really challenging and happens in family medicine and anywhere that is the first place the patient goes for advice. We all recognize the so-called ‘heart sink’ patients, who often have very thick sets of notes and wander around seeking advice from many health professionals in the search for the answer, hoping that someone will fix their problems.  These patients are usually unpopular with healthcare professionals because they attend frequently, are usually demanding, but also quite dependent and passive in their responses.

 

Unravelling the long stories of their illnesses and life events that have led them to be in the position they are now in takes time, patience and perseverance.

 

Peveler (1997) showed that about a fifth of patients who consult their general practitioner present with physical symptoms that the doctor thinks are not explained by physical disease. Appropriate care of these patients represents a substantial workload but if it can be done effectively it is a great service to these patients. A paper by Ring et al (2004) looked at the consultations of 36 patients who were thought by their general practitioners to have unexplained medical symptoms. They typically presented complex patterns of symptoms that did not fit together medically. All the patients but 2 were offered a physical treatment or a test. The patients didn’t actually ask for these, but their behaviours made the doctor want to ‘fix’ things for the patient. They put pressure on the doctor by describing their suffering in graphic and emotive terms, emphasising the effect their suffering had on their lives, frequently referring to friends and family as witnesses to their suffering

 

So what do doctors feel when put in this situation? The doctors in the study felt under pressure from the patient because of the emotive language used and the depth of suffering presented by the patient. Although the doctors often tried to make explanations, these were rapidly dismissed by the patient, leaving the doctor with a deep desire to make the patient better but feeling helpless to relieve their suffering.

 

Actually it seems that these patients really wanted engagement with the doctor rather than a physical explanation. They were crying for help, both emotional and spiritual. Interestingly the doctors responded by giving a symptomatic treatment or a test of some kind, thus continuing the deceit of there being a physical cause for an emotional or spiritual problem.

 

So why did these doctors not engage with the real problem? Is it a fear of involvement with the patient at a deep level, lack of time or skill, or the feeling that they will not be able to win however hard they try? I do not blame them at all, and have felt under similar pressure many times.

 

However, here are a few ideas of how I think these people can be helped….

 

·         Listen without judgement to the whole story of the problem.

·         Believe the patient, they do not usually lie, but you may not understand them easily.

·         Be careful not to make assumptions too early and miss serious disease.

·         Try to gain an impression of what sort of person the patient is and how and why their background influences their reactions.

·         Work to gain trust… be faithful in the relationship and never promise what you cannot deliver or where there is no evidence of benefit.

·         Say it as it is…if you don’t know what is going on, then do not pretend that you do. Be honest.

·         Explain why stress anxiety and depression can cause physical symptoms.

·         Hear the concerned witness of family and friends; they usually wish to help.

·         Reflect your emotional and spiritual diagnosis back to the patient and hear their response. The spiritual problems tend to be to do with close relationships, and may involve guilt, loss, jealousy, rejection and lack of love. These will frequently continue to cause symptoms without a relationship with God with whom they can share and ask for healing.

·         Bring in someone with special knowledge of emotional or spiritual issues when necessary.

·         Don’t expect a quick fix… This sort of healing takes time.

 

Remember that despairing patients will make you feel despairing, confused patients will make you feel confused and anxious patients will make you feel anxious. Be wise and think about your responses before you reach for a quick fix.

 

The interesting thing is that people with a faith are used to uncertainty. The definition of faith is to believe in something for which you have no scientific evidence. Our acts of faith help us to accept uncertainty. If our faith involves expecting a loving and positive outcome from a God who cares for us whatever happens, then we believe it all works for good and can live in uncertainty with hope.

 

Can you give these needy patients time, patience, faithfulness, love and hope? Can you help them to trust you and to trust God?

 

Ros Simpson

 

References:

Peveler et al.  Medically Unexplained symptoms in primary care ; a comparison of self reported symptoms and clinical  opinion. J Psychosomatic Research 1997, 42: 245-252.

 

Ring et al. Do Patients with Unexplained physical symptoms pressure GPs for somatic treatment? A Qualitative study.  BMJ; 2004 :328:  1057-1060

 

 

 

Beyond the Hidden Curriculum

It is widely acknowledged by medical teachers that undergraduate medical training involves three curricula – the official or overt curriculum (what the university has defined as the content and methods of teaching), the taught curriculum (what and how it actually teaches) and the hidden curriculum (the set of influences that work below the surface, creating the culture of the institution, such as implicit rules that have to be followed to survive and customs and rituals).*1

The hidden curriculum has been found to have a very significant effect on how medical graduates develop. Six learning processes of the hidden curriculum of medical education have been identified: loss of idealism, adoption of a ‘ritualised’ professional identity, emotional neutralisation, change of ethical integrity, acceptance of hierarchy, and the learning of less formal aspects of ‘good doctoring’. Together they achieve the enculturation of students as they develop into both practitioners and members of the medical profession.*2   This correlates with other studies that have shown a loss of idealism and development of cynicism as students progress from new medical undergraduates to young doctors.*3

What was/is the hidden curriculum in your medical school? Were the role models to which you were exposed examples of caring, compassionate and conscientious physicians who treated you and their patients with respect and consideration? Or was there a hierarchical and competitive atmosphere in the medical school, in which haphazard instruction and teaching by humiliation occurred? Sadly, in many parts of the world, it is the second that most medical students experience.

It takes courage and determination to resist the hidden curriculum that would seek to turn us into emotionally neutral, ethically compromised, hierarchy loving ritualised professionals. Doctors of that kind are of little use to their patients except perhaps in a very narrow technical way, and will not encourage their patients towards restored wholeness (health). We need spiritual resources to enable us to consistently practise and demonstrate love, joy, peace, patience, kindness, goodness, faithfulness, gentleness and self-control*4 with our patients and colleagues. This curriculum must accompany that of good evidence based scientific medicine if we are truly to act as bringers of healing.

It is PRIME’s  (not hidden!)  curriculum to restore these spiritual, God breathed values and attitudes to the teaching and practice of medicine. Which of these curricula most influences your practice?

Dr Huw Morgan

PRIME Desk Holder,

South Asia

.

 

References:

*1. Lemp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ  2004;329:770-773

*2. Ibid

*3. Hojat M et al. An empirical study in decline in empathy in medical school. Med Educ 2004;38 (9): 934–941

*4. Galatians 5:22-23.

 

Face the scars

“Would you like to see my scar doctor?” said my patient today, a young single parent. She had needed a caesarean section for failure to progress in labour and had had an emergency operation for the birth of her first son. “Any problems with the scar? “ I said. Subconsciously I was trying to avoid having her put the baby down get up on the couch, expose her abdomen, only to for me to glance at a normally healing abdominal wound. “Not really” said the new mother and she looked down. I realised that the procedure of looking was going to be necessary. What a waste of my time I thought. “Let’s have a look shall we?” I said patronisingly.

 

The scar was unsurprisingly normal, red but clean and although wide and a little tight it was a reasonable result. I pronounced that it was a good scar, and so began a conversation about what actually happened to her during the operation.

 

She had had a difficult labour, was quite alone during that time and when a caesarean section became necessary. She knew that a section was a possibility, but was not prepared for the suddenness of the decisions nor for her sense of loneliness in a crowd of professional healthcare workers that she had never met before. They called her “sweetie”, “pet” and “mum” and did not even use her name. They were over familiar with her and yet cold and distant. They behaved as if they cared, but she felt no genuine warmth, no understanding, no hugs and no physical reassurance that all would be well. Even worse, she had to sign her life away on a consent form, wondering if she could trust them with her baby’s life and her own. She was terrified by all this and gave birth to her first son under a general anaesthetic, only to wake up and find the baby had been taken away from her to give him some oxygen.

 

The whole heartfelt story came out as she told me tearfully of her alarm, fear and loss of control.

 

In fact the baby did well, my patient recovered quickly and her mother came the next day to help her, and she is now doing well but finding it difficult to adjust to being a young single mum in a hard society.

 

I realise now that my patient wanted me to see a lot more than her physical scar, that there were emotional scars and ongoing fears about how she would cope in the future. She needed to tell me about the experience she had had, to describe the scars it had left her with and that we needed to make a plan to heal both the physical and the emotional scars.

 

In an article in the BMJ, Stowell describes her adjustment to having a wound after an operation for rectal cancer. She says that “In the first days after my operation, my allowing those closest to me to see my wound was crucial in coming to terms with what had happened.” Doctors see parts of us that we will never see, they take things from us, they give us scars that our bodies will show for life, all while we lie unconscious. It is not surprising then that our patients need us to look with them at the scars they bear and come to terms with the deformation of their once perfect bodies. The emotional scars are equally important and can to a large extent be healed by listening to the patients experience, discussing aspects they don’t understand and helping them love their new body, scar and all.

 

So when the next patient says to me “Do you want to see my scar doctor?” I will say “Yes please”.

 

Dr Ros Simpson.

PRIME Desk Holder

References :Stowell, G. Personal View. BMJ (2008) 337: 296.

Acton, A. When we leave hospital: a patient’s perspective of burn injury. (2004) 329: 504-506. This article describes how you can help someone come to terms and face the world with a facial burn injury.

CAN PATIENTS BE FRIENDS?

Patients in hospital experience a wide range of emotions. Those of us who have been “on the other side of the stethoscope” will know some of these first hand – apprehension, fear, confusion, questioning (why has it happened to me?). Sadly, many also experience other things – isolation, loss of control, and depersonalization.  Staff seem so busy doing their professional things that there is no time even to acknowledge the existence of patients as human beings.

When I was in hospital following an operation for cancer, I experienced some very good compassionate care, but I also experienced one of the bleakest moments of my life. Three days post-op I had been taken to X-ray as there was a fear I had a pulmonary embolus. It was Easter Sunday and no one was there, so I was left alone on a stretcher whilst the duty radiographer came in. The time seemed immense, I felt abandoned, and then my drip ran out. There was no-one to call – and then someone in a white coat came past. The relief was enormous and I called out. Instead of responding, she walked past with a gesture that said “you’re not my concern”. I can still remember the feeling.

The artist Robert Pope was a patient suffering from cancer. He painted his experiences of his time on the wards. Some of his paintings are full of tenderness, but others (sadly many of them concerning his encounters with doctors) convey remoteness and a lack of love. In this one (remember he, the patient, was in the room) the medical staff are so busy doing medical things that the patient is forgotten.

At such a time, the basic human need is to feel secure, loved and cared for; to know that the organization as a whole cares for him or her. Even though you may not have direct responsibility for a particular patient, how you treat them affects them deeply. Just an acknowledgement that they are there, as a fellow human being in distress may bring a reassurance that takes away some of the fear that may harm their recovery – and the reciprocation is that their warmth towards those who care brings its own reward to our own stressful lives.

May I commend to you a recent article in the British Medical Journal (BMJ 2008;337:a528) by David Loxterkamp entitled A Friend in Need. The idea of friendship with patients may seem strange to many, but as Dr Loxterkamp points out, if we can establish this professional attitude of friendship:

“What we give our patients—in spite of our pace and preoccupation—is a sense of connection, the feeling that they are personally known. And to be known and loved in spite of everything is the deepest of human desires. It grows especially keen during illness, when patients are frightened, battered, exhausted, or hopeless, and they suddenly realise that time is running out.”

The full text can be accessed at: http://www.bmj.com/cgi/content/full/337/jul01_1/a528?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=friend&searchid=1&FIRSTINDEX=0&volume=337&resourcetype=HWCIT

Please read it.

So may I suggest next time you pass by the bed of a patient or an anxious relative, at least acknowledge their existence with a nod, a smile or a simple greeting. They will feel better – and so will you. If riches can be measured by the number of friends we have, then doctors and nurses can be the richest people on earth.

 

Dr John Geater

PRIME International Director

What is whole person healthcare?

Dear Friend,

 What is Whole Person Medicine?

You probably already know what this is, although you may not have given it any particular thought. Like many of the most important things in life the idea is so simple that in all the business of modern life, let alone modern medicine, we simply overlook it.

At its most simplistic it is the balance between the body, mind and spirit that make up the individual. In medicine an imbalance in any one of these inevitably affects the others.

This may seem obvious but in much of modern medical education and practice the focus on the complexities of physical diagnosis and treatment means little time may be taken to discover the emotional or spiritual effects of the disorder.

For example, a chronic, enduring pain will inevitably affect the patient’s ability to do everyday things such as hug their children or take the dog for a walk. It may also lead to an inability to cope with daily tasks or the needs of others. A physical or psychological illness has an effect on emotional and spiritual wellbeing and this should be taken into account by healthcare workers. In palliative medicine a care plan will probably include some practical and pharmacological interventions but it may also include the offer of some form of spiritual care such as from a counsellor or hospital chaplain. This is a good example of whole person care.

Patients know that a hospital stay, particularly an extended stay, may lead to feelings of isolation, loss of hope, fear of being unable to cope in the outside world or depression - any of which can have a profound effect on recovery time. Research shows that those receiving care from a chaplain actually go home earlier on average.1 A routine visit to your GP can cause high levels of anxiety. Even the common cold may leave us feeling low, or lacking energy. Physical problems affect our mind and spirit. The converse is also true – there is evidence that shows hopelessness can lead to increased levels of heart disease and cancer.2

Sometimes people complain that the medical profession treats them as a number and not a person, with no proper explanation of what is being done or what will happen next. This lack of thoughtfulness or regard to hopes and fears happens when the whole person – body, mind and spirit – is not being considered. We all know how we would like our mothers to be treated, with courtesy, concern and kindness, but think how many times you have spoken to a friend or colleague who has not received these things.

It seems that in our desire to find new treatments and diagnostic tools we may have overlooked a basic need of all patients – that of being seen, diagnosed and treated not as a leg, a kidney or a brain, but as a whole person. Body, Mind & Spirit.

This is the balance that we as medical practitioners should seek to redress.

References:

1 Florell JL, Bulletin of the American Protestant Hospital Association 1973; 37: 29-36

2 Psychosomatic Medicine 65:201-210 (2003) © 2003 American Psychosomatic Society

On behalf of PRIME – Partnerships in International Medical Education

www.prime-international.org.uk

Looking for God

One of my bad habits is failing to see God when circumstances don't live up to my expectations. In fact, I am often blinded by my sense of entitlement to happiness and "good things". Instead of looking for God, I whine and complain or look for God in the wrong places.

A Hungarian friend demonstrated a better way for me early one Saturday. Showing up for an appointment on the wrong day did not frustrate him. Rather he began to cast his gaze to and fro around the room causing me to ask what he was doing. His response, "I am looking for God!" After determining that he must have been sent to encourage and pray for me, he encouraged, prayed and went on his way. He looked for God and found purpose in the unexpected.

The patriarch, Joseph, learned this lesson as well. His journey was filled with not only the unexpected but the downright difficult. Yet in the end he found God and His purposes as he told his brothers,

You intended to harm me but God intended it for good to accomplish what is now being done, the saving of many lives. (Genesis 50:20)

This week's unexpected and unwanted events in my life offer the opportunity to stop and look for Him, then respond to His purposes. Will you join me in looking for Him? He is there!!!

Sharing the journey with you,

Bob Snyder

IHS

Faith, hope and transformation

“We continually remember before our God and Father your work produced by faith, your labor prompted by love, and your endurance inspired by hope in our Lord Jesus Christ.” 1 Thess 1:3

Last Sunday I heard a pastor say that, “Transformation always starts with hope! You have to believe that God can actually do something!”

Hope and faith are interdependent as the Word of God declares, “faith is being sure of what we hope for and certain of what we do not see.” Hebrews 1:1 NIV

The Message translation says, “The fundamental fact of existence is that this trust in God, this faith, is the firm foundation under everything that makes life worth living. It's our handle on what we can't see. The act of faith is what distinguished our ancestors, set them above the crowd.” Heb 11:1-2

I went on to read again the acts of faith of our ancestors and found that I was lost in amazement at all that they had done in faith and yet, “Not one of these people, even though their lives of faith were exemplary, got their hands on what was promised. God had a better plan for us: that their faith and our faith would come together to make one completed whole, their lives of faith not complete apart from ours.” Hebrews 11:39-40 Message.

It seems that God is saying that their faith would influence us to greater acts of faith. Jesus said that we would do even greater works than His. He is also saying that we together with the heroes and heroines of faith constitute His Body – “one completed whole”. We are not to be independent of one another but to stand in unity, corporately.

It is this thought, our need to stand together in unity that has inspired the Global Prayer Summits for Health Care that were held in the last few years. The next one is 18-22 October in South Africa and Ken and I will be attending it.

In Australia the drought is bringing us to our knees. There was rain after the National Solemn Assembly in March but we need so much more. Australia is in need of rain both physically and spiritually. The land is crying out and in health care, we hear it clearly.

Just today, a woman was in intense pain for 2 hours in the waiting room of a Sydney hospital and miscarried before she was seen by staff. Her husband said that he will never forget the anguish on the face of his wife as she held their child. It was not still born. We can’t ignore their cries.

I can imagine that the staff members were so pressed that they could not respond in time. There is a drought in health care – there is either not enough staff or facilities or there is confusion and chaos in the management of them. In another headline today, the Minister for Health in NSW was being called to account for inefficiencies at this hospital. We need to rise in faith and hope and cry out to the Lord.

In the midst of it, The Global Prayer Summit for Health Care will be held in South Africa 18-22 October. Also Healthcare Sunday falls on 21st October. This is an initiative that began in the UK and is spreading around the world as a day to pray for health care and health care workers.  http://www.healthcaresunday.org.uk

God is calling us to pray corporately to see Godly outcomes in the many crises in our nation and in health care that will glorify the Lord and further His Kingdom. We would encourage you to join in the National Synergy of Prayer in Australia and to join us in praying for rain for global health care as well, especially from 18-22 October. It would be wonderful if you could pray with others at your workplace or in your church. Let us join our faith together and believe that God will break the drought and send rain both physically and spiritually.

Ken and Ros Curry

Health Care in Christ

Do not lose heart

Discouragement comes so quickly to me. Looking at the sad state of world affairs makes me wonder, “Is there any hope?” Staring daily at the pile on my desk representing important tasks can also cause me to wonder, “Is there any hope for completion?” And that does not take into account my own personal issues. Oh my! What I see does not look pretty. Is it any wonder that I lose heart?

The Apostle Paul admonished the church at Corinth on this very issue of losing heart, saying:

Therefore we do not lose heart. Though outwardly we are wasting away, yet inwardly we are being renewed day by day. For our light and momentary troubles are achieving for us an eternal glory that far outweighs them all. So we fix our eyes not on what is seen, but what is unseen. For what is seen is temporary, but what is unseen is eternal. (2 Corinthians 4:16-18 NIV)

I lose heart when I dwell on what I see rather than on what God promises. “Don’t lose heart” are great words for me today. I hope they are for you as well.

Sharing the journey with you,

Bob Snyder

International Health Services

Transforming power of hope

A few years ago I heard a story from a nurse in an eastern European hospital. She was looking after a patient who had cancer. The diagnosis was quite clear but the senior doctor had decided that the patient should not be told. Quite the contrary he was to be told that there was nothing serious wrong with him. All the staff, including the medical students, were instructed that under no circumstances was the patient to be told the truth. This turned out to be too much for most of them.

They could not face the patient they had lied to, so they avoided him. He died isolated from human contact during the last weeks of his life.

The reason for this deception? Apparently it was that ‘Giving the diagnosis might cause him to give up hope.’

What hope?

I suspect that, like many patients with advanced cancer, he knew perfectly well what was wrong with him. In the end he died without hope because there was no one there to give it to him. Indeed, there was nobody there to give him even the most simple human comfort.

Hopelessness is a serious condition, reaching epidemic proportions, particularly amongst the young of Europe. Not only is it a risk factor for suicide independent of depression, it is also a predictor of future heart disease and cancer. In a prospective study of 2428 otherwise healthy Finnish men aged 42 to 60, those with high levels of hopelessness experienced a fourfold increase in new heart attacks over the next six years. They also experienced more than twice the incidence of new cancers compared to men with low levels of expressed hopelessness. (Everson SA et al Psychosomatic medicine 1996; 58:113-121).

How much did hopelessness contribute to our patients’ cancer? We will never know. How much does hopelessness contribute to the burden of cancers and heart attacks in your country? We don't yet know.

But one thing is certain, your patients will look to you for hope and comfort in their confusion and distress. Will you be able to give it?

Never forget - you cannot give what you do not have.

Dr David Chaput de Saintonge

PRIME Education Director

On behalf of PRIME – Partnerships in International Medical Education

www.prime-international.org.uk