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.

 

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

Religious Commitment and Health Status

It is very encouraging that PRIME has a growing family of friends in many countries. I have just returned home from Romania where once again we met many students and doctors from all over the country who share our belief in the high value of the dignity of our patients and wish to encourage this spirit in the middle of medical teaching and practice.

If any of you have sadly been ill yourself and had to ask for a doctor's help you will have experienced the value of such "spiritual care" as a really important partner to the academic and surgical skills of your colleague

We tend to call this "spiritual” care - it is slightly confusing to use this word which can be used also in the context of religious belief. It refers to the awareness of the deep personality of the patient, the story or "narrative" of his life which thus gives unique significance to this particular illness.  So the same medical facts can be manifest totally differently in different people and have to be cared for and managed differently.

Many of our patients have deep religious faith which determines their "narrative".  You might be very interested to look up a fascinating article that shows how much we can improve a person's physical health and healing if we as doctors take full account of their personal faith. Please read the following excellent article:

http://archfami.ama-assn.org/cgi/content/full/7/2/118

With very good wishes to you

Dr John Caroe

PRIME Chairman

On behalf of PRIME – Partnerships in International Medical Education

The fullness of Christ and transformation in healthcare

Fullness is being full, that is holding all within its limits with no emptiness (for example a container), abundance, completeness.  "The fullness of Christ."  What does this phrase mean?  How does it affect healthcare?

Let us see something of what the Holy Spirit has revealed to us in the Bible.  He delights to honour and glorify Jesus.  He takes what belongs to Jesus and reveals it to us.

In Colossians 1:19, we read that "it has pleased [the Father] that all the divine fullness – the sum total of the divine perfection, powers and attributes – should dwell in Him permanently." *  This is true of no other man.   No wonder that in the previous verse (18), we are told that He is the Head of His body, the church, and He alone in everything and in every respect occupies the chief place, standing first and pre-eminent.  "In everything" includes our lives and our work. Recognition of this in practice would transform healthcare!    The next verse (20) reminds us of the central message we are to bring to healthcare, reconciliation to God and peace through the blood of His cross.

In Colossians 2:9, we read that "...in Him the whole fullness of Deity (the Godhead), continues to dwell in bodily form – giving complete expression of the divine nature."  "In bodily form" – a man, yet fully God, who could say "before Abraham was born, I AM."  This is true of no other man.  Amazingly, the very next statement is "And you are in Him, made full and have come to fullness of life – in Christ you too are filled with the Godhead: Father, Son and Holy Spirit, and reach full spiritual stature.  And He is the Head of all rule and authority – of every angelic principality and power."  Those who are born-again believers are in Christ, are made full in Him, are complete in Him and have abundance.  The fullness of Christ means that we have need of nothing else for life and work!  Fullness means fullness - no empty parts, nothing lacking!  I have never forgotten Joni Eareckson Tada's closing remark to us at a HCF international conference - "all you need is Jesus."  And, for that which is outside of us, in the spiritual realm, He is the Head of all rule and authority – every angelic principality and power.  He will send us angelic help when needed and will protect us from spiritual forces of wickedness in the heavenly sphere.

In Ephesians 1:22,23, we read that "He (God) has put all things under His (Christ's) feet and has appointed Him the universal and supreme Head of the church...which is His body, the fullness of Him who fills all in all – for in that body lives the full measure of Him who makes everything complete, and who fills everything everywhere [with Himself]."   Born-again believer in Jesus, no matter where you are working, in a sophisticated modern hospital or in the most obscure poor part of the health field, or facing hostility wherever you are, Jesus is there, for He fills everything everywhere.

In John 1: 14 we read "And the Word [Christ] became flesh (human, incarnate) and tabernacled – fixed His tent of flesh, lived awhile – among us; and we [actually] saw His glory  His honor, His majesty; such glory as an only begotten son receives from his father, full of grace (favor, loving kindness) and truth.  And in verse 16, we read "...out of His fullness (abundance) we all received."  He is full of grace and truth and our lives and our work should therefore be characterized by grace and truth.  Both, not one without the other!  But who is sufficient for these things in this present, pressured world of healthcare?  Let's read the rest of verse 16, " – all had a share and we were all supplied with – one grace after another and spiritual blessing upon spiritual blessing, and even favor upon favor and gift [heaped] upon gift."  Our sufficiency is of Him.  We have received grace from Him, free, full, infinite, never-ending. 

                            His love has no limit, His grace has no measure,

                            His power no boundary known unto men;

                            For out of His infinite riches in Jesus

                            He giveth, and giveth, and giveth again.   

                                                                                          Annie J. Flint

As we act on His grace received, we receive more and more from His fullness.  Our lives come more and more in line with the reality of the fullness we have received in Christ.  The grace we receive from Him changes us into the same image.  As Chris Steyn has written, “healthcare transformation begins on the inside.”

May Ephesians 3:16-19 be our prayer for each other in healthcare and the prayer of those who are our faithful intercessors.  "May [the Father] grant you out of the rich treasury of His glory to be strengthened and reinforced with mighty power in the inner man by the (Holy) Spirit [Himself] – indwelling your innermost being and personality.  May Christ through your faith [actually] make His permanent home – in your hearts!  May you be rooted deep in love and founded securely on love, that you may have the power and be strong to apprehend and grasp with all the saints (God's devoted people, the experience of that love) what is the breadth and length and height and depth [of it]; [that you may really come] to know – practically, through experience for yourselves – the love of Christ, which far surpasses mere knowledge (without experience); that you may be filled (through all your being) unto all the fullness of God – [that is] may have the richest measure of the divine Presence, and become a body wholly filled and flooded with God Himself!

Yours in His amazing grace,

George McDonald

HCFI President

Healthcare transformation is needed

Healthcare is in desperate need of transformation. Two crucial gaps reveal the gravity of the problem.

First, the gap between Jesus Christ and sick people. They really need His love. He certainly wants them to experience it. Healthcare workers are in an ideal position to express the love of Christ on His behalf.

Second, the gap between the local church and healthcare. Local churches have vast numbers of volunteers who should be part of God’s ministry team for blessing the sick and dying. However, many local churches only minister to their own members. Some want to do more, but they do not know how.

Some related powerpoint presentations can be downloaded from the Download Resources page of www.hcfi.givengain.org