Proposed introduction to my book (work in progress)
Beyond the Stethoscope: Restoring Hope Heart and Healing in Medicine
“A professional training often wounds us. It encourages us to repress certain parts of our human wholeness and focus ourselves more narrowly and cognitively on the grounds that this will make us more useful and effective…Often parts we have repressed…are human strengths – the heart, the soul, the intuition, aspects of ourselves that are our resources in times of stress and crisis and enable us to understand and strengthen others. Few people realize how repressive medical training can be…every doctor can give you examples of falling away from wholeness”
Rachel Naomi Remen (Kitchen Table Wisdom).
“How was your day hon?”
The question is almost on autopilot, and I expect no interesting reply tonight beyond the usual: “yeah, not bad,” as I roll over, turn my back on him, yawn and claim my side of the bed on this humid Queensland night. I am almost asleep when the reply comes.
I roll back towards him. “What happened?” I ask.
There is often not much that my doctor husband can tell me about his day beyond the superficial, for fear of breaching confidentiality. And there is often not much understanding I can lend to some of the nuances of that day, and the depth of the weight he carries home with him from the various dramas, tragedies, diagnoses and pathologies he has encountered. In his day he wrestles with patients and pharmaceuticals. In mine, I wrestle with toddlers and traffic. They lend themselves to different kinds of exhaustion, and not ample possibility for connection at the end of the day.
He rolls towards me and has a go at translating his planet to mine. “I had this woman in her 60s today who came in with menopausal symptoms and was wondering about having hormone replacement therapy.”
Not as interesting as I had hoped. I calculate whether I can stay awake, and murmur to him that I am listening. He obviously needs to talk.
“I looked at her list of medical problems. She had been put on Lipotor to control high cholesterol so I realised there must be a risk of heart disease. I had just been to a lecture about the controversy surrounding cholesterol and its job in regulating the hormones and it dawned on me that we had jumped in with a cholesterol lowering tablet which probably explained the increased difficulties with menopause. Just before we ended the consult, she said she needed a script for her thyroid medication – another hormone area. It was suddenly so apparent to me what a mess we can make when we don’t look at the body as a whole system. There is such pressure to put people on cholesterol tablets to reduce the risk of them dying, but then we end up effectively killing them slowly by upsetting the whole system, putting them on one drug which leads to the need for another drug, and then another. This woman probably ended up feeling sicker, where a lifestyle intervention may have been all that was needed in the first place to lower the cholesterol and have her feeling well.”
“What did you do?” I asked.
“Gave her the drugs. That’s what she wanted. That’s what would be expected of me. I’m not her regular GP, I’m just a locum – I didn’t have time to talk to her about untangling the mess, casting doubt on her regular doctor, getting to the bottom of her symptoms. But I just suddenly had this flash of all the times I have done this to people. That is what we are trained to do.
I just thought I can’t do this anymore.
When I spend too long with patients trying to get to the bottom of things with them though, I get so far behind, my colleagues end up wearing the load. But I just can’t do ten-minute medicine anymore.”
Now I am awake and listening.
We had moved to Queensland from a small town rural practice in Victoria because he had been burning out. We had thought that the sea change and a broader geographic practice area would help him to restore the balance. It seemed though, that the burden of medicine was for him something beyond the location of his practice. And yet, the irony: this was a job he loved with passion. It was meaningful work which went to the very core of who he is.
I had recently read an article in Australia’s GP Review Magazine (they pile in tall, mostly unread towers on our breakfast table), entitled ‘Enough is Enough.’ It told how studies had shown that “more than half of Australia’s general practitioners have considered leaving the job because of workplace stress, and that eight in 10 have said their emotional health has suffered due to their work. There’s no doubting it: Australia’s GPs are more stressed than ever. So what’s wrong with general practice, and what can be done?”
My husband was very close to becoming one of these statistics, if he wasn’t already, and probably will be again.
We met at Uni. I have walked with him and watched his path to doctoring: from intuitive calling, to earnest study, through dogged training, then self-doubt, hope, exhaustion, hope, overwhelm, hope, and then to near burnout, depression and disconnection – from himself, us, his family, and from his patients. I could see it in the shuffle and stoop as he walked, in the mumble he had adopted, and in his words this night. He was sinking again.
I sat up. “You’re an amazing doctor. Don’t apologise that you want to spend longer with patients, that you want to go deeper than their presenting complaint, that you want to help them towards long term wellness, not just short term band-aids. The way you see it is the way it should be. That is what the patients want, that is the future of medicine, and that is what will sustain you.” I was gripped by a ferocious certainty, and an urgency that he had to be bringing his craft to the world in the way that he instinctively knew how.
And in this moment of protectiveness and passion I spat out the words: “You are not alone. There are plenty of doctors who think and work the way you do. They are powerful healers. They sustain themselves. I’m going to go and find them.”
And I did. Some of them. There are many, many more, and their ranks are growing.
And so began this book.
When we hear about the health system in the media, we most often hear that it is in ‘crisis,’ or at the very least, that it is unsustainable. Concerns include public hospital waiting lists, the ageing population, the burden of lifestyle illnesses of our times such as diabetes, mental illness and other chronic diseases, conveyor-belt general practice, the affordability of private health insurance, and therefore the affordability and polarisation of care.
We have seen enormous life-saving and life enhancing technological advances in medicine in the last century, and with them raised expectations and costs. Our knowledge and understanding of the vastly complex system that is the human body has been part of this revolution and yet, through lifestyle choices and circumstances, and environmental ignorance and blindness, and our very humanness, we continue, in spite of all the advances, to get sicker. Our doctors are caught somewhere in the midst (at the forefront of this story), and they, just like the system and the patients, are under pressure and struggling.
At this time, when the costs of health systems around the world are spiraling out of control and our collective health is doing much the same, when the waiting room is, according to one of the contributors to this book, “like a siege mentality,” those at the front lines are a rich source of insight. The economists and government have had their say (put prices up), the pharmaceutical industry (the fourth biggest industry in the world) has had its say (new drugs), the patients are having their say (walking at increasing numbers across the road to alternative and complimentary medicines, or alternatively popping vast volumes of pills), and the doctors, the ones at the front line, are too busy and too tired to have their say. Or no-one has thought to ask them. Some, who have tried to speak up, have been knocked back into place. Some have given up trying, and have found other paths, usually believing the failure is theirs. Some have found a way around the system, the training, the professional culture, the status quo, and the day to day challenges of their work, in order to provide a service which is actually healing, and which is fulfilling and sustainable for the practitioner to provide.
These are some of their stories. They are challenging, pioneering, heartening clarion calls for a new future in medicine.
I have to admit, I have been selective about the doctors I have spoken to. This is no scientifically produced, evidence-based theory on health care reform, this is a heart and soul investigation of deep wounds and deep wisdom, told through story. That ancient art which binds us and humanizes us. And, just like the ancient art of medicine, so too does shared story heal.
So what happens when you put doctors into a safe space, put the words: hope, heart and healing in front of them, and turn the listening chair, which they so often occupy, the other way? When you ask them what it is like to be in their shoes, how they make meaning in their work, how they sustain themselves, what ‘healing’ looks like, whether compassion can be taught, the highs, the lows, and their dreams for the future of medicine? What happens when you sit, mostly in silence and bear witness to the story of the doctor, as they do to so many, day in and day out?
The wisdom that speaks from these doctors, about life in general, can perhaps only be held by those who hear and see all the reaches of the human condition and story approximately thirty times a day.
Behind the scenes of the ‘health system,’ behind the stethoscope, are human beings doing their best to keep us all ticking along for as long as possible. What about their wellbeing? Have you ever wondered when you sit and offload your concerns and pathologies to your doctor what it is like for them to be a critical partner in your life and wellbeing, and that of scores of others, day in and day out? Those people we hold up on pedestals, needing them in our time of illness to be all knowing, all-fixing, infallible – in-human, really. And yet, while needing them to never make a mistake, to not be having a tired day or a midlife crisis in the background, we call for them to see our humanism, and to meet it with theirs.
In the midst of these galloping technological advancements, political pressures, incentives to implement complex public health campaigns, and increased public expectations for quick fixes, combined with the patient’s new status as internet-informed, demanding consumers of medicine, doctors are having to maintain themselves, their knowledge, their personal and professional boundaries, and some semblance of control. And some semblance of professional satisfaction. One of this book’s contributors describes the current landscape as factory style, conveyor-belt medicine. Demand is seemingly insatiable, the medicare system (and its New Zealand equivalent), along with the corporatisation of medical services incentivises quick consultations and quick solutions, and doctors have to watch their back and cover their tracks at all times for fear of being sued for making a mistake. There is enough high stakes fear of making a mistake built into the emotional pressure cooker without the added legal burden of more recent times. Hospital based medicine is led by non-medical managers and is all about the bottom line. It is not hard to see how a doctor who most likely has entered the profession with the desire to help people heal, who has taken an oath to do just that, who has studied for between six to ten years to be entrusted to the task, who intuitively understands (although possibly hasn’t been trained in) the socio-psycho complexity of illness, might be left feeling a little bereft.
None of these doctors signed up to be factory workers. Some might say: ‘but they get paid well to do it.’ In fact they’re not, especially the ones at the coal face – GP’s. I don’t know of many high demand, high risk, high responsibility, high overheads (including ever increasing insurances), emotionally, physically, intellectually and physiologically demanding jobs where your pay is determined by the government, where it crawls up in line with the CPI, and where it never increases more than that despite your growing experience and expertise. While specialists can and do charge a significant gap to cover the difference, GPs as the front door of medicine are under pressure, both as a business choice and as a moral choice, to keep their costs accessible to the public. Our plumber earns more per hour than my husband.
“How was your day?” I ask my husband, most days. “Yeah,” he replies some days, in a voice tight with exhaustion, “people are just really sick at the moment.” Yes, I think to myself, that is your job, get used to it. God, I think to myself, that is your job. That’s full on. You go in wanting to help people, fix their ills, they go in there expecting you to, and quite often you can’t. It must be like professional failure staring you in the face day after day, patient after patient.
“We are under siege,” writes Doctor Kerryn Phelps, “like never before.” Doctor Phelps, former President of the Australian Medical Association and of the Australian Integrative Medical Association, believes that it is the policies, pressures and paperwork which are conspiring to force doctors to more closely examine their careers, their lifestyle and their options and that these mounting pressures are “an unprecedented threat to the health of the doctor.”
Dr Atul Gawenda (?) has said that “the doctor’s plight is inexorably tied up in that of their patient.” (Ted Talk, pre 2002) You could look at it the other way too, the patient’s plight is inexorably tied up in that of their doctor’s. Even if we have no sympathy for the plight of the doctor, we can at least have some concern about the impact of the doctor’s wellbeing on the quality of their medicine.
Medical representative bodies are rightly concerned and recent figures on the mental health of our doctors leave no room for complacency or denial. A recent Australian study surveyed 50,000 practicing doctors and medical students about their health and wellbeing. The results were shocking. The study found that doctors showed a dramatically increased incidence of severe psychological distress and thoughts of or attempted suicide compared to both the Australian population and other Australian professionals. A quarter of all doctors surveyed had had thoughts of suicide in the past. The researchers postulated that the statistics could be even higher and that suicide as a cause of death is quite possibly under reported by sympathetic colleagues.
We have seen in Australia that the rate of suicide amongst doctors is three times the national average. Professional peak bodies scratch their collective heads at this and wonder if they can somehow free up a bit of the paperwork burden. This book tells a much deeper story.
The doctors whose stories make up this book use language such as love, compassion and intimacy. Which is likely to be uncomfortable, and certainly unmeasurable, to policy makers and those pulling the strings in the delivery of medicine. To those actually doing the delivery of medicine though, these stories may feel like a welcome mirror. To those of us on the receiving end, it will come as a relief to know that so many doctors out there are earnestly interested in big picture wellbeing and in us as a human being first, and a conglomeration of cells second.
For patients don’t just come with their bodies. They come with their emotions, their mindsets, their list of internet solutions, their hopes, their fears, their needs and the impacts of the profoundly complex mix of life and living, of their eating, their doing and their relating, on their own unique balance of physiology and psychology.
And medicine is delivered by another set of profoundly unique and complex human beings with their own set of needs, hopes and fears. “My medicine is much more about art than it is about science,” says one of the book’s contributing doctors, Dr Glenn Colqhoun, a general practitioner from New Zealand. “Our medicine becomes who we’re connected to, what we care about, what we carry and haven’t dealt with, and our sense of spirituality in the greater context. Those aspects of ourselves necessarily become much more a part of the conversation, although they remain unspoken. These parts of ourselves, and our relationships can be a good part of the consultation. But we’re slapped over the fingers all the time as doctors for bringing our subjectivity to the consultation. As if we don’t? I mean, really? We just need to learn the power of our own well examined subjectivity.”
The Stethoscope. One end attached to a pair of ears. The other, connecting them to a heart, chest and lungs. A fundamental, two-hundred-year-old, relatively simple tool in the practice of medicine. A routine checking device which immediately forces intimacy into the exchange between the listener and the bearer of the heart. The listener requires a broad base of knowledge to read important information into the messages that the heart and chest emit. The heart bearer requires a degree of vulnerability and trust to raise their shirt and allow these key organs to tell their story.
Stethoscopes are seen as symbols of the doctor’s profession, indeed as an icon of perceived trustworthiness. Doctors are often seen or depicted with a stethoscope hanging around their neck. One medical commentator contends that “the stethoscope best symbolises the practice of medicine. Whether absentmindedly worn around the neck like an amulet or coiled gunslinger-style in the pocket, ever ready for the quick draw, the stethoscope is much more than a tool that allows us to eavesdrop on the workings of the body. Indeed, it embodies the essence of doctoring: using science and technology in concert with the human skill of listening to determine what ails a patient.”
The stories in this book place great importance on that very ‘human skill of listening.’ Not because it is the most important skill in the doctor’s tool-box, but because it is not as often formally recognised or acknowledged for its fundamental role.
“The most important thing that doctors can do for their patients is listen to them” says immunologist and founder of the multi-disciplinary Auckland University Mind Body Medicine course, and contributor to this book, Dr Brian Broom. “Listen to them at the beginning and listen to them at the end, and find out who they are. If you fail to listen to them beyond listening for diagnosis and treatment, without listening to them as a human being, you will miss something. Diagnosis is a pattern of dysfunction in a person, recognised by a group of people who look at people in a particularly peculiar type of way, and who all agree on what treatment should be applied, according to that peculiar way of looking. The person you are treating who has been reduced to a diagnosis, has been reduced down to your limited way of looking.”
As doctor and writer Rachel Naomi Remen writes in her book ‘Kitchen Table Wisdom,’ “Everybody is a story. When I was a child, people sat around kitchen tables and told their stories. We don’t do that so much anymore. Sitting around the table telling stories is not just a way of passing time. It is the way wisdom gets passed along. The stuff that helps us to live a life worth remembering. Despite the awesome powers of technology many of us still do not live very well. We may need to listen to each other’s stories again.”
My own GP postulates that some of the additional burden on front line doctors these days may in fact be in part due to the loss for many of the priest and church community (in addition to the kitchen table, perhaps) as a listening ear. Dr Glenn Colqhoun acknowledges the complexities of this in general practice. “We need to unload and repackage the model. The waiting room really does drive a lot ….. I’ve been at my current clinic for five or six years now and there are some I saw on the day I started and I’m still finding things out about them now, which I didn’t in a million years know about them, and I’m embarrassed. But taking a full social and family history, which can be hugely revealing, is very inefficient and just not economic at all. In the long-term it has efficiencies but in the short term it means you get through a quarter of the patients. But, general practice without that, you’d want to stab yourself in the eye wouldn’t you?”
It felt to me, as I travelled around Australia and New Zealand, seeking out doctors and their stories, that I became a kind of curator of the art of human story. My original intention in ‘catching’ these stories was to draw out themes, weave together some kind of social commentary about big picture, sustainable medicine, and to speculate on the future of medicine. And yet, as I tried to work my craft with the threads, I felt I was denying them the purity of their context. It became clear to me that, like a curator of art, it was not my job to comment – it was merely my job to hang these stories in the gallery of this book, and to invite you to come along and make your own meaning of them.
“Breathe deeply please,” says the medical practitioner, when listening to a heart and chest through a stethoscope. May we be reminded of our power when we breathe deeply, listen deeply, feel deeply and connect deeply.
 ‘Medical professionalism and ideological symbols in doctors’ rooms.’, Schuklenk U
J Med Ethics. 2006 Jan; 32(1):1-2.