Medicine

The empty tool box

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At some point, the tool box is empty. There is nothing else you can offer. This is hard to acknowledge, both as a professional and a patient.

For a complementary practitioner, practicing honestly, this is the point where you have a conversation with the patient, and offer to refer on, either to a fellow professional or back to their medical practitioner.

For the hospital medic, they often carry out one more test, make a referral to another team or wait and see. This is almost always with the best intentions, but also because admitting you’ve reached the bottom of the toolbox is hard.

For the GP, at the front of patient care, it can be especially hard, since the patient has spent their life believing that medicine can fix whatever the problem is and finding out that there isn’t an easy pill, operation or test that can solve it all is challenging.

But sometimes it has to be admitted that the issue doesn’t have an answer, especially with some chronic conditions and mental health. Its at this point the person is vulnerable to quacks, charlatans and an alternative health tribe who offer an apparent quick fix in return for lots of money.

A lot of alternative treatments are wonderful, offer real benefits to people and can improve lives if used sympathetically and appropriately, but there are always grifters and con artists in every field.

Reiki may offer space, acupuncture can take a completely different view of a problem, an antidepressant can numb the emotions and help the patient get on with life, perhaps while waiting for the world to change around them, a painkiller can allow a return to activity that may help resolve the pain if well managed.

But sometimes, the toolbox is empty.

And then we have to get on with life anyway, rebuilding what we have into a structure that supports us now.

Find the tools that work for you, learn how to use them effectively, add to the box as often as possible and acknowledge that sometimes, the box is empty.

On: Testing and Imaging

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Just because you can, doesn’t mean you should.

As a clinician, there are a huge range of tests and investigations available. Blood tests, scans, investigations, the list of what you can order goes on and on.

Some of them are quite invasive and unpleasant for the patient to go through. Others can expose them to small doses of radation. And all of them have a cost.

How do you choose which to use? The first step is to listen to the person and understand their clinical history. From that, and in conjuction with an appropriate and consented examination, one develops differential diagnoses. And only then, do we start to consider tests to confirm or exclude the diagnosis.

And of course, we have to consider, or at least should take into account, what we will do with the result of the test.

Blood tests can give an idea of the current status of many organs, but if you are complaining of UTI symptoms, i don’t need bloods, I just want a non invasive dip and will treat according to that. However, if I believe that you are anaemic and want to understand why, then a blood test may help, and guide the treatment. And if I believe there is something complex, where it shouldn’t be, then I will want to image it, whilst referring you to the most appropriate speciality.

This is especially true for complex and expensive imaging routines, such as MRI or CT. If you have simple musculoskeletal back pain, and no indication for surgery, then an MRI is not going to change matters. If your clinical history indicates a complex presentation that may require intervention then an MRI or CT is an effective next step. For context, a CT is Computed Tomography, essentially a three dimentional thin slice x-ray model, which is good for seeing hard structures. MRI is Magnetic Resonance Imaging, and best suited to soft tissues and organs.

However, far too many professionals request tests as a holding pattern, so that they feel they are doing something, and are reassuring both the patient and themselves that they are being proactive. This is not a judgement on clinical practice, simply an observed trap that we all fall in to and should be aware of.

So, as a patient, or patient advocate, take the time to check with the person what the test is for and why they think it will help. This will give them the opportunity to educate you, explain their thinking and hopefully answer any questions you may have.

From knowledge comes understanding. From understanding comes courage.

On: Galen

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The history of medicine is littered with men, and women, who even today, have an impact on the way we treat and are treated when we are ill.

One of these, and one of my favourite, was Galen. A Greek physician who practiced in the 1st Century CE Roman Empire, he studied extensively before moving to Rome and eventually becoming physician to the Emperors, and Gladiators. This gave him significant insight into many areas, and although we now know that many of his thoughts on illess and physiology are incorrect, a great deal of his work is still relevant.

Two of his tenets, which I believe still stand, and we still use are:

The body is a complex interconnect system, which has the capacity to heal itself. This is very similar to the osteopathic principles.

Use physical therapies first, then drugs, then surgery.

This last principle is still undervalued by both patient and practitioner, as it is not an easy fix, and given today’s current phamacopea, it is too easy to reach into the cabinet and take a pill rather than look for an underlying cause.

I would advocate to choose to be different. Seek the cause, make a change and overall health will improve.

On: Advocacy

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I don’t have your best interests at heart. Why would I? I have my own stuff to deal with once our interaction is over. The criticism, fear of failure, and self doubt in my mind. Administration, other patients, personal and family concerns, my own health issues, background noise, the passing comment from a colleague that got stuck in my head and keeps rattling around, the alerts and distractions on the screen in front of me. That’s not even counting the 30 or 40 other interactions I will have today, another 8 patient appointments and the meetings related to those.

As a medical professional I try my best to push those aside, to silence them and focus on you. To give you the time and attention you need and deserve, to bring the years of training and experience to bear on your behalf. To know when to treat, when to advise and when to refer. And hopefully at the end of our consultation together, as we conclude our interaction, you will feel listened to, reassured and aware of the next steps.

But I don’t have the time to advocate for you, to have your long term best interests at heart and ensure a life plan is laid out before you. You simply get the time slices I can afford, amongst all the other pressures.

Thats your responsibility. It has to be. This is a 2 way relationship. Come to me for treatment, support, advice and reassurance. Then take control of the other elements yourself, to make sure everyone is working towards the overall goal of longevity and optimal health.

Be your own advocate.