Abstract
As GPs we meet, each day, many people facing adversity of various kinds. We encounter a huge variety of people who have made remarkable and admirable progress in overcoming personal difficulties, and some who struggle.
After a lifetime in general practice I met with three equally experienced colleagues to share thoughts and experiences that might inform the promotion of wellbeing for patients and help in overcoming adversity. It is not intended to be an exhaustive or prescriptive list, but aims simply to offer prompts for further discussion between doctors and patients.
Creativity
People often need reminding that creativity goes far beyond the usual duo of art and music. I have two patients who repair motorbikes in their mid-70s and the challenge of bringing the machines back to life gives them purpose, enjoyment and company. ‘When do you think you are being creative?’ can be a useful prompt. People are likely to return to solutions that have worked for them in the past rather than risk something entirely new.
Discipline
For some people ill-health or retirement removes the routine and discipline of work. For some, this considerably increases watching the TV. There is ample evidence of the deleterious effect of such inactivity. It also offers the unfortunate and conflicting impression that other people are having more fun, while at the same time, displaying terrible events and suffering from around the world. Having a discussion about the loss of work-related discipline can introduce the idea of restoring structure and discipline in life when people feel they are drifting or lack purpose. I am still surprised that people need permission to do enjoyable things.
Exercise
It is good to remind patients that exercise releases endorphins, which will lessen perceptions of pain and enhance mood. It is important for exercise to be enjoyable and sustainable; a setback may otherwise stop it for good. There are many exercise bikes and rowing machines lying idle because their owners find them boring. For many people, exercise needs a social element and sport can provide this and exercise. Many sports become increasingly difficult to pursue with age. However, there are other activities and different sports to maintain the healthy combination of exercise and social interaction. Try asking ‘What exercise have you enjoyed in the past?’ Encourage patients to take things up with a friend. Activities such as dancing often find favour.
Faith
For many people, religious faith is an integral part of life and requires no encouragement or discouragement. Seeking and finding meaning to life’s questions, joys and difficulties may draw some to religion and religious communities. Life events can prompt many to review faith and a spiritual component in their lives. Churches and organised religions, despite their failings, offer a sense of community often with buildings that remain open, free and accessible. We have recently been reminded that good spiritual care by GPs is important (Hamilton et al., 2017)
Hobbies
As someone who acquires hobbies easily, I struggle to see how others may have missed out on them. The phrase ‘I need a hobby’ mystifies me. It is useful to ask patients about past and current hobbies. This can give insights into mood and health, but may also reveal opportunities to encourage activities with the potential to improve wellbeing.
Holidays
Answers to the question: ‘When did you last take a holiday?’ can be revealing. Is the patient working too hard and getting overtired? Not everyone can afford to take time off work, let alone go away for a holiday. However, holidays can help improve health and wellbeing and encouragement to take a holiday may be well received and helpful. ‘Be sure to leave the mobile phone at home’ is a good suggestion to make but increasingly unrealistic for most people!
Music, singing and choirs
Music-making can be neglected in early adult life, but resumed with remarkable benefit later. Many patients have abandoned singing and making music due to work and family constraints. People often need to attend with someone to overcome initial reluctance. Again, it can be a group activity with obvious physical, social and psychological benefits. The key question for many seems to be, ‘Who could you go with to break the ice?’
Pets
Many, but not all, people are aware of the therapeutic benefit of pets. I have only recently discovered pet-sharing schemes such as the Cinnamon Trust to help those unable to make a whole-time commitment. Lots of people seem to dog-sit and gain physical, social and psychological benefits.
Purpose – responsibility
Some people clearly miss the purpose and responsibility created by paid employment, and may not be thriving in retirement without realising why. As GPs, we have the great privilege of being able to ask almost any question. The right question can sometimes prompt thought and insight. With hindsight I should have been bolder when asking about retirement. The question ‘How much do you miss work?’ is sometimes followed by discussion about opportunities to restart some form of employment. Patients are increasingly able to continue working longer and the right work has the potential to improve wellbeing for some. Questions can prompt thinking without necessarily providing answers.
Visiting others; avoiding isolation
Loneliness causes enormous malaise. Visiting a nursing home I encountered a lady who came on Sunday afternoons to do puzzles with an extremely frail, but mentally sharp, resident. Why not more of the same? Conversation may dry up but a shared activity, whether ‘Scrabble’ or something else can be a focus for visits and shared activity. It is likely to be healthier than falling asleep in front of the TV.
Voluntary work
I had a patient with a great variety of ailments and made no progress in alleviating her suffering. She then, quite suddenly, stopped coming to see me. When she did reappear I asked her what had happened. ‘Oh, my friend asked me to serve teas in the hospice and I do this with her several afternoons a week’, was her reply. Since then she has been my stock example of the huge value derived by some from volunteering to help others. Volunteering in charity shops seems a popular option for some, but there are many other examples.
Writing
There are many and varied forms of writing, perhaps more so with the development of information technology. Expressing thoughts by writing can be a way of gaining insight. Diaries have helped people gain perspective and release for centuries. There are things we hesitate to tell others. A Chinese proverb says, ’I hear and I forget, I see and I remember, I write and I understand’. I often suggest to patients that they write down their thoughts. Often these are thoughts they go over in their minds, often in the middle of the night (Mugerwa and Holden, 2012).
Overcoming adversity: An aide memoire.
The College recommends that, ‘An exploration of physical, psychological, social, cultural and spiritual issues should be integrated into both the consultation and the management of illness’ (RCGP Clinical module 3.10). We may feel cautious and uncertain discussing such issues, particularly when time is short, but we can be more holistic in our care if we choose to recognise the importance of these issues and their role, when appropriate, in overcoming adversity.
Footnotes
Acknowledgement
I thank Drs John Brindley, Seamus O’Donnell and the late Jon D’Arcy (the ‘St. Helens Old principals Group 1987–2017’) for their help