Abstract
Mrs Y is 48 years old, although she looks about 58. She suffers from chronic pain in her low back and in her shoulders. She has a neurological disorder that causes distress but is not progressive. She is obese, she does not smoke. She is a victim of domestic violence (previously) and is separated from her children’s father (who was the perpetrator). She is on a cocktail of analgesics, laxatives and preventative medication. She is intermittently seen by the Pain Team and I see her about once a month.
When our therapeutic relationship began, I was fresh from the Vocational Training Scheme (VTS). I was keen to be sure of her diagnoses, I referred her for investigations and to the hospital. We experimented with different pain killer combinations and antidepressants. I referred her to an exercise programme and to our local talking therapy service. Every time she attended I had a new idea and she was open to it all.
Of course, I was soon exhausted. I found it frustrating that no intervention cured her mysterious maladies and started to feel it was her fault somehow. After fruitful discussion around ‘heart sink’ patients with my peer learning group, I changed tack. I began to subject her to pain scores and information sheets explaining chronic pain theories. We watched a YouTube video on chronic pain together. We both gained a thorough grounding in the fibromyalgia literature, but her pain remained persistent and problematic.
The current stage of our journey is more peaceful. Mrs Y is no longer a ‘heart sink’ patient. Sometimes she cries with pain and frustration, but she does not seek inappropriate medication. She cares for her children (also my patients) well and I know that she leads a full, meaningful life, of which I am only a small part. When she visits, she tells me about her current pain, some of her coping strategies and checks new or changed symptoms against my understanding of her physical conditions.
This sensible, resourceful lady does not attend my clinic in the hope that I will recommend a new wonder drug. I believe I have become a coping strategy. I make sympathetic comments when she describes her pain, I listen attentively when she tells me about her horrific ex-partner and I often ask her if there is anything I can do for her. I wonder if I have become ‘the drug’.
More erudite and eminent people than I have written about the doctor as a therapy and the value of listening. In the 1950s, Balint argued that the therapeutic relationship was just that. More recently, Atul Gawande touches on this theme in his writings. We do have some useful interventions and there are true cures for some illnesses, but more often the doctor is there to guide and listen. Few illnesses are solely cured by medicine. More often, the act of visiting an ‘expert’ is at least part of the remedy. It is possible that some would argue NHS resources are not well spent in this way, that GP time should not be used just to listen. I would argue exactly the opposite. GPs are ideally placed, as experts in common and chronic conditions, to deliver one of the best value and safest treatments available in modern medicine. Ultimately, words of comfort are the only medicine we should always be able to offer.
A year ago, Mrs Y complained of a new pain. She described central abdominal pain that was worse with certain foods. There was nothing to find on examination, but when I arranged for blood tests she was markedly anaemic. An upper GI endoscopy confirmed a duodenal ulcer and I was able to finally give her some tablets that I knew would help. Her anaemia and abdominal pain have improved and she is less tired. Because I was not fretting about curing her incurable ills, I was open to the possibility of a simple, easily treated, illness.
The beauty of accepting the limits of what we can do, frees us to do those few things well. Making sure we are using sensible medication, not overprescribing, utilising services that can help – these are all crucial. Monitoring for significant changes to symptoms and sometimes investigating, carefully, are also part of our job. But more than that, we are a constant. We are there to listen, to empathise and to witness suffering. Often that is all we can do and often that is all that is wanted.