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Infidelity and ‘beginner’s mind’ in the consultation

Bhupinder Goraya has taken early retirement from general practice. He has also been a Buddhist monk, and is now training to teach mindfulness.

Whilst I was working as a GP an infrequent but important presentation was ‘My partner has run off with another… who knows how long it was going on for?’ My heart would sink for two reasons, partly in resonance with the patient’s distress, partly because I knew my surgery would be put on hold for at least half an hour. Watching someone desperately trying to form coherent thought whilst in floods of tears is distressing. ‘I promised myself I wouldn’t be like this in front of you doctor. I’m really sorry.’ I would call on my meditation training to really relax my own mind and hold the distress without judgement. Most importantly, not trying to move the patient past tears until they were naturally ready to move on. When the story started to come out, the pain was palpable in the silence between the words. The ‘Others’ could be best friends, siblings, treasured neighbours etc meaning a double loss of relationship. What was most distressing though was the feeling that, for years perhaps, the person ‘they thought they were with’ bore no resemblance to who they ‘really’ were.

To have reality turn out to be the opposite of what we perceived is deeply troubling. We can no longer trust ourselves with the basics of life, seeing things how they really are. Usually, there would have been arguments over the trivial. The victim expressing discontent with reality but not really understanding why and blaming it on the toothpaste being left uncapped or toenail-clippings left on the bed.

In a similar way, we can often feel discontent with our relationship with patients, especially the ‘heart-sinks’. The easiest route out of discomfort is to blame the personality of the patient. ‘What does Mrs Smith want me to do about her arthritic knees when orthopaedics refuse to operate? I’ve followed NICE [guidelines] to the letter and there are no options left save mindfulness and that’s a non-starter at seventy.’

…with the guidance we skip the assessment section and go straight to the management…

This is because largely with the guidance we skip the assessment section and go straight to the management. However, the assessment section is critical to good care but is so ‘third-year medical student’ we feel we know it already. In NICE’s clinical knowledge summary topic on knee-pain assessment, the history section asks us to go deep and is understandably directed at diagnosis. But the x-ray has already given us the diagnosis so why trawl through the history again? We steadfastly are faithful to the management guidance whom we see as our faithful spouse. Does this leave the patient playing the role of the adulterous partner? Asking to be taken seriously in our affections but knowing we will never leave our spouse? The guidance allows us to bypass feeling, we don’t have to care, our caring won’t make a jot of difference to the management as prescribed. This is infidelity to the patient. Perception is everything in life and it’s logical to presume that if the clinician doesn’t care they can’t possibly hope to get to the route of the problem.

…if the clinician doesn’t care they can’t possibly hope to get to the route of the problem…

So why don’t we put genuine caring centre stage in our consultations rather than the management guidance? What would that look like precisely? It stems from taking a really detailed history as prescribed in the assessment guidance. This is not just directed at diagnosis but is an expression of our caring. Really going into the impact on daily living makes the patient feel we have really walked in their shoes. A detailed history is not only perceived as caring but makes us look like we’re on the ball. ‘I would have forgotten about that doctor, so thanks for asking.’ Above all, a detailed history and examination is an act of charity. Rather than emotionally stonewalling, we are guiding the patient through conversation and physical contact, understanding that the journey is not the same as the destination. In this example the destination is no different, all treatment options are exhausted. But the journey to that is through considerate medical practice just as we did when students. In meditation circles, this is called ‘beginner’s mind’. Treating each moment as a fresh and unknown arising. We may end up spending much more time on history and examination but this is being faithful to good medical practice rather than faithful to evidence-based management. When we don’t do this we spend just as much time with the patient, but now as disparate parties becoming ever more entrenched in dogmatic positions. Just like a divorcing couple, both sides accuse each other of adultery. The patient feels the doctor is not being faithful to genuine caring, the doctor feels the patient is not being faithful to the evidence.

 

Featured image by Wilson Sánchez on Unsplash

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Thank you so much for this. I’m reminded of Hilary Mantel who I’m fond of quoting, who said, a few years ago in the British Society of Pain journal, “my neurologist’s history was so structured, so searching, so thorough, that I felt that, for the first time, my pain was being listened to. The consultation was, in itself, therapeutic.” In spite of this still find myself ruining consultations by telling the patient that we already know the diagnosis and they just need to get on with managing their symptoms. I’ve also just done a 5 day mindfulness and meditation course with Breathworks and I’m embodying the learning necessary to bear witness to pain and give focused attention with open awareness and kind intention, Thanks again, I will be using this in my VTS teaching session next week

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