This incredibly well written Irish Times article by Lauren-Shannon Jones outlines the difficulties facing a young person seeking help for anxiety today in Ireland.
“I was wearing tracksuit bottoms and a T-shirt because I hadn’t been able to dress myself very well for the previous few weeks. Everything I wore made me feel ridiculous in the face of what I was going through. With mental illness there is often an impulse to bring the inside out, to show some physical evidence of the screaming turmoil within. In the past I would burn myself with cigarettes and bang my wrists on the corners of furniture. Now even that felt stupid and exhausting so instead, I didn’t wash my hair”
I think this highlights the various non-medical priorities that come into play when we force Patients to fit in with an office visit only model where there’s likely to be the prospect of some time in a waiting room (where they are likely to coincidentally meet with locals/friends/family who will invariably tell you what they’re in for before ask ‘what about you?’).
Perhaps GPs need to be aware that when you have an office visit only model you are also inadvertently enforcing a “Patient-Clinic/WaitingRoom experience” and it’s not always going to be conducive to openly sharing personal information.
“I thought afterwards that maybe that had been a mistake, that I should have dressed up a little. That maybe looking too much like a self-neglected crazy person had sold it too hard”
When we know you get 18 seconds before the Doctor interrupts you it’s hardly surprising that Patients will focus so intently on the image they project (how they appear and act) but imagine if we could utilise the time/energy we waste styling ourselves for our Doctors and invest it into sharing our medical history and concerns upfront?
“It was too hot in the waiting room and I couldn’t take my coat off, and I could feel the panic starting the moment that I sat down. My heart was punching out of my chest and I felt a sense of desperation. That’s always how it begins, with a desperate impulse to escape that comes from nowhere. It’s a fight or flight response that doesn’t make any sense… …I went to the receptionist and asked if I could wait outside for a while. I told her it was because it was hot in the waiting room and I felt faint, but really I badly needed to get my heart back in order, because I felt if I didn’t, I was going to die”
“Rush of tears… …I sat down and took my coat off, taking a moment through the panic to be ashamed of the dog hair. I felt it was horribly inevitable I was going to cry. I had come all this way, walked here with as much dignity as a girl wearing a gigantic coat over three-day-old tracksuit bottoms could muster, and now I was going to cry in front of the doctor. It all came out in a big rush. I needed to get as many words out as possible before having to swallow the cry down. “I’ve been having a lot of trouble with anxiety and now it’s at the point where I can’t do much anymore.” Swallow. “And I was wondering if there was something I could take for that.” She took a long moment to stare at me before asking if I’d tried therapy. I told her I had been in therapy fairly regularly since I was 11”
We constantly hear warnings about the urgent need for more GPs to be trained by the organisations that benefit from the training schemes and registration and revalidation fees but there’s so little talk about how we’ve got GPs in 2017 still working in this incredibly efficient way.
What hope is there of communicating anything to someone after such an emotional outpouring if we’re also expecting the GP within the time constraints of 10 min appointments to take the history and data input it into a computer before they even get the chance to begin helping the Patient?
“Personally I don’t know anyone who’d be willing to take medication as a first resort . “We don’t give out Valium and Xanax here because they’re habit-forming,” the doctor told me. I hadn’t asked for Valium and Xanax. “We don’t have any record of you at this office. Who is your GP?” I told her my GP was in Ballsbridge. “Then why did you come here?” she asked. She looked put out”
When we fail to listen it’s easy to jump to the wrong conclusions. In 2017 it should be obvious a GP consult should not start until a Patient (or their Carer) has already answered the question ‘why they want to talk to the GP’.
“I tried to explain to her it was because I couldn’t take the bus anymore. I couldn’t get on any public transport, and taxis weren’t an option either today because the panic was so bad. All of the things I couldn’t do anymore started piling up in my head, and I realised that this really was it. This was my last chance to solve this, because I was too sick to go to brunch, go for a drink, get in a car, or go to a friend’s birthday party, and nobody can live like that for very long. My options at that point were sitting in my house, shaking, or walking my dog, while shaking”
For me this paragraph brilliantly highlights the importance of providing Patients with clinically validated structured medical history questionnaires. I remember Adam Bosworth (a genius of consumer online retail who was at the time the executive leading Google Health) once telling me at a speakers dinner at an event in Denmark that with 3G Doctor we had designed ‘the perfect system for Doctors and the worst possible system for Patients‘. He couldn’t understand why we didn’t just let Patients text us what their problem was instead of requiring them to go through with what he saw as nothing more than the rigmarole of completing an interactive medical history questionnaire and I think this paragraph brilliantly explains the challenge: Patients don’t always know what’s wrong with them even if it’s obvious once they say it and it’s not just helpful to the Doctor to be more informed eg. people are complex and when Patients/Carers can see written down the history they gave before seeing the Doctor it can not only help them but it can also help them gain an understanding of the reasons that underpin the advice that the Doctor has provided.
“Unsympathetic woman… …I started crying. It just melted out of me in horrible, desperate sobs. I was alone in this room with this incredibly unsympathetic woman, and this was my last chance to get my old life back. My old self back. The doctor pushed a box of tissues across her desk and sat back in her chair with her arms crossed. She looked like somebody not enjoying a terrible play. I was trying to get myself together in all the best ways, by reassuring her over and over that I was okay (when I definitely wasn’t), pressing the heels of my hands onto my cheekbones and looking up at the ceiling while making insane gasping noises. This went on for ages. The doctor didn’t say anything. When I had finally exhausted myself, she asked me why I was crying. She sounded very bored. I realised then that if I left now, I would walk straight out into traffic, so I went very calm and asked her to please refer me to a hospital because I didn’t feel safe. She shrugged. “You can go to the emergency room but they won’t be able to do anything for you there,” she said. She was acting as though I was a normal person and not a trembling, covered-in-snot person. She was speaking to me breezily, as if me breaking down had been very awkward for both of us and she was now doing me a favour by pretending it hadn’t happened. “I’ll refer you to the unit in your area, but it will take a while to process,” she warned me…. …I was treated like a criminal for trying to climb out of the pit of depression and anxiety that was slowly destroying my life. In the moment I most needed to be understood, a doctor misread me so absolutely that they sent me back out onto the street in a far worse condition that I had been in when I arrived. It felt like a suckerpunch to the gut. It felt like complete hopelessness“
The Born Mobile generation who think nothing of pressing a button on their phone and shopping or a taxi arriving at their door just don’t understand the office visit only model. Bring our imaginations to work and flip the clinic and even with the most basic joined up thinking this interaction would be completely different eg. without the need to make an appointment or travel anywhere Lauren-Shannon Jones’s Family Doctor would’ve been able to review her Electronic Medical Record (detailing the decade of therapy etc) and the Instant Medical History output on her concerns and could’ve got the Clinic’s counsellor to reach out with a call instead of ever requiring this terrible appointment experience.
“Last resort. In retrospect, I suppose the behaviour of someone deep in a mental health crisis does somewhat resemble the drug-seeking behaviour this doctor clearly suspected me of. The thing is, when somebody goes to seek help, that can often be a last resort rather than a first step. It needs to be treated with delicacy to stop it turning into a final straw. I stood on the street outside the surgery and managed to call the helpline at St Pat’s. I don’t know who the woman was who answered, but she saved my life. I made it home that day, and I’m slowly getting better.”
It’s incredible how quickly Patients will accept blame for the failure of how we’ve designed the healthcare system. Last night I watched Hospital on BBC2 and an 83 year old lady who had received an operation for bowel cancer labelled herself ‘greedy’ (no doubt because of the work politicians – aided by the media – are doing to peddle the ‘we can’t afford the NHS’ story) for taking up the resources of St Mary’s Hospital (the same hospital that is so flush with cash it can waste it building apps for bereaved children to make music that don’t even make sense to the designers).
Sometimes all we can hear are Doctors moaning and arguing with Patients because they don’t have enough information to know how to motivate them but it’s very often the case that we just need someone (like the lady who answered that phone at St Pat’s) to hear us.
I’ll leave the last words to this very brave Patient:
“The Irish mental health system is incredibly difficult to navigate. It needs to change. And it really does start with talking about it”