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Archive for March, 2014

Is it all in your head? – not quite…

31 Mar, 14 | by Toby Hillman


A paper in the current issue of the Postgraduate Medical Journal tackles a relatively modern concern: chronic postsurgical pain.

With the advent of modern anaesthetics, and advances in surgical technique, the potential for surgical intervention to tackle disease exploded.  Indeed, there is now a whole industry based on surgically changing the way people look, which in the early days of surgery would have been almost unthinkable. For example, Samuel Pepys put off an operation for his bladder stone (which caused great pain and many infections) for many years before submitting to be cut by Thomas Hollier. [The lithotomy is now a rare beast, having been superseded by less invasive means of removing stones from the urinary tract.]

So surgery is now a much more accessible, and much safer option for the management of disease than it once was.  However, it is not without its problems, and one which may have been under-represented for many years is that of ongoing pain.  The incidence of chronic pain is quite remarkable, with up to 35% of patients undergoing hernia repair reporting pain more than 3 months after their surgery, and higher percentages in patients  undergoing cardiac or thoracic surgery, and even in cholecystectomy rates of CPSP of up to 50% have been reported.

The paper discusses the pathophysiology of pain, and strategies to reduce the likelihood of developing chronic pain. The concepts of central sensitisation, secondary hyperalgesia, wind-up potentiation and pre-emptive and preventative analgesia are of great interest.

However, as one progresses through the article, a change takes place.  One is guided into the realm of the pain clinic.  Here, it is recognised that pain is not simple, it cannot be neatly captured in a line diagram of the spinothalamic tracts, but that pain is a multi-faceted experience for each patient, that can be influenced by a whole range of factors.  The physical risk factors identified for the development of chronic postsurgical pain are important to note, including surgical technique, repeat surgery, and radiation to the surgical site, but what struck me more was the number of risk factors which could be described as relating to mental wellbeing.  Six of the listed risk factors relate to mental state.

This key component of chronic postsurgical pain is borne out by the authors as they discuss the importance of the fear-avoidance model, and how anticipation, and fear have measurable influences on pain perception – confirmed through neuro-imaging studies.  These insights into the development of a chronic condition, and how patients respond to their pain is hugely important, and their application extends beyond chronic postsurgical pain.

One of the key interventions the authors highlight is the provision of information to patients who are undergoing surgery to enable them to understand what they were experiencing post-operatively.  The paper refernced was the report of an experiment conducted about 50 years ago   that examined the effect of an enthusiastic anaesthetist discussing the expected levels of post-operative pain, non-pharmacological methods of alleviating that pain, and a daily reinforcement of this message.  The results are quite impressive, with a reduction in narcotics required, improved comfort, and a 2.7 day reduction in length of stay.

It is on similar techniques that the enhanced recovery programmes employed by many NHS trusts are founded. Essentially, patients are encouraged to take an active role in understanding their condition, the surgery they are undergoing, and are briefed as to what is normal with regards to pain and limitation post-operatively.

The key intervention for me here is that patients are fore-warned about what they are likely to experience, they are given ‘permission’ to be in pain – and to know that this is not a harbinger of doom, or that they are doing irreparable damage to their newly fashioned wounds.  By being up-front about these experiences, fear is dissipated, patients are empowered, and outcomes tend to be better, even though the surgical technique, anaesthetic technique, post-operative pain regime and environment are all pretty much the same.  The major difference is that the patient has been offered some psychological protection, even if it is not labelled as such.

The lessons learned through the experiences of surgical patients over the years can be translated across many spheres of medicine – the marriage of body and mind is not always perfect, and yet, if we only pay attention to one side of the equation, our patients may well pay the price in the longer term. It is a shame that the lessons published in 1964 are not more widely employed, although the tide is changin.  I am convinced that psychological interventions can play a hugely important part in enabling patients to cope with their long-term conditions, of all sorts.

Despite being the calling card of politicians recently, it really is true that there is not such thing as health, without mental health.

Can do, or should do?

17 Mar, 14 | by Toby Hillman


Modern medicine is advancing at an eye-watering pace, and treatments are being utilised for ever-widening patient groups, who might not have been offered similar therapies even a few short years ago.  In this context, it is increasingly important to know that these remarkably effective, expensive, and life-changing treatments are aligned with the wishes of our patients.

Renal medicine is just such an area where a once relatively rare treatment, offered to relatively few patients (HD) is now being offered to an expanding pool of patients.  In a paper in last month’s PMJ, Davison and Sheerin describe some of the challenges around the provision of HD to patients with CKD.

There can be no doubt that HD makes a huge difference to patients with CKD who require it – both positive and negative.  However, it was surprising to read that some studies have found up to 60% of patients on HD regretted the decision.  Sadly it was less surprising to see that a number of these patients felt that either their families or their physicians played a role in ‘pressuring’ patients to embark on this treatment.

Doctors train for many years to be able to manage diseases, put off the inevitable, and maintain the functioning of vital organs through acute and chronic illness.  As such it is entirely understandable that they would wish to offer treatments they have at their disposal to their patients, especially where these treatments can confer a survival advantage. However, the doctors involved in these decisions may not be best placed to ensure that these treatments are initiated for the correct reasons… and it is a feature of many consultations I have had with patients over the years that they often take actions to please their relatives – even if their own preference might be something else entirely.

As we enter the sunset of the baby boom generation, and we develop ever more effective treatments to treat once terminal illnesses, the medical profession must start to take the idea of patient preference more seriously.  This is especially so where resources are scarce, and making the wrong diagnosis of patient preference can lead to (potentially) years of treatments which the patient may well regret starting in the first place, or to missed opportunities to intervene when assumptions have been made in the opposite direction.

There are two key steps that we must make to move towards true patient choice.

One is by enhancing our skills at sharing decision making with our patients and for specialist services to start developing relationships with patients that allow a better understanding of their hopes, concerns and expectations for the future. As Iona Heath pointed out in her fantastic Harveian Oration in 2011 – GPs tend to deal with one set of patients, but their illnesses change over time, but specialists tend to deal with fewer diseases, but it is the patients that come and go.  As such, specialists will be on the back foot when it comes to developing a deep understanding of the true wishes of their patients, but with time, care and with the right tools  it is possible to get nearer to the ideal scenario for our patients.

The other is to realise that just because we can do something, doesn’t mean that we should.  This last issue may take a little longer to resolve.  Diane Plamping highlighted this ‘can do, should do, and that doing means treatment’ thinking as a central tenet of working in the NHS  in an article for the 50th anniversary of the organisation.  She offered no quick fix, but does encourage us to talk about ‘can do, should do’ with our colleagues.  I would suggest that we should discuss this with our patients.  For those we have known for a long time, we will be halfway towards knowing their true preferences, for those who we have met more recently, we need to afford a little more time to ensure that we make perhaps the most important diagnosis when it comes to long-term conditions – the patient’s preference.

Proper preparation and planning… part 2

2 Mar, 14 | by Toby Hillman

I have blogged previously about the readiness of medical students to take on the role of a doctor when they exit medical school.

The previous paper I looked at highlighted that a significant proportion of medical students felt unprepared for the jobs they were ostensibly trained for, and that this proportion was variable across the different medical schools in the UK.

In this month’s PMJ a new paper continues this theme of preparedness.

The authors designed a questionnaire for all medical students at one UK medical school who had recently completed their elective attachment.  The students had gone to a variety of locations around the globe on their electives, and their experiences of death whilst abroad were compared with their experiences in the UK on other placements.

As one might expect, students who travelled to less developed countries were exposed to a greater number of young patients dying, and less elderly patients. Those students who travelled to less developed countries were also exposed to resuscitation attempts in greater numbers, and a high percentage (26%) were involved in solo resuscitation attempts – which would be incredibly unusual in a healthcare setting in the UK.

The impact of this direct exposure to death amongst medical students was explored with supplementary questions about the availability of time to reflect on the experience of being close to death, and if talking to others (and whom) was useful.

The free text responses to the questionnaire are revealing about how the hidden curriculum of the medical profession is at play in this sphere of clinical practice – with one medical student commenting that, having witnessed a resuscitation attempt, ‘I had partaken in what I thought to be a very important part of practical medical training’

This ‘rite of passage’ is undoubtedly an important part of becoming a medical practitioner – and I would consider a vital experience to have at medical school, rather than finding oneself at a cardiac arrest call for the first time when expected to play a vital role within the arrest team.

Another response quoted in the paper exposed the raw emotions which affect students who witness death : ‘shock—never seen anyone die before’  It is this reaction which should perhaps prompt us to examine how we train medical students and how involved we allow them to become in our clinical teams.

The proportion of deaths which take place in hospital varies widely throughout the UK – as low as 45% of deaths in some areas, and as high as 70% in others(see this interactive atlas for more information) However it is likely that medical students will be working on wards where there are patients who are approaching the end of their life, or are living with incurable or progressive long-term conditions.

Very often – and I know I do this myself, these patients are protected from the parade of medical students looking for ‘signs’ and examination practice.  As such, I wonder if we somehow sterilise the clinical experiences of our students, and create the conditions which pre-dispose our students to unpreparedness for facing death in practice.  If we are to train the next generation of physicians and surgeons who will be skilled enough to discuss end of life care issues, help facilitate advanced care planning and ultimately enable patients to die as they wish to, then we must consider how we can allow medical students to become more familiar with death and dying.

I am certainly not suggesting that we thrust medical students into the mix at the end of a patients life just so that they can ‘experience’ this aspect of care, but we certainly should be bringing death and dying into our conversations with medical students more, and looking to develop learning around death and dying when medical students are attached to firms whose patients may be approaching the end of their lives.

Charities like Dying Matters, the Natural Death Centre, and The National Council for Palliative Care work hard to develop resources for patients, families and professionals who are dealing with end of life issues.  We need to ensure that we bring some of this knowledge into training for our medical students.

It is a shame that  87% of medical students on one course felt that they were unprepared to deal with the death of a patient, and I suspect that this would be a similar finding on other courses.  It is beholden on all who train the next generation of doctors to ensure that our most junior colleagues are equipped with the tools to do the job they are being trained to do – not just up to, but including tending to the needs of patients who are approaching the end of their lives.

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