Mayu Otsuka reflects on a clinical attachment with a General Practitioner: an experience which provokes some striking revelations.
St Andrews RCGP Mackenzie Prize in Community Medicine 2011
“That patient is suffering from an illness, but not a disease.” The GP told me on the way back from the home visit, leaving a slightly unsatisfied looking patient behind. As she said this, I remember the first thing she told me when I saw her; “When you are observing me, I want you to explore the difference between disease and illness”. Most doctors I have been attached to were very keen on telling me about the medical conditions that the patients had. “This patient had oesophageal spasms and she takes this drug,” or “come and have a listen to the friction in the lung.” I did learn a lot about the doctor-patient relation- ship in terms of communication skills and emotional aspects from other doctors, but this doctor, Doctor A, taught me the most interesting facet of the doctor- patient relationship, from an ethical and cultural viewpoint.
“Why did you not give any medication to the patient?” I asked Dr A in the car. It was about the patient whom we had just seen during the home visit. She stated that she had a headache and a burning sensation and aches down her arms. “Because she does not need it,” the doctor continued, “she has done many tests in the past and there is nothing wrong with her. It`s not caused by any other health conditions she suffers. She was already given painkillers including morphine but it did not work. She suffers from chronic pain syndrome. ”
I wondered why the doctor could not prescribe her with other painkillers. I think Dr A sensed what I was thinking and said “I asked you before what the difference was between illness and disease. This patient suffers from an illness which does not have any underlying disease caus- ing it. What she needs is not medication like painkillers and antidepressants. It`s psychological support and exercise.” What I understood from this is that a patient can be ill without disease and that treating patients is not all about giving drugs.
“Can the pain be healed using the placebo effect by giving different drugs?” I asked. The doctor then pointed at the piece of paper I was holding with a list of all her medications. “This is poison,” she continued. “A lot of doctors just prescribe drugs to patients to make them feel like it was worth coming. I, on the other hand, don`t like to give drugs to patients if I feel it is not going to benefit them. All these drugs we prescribe will eventually be poisonous to her. All have potentially harmful effects and we choose to give them having weighed the benefit against the harm.” I see a dilemma here.
Dr A only wants to prescribe drugs when it truly benefits the patient – not when patient DESIRES it. However, patients WANT the drugs because they feel that it will make them feel better. She told me that what is important at the end of the day is not the disease itself, but how the patients MANAGE THEIR ILLNESS.
“Remember the gentleman who came for chronic joint pain – I referred him to a pain clinic but his pain was still not relieved. He keeps coming back even though there is nothing much we can do about it. He stated that he cannot lift a kettle and he needs his wife to help him with daily tasks. Having a disease and perceiving that he cannot do anything is just going to worsen his life. A lot of patients think positive, accept and deal with pain and disability and keep challenging themselves to complete their daily tasks”.
I felt slightly uncomfortable in this conversation as I faced the realistic view that some patients visit doctors with cries of help and fear, but sometimes doctors cannot do much about it. “You become a doctor to practice medicine and treat patients, not to do good,” she told me, “When I ask students ‘why medicine?’ ,a lot of them answer ‘to help people’ and ‘to do good.’ Though doctors don`t always do good. We have to say ‘no’ to patients all the time. Sad, but it is true.” A GP I shadowed in high school had said the same.
It is a harsh reality that doctors need to deal with. Having said this, I feel that a lot of patients understand this concept. A lot of patients whom I see accept their difficulties. Sometimes they only want emotional support – not to treat the disease, but to relieve illness. Changing illness perception and behaviour and being positive can improve a patient’s life. Patients may present very ill without any disease, and patients may have disease but yet are able to have a normal life. I thought it was an interesting concept.
During my attachments, I have seen many patients being prescribed antidepressants at different dosages. There was a 32-year old lady whom Dr A knew since she was a teenager. She came to receive a prescription for new antidepressants as the previous one did not work. Dr A did prescribe her a different antidepressant. However, after she left the consultation room, Dr A signed and said, “I don’t think antidepressants are going to work.” I was slightly confused. She prescribes antidepressants to so many patients with emotional difficulties and she already knows who is going to benefit from it? “I’ve known her since she was a young girl. She has always been miserable. Her mother, sister are also miserable. They are all overweight, are all on antidepressants. It is not genetic. They all say they have depression, but it is their personality and how they cope with life. Life is tough and people sometimes need to just get on with it. Antidepressants work very well for patients who are unhappy and lacking energy for no reason. Like the first patient you saw this morning. But in her case, it is obesity, a lack of money and a lack of self-esteem. She is depressed and complains about her misfortune, yet does not make efforts to improve. I advised exercise and getting a job but she does not want to do it.” I thought it was similar to an alcohol or smoking problem. “It must be hard for patients to change their lifestyle,” I said. “Yes, but patients are becoming too dependent on drugs. Not just her, patients take drugs even if they have no underlying disease – because they feel ill. While making an effort to change their behavior helps more than drugs, they just believe that taking drugs will do something good for them.”
Dr A was more disciplined about this kind of issue as she herself was brought up in a difficult environment. She be- lieves that although your socioeconomic factors and childhood upbringing cannot be altered, you can control how you behave towards these factors. “Why did you prescribe antidepressants knowing that she will not benefit?” I asked. “I prescribe her antidepressants because it may improve her feelings slightly and that could push her to cope with her challenge”. I agree with her prescription. She is not giving the drug for a placebo effect, but to give her a little push to cope with life. It was the same in another patient who was being prescribed antidepressants for her fear. She had cancer twice in her sixties and was having GI problems due to surgical removal of half her oesophagus. The patient said that the drug was not making much difference, but she was trying to be optimistic herself in coping with her fear. Hence she said she was generally happy with her life. I understood that antidepressants may help her with some activities, but at the end of the day, what actually makes life happy is not the medication, but the patient’s own feelings.
Hearing Dr A, I remembered another patient she had seen – a two-year old boy who had a cold. It taught me that patients have different perceptions about the same disease. Some mothers never come back after their child is diagnosed as having a cold, because it will get better in a few days. However, though the mother of this two year old had just visited the doctor the day before. She came back because the symptoms were not getting better and she went on to mention antibiotics. Dr A, having examined him, said that antibiotics were not necessary and that they would not treat any of his symptoms. The mother gave a confused look at first but eventually accepted what Dr A said. Dr A tells me that there are many patients with infection or worried mothers who come to see her specifically to get antibiotics. However, she does not prescribe antibiotics unless the patient needs it because of the matter of side effects and resistance. Nonetheless, patients believe that antibiotics should help as a lot of doctors are prescribing it all the time. Since antibiotics have becomes such a commonly-prescribed drug, it is difficult to tell them it is better not to be pre- scribed.
Reading my story, some may think that Dr A is a harsh doctor. I must say that she was more disciplined than other doctors I had seen in the past. However, she understands the patients a lot. She knows what they truly need. I could tell by the passion in her voice that she loves her patients and is keen to teach students about the importance of treating ‘illness’ as well as the disease. Also, despite what she said about the 32y-ear old patient, I picked up that she said it is very humbling to be able to see her grow up and look after several generations of the same family. From her, I have learnt that it is important to look at the patient as a whole, not just the disease.
In addition, what patients want are not always medication, but emotional support and encouragement, along with appropriate advice. In order to do this, I realize that it is important to understand the patient, recognize their needs and think carefully about what is going to truly benefit them the most.