Ultradian

Transference, Empathy, and Compassion

2017-11-01T14:45:00.003+00:00

"Beyond transference, empathy and patient centred medicine - towards compassion, self compassion and a collaborative model of care. "

Conclusions from a GP VTS (General Practice Vocational Training Scheme) seminar, 26th October 2017 - Dr P J McNally.

Is Transference a hopelessly dated, doctor-centred concept?
Is Empathy hopelessly patient centred, and (almost) as bad?
Is Compassion a way forward, and better suited to 21st Century medicine?

What follows is a write-up of a GPVTS teaching session I delivered, aiming to promote thought and understanding in this fascinating area.

Dear all GPSTs,

Thank you for joining together to consider this subject.

I had several requests afterwards for the videos and source material.

We started by defining transference, and rapidly came to some everyday working GPs' descriptions:

"If I start feeling XYZ, it may be that my patient is feeling XYZ too"

"when my patient is sad, I start to feel sad too"

"be aware that the feelings you're feeling, may not be your own"

We shared experiences of this in our own working lives.

We then noted that Sigmund Freud's concept of transference was something quite different:

"Transference is a phenomenon characterized by unconscious redirection of feelings from one person to another. One definition of transference is "the inappropriate repetition in the present of a relationship that was important in a person's childhood". Another definition is "the redirection of feelings and desires and especially of those unconsciously retained from childhood toward a new object."

"Countertransference" is defined as "redirection of a therapist's feelings toward a patient, or more generally, as a therapist's emotional entanglement with a patient".

We noted that our everyday GP definition is actually more like "Emotional resonance" (also known as "emotional contagion").

For the social context we then watched the beginning (00:00 to 10:22) of:

Adam Curtis' "The Century of the Self" - Part 1: "Happiness Machines"

https://www.dailymotion.com/video/x2d29tf

This illustrated the psychoanalytic insight, that much of human behaviour is decided by feelings, not thinking.

We then broke into small groups, to define:

- sympathy

- empathy

- compassion

At this point we again shared examples from our own working lives.

There was a brief, interesting digression into consulting patients with personality disorders. We noted that our usual "Comm Skills" often don't work, and that these patients can invoke strong "somatic countertransference" or "Body-centred countertransference".

We noted how exhausting Empathy could be, for the doctor.

The Compassion group suggested that compassion might be more holistic; "I see you hurting", "caring concern", "I want to help". Altruism or kindness was mentioned.

We then watched 00:00 to 06:47 of:

The Trap Part 1 "F**k You Buddy"

https://www.dailymotion.com/video/x4p9nwg

This included the economist Friedrich von Hayek, asserting there is no role for altruism in his social theory. It gave useful context about the society in which we're practising.

Next, our small groups considered 3 problems:

Group 1:

What are the effects of empathy within the consultation, ouside and beyond the consultation?

Is there a role for staff to staff empathy?

What about patient to staff empathy?

And how can we promote this?

Group 2:

Context - how does this influence empathy - eg: our human world (you may wish to consider society, economy, family, community, culture, setting)

Group 3:

Do you need to feel (in the consultation / in work)?

Or is it enough, to try and understand?

How can we promote / improve this?

What actions, behaviours etc can demonstrate that empathy is being expressed?

We rejoined the main group and shared the conclusions.

We noted the need for time, resources etc, but also clear boundaries, and mutual respect, between doctors and patients.

A colleague shared a story about a time on the ward when she had to speak to relatives of a patient. She recalled one relative asking "Doctor, are you sure you're ok? Would you like a glass of water?" She remembered this feeling strange, and rare. She described realizing, "I'm allowed", and this being surprising.

We noted that compassion begins at home: with self compassion, for the doctor. We noted Carl Jung's description of "the wounded healer".

By now we had identified 3 steps of compassion; recognizing suffering, sitting with it (acceptance), and a commitment to doing something about it.

We then watched:

Kristin Neff: The Three Components of Self-Compassion

https://www.youtube.com/watch?v=11U0h0DPu7k

This reinforced that we may try to jump straight from "there is a problem" to "I need to fix it", without taking the time to accept and acknowledge the suffering. She described self-compassion as "self-kindness, common humanity, and mindfulness".

We concluded, noting that transference is a doctor-centric concept, while empathy is a key component of patient centred care.

In the current environment, we may therefore find it more sustainable to move towards a more collaborative model, neither patient nor doctor centred. Key elements of this include clear boundaries, mutual respect between doctors and patients, and compassion (to include self-compassion).

We then learnt a brief mindfulness / self-soothing intervention we could try during our consultations, involving awareness of our pulse or bodily warmth. This resembled "giving ourselves a hug". Finally, we turned this outwards, and gave a hug to our neighbours!

I hope this was useful.

For more on the subject:

Aronson, October 14th, 21st and 28th 2016:

http://blogs.bmj.com/bmj/category/columnists/jeff-aronsons-words/page/6/

Dr Kristin Neff, self-compassion.org

http://self-compassion.org/category/exercises/#exercises

ACT, acceptance and commitment therapy

http://www.actwithcompassion.com/homeworks

"Against Empathy: The Case for Rational Compassion" -

Paul Bloom, Penguin Random House, 2016. http://amzn.eu/hKK6mYU

Oxford Empathy Programme

https://www.phc.ox.ac.uk/research/oxford-empathy-programme

Pauline Cafferkey and the NMC

2016-08-18T22:05:00.001+01:00

The NMC have the amazing ability to make the GMC, my own regulator, look positively cuddly in comparison.

Yet again we see them go after individuals rather than address the fundamental challenges facing nursing in the UK.

Because it's much easier to say "this nurse is bad" than "nursing, and the NHS, are fighting for survival".

Pauline Cafferkey has been accused of covering up a temperature, on arrival back to Heathrow after treating Ebola patients.

I know I'd be terrified, if I developed a temperature after that. Denial is a powerful and common, understandable coping mechanism. How many NMC bosses can honestly say that they would raise their hand, "I have a fever", having just seen what Ms Cafferkey must have seen?

https://www.theguardian.com/world/2016/aug/18/pauline-cafferkey-ebola-nurse-accused-concealing-high-temperature

Rotas, time formats, "XLS", CSV, and Google Calendar

2013-04-07T09:56:00.001+01:00

Upload your .xls rota to Google Calendar! Using my easy .csv template!

This is probably only useful to you if you use Google Calendar (or possibly other appllications that accept .csv imports - ?iCal, perhaps?), and your workplace issues rotas in their own inimitable way - e.g. as an xls file.

This was prompted by a move to work in Acute General Medicine in Oxford.

No problem should ever have to be solved twice. Therefore, this is my solution.

I wanted my rota info to show up as a calendar in Google Calendar. Unfortunately, work only provides rotas via a browser, or in an idiosyncratic .xls, using whatever date and time formats that the author personally favours (I assume).

(As an aside - XKCD has covered this topic - date conventions and ISO 8601 - with the usual authoritative tone)...

I'm indebted to Kevin Burke who came up with much of this solution here.

So:

- You can import calendars to GCal, as long as they are in .csv format.
- Oxford Medicine rotas come as an odd .xls, one that seems to be in "Western European (Apple Macintosh/Icelandic)" format.
- By tweaking column headers and exporting as .csv, you can create a file which GCal accepts!

Disclaimer - I've used LibreOffice throughout - those using Excel may find a few differences.

Put simply, your .csv just needs a strict set of column headings for GCal to accept it.

These are as follows:

Subject, Start Date, Start Time, End Date, End Time, All Day Event, Reminder On/Off, Reminder Date, Reminder Time, Meeting Organizer, Description, Location, Private

Every event (every row in Excel) needs to have a Subject, Start Date, and Start Time. The other headers are optional and you can mix and match them as much as you please.

Because I'm feeling kind, I've supplied a template .csv, which you should edit to suit your needs e.g. in LibreOffice or Excel. You can get it here, or:

https://docs.google.com/file/d/0B5OjGQrd1AYyWklnVTRKSGNWWHc/edit?usp=sharing

I recommend copying your .xls columns into the right places. Counter-intuitively, you should put your shift times in under "Location" so you can see them in GCal, on your phone etc.

The actual column "Start Time" is irrelevant as you will be putting "TRUE" in the "All Day Event" column.

Also - Make sure you FORMAT your columns appropriately (by selecting each column, going to "format"... "cells"... or similar). The formats you need are MM/DD/YYYY for dates (note this is neither ISO 8601, or UK, but US standard), and HH:MM AM/PM for times. GCal is very picky about this.

Weirdly, in my case, the values in the cells still show as DD/MM/YYYY, but as long as you've set the formatting to MM/DD/YYYY, things will work.

( Check your dates once you've put this into GCal! You don't want a mix-up between 3rd April, and 4th March, for example! )

Then - "Save As" a .csv (ignoring the error you'll receive saying some formatting will be lost).

Upload to one of your Google Calendars.

I HIGHLY RECOMMEND you create a NEW calendar and call it something descriptive e.g. "AGM Rota". Do NOT import the .csv to your DEFAULT calendar. By using a separate calendar you can delete the whole thing if you've made an error (e.g. DD/MM/YYYY instead of MM/DD/YYYY) and try again. If you upload to your main calendar, you'll have to go through and delete each event manually.

Make sure you tick to display this calendar.

If things have gone well, you should have your rota displayed as all-day events, each with shift times as "locations", along the top of your calendar! Mine has the letter codes, e.g. DT for Day Take, D for Day shift, O for Off etc, but experiment to find what works for you.

You can even share this with your loved ones / job-share partner / pet hamster / whatever, to make sure everyone knows how hard you're working.

Have fun.

Doctors, pseudonyms, social media, Good Medical Practice, an impossible standard and the GMC

2013-03-26T12:30:00.004+00:00

The future for doctors on the internet? I kind of hope so...

The GMC (the UK's General Medical Council) has today published its updated version of good medical practice, which comes into effect on 22nd April 2013.

Doctors rely on this document as a description of the standards expected of them. I hope that most of us will find that most of it comes as no surprise. The areas it covers are below:

Knowledge, skills and performance
Safety and quality
Communication, partnership and teamwork
Maintaining trust

All areas where we should aim for the highest standards.

Those that know me may know that, while I find good medical practice to be extremely helpful guidance overall, I have always taken issue with the very first standard it sets.

According to GMP, doctors should:

Make the care of your patient your first concern.

This is, of course, an impossible standard, and often an inhuman one. Many doctors trying (consciously or unconsciously) to meet this standard over the years have lost perspective, or "burnt out".

But I believe it is reasonable, commendable even, to set a standard for yourself that you know is unattainable. Therefore I would restate this very first standard:

Aim to keep the care of your patient foremost;

Be mindful of situations where you may find this difficult.
Take appropriate action, if your situation may put patient care at risk.

This is a more sustainable and human approach, and I think, a compatible one.

The accompanying standard in the "Knowledge, skills and performance" section that GMP provides is this:

Provide a good standard of practice and care.

Keep your professional knowledge and skills up to date.
Recognise and work within the limits of your competence.

To my understanding, this should encompass some very real limitations of doctors as human beings, whether they are biological (e.g. hunger, sleep), personal (e.g. illness or responsibilities outside of medicine), or wider concerns (e.g. organizational failings, unsafe working practices or shift patterns).

Encouragingly, therefore, the GMC has spelled things out, or "added some new duties, or made existing ones more explicit", and has restructured the guidance under the four headings used in appraisal ( licensed doctors must have an annual appraisal based on Good medical practice) -

ensuring continuity of care – for example, checking that a named clinician or team has taken over responsibility when your role has ended
taking prompt action if a patient is not receiving basic care to meet their needs
taking part in structured support, such as mentoring, if you are new to practice or in a new role
mentoring less experienced medical and other colleagues.

My rephrasing of the first standard, then, would fall well within point 2, "taking prompt action if a patient is not receiving basic care to meet their needs".

I wonder if anyone from the GMC is reading this, and if so, whether they would consider rephrasing that first standard in the next edition?

Social Media:

As well as the revised Good medical practice, we also receive explanatory guidance for certain specific issues.

One of these, "Doctors' use of social media" (headlined as "The benefits and pitfalls of social media"), is particularly interesting. Any doctor who blogs, or tweets, or uses facebook, google+, myspace or orkut... etc etc should read it.

It all boils down to, of course:

"You are personally accountable for your professional practice and must always be
prepared to justify your decisions and actions."

That's the last line of the summary slide of good medical practice, and probably the best principle doctors could stick to; with a little imagination, you'd then know how to act.

But the theme today seems to be making things explicit - perhaps to spell things out to colleagues whose imaginations are exhausted, perhaps to cover every eventuality ahead of time, so the GMC can say "you can't say we didn't warn you" when someone next pleads ignorance of basic ethics as a defense to Facebook-stalking their patients (or some such transgression).

Read it, please - I won't cover it all.

Some selected points, and my take on them:

"The benefits and risks of using social media",

or

"To support you in getting the most out of social media and online working, without compromising yourself or your patients, we have introduced the guidance Doctors' use of social media."

YES! It's a complex area! With benefits and risks! But we're going to tackle it! Yay, go GMC!

"As well as this guidance, you should keep up to date with and follow your organisation’s policy on social media."

NO! Boo to this! Have they even read any organizations' policies?

For example, from my Trust's "Internet Use Policy" - "No member of staff is permitted to access, display or download from internet sites that hold offensive material".

So I mustn't go to Wikipedia, because it probably has a page about [insert something which offends you here] [if you can't think of anything, I suggest the article about the Daily Mail] [No, I'm not hyperlinking that for you, because it might be offensive, I haven't checked]? Offensive to whom?

Actually, having said that, the Daily Mail offends me greatly, but I will defend your right to read its bilious nonsense about underage celebrity immigrant house prices, if you must. Just don't expect me to link to them.

"Many doctors use professional social media sites that are not accessible to the public. Such sites can be useful places to find advice about current practice in specific circumstances. However, you must still be careful not to share identifiable information about patients."

Hmmm. Having never used these sites (disclaimer - I have a doctors.org.uk account, but have never used their forum), I'm not the best person to comment, but I do view these with suspicion. Light is the best disinfectant.

"Doctors’ use of social media can benefit patient care by:
a engaging people in public health and policy discussions
b establishing national and international professional networks
c facilitating patients’ access to information about health and services."

YES! Actually, can I pick d, all of the above? Oh, I'm sorry, that wasn't an MCQ?

Pseudonyms:

Regarding anonymity:

"content uploaded anonymously can, in many cases, be traced back to its point of origin"

YES! You dun goofed! Because I BACKTRACED it! The consequences will never be the same! (possibly NSFW, link is to reference i.e. knowyourmeme.com).

"If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely."

YES! Anything less is not good enough.

I'm GMC 7140564, Dr Patrick James McNally, by the way. I have a rubber stamp with that on and everything.

(Pseudonyms are all well and good, but posting things anonymously should be the rare exception, not the rule).

Trip to Genetica is a track by Tonic on the seminal 1998 Adam Freeland breaks album, Coastal Breaks II. A name I use online where unique usernames are required, because usually no-one else does.

Comments welcome.

Active Travel Bill for better walking and cycling (for Wales)

2013-02-18T15:51:00.000+00:00

This is one bill that will pay for itself...

News today that the Welsh Government's "Active Travel Bill" aims to make walking and cycling safer and easier is very welcome news indeed.

This is excellent news!

While still at university I wrote a dissertation on active travel. I would be first to admit that I did focus on England (and Benelux) to an extent. So it's a pleasant surprise to see Wales coming out with legislation.

The medical community, particularly the Royal Colleges which represent the different specialties, need to support this loudly, and not let governments water it down.

Also - why just Wales? Can we expect the Coalition Government to come out with something at least as strong?

Now - let me reproduce the "mission statement" bit of the article:

The Bill, which is a key commitment in the Programme for Government, is aimed at making walking and cycling easier and safer by requiring local authorities to plan fully integrated active travel networks. The legislation will require local authorities in Wales to:
identify and map the network of routes within their areas that are safe and appropriate for walking and cycling;
identify and map the enhancements that would be required to create a fully integrated network for walking and cycling and develop a prioritised list of schemes to deliver the network;
deliver an enhanced network subject to budget availability and following due process;
consider the potential for enhancing walking and cycling provision in the development of new road schemes.

http://wales.gov.uk/newsroom/transport/2013/120218-active-travel-bill/?lang=en

I'm all for high quality segregated infrastructure - and I believe that's the only way we'll get significantly more bums on bikes - but this bit has me worried:

"The legislation will require local authorities in Wales to identify and map the network of routes within their areas that are safe and appropriate for walking and cycling"

My concern here is, if you are riding from A to B on the only realistic route - eg rural A roads such as the A4165 from Oxford to Banbury - and the local authority has not identified that road as "safe and appropriate for walking and cycling", then if you are injured (or worse) by a "careless" or dangerous driver, are they and their insurer going to argue that you shouldn't have been there in the first place?

These concerns are probably ill founded. They state further duties to:

"identify and map the enhancements that would be required to create a fully integrated network for walking and cycling and develop a prioritised list of schemes to deliver the network;"
"deliver an enhanced network subject to budget availability and following due process;"
"consider the potential for enhancing walking and cycling provision in the development of new road schemes."

Therefore it's unlikely an insurer could argue that you shouldn't have been on a particular road, when there is no realistic alternative. I've no great love for vehicular cycling - it's a stop-gap solution for a few fit young cyclists like me - but it looks like it's safe for now.

The further undertakings are vague, but promising. Once there's a document showing the network we SHOULD have, it will become increasingly difficult to put off building it. And the "enhanced network" they mention could be all talk and no tarmac, but could be an example of "aim for the Netherlands, get Denmark" in terms of improving cycling infrastructure.

Most of all, it's nice to see politicians (and others) taking seriously about bikes!

This Bill is a great first step in the right direction; now let's see the rest of Team GB (and Northern Ireland) commit to it, and more.

BNF simplifies advice - today on paracetamol poisoning, tomorrow on..?

2013-02-18T14:15:00.003+00:00

Medical guidelines have a habit of becoming more and more complex with time.

Doctors are quite good at adding complexity to any given situation, but not so good at recognizing when things have become a little too complex to be really useful.

I can think of any number of examples, even over my career so far. E.g. when I started out, acutely unwell people were to be given oxygen, and lots of it, to make things easier for their metabolism. Except some people with COPD (Chronic obstructive pulmonary disease), who shouldn't be given too much oxygen. Then we find out that one large group of acutely unwell patients - those having a myocardial infarction, acute coronary syndrome or "heart attack" - shouldn't be given lots of oxygen after all, as it might mean a worse outcome for their heart. Now it seems that oxygen therapy has become so complex, that nurses and other staff are sometimes afraid to give the patient any oxygen at all, for fear of doing the wrong thing.

Two more examples - hypertension, and type 2 diabetes mellitus - have also undergone this change. Both these conditions used to be simple to diagnose, and we had a few simple treatments for each. Now the diagnosis has become complex - with ambulatory blood pressure monitoring for hypertension, and use of HbA1c for T2DM - and the treatments even more so, with many competing drugs offering little in the way of comparative data or data on real-world outcomes.

This is why the latest BNF (British National Formulary) update is so refreshing. Paracetamol overdose is common, and the guidelines for its management can be hard to follow.

For example, there were helpful graphs for "high-risk" and "low-risk" patients, showing at what level of paracetamol you should get excited and start giving the antidote, depending on how many hours have elapsed since your patient took the tablets.

But consider the common case of an overdose taken over a few hours, with perhaps 8g of paracetamol taken the previous night, and another 8g taken the next morning. How do you plot this patient on the graphs?

Or imagine that you have plotted your patient as being below the threshold ("treatment line"), assuming they are in the "low risk" group. But if you consider them "high risk", they are over the threshold. They tell you they didn't have much to eat for a day, maybe two - what will you do with that information? Are they now "high risk"?

http://www.medicinescomplete.com/mc/bnf/current/PHP188-analgesics-non-opioid.htm - New BNF guideline

The new guidelines eliminate the old "High risk" and Low risk" categories, drawing a single treatment line and expecting you to use your judgement. I have reproduced the basis for having a single line below:

"Although there is some evidence suggesting that factors such as the use of liver enzyme-inducing drugs (e.g. carbamazepine, efavirenz, nevirapine, phenobarbital, phenytoin, primidone, rifabutin, rifampicin, St John's wort), chronic alcoholism, and starvation may increase the risk of hepatotoxicity, the CHM has advised that these should no longer be used in the assessment of paracetamol toxicity."

New graph:

Old graph:

In addition, they have made the following change:

"For ease of use, recommendations on management have been categorized into:

• acute overdose;

• 'staggered' overdose, uncertain time of overdose, or therapeutic excess"

There then follows clear management plans for each category.

The BNF should be commended for these changes, which will help clinicians and provide greater confidence in treating this common problem; I hope this represents the start of a realization that "more is not always better", particularly where guidelines are concerned.

Update: The MHRA Drug Safety Update for this topic is from September 2012 (before I subscribed to their RSS!) and forms the basis for the updated info in the BNF:

http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON185624

I reproduce their summary below:

Summary

New simplified guidance on treating paracetamol overdose with intravenous acetylcysteine is now in place. This includes an updated treatment nomogram. The new guidance is as follows:

- All patients with a timed plasma paracetamol level on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours after ingestion should receive acetylcysteine (Parvolex or generics) based on a new treatment nomogram, regardless of risk factors for hepatotoxicity
- Where there is doubt over the timing of paracetamol ingestion including when ingestion has occurred over a period of one hour or more – ‘staggered overdose’ – acetylcysteine should always be given without delay (the nomogram should not be used)
- Administer the initial dose of acetylcysteine as an infusion over 60 minutes to minimise the risk of common dose-related adverse reactions
- Hypersensitivity is no longer a contraindication to treatment with acetylcysteine