‘I went to the woods because I wanted to live deliberately, I wanted to live deep and suck out all the marrow of life; to put to rout all that was not life and not, when I had come to die discover that I had not lived.’1
The latest initiative to improve patient care by means of personalised care plans has generated some interest lately. We are being encouraged to sit down with patients and generate individualised advice on how to go about their day-to-day lives to maximise their health. What could be more patient centred than that?
Nobody would deny that suggesting patients with diabetes stop smoking, eat healthily, and take more exercise is anything other than good advice. And it would of course be good if people were more motivated to take responsibility for their own health. But I wonder how effective such interventions will be. Won't those who are motivated remain so without the additional input, while those who aren't will simply fail to engage in the process? Of course some may move a little towards taking more care about their lifestyle given enough information and support to do so, but I wonder if we might be missing the point.
With apologies to Henry Thoreau:
‘I went to the woods because I wanted to lower my BMI, I wanted to live a bit longer than I might otherwise have done and reduce my HbA1c; to reduce my serum cholesterol below 5.0 and not, when I had come to die, discover that I really should have switched to a low fat spread.’
It doesn't have the same ring to it somehow. There is nothing as tedious as a health bore and there is no such thing as a motivational talk on diabetic control.
To get people motivated in their health I think they need to be more motivated in their life. If life is rich and rewarding for them, they will be more motivated to live. I realise that it sounds obvious, but I believe this statement to be significant. If life is unrewarding and the biggest thrill you get in a day is the momentary pleasure of a fag, a bottle of scotch, or a Happy Meal™ you will continue to seek your pleasure in these things. There is more to life than being alive.
A preoccupation with health is a distraction to what is really important — namely living. Drawing people into more complex care pathways, even if it did produce a response, may only serve to make a more healthy population of ‘dead’ people where health becomes the goal of life.
I want people to be less interested in health, seeing it simply as the servant which enables life, rather than it being the end in itself. The nation's demand for health has steadily increased as medical science has made medical interventions possible that could once only be dreamt about. And yet are we any healthier? Our sedentary lifestyle and epidemic levels of obesity suggest that the best efforts of healthcare professionals have failed to achieve what we would have hoped. Indeed medical advances may even be considered to have encouraged unhealthy practices by their promise of sorting the problems that such practices inevitably cause.
Now don't misunderstand me. If one is suffering from appendicitis, then a doctor is undoubtedly a handy person to have about. But, if we are to be healthier as a nation, we are going to have to want to be healthier because life is worth living. We'll need to be drawn towards health rather than driven, cajoled, and bullied towards it.
And this makes me consider whether there is an arrogance about healthcare provision. Have we got ideas above our station? Do we overestimate our importance as we set ourselves up as high priests of the god of health — laying down the laws of health and threatening terrible consequences to those who contravene that law? The way we talk about health advances suggest we do. How often do we hear of some new medical advance promising to save any number of lives when, in truth, such advances will save none — at best only prolonging some?
All of us who deal with patients have experienced the anxiety that inevitably accompanies such interactions. And dealing with that uncertainty is one of the challenges that every doctor has to face because, of course, we can not know what we can not know. And therein lies the problem. None of us are quite as able as we'd like to think we are. Could it be that our anxiety is just another form of arrogance? Now hold on a minute, you might think, that can't be right. After all doesn't anxiety convey feelings of uncertainty and inadequacy — hardly the characteristics of the proud? But think again. Could it be that my anxiety is born out of a belief that it all depends on me — that the outcome is entirely down to me, that in some way I have the power to determine the future if only I could do the right thing guided by my god-like qualities of omniscience and omnipotence with which I must save the world or at least my little corner of it? Now that would be arrogance.
An example may help. Take that patient who attended the other day with a headache. For all the world it seemed like a common or garden tension headache with no sinister sounding features whatsoever. The advice to take two paracetamol and call me in the morning was never more apt. Yet, as the patient left my anxiety began to grow. What if the patient has a brain tumour, what if they die, what if it's my fault? Now the truth of the matter is that if the patient has a brain tumour then there was no way that that could have been determined from taking a history and examination. Sad to say I do not have the god-like quality of an MRI built into my forehead enabling me to see what is otherwise impossible to know. I have to accept that I am only a doctor.
And it's about time we all acknowledged the fact that that is all we are. We are limited in what we can do. Now that is not to say we shouldn't do our best — of course we should but we would, I think, all be a lot less anxious if we realised it didn't all depend on us. Our patients' health does not depend wholly on us. Perhaps we should, at times, allow ourselves to step back as doctors, and, rather than killing our patients with health advice, somehow encourage patients to look away from health as the source of their happiness to something bigger and better — something really worth living for.
Then we might see an increase in health flow from a reduced concern about health.
Notes
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2012
