Quick Slow Quick Quick Slow (foxtrot)

Time had flown by. Luckily my next appointment had cancelled. The first thing she mentioned she mentioned was her health anxiety. 30yrs old. Low back pain since giving birth age 18. Worse with time, and aggravated by relatively little effort and prolonged rest. She reports lethargy, being underweight, family history of diabetes and breast cancer. She has 2 jobs, a waitress and receptionist. She is a mum to a 6 + 3yr old. Her husband works away a lot. Describes being a light sleeper with poor quality since having kids, and significantly worse when husband is away. She reports significant stress around her family and work situation, as well as her own health. She also mentions PTSD symptoms including flashbacks relating to traumatic childbirth. Her diet is reported as healthy with plenty of fresh food although she recognises she is underweight and denies eating disorder or disordered eating and has set eating patterns. She reports an inability to relax due to pain but also admits problems relaxing before this. She reports no intentional exercise but describes high levels of general activity and rarely sitting down due to “time and personality”. She has had full bloods and xray with nothing significant found. She reports acute anxiety at the possibility of underlying pathology and about having to stop everyday life. On assessment she displayed non capsular, passive = active provocation, with no neurological deficits (although previous Bell’s palsy episode). Provocation with resisted side-flexion and extension was also noted. She was hoping for a fix to her pain so it was “one less thing to be anxious about”.

My day often has an ebb and flow to it. This was definitely an ebb. I remember feeling exhausted. One of those moments where I consider the potential benefits of being more robot! Robots can churn work out. They are productive. They don’t have to bother with the exhausting tasks of thinking, feeling, understanding, displaying emotion. Stuff that doesn’t compute. They just follow circuitry. Maybe there is some value in this. 

There seems a deep rooted drive for productivity in healthcare in this age. Maybe not surprising considering the politico-economic climate (see previous blog Amanuensis). Each time I see productivity and healthcare mentioned in the same sentence (or tweet) immediately a cautious (dare I say sceptic!) spirit comes over me. Productivity is an ideological notion. That we can get the same for less. It is primarily an economic ideology. So each time we see the word productivity we should be aware that someone somewhere is wanting to cut costs. By itself this is efficiency and not unhealthy. Further questions are warranted. At what cost? Who is that someone? Where is that somewhere? What may influence their motive?

There is a danger that domains under economical or political influence are pushed in this direction. Think for example the NHS or academic institutions. These rely heavily on funding from the government in the UK. Which may become reward or motive for aspiring and ambitious employees. It is not hard to see a culture of productivity and other potential neo-liberal influences. A quantity of ideas, publications, citations, audits, cost savings are rarely measured against a quality of the same. Possibly because a quantity is much easier to measure. In healthcare an explosion of systematic review and meta-analyses flood hungry journals (in 2007 the equivalent of 11 every day!). Why now? This big data can give us an inkling into cost effectiveness and population size effects. But it is hard to argue that these don’t also serve political economic purpose. Equally it is foolish to dismiss them on this grounds. Economic and political pressures are of course real and important.

Quality of care requires time and space. You need to hear their history. Their hopes. Their fears. Their circumstance. To understand what makes them tick. You need time and space to craft a new direction or consider counter narratives. To help the person experience new things. Question existing beliefs. Discover new strategies. So with immense frustration I watch healthcare being squeezed into less and less. Some trusts proposing maximum 2 visits others 4 or 5. Some physiotherapy departments cutting down new appointments to 30 mins and follow ups at 15mins. This will make us more productive! Should we be celebrating in this productivity? We wouldn’t even have time. Complexity needs less productivity not more.

Not that we should fetishise being slow. I described earlier a natural ebb and flow to our work in healthcare. I have certainly been at both ends of the continuum. Initially spending as little time possible on assessment “how sensitive or specific is any of it anyway?” and systematically prescribing plausible treatment. Disengaged. Then as much time as possible “I don’t want to miss anything!” And looking for complexity at every turn. Exhausting. Now I attempt to hold tension in between them. Taking a history takes the most effort as it naturally sprawls from start to end. However I find that time here is well invested and often returns more flow further down the line. With the odd exceptions most follow ups require a lot less investment. Often just some ad hoc adjustments (yep that’s right I’m an ad hoc clinician!). Often my day is like a good foxtrot. Quick. Slow. Quick quick. Slow. Using this method I rarely tell my wife about a horrific day. Although these still occasionally happen. I commonly see 25 patients a day. So productivity isn’t an issue. But this way I feel I can inject quality and sustainability to my day. 

The above lady made a miraculous recovery and now has a shrine devoted to me! The real story is a lot less glamorous. Initially she struggled to engage with exercise due to life circumstance. Then when she did comply she had ‘exaggerated’ pain responses to even very basic RoM and static work. All this delivered on a backdrop of re-assurance, alliance and graded exposure to avoidance behaviours but on the 4th visit we chatted honestly regarding the complexity of her condition and she agreed that her LBP was likely a symptom of her bigger problem. Luckily her GP had been trying to get her to have some psychological input and this is where I left her journey. Her N = 1 pointed to something much bigger than I could provide. ‘Failure’ of treatment is never easy. We must embrace failure and error as humans. Which may lead in nicely to another blogpost.

Be more human. Be less robot. 

Thanks for reading this far!

Neil

3 thoughts on “Quick Slow Quick Quick Slow (foxtrot)”

  1. Good afternoon Neil,

    Another accurate narrative regarding the patient and the macro environment.
    I think the situation the NHS faces is alarming. Not one AHP or Doctor that I know enjoys their work anymore. In a time when we are trying to develop better evidence bases and care for people it is inexcusable. I doubt if there will be a single AHP employed by the NHS directly in ten years.

    I reluctantly left the NHS about twelve years ago; not for fortune (money does not drive me) but to have more time with the people is see. The time resources you write of are inadequate.
    We are an era of ‘the price of everything and value of nothing’ regarding healthcare and everything else at present. I suspect this involves our university colleagues as well.

    It is ironic how people quote poor evidence to do something in their idealistic world but ignore better data when it comes to increasing resource e.g. number of sessions needed to treat specific shoulder conditions.

    To quote John Ruskin ‘ there is hardly anything in the world that some man cannot make a little worse and sell a little cheaper and the people who consider price only are this man’s lawful prey’.

    In spite of what is happening we should all strive to treat out patients better.

    The lady you mention is instantly recognisable to physiotherapists. Too much psychosocial overload and not enough physical.

    Keep on blogging but save something for May.

    Kind regards,

    Adrian

    Liked by 1 person

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