I received a phone-call recently with some sad news. A patient with a complex psychiatric history who I had been seeing over the preceding 6 months had attempted suicide and was in intensive care. She died later that day. My experience of working with this patient was of a life filled with pain and chaos. She regularly missed clinic appointments and would then present to the emergency department in the evening intoxicated and suicidal, be admitted and discharge herself the next morning. Psychiatric reviews and medication changes were unsuccessful: she seemed to be on a rollercoaster of distress and no one seemed able to help her get off.
Live in joy, in peace, even among the troubled. (From the Dharmapada – a collection of sayings of the Buddha.1)
For days after that phone-call, I found myself sifting through my encounters with this patient and wondering if I could have done anything differently, and if so, whether it would have altered the outcome. The conclusion I came to was probably not. As her general practitioner, I could only respond to how she presented on the day each time I saw her and make sure she had supports around her and refer her for specialist care as needed. The final outcome was simply, very very sad. The trauma my patient had experienced in early life had brought about an emotional pain that was, in the end, just too much for her to bear.
Inevitably in our work as GPs, we will come into contact with patients such as mine who, despite our best efforts, will eventually complete suicide, and others who suffer terminal illnesses or live with chronic emotional and/or physical pain. In their excellent articles in this issue of Australian Family Physician, Votrubec and Thong,2 describe the diagnosis and management of four common neuropathic pain presentations, Holliday et al discuss the role of opioids in the evidence-based management of chronic non-cancer pain,3,4 and Hassed outlines mind-body approaches that can be effective in the management of chronic pain.5 Hassed also touches on how working with empathy, and hence vicariously experiencing another’s pain, can cause significant stress and lead to an increased risk of burnout in health professionals. While this is recognised by the RACGP (http://curriculum.racgp.org.au/statements/doctors-health), the AMA (https://ama.com.au/doctorshealth) and state-based doctor’s health programs (www.vdhp.org.au/website/home.html), our medical culture is not always conducive to the self-care necessary to reduce this risk.6
It is unavoidable that sometimes we will leave the clinic carrying a difficult emotional weight, like the sad news of the death of a patient. Lately I find myself drenching these feelings in long laps in the deep waters of the local pool, airing them in a Balint group (http://balintaustralia.org), or leaning into and beyond them while practising yoga. Colleagues have other ways, such as running, doing Qigong, drawing or playing music. Still, it is easy to bow to the pressures of a medical culture that values self sacrifice, especially when our patients’ needs seem to exceed our capacity. I look forward to being part of a generation of doctors that works to change this culture and places value on time and space for reflection, exercise, good food, meditation or whatever it takes to deal with what comes our way in the consulting room.
Ongoing self-care is essential to survival as a GP. In this way, when the inevitable difficult days come, it becomes possible to show up to work the next day ready to care for another waiting room full of patients and still have enough emotional energy to play our other important roles in life: as partner, daughter, son, sibling, parent and friend. And, even in the midst of terrible suffering, remain capable of joy.
This is my last editorial as Medical Editor at AFP as I move on to new challenges in work and life. I was the inaugural RACGP Publications Fellow in 2007 and have been so pleased to see this post filled every year since with exceptional registrars interested in research, publishing and general practice education including Jenny Presser, Rachel Lee, Deepa Daniel, Kate Mollinari, Nyoli Valentine, Sophia Samuel and Sarah Metcalfe. I would like to take this opportunity to thank all the wonderful people who have made working in the RACGP Publications Unit such a joy over the past 6 years including Denese Warmington, Meg A’Hearn, Jenni Parsons, Steve Trumble, Carolyn O’Shea, Rachel Lee, Nyoli Valentine, Jason Farrugia, Beverly Jongue, Sally Kincaid, Sharon Benson, Morgan Liotta and Nicole Kouros.
- Available at www.buddhanet.net/dhammapada [Accessed 5 February 2013].
- Votrubec M, Thong I. Neuropathic pain: a management guide. Aust Fam Physician 2013;42:92–7.
- Holliday S, Hayes C, Dunlop A. Opioid use in chronic non-cancer pain. Part 1: known knowns and known unknowns. Aust Fam Physician 2013;42:98–102.
- Holliday S, Hayes C, Dunlop A. Part 2: prescribing issues and alternatives. Aust Fam Physician 2013;42:104–11.
- Hassed C. Mind-body therapies: use in chronic pain management. Aust Fam Physician 2013;42:112–17.
- Rowe L, Kidd MR. First do no harm? Being a resilient doctor in the 21st century. North Ryde, NSW: McGraw-Hill, 2010.