“Depression and anxiety is an epidemic! I can’t believe it!” said my medical student after a week working with me in my inner city General Practice in the UK. “I am from Bangladesh, and we don’t see anxiety to this level at all.”
I have to agree with him; the majority of my patients are aged between 18 and 40 years old, and have grown up in a commercial individualistic society where family cohesion has weakened and boundaries have become blurred. They have difficulty understanding and balancing risks, and often have black and white thinking about their health. Through no fault of their own, many of my patients have had difficult childhoods with absent fathers, poverty, substance abuse and mental health problems in their parents.
In the last 10 years my job as family doctor has changed considerably – from diagnosing and treating illness to disease prevention, the early diagnosis of cancer, the management of chronic diseases and arranging support and care for an increasingly elderly population living in their homes often alone and unsupported.
This means that we routinely screen for many diseases in most of the population: raised blood pressure, bowel, breast and cervical cancer, aortic aneurysm, heart disease, high cholesterol, atrial fibrillation… The list can feel endless.
A few years ago, there was much re-labelling and one with huge detrimental impact has been re-labelling renal compromise to “chronic kidney disease”. Suddenly overnight over a third of my patients were labelled with kidney disease, and anxieties about this rose exponentially with other re-labelling – pre-diabetes, fatty liver on ultrasound, ASD, autism spectrum disorders and so on.
There are many diseases such as prostate cancer, bladder cancer, dementia and so on, that are diagnosed early, but it is uncertain which treatment in the early stages gives the best outcome in mortality, so many folk are classed as needing to ‘watch and wait’ – until the cancer goes away, does not develop or becomes serious enough to treat.
So, we seem to be in an unstoppable spiral of screening, measuring, waiting and worrying; and anxiety is the commonest disease I see. Are we as doctors contributing to it?
Publicly acknowledged corruption and duplicity in high places have eroded truth and trust in our society. Often with little evidence newspapers criticise public figures in our society that people have traditionally trusted: police, nurses, bankers, doctors… Who can you trust? Yourself alone is a common answer.
Is it any wonder our patients develop health anxiety?
Andre Matalon, director of the department of family in Tel Aviv, in an article in the BMJ in 2008 wrote, “In recent months I have being thinking about what the most important value in family medicine is. Some doctor friends say that the single most important value is knowledge. I initially thought that experience was the most important, but then what about compassion? Compassion means bringing your whole presence to treat your patients—by listening and understanding and offering love and hope.”
He goes on, however, to describe how in his rural clinic serving poor country people, the health outcomes were not always as good as in cities. Labelled as failing, new management ideas were brought in, measuring outcomes and using these databases to push up surveillance of chronic diseases, and screening programmes. Dr Matalon noticed that many more people starting attending the hospital, all very anxious and unable to understand the concept of prevention and risk. He felt that the ethical principle ‘first do no harm’ had been
breached and that this population had many other things in their life to worry about that were in fact more important to their health, water supply, food sources, sanitation, jobs and so on.
Dr Matalan concludes, “Instead, the right advice, given at the right moment, can be much more effective and does not endanger the patient’s wellbeing. Person-centred care is not just a slogan from the past. It is both good medicine for the patient and an answer to doctors’ burnout and disenchantment. It is also the answer to the question I have been pondering: it is perhaps the single most important value in family medicine.”
Person centred care or public health improvement?
BMJ2008;337doi: 10.1136/bmj.a2129(Published 1 December 2008) Andre Matalon, director, Department of Family Medicine, Rabin Medical Centre, and lecturer, Tel Aviv University, Israel