GP Roy Alexander Briggs Prize

Roy Alexander Briggs GP prize

In 2017 we introduced creative enquiry into the Roy Alexander Briggs GP prize. Each year there are different themes. For some of the entries see below, with kind permission of Barts and The London medical students.

2022-23 Themes:

a) Person-centred care

b) Welcoming others and being ourselves: belonging, dignity and justice

As I Walk Up the Stairs by Serena Jayshree Ramjee

Theme: Welcoming others and being ourselves: belonging, dignity and justice in primary care education.

Earlier this year, during my Near-Peer Student Selected Component (Medical Educator and Clinical Development in Primary Care), I was acquainted with psychological safety, a term defined as “a shared belief held by members of a team that the team is safe for interpersonal risk-taking” [1]. My role consisted of working with faculty and supporting third-year students, an experience resulting in the formation of a dual perspective on psychological safety as I was both a learner and educator.

As a Learner

Initially, I felt a sense of accomplishment assisting younger-year students in their GPCD (GP Community Diagnosis) module. Having a more senior role positively affected my professional identity, allowing me to view myself as an educator for the first time. However, my previous similar experiences occurred in more informal settings, so I was concerned about a gap in my knowledge and skills. I felt a steep learning curve lay ahead of me. This realisation led to a shift in my confidence, and my sense of seniority disappeared, leaving me unsure whether I could rise to the challenge.

Now that I have completed the module, I believe my positive experience can be partly attributed to the treatment I received from the faculty I collaborated. I was given responsibilities (e.g. focus group interviewer) with confidence in my capabilities, evidenced by the lack of micro-management, alongside various avenues of support (e.g. Dr Mistry). I also felt that the staff respected my views and took my suggestions seriously. Imposter syndrome often afflicts medical students, including myself [2,3]. As a learner, working with faculty in this manner gave me an understanding of how psychological safety can ease imposter syndrome and the comfort that educators never really stop being learners. It was also valuable to watch how co-creation between staff and students can positively impact primary care education, an observation I will take forward to my vocation as a doctor in August.

As an Educator

In addition to supporting the GPCD, I independently taught General Practise 3 (GP3) students clinical skills. This role also resulted in me feeling a great sense of responsibility. However, I also felt this self-inflicted pressure to re-create the previously mentioned psychologically safe environment the faculty had given me as a learner. This pressure was eased by the knowledge that near-peer environments inherently create some safety due to reduced seniority [4,5]. But as an educator, I wondered how I could further this aspect and create a welcoming environment in a GP setting. To answer this question, I recalled teaching sessions and placements where I felt psychologically safe, considered how they achieved that and then supported these ideas by researching the topic. My mind first went to the role-play-based teaching I received throughout the university. The session lead and my peers typically provided feedback using the Pendleton model [6]. I found this process encouraged self-reflection, provided a chance for everyone to participates, and was much less intimidating than other feedback methods, leading me to utilise this model. Other aspects I used were ensuring that I learned, correctly pronounced and used my students' names, clearly stating that any response was acceptable, and affirming my student's emotions (e.g. empathising with their frustrations about remembering large volumes of content) [7]. I was proud to see a high level of participation from students and that they felt more confident in their skills at the end of the session. I hope that, like my experience, my session can one day inspire these learners when they become educators.

Creative Enquiry Explanation

As I Walk up the Stairs captures the previously mentioned dual perspectives, the learner and the educator, using symbolic imagery.

The poem details a figure (the educator) leading another (the learner) up some stairs. Both figures are shrouded in darkness, guided only by a torch. Despite this, the first figure adeptly leads the second through the darkness, indicating to the second figure that they are safe. The first figure then passes the torch to the second, who takes it in their hand, knowing it is safe for them to do so.

To capture the dual perspectives, I wrote the first two stanzas from the learner's point of view and the last two from the educator's. It was essential that they were similar to illustrate my experience of simultaneously being in the two roles. The stairs are the journey, with the darkness representing uncertainty. This darkness persists throughout the poem showing that, even as an educator, you never stop learning and growing. The educator holds a torch, symbolising the knowledge and skills vital for orientating new challenges and guiding learners. In this poem, I illustrate the educator's role as a guide by using the literal word "guide" alongside a ship metaphor in the first and third stanzas. Our learner is treated in such a way that even though there is uncertainty, they know the educator is there to support them. This treatment tells the learner that they are (psychologically) safe. In stanzas two and four, the educator passes on their knowledge and skills to the learner. Now confident they are in a safe environment, the learner stands alongside the educator, ready to go forth using the provided tools.

References

1. Re:work - guide: Understand team effectiveness [Internet]. Google. Google; [cited 2023Apr27]. Available from: https://rework.withgoogle.com/guides/understanding-team-effectiveness/steps/foster-psychological-safety/

2. Khan M. Imposter syndrome—a particular problem for medical students. BMJ. 2021;

3. Villwock JA, Sobin LB, Koester LA, Harris TM. Impostor syndrome and burnout among American Medical Students: A Pilot Study. International Journal of Medical Education. 2016;7:364–9.

4. Henderson S, Needham J, van de Mortel T. Clinical facilitators' experience of near Peer Learning in australian undergraduate nursing students: A qualitative study. Nurse Education Today. 2020;95:104602.

5. Alexander SMK, Dallaghan GL, Birch M, Smith KL, Howard N, Shenvi CL. What makes a near-peer learning and tutoring program effective in Undergraduate Medical Education: A qualitative analysis. Medical Science Educator. 2022;32(6):1495–502.

6. Burgess A, van Diggele C, Roberts C, Mellis C. Feedback in the clinical setting. BMC Medical Education. 2020;20(S2).

7. University College London. Creating safe spaces for students in the classroom [Internet]. Teaching & Learning. 2020 [cited 2023Apr25]. Available from: https://www.ucl.ac.uk/teaching-learning/publications/2020/apr/creating-safe-spaces-students-classroom

As I walk up the stairs.pdf

Colours of Unity by Ayushma Gurung

Using a variety of colours and brush strokes, this painting aims to illustrate the importance of embracing our unique identities and values while recognising the diversity in others. Each colour and pattern represents a particular aspect of an individual's identity, such as culture, ethnicity, religion, and personality. By combining these colours and strokes, the painting represents the unity and sense of belonging that is created when we embrace diversity within the wider community. This artwork reflects the interconnectedness of all individuals, highlighting that we are all part of a collective whole.

Creating a safe and inclusive environment that cultivates a sense of belonging for all patients is crucial in healthcare. To achieve this, it starts with primary care education by teaching students to learn, recognize, and appreciate the diversity that exists. This can be achieved by taking the time to understand the unique backgrounds and experiences of the patients that students are exposed to early on. It also requires reflection on one's own biases and assumptions. Patients must feel heard without judgment to be able to develop a deeper understanding of their needs and concerns, which ultimately leads to better outcomes in their care. Ensuring dignity in care also involves guaranteeing a safe space and privacy during examinations, providing care that maintains an individual's self-respect, and avoiding actions that may undermine them. For instance, treating patients with respect and autonomy, while taking into consideration their cultural beliefs and values in the care provided, acknowledges their individuality and promotes patient-centred care, thereby upholding their dignity.

Another interpretation of this painting is that it can also represent the different communities that exist in our society, which share commonalities while highlighting their unique differences. In relation to justice, it is essential to recognize that discrimination still exists in clinical practice, as some minorities still experience prejudice based on the colour of their skin (1). It is crucial to recognize the impact of cultural competence and awareness of healthcare disparities and actively work towards enhancing it through education to overcome these barriers. A lack of awareness can result in unconscious bias and perpetuate inequities in access and quality of care, as seen in racial disparities in pain management (2). Cultural competence can be developed through exposure to understanding of the various cultural, social determinants, economic factors, and addressing healthcare disparities that affect the health of patients from different racial and ethnic backgrounds. Being taught on ethics and professionalism can help guide medical practice on the principles of justice, fairness, and respect for patient autonomy. Ultimately, to overcome these barriers, students should learn how to advocate for their patients and work towards creating a more just healthcare system. The colours of unity serve as a reminder of the interconnectedness of all individuals and the importance of embracing diversity and recognising the different communities of our society.

REFERENCES

1. Hoffman K.M., Trawalter S, Axt J.R., Oliver M.N. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296–301.

2. Badreldin N, Grobman W.A., Yee L.M. Racial disparities in postpartum pain management. Obstet Gynecol. 2019;134(6):1147–53

Observing Privilege: A Medical Student’s Perspective on Inclusivity in Healthcare

by Abigail Atie

For this creative enquiry I created a video filled with my first two years of memories from medical school. Initially my intention was to reflect upon the general theme of inclusivity in healthcare, however I found through making a scrapbook like curation of my own memories, I was really exploring how I fit into the practitioner pyramid as a student and as a future doctor. I also used GarageBand to create the music which mirrors the mood of the narration. Initially there is a solitary piano, but this expands to include an array of instruments reflective of diversity. The narration cites sources like Steven et al. [1] and Mukherji et al. [2], the presentation shows the importance of practitioners recognising their privilege and how this impacts patient care. Hopefully, more practitioners recognising this will foster awareness and improve rapport between patients and clinicians.

Creative enquiry.mp4

Through the highs and lows by Jit Yih

In today’s current healthcare scene, general practitioners (GP) are flooded with patients on a daily basis. They serve as their community’s first port of call, being there for the residents through sickness and health, and seeing a wide range of patients that vary in age, gender, ethnicity and more. As such, they are required to know how to diagnose and treat a wide range of conditions across the board, as well as when to know that their patient requires referral to specialist care or social services. They provide a continuity of care in the community, often seeing patients from birth to old age, and are able to foster that ever-present and important patient-doctor relationship and human connection.

When I was on my GP placement, I noticed that each consultation is meant to be limited to 10 minutes per patient, however it often overruns and causes subsequent appointments to be delayed. I feel really frustrated on the patient’s behalf because 10 minutes is often quite short a timeframe to really relay your medical problems, especially if there’s more than one issue bothering you, and you also require the GP’s help for referral to social services or more. Yet, I also understand the need to maintain a time limit, for there are so many other patients who require the attention and services of the GP, and there is only so much time in a day. Thus, I have seen many GPs rushing through their consultations, paying more attention to typing down and clearing the patient’s worries and concerns than actually listening to the patient.

Especially in today’s hectic society where burnout is becoming a major issue for many, a lot of patients come in with mental health issues accompanied by different socio-economic circumstances, which is vastly different from those in hospital who generally came in with physical illnesses. Oftentimes, I think we overlook the fact that mental health issues can coexist with physical illnesses, and that it is vital to acknowledge it and address it immediately. Though invisible, mental health is a crucial part of our daily life and it is important that we always ask our patients about their mental well-being and how they are coping. Furthermore, we often associate mental illnesses with old age or youths with troubled backgrounds, but this patient reminded me that mental health issues can affect anyone of any age, and that its effects are just as devastating. The GPs have to be highly sensitive and empathetic to their wide range of patients, having to be very careful and on their toes, ensuring not to miss out on the whole history taking, compared to hospitals where the consultants tend to focus on a specific area. Also, they have to be aware of the different non-pharmacological ways to help their patients, be it through lifestyle changes or referrals to the appropriate social services. Seeing a wide variety of patients presenting with multi-morbidities across different bodily systems within such a short timeframe is definitely insufficient to really give the patient the thorough care I feel they should be afforded.

If possible, should we be able to give patients in GP a longer consultation time, more of us, doctors and students, would be able to again take a more proactive effort on remembering how we need to see our patients as humans and not their illnesses. GPs would be able to really listen to their patients and their worries beyond their physical or mental ailments, providing a shoulder to cry on, and also begin to act as a partner in patient empowerment. As a past social prescribing champion at school, I have learnt the importance of thinking of a solution with the patient that empowers them to take action to better their lives. It’s about enabling them to really think about their own health and do the activities because they want to, to give them autonomy over their own lives and well-being. I really believe in the power of social prescribing, such as encouraging community gardening, volunteering and more, because these activities provide long-term benefits to the health of our patients without them relying on artificial medicines to cure them. Oftentimes, the solution is simpler than we expect – social prescribing gives us the opportunity not only to treat the issue (e.g obesity) at its core, but to provide additional social benefits as well. By involving the patient with their community, I see how much better and more motivated they are to take steps to make a healthy change. With social prescribing, we are giving our patients greater autonomy and responsibility over their own health, by guiding them on the necessary steps to help improve their condition or even prevent further illnesses. Currently, we already face shortages of medications to patients - as well as the issue of antibiotic resistance - hence with this alternative method we are able to help improve the social wellbeing and health of the population without over-reliance on medications. By empowering our patients, we are encouraging them to not only be more aware of their own health and wellbeing, but to also improve their communal ties as they learn to look out for others as well.

Furthermore, besides having a longer consultation time, I believe that promoting an after-work group reflection among the practice could encourage better patient care. By taking the time to introspect on their actions and responses of the day, as well as hearing the reflections of their fellow colleagues, GPs and students alike can gain insights on what they can improve on and better do to facilitate a more welcoming and patient-centred care. In addition, having an after-work group session can also provide the space for GPs to confide in one another any problems or issues they faced during the day - it could be a difficult patient hurling verbal abuses, or even a heartbreaking case in which they felt helpless. By being given the space and opportunity to process these emotions and thoughts, I strongly believe that GPs can improve the care tailored to their patients, as they learn from past mistakes and make the effort to provide more holistic care.

Through the highs and lows.pdf

2021-22 Themes:

a) Lived experience of medical students during the COVID-19 pandemic

b) Welcoming others and being ourselves: how to build inclusivity in primary care education

Cognitive Disconnect

Lived experience of medical students during the COVID-19 pandemic by Anamika Pereira Pai

This piece is meant to capture the idea of isolation and loneliness that is brought by having your education take place through the computer screen.

University is meant to be a time to bond with like-minded people and make connections with your classmates and professors. Furthermore medical students have even more of an interpersonal aspect in their degree. We need to interact with doctors and patients.

That is why the transition to fully online learning was extremely jarring. Problem based learning went from a classroom to over zoom. As someone who has experienced both in person and zoom sessions I can say that through zoom, discussion became less collaborative and lively. Verbal expressions and facial cues are missed and overall it feels more disconnected.

This piece is intended to depict that disconnect and loneliness. Even though the central figure is sitting with other people and seemingly in the middle of a lively discussion, they are looking into the camera instead of interacting with their environment. Furthermore the other people at the table have obscured faces and one cannot make out any discerning features. Although the figures can make gestures of interaction with one another, they cannot truly connect.

The lighting of the piece is head down, subtly isolating the central figure and separating it from the rest of the figures.

Overall, all the elements are trying to demonstrate the dichotomy or contrast between the inherently collaborative nature of medical education with the robotic and stiff interface of online education.

2020-21 Themes:

a) Health inequity and COVID 19

b) Compassionate care – for patients and for ourselves (clinicians/students)

a) The COVID-19 pandemic has further brought to light health inequity across the UK, where different groups of people experience ‘inequalities in health that are deemed to be unfair or stemming from some form of injustice’ including race and class. Tackling health inequalities is more urgent than ever although there have been calls to tackle health inequalities dating back over a century. Social accountability as a medical school has been described as:

…the obligation of medical schools to direct their education, research and service activities towards addressing the priority health needs of the community, region, and/or nation they have a mandate to serve.

b) ‘Being compassionate is not as simple as flicking on a switch or turning on a tap. Despite the best of intentions, compassion like other mental states (for example, joy, fear, sadness, gratitude, awe) is transient and impacted by internal and external variables’. To be in a place to offer compassionate care to our patients, health care professionals may also need to be compassionate to themselves and each other (Self-compassion website, Self-compassion questionnaire).

Buy yourself some flowers by Felicity Smith

“Buy yourself some flowers”

I bought myself some flowers last week. I picked them from a flower stall, a bunch of daffodils, their bright yellow heads not quite escaped from the green buds. I carried them home in their elastic band, tucked in the side pocket of my rucksack trying not to crush them with the weight of my laptop and textbooks as I sat on the tube. They felt very fragile in the bustle of the commute. The flowers sit on my desk as I write, in an old kilner jar I bought to make marmalade in but still have not. I bought them to make me happy, no other reason. Two pounds down the drain, or perhaps a small act of self-care.

I had been in the hospital all day, it was my first week at a new placement. Even though I didn’t know what I was doing or where I was going I tried so hard to be confident, assertive and impressive. Who I was trying to impress is not clear, was it my consultant (we hadn’t met them yet), was it the patients (we are all the same to them), was it myself? I had been asked questions I couldn’t answer and when I left I was stressed and I was embarrassed. If I still don’t know the basics, how will I ever learn what I need to know?

The Greek name for the daffodil is narcissus. In Greek mythology Narcissus was a beautiful young boy, who fell in love with his own reflection in a pool of water. So strong was his obsession he was unable to look away, eventually he realised that his love could not be reciprocated. He faded away and in his place he was left as a daffodil. When I got back home I wanted to fixate. I wanted to sit there and obsess about all the things I don’t know, all the things I got wrong and all the things I am bad at. I wanted to wallow in my inability, become paralysed in my learning and just pretend that medicine didn’t exist.

Behaving like this way will not get me anywhere, I will fade away looking at my own reflection like a self-loathing Narcissus. As a medical student it is important that I keep reminding myself of why I am doing this. I want to be a doctor, and this takes years of learning many different skills. You need to work hard to become a doctor and this requires energy and compassion. However, doctors are humans too. We have strengths and we have weaknesses. We have good days and we have bad ones. Being kind to yourself is important, we don’t always get the support we need and burnout is common at all stages of a medical career. To care well for our patients we must first learn to care for ourselves.

So instead of wallowing, I recognise these weaknesses, I remind myself I am human and medicine is hard, and I carry on. I spend the afternoon drawing my daffodils. I use my iPad as it is new and makes me feel like David Hockney and I enjoy the images I create even if they won’t sell for millions. I love the striking shapes, the bright colours and the ability to animate the process. I chose the colours for their boldness, their happiness, and because they make me think of holidays and summer and childhood colouring books. I don’t want the image to fade away once the flowers have gone. I want to be able to see them from across the room, to represent the calm these flowers brought and the joy I associated with them. The daffodils remind me of my mum who always used to have them in the house. I ring her and talk about my day. I sit down and go over some of the questions I couldn’t answer that morning. The process of drawing was my self-care, allowing myself the time to draw was my self-compassion.

Daffodils are some of the first flowers to bloom in spring. They emerge from the frosty ground alongside snowdrops and crocuses. They are associated with new life, new beginnings and the end of the hard winter. The next day I left for the hospital again. I had read up on the questions I had not been able to answer the day before. I was relaxed and I sent my mum a picture of the daffodils on a card for her birthday. I knew only a little more medicine than I did the day before but that was okay, I have the rest of my life to learn and I needed that time to draw my daffodils.

As the daffodils sit on my desk I am still enjoying them and I hope my drawing gives you a share of my enjoyment. So, buy yourself those flowers. Don’t see two pounds spent on yourself as money down the drain. Whatever you choose to make your act of self-care, a fancy coffee, or a conversation with friends, make it whilst encouraging self-compassion to become part of your day to day attitude and conversation with yourself.

Medical Student, 2021

Breaking Free from the Chains of Expectations by Natasha Alia Razman

This piece is a symbol of all the hardships faced by everyone in the medical profession, including even medical students. Different mediums such as a digital tablet, newspaper and yarn were used in this piece as it gave it more of a physical connection and more significance to me.

The faces represent the ‘mask’ healthcare workers tend to put on, by pretending that nothing fazes them. We often hear that healthcare workers need to pretend that they are not affected by any form of emotion when treating patients, as it could be seen as a sign of unprofessionalism. Unfortunately, sacrificing compassionate care towards patients, as well as compassion to oneself. The strings are connected to the faces, which symbolise the big expectations that are weighed on healthcare workers’ shoulders. People often expect them to never make mistakes, and achieve extraordinary feats. As a result, healthcare workers become too hard on themselves for not being perfect.

Finally, the hands at the bottom represent the power that we potentially hold. The power to potentially break free from expectations and take control of our own lives. The power to be more gentle with our souls and allow ourselves to flourish, instead of pursuing perfection. The power to be able to grow from a difficult situation instead of simply persevering. Regardless of interpretation, I hope this piece allows others undergoing their own struggles to connect with it and inspire them to be more compassionate in their journey to become a better, happier version of themselves each day.

Compassion by Baek Seung Hee

Having just entered medical school, I found myself habitually comparing my current perspective with a perspective that I had before this journey – the one of a patient unaware of the other side of medicine. In the position of the sick and unwell, it is common to not find the expense to empathise with others at the level you would usually find yourself. This is even more so with healthcare professionals that we intentionally seek out during times of need, whom we expect to lean on during our struggles. Looking back, clinicians always seemed so put together and intelligent, and imagining them in distress was simply an impossible image in my mind.

This impression of mine soon changed during clinical attachments. I learnt that the display that health care professionals are expected to put on to be the pillar of medical support for the public was sometimes harmful. Not to the patient, but to the professionals themselves; the maintenance of this profile was sometimes at the expense of their own mental and emotional state of mind.

Having first-hand heard from a clinician about the brutal onslaught of words she had once received from a patient, and only letting herself break down emotionally after work, was not easy to listen to. I have also heard numerous stories about General Practitioners (GPs) having to bear their own personal struggles while putting on a professional front, who only allowed themselves to show their grief after they had finished caring for their patients. These never-ending incidents behind the scene of medicine were difficult to listen to, and was a hard pill I had to swallow before committing myself to this road.

I did not expect to learn about compassion fatigue during these attachments but I found myself grateful for the opportunity. While hearing about the professionals’ experiences, I was continuously reminded that as someone whose role is to take care of others, you’d have to first take care of yourself. Moreover, hearing the support they received from their peers and staff during difficult times was inspiring, and showed me how far showing compassion to those experiencing similar hardships could go. These were definitely lessons that I had brought with me in medical school, even years after the attachment.

I made this creative piece as a reminder, not only to our GPs on the frontline of the NHS to spare some compassion for themselves, but to the general public, hoping that the people would not only look at GPs as a source of medical advice and treatment on a pedestal, but as a human being with emotional needs just like everybody else. From top to bottom, I have included misconceptions that people might have about medical professionals, and from bottom to top, I hoped to dispel these stereotypes, and hopefully shed light on the compassion burn-out that GPs so frequently experience.

Compassion is not an infinite source that can be expended continuously. I personally like to think of compassion as a double pan balance; the more unbalanced the weight on both ends, the more volatile and unstable the pan would be. For healthcare professionals to give away compassion, they would need to fill up the other end of the spectrum by fulfilling their own emotional, and mental needs.

RAB Cand 03 2021 Item 2.pdf

Self-care by Rebecca Walker

Plants need compassion to grow. They need water, they need sun and they need space to be able to thrive. Without these essential components, no one would expect a plant to grow and flourish. Without love and nurture, a plant inevitably fails to grow to its full potential.

So why do we expect this of ourselves?

Personally, I have been very guilty of not showing myself enough compassion. For many years, I have suffered with an anxiety disorder and depression. I did myself a disservice by not seeking help- at the time, I did not think I deserved it. I pushed my body and mind to extremes not only trying to cope with everyday activities but also to hide what I was going through from everyone. I would smile and laugh my way through social activities and then go home exhausted and cry. It was no way to live.

From my experiences, I have learned that compassion is not something that we are born with, nor is it an innate trait. We choose compassion and we choose to act in a way that is compassionate, to others or to ourselves. In my early years as a medical student, I mistakenly thought that showing myself compassion and putting my wellbeing first was selfish. I felt lazy for falling asleep too early when I was tired or unworthy of being a doctor if I did not stay up late enough to work. It is a cycle and attitude that inevitably leads to burnout and there is no doubt in my mind that I made myself sicker, mentally and physically, when I made these unhealthy decisions.

I think plants are a simpler example, compared to a human, of the importance of compassion. In the right conditions, which differs from plant to plant, a sapling can evolve into its healthiest and best form for survival. In my piece, the best form of the sapling is a sunflower. As the first hand waters the sapling, it gives it something that is essential for its survival and it is able to bloom into a beautiful sunflower. I chose this plant because it has become a symbol for people with hidden disabilities and as someone who is a part of that group, it was important to me for it to be represented in my piece.

On the other hand, there are factors, environmental and internal, that act as barriers to showing compassion. In my case, the factors that were harming me were predominantly internal, but it is an ubiquitous experience that internal conflicts are exacerbated by environmental stresses. As medical students, this can be the emotional effect of being with people who are seriously ill and dying or the frantic studying for exams that not only do you need to pass but excel in.

This brings us onto the hand holding the caterpillar. I chose the caterpillar because, from its perspective, the prospect of being able to eat all of the sapling is incredibly positive for it. It will be better off for it and be more likely to develop into a butterfly. As a medic, I have rationalised giving myself less compassion because the patients I see need it more. I have since learned that there is enough compassion to go around, and actually it is far more important to show ourselves compassion because, in the long-term, we would be unable to show other people compassion if we are burnt out.

As an aspiring GP, it is incredibly important to me that I learn how best to show myself compassion. The aspect of GP that excites me most is also the most challenging aspect of this specialty- the possible variety of diagnoses is huge and intimidating. When a patient walks into a particular department in a hospital, it is a given that they have an issue related to that specific specialty and will be seen by specialists. When a patient walks into primary care, there is any number of problems and the GPs job is to narrow it down to discrete diagnoses that can be managed and treated. This can be extremely discouraging as it can take time to diagnose a complicated patient and it can feel like you are not doing a good enough job for that patient. I think an important part of compassion in primary care will be to not expect perfection, which is something I often demand from myself. Sometimes reaching the right conclusion is a lengthy process of trial and error and being sure that you did everything you could at each step in the process should be enough to not feel guilty or inadequate.

So, the question remains, how can we show ourselves compassion? What does it look like? For me, showing myself compassion meant seeking help I deserved and accepting treatments that have changed my life. I have had my eyes opened to a way of being I did not even think was possible for me, and I have energy to dedicate to both patients I meet and, most importantly, myself. At the end of the day, looking after our own wellbeing is the most compassionate thing we can do for ourselves, and by giving ourselves the love and respect we would give to any other human being we can develop and grow into our best selves.

2019-20 Theme:

Isolation and the encounter

‘The hidden curriculum: If you get emotionally connected with your patients, you will burn out by the age of 40…

This is the most comical message I hear, because after 28 years of practice, I know the exact opposite to be true’ Prof Paul Haidet (twitter)

Health care professionals working at the coal face spend their working life bringing their learned knowledge and skills to the interpersonal meeting with a patient. These meetings can be high stakes, emotional, challenging as well as enriching, nourishing and meaningful. Our encounters can be a birthplace of learning, about ourselves, the other, the medical system, suffering and more…

At a time of unprecedented change with viral driven isolation, this is an opportunity to reflect on themes of clinical encounters or loneliness/isolation through the different lens of creative enquiry engaging with any of the arts - music, dance, painting, photography, prose, poetry, sculpture etc. The accompanying reflection should consider your creative text and what it means to you as well as references to any relevant literature. Confidentiality is important if you are submitting a text based on a patient encounter. Particulars about patient encounters should be changed so they are not identifiable.

Isolation by Ellie Watkins

Isolation

It comes from insula, they say.

(If etymology is your play).

From Latin, meaning “island,”

But here, no sea nor golden sand.

To be on one’s island – what does that mean?

For some, more strain than there has ever been.

To not leave their homes is incarceration.

All they can feel is resentment, frustration.

The recovered addict from cocaine

Craves his kickboxing to stay sane.

The lady with high blood sugar

Who daren’t run outside (she feels vulgar).

Overworked parents who have to home-school.

Oh screw it! There are no more rules.

Let’s just put on “Disney Plus,”

Now do your homework please - no fuss.

But these poor children, all they desire

Is to see their friends, kick a ball, be inspired.

For some, these islands are places of fear.

Threats of domestic violence domineer.

Some children may not get their main meal.

(Perhaps a slice of bread, or an orange to peel).

How do we cease this negative spiral

And stop this resentment going viral?

Those same walls that kept out the wind and the rain

Are going to make us completely insane.

Indeed for many – far more than we know –

Isolation is simply normality. How so?

Being housebound is part of everyday life.

Do we think of these people, their woes and strife?

A lady – let’s call her Lucy – in East London.

Her little front garden, a place of abandon.

The stroke that rendered her unable to walk.

Paralysed down one side, but able to talk.

She told me it had been at least five years,

Since she had been outside, in tears.

The mere five steps to her front door

Left her stranded on her island, washed ashore.

Her grandchildren visited often, she said.

“Thank God for them, else I’d be better off dead.”

A man, let’s call him Jim for short.

Had a car accident: he never thought

That aged 33 and eager, with everything ahead,

He would be paralysed from the waist down: “don’t drink and drive,” he said.

Guilt and depression consumed him, ate away at his bones.

How awful to feel so terribly alone.

Seven years later, he sits in his flat.

What he wouldn’t give for a cup of tea and a chat.

Exhaustion from myalgic encephalitis,

Painful joints from osteoarthritis

Too breathless to walk, with chronic bronchitis.

Incontinence might strike, oh that dreadful colitis.

Palliative care from incurable cancer,

Unable to walk or talk from dementia.

The reasons are countless

But only now has isolation found the rest of us.

Indeed, physical isolation does not reign alone

Paired like a demon: social isolation, on the next throne.

The pandemic of loneliness was already rife.

Who do you talk to when you’ve lost your wife?

They say it’s as bad as smoking 15 a day.

So how many are there, in the UK today?

Nearly 400,000 don’t talk with others for a week.

(That was before Covid; it becomes more bleak).

A 96 year old man – let’s call him Dave.

Incredibly able for a man of his age.

Bright as a button, sharp as a knife.

He tells so many tales of his old Navy life.

But still needs help with cooking and cleaning,

And washing too (he finds that chagrining).

The carers come two times a day,

(He does have family, but they’re far away).

These ladies were lovely, put a smile on his face.

They were the only people that came to his place.

Indeed, the only people he spoke to at all.

But who now, who can he call?

Now that Covid has swept the nation,

No more visits “for his protection.”

“We must help the elderly!” people now say,

And we all chipped in, without delay.

Reaching out to our neighbours with supplies

A whole new community, in front of our eyes.

A community that had always existed.

But only since Covid, our help enlisted.

We must strive to continue this net of support.

For Lucy and Dave, no phone call is too short.

They couldn’t possibly “skype” or “zoom,”

But for the younger people, social lives resume.

Let’s build more bridges between our islands.

Construct a metropolis of love: let’s all join hands.

To appreciate this new way of living

We must be try to be more forgiving

Of ourselves, our neighbours, our daily lists

Kindness, meditation, that cheek unkissed.

A journey of quiet discovery

It might bond us, in our recovery.

On these islands, there are golden sands and more

We just have to find our way to the shore.

For many of us, although isolation at home is highly alien, it is temporary: the boredom, anxiety and frustration will eventually pass. But when reflecting upon the effects of isolation upon society, I was struck by the number of people for whom spending every day at home is normality.

Working as a carer before medical school highlighted to me how different people cope with relative isolation inside their homes. I worked with several elderly clients who were perfectly content at home, many of whom received frequent visits from family. But for many, their sole source of human contact was us, their carers. Drawing upon my experience with “Dave,” our daily chats were as essential a part of his care as preparing his meals. Many people are currently not receiving their normal care at home: partly due to care staff self-isolating, and several people are also refusing care for fear of catching the virus.

Physical isolation can be accompanied by social isolation, which can in turn lead to loneliness. However, these three concepts can be viewed as separate and independent entities(1). Whereas physical isolation signifies a separation in space, social isolation means a lack of social contact, and loneliness refers to feeling alone. Both social isolation and loneliness can still occur in the physical presence of others, and equally, there are many people who experience social isolation but do not feel lonely.. In recent years, the advent of multiple electronic platforms, such as video calls, has enable the connection, and indeed reconnection, of relationships with others, even across the other side of the world. Thus physical and social isolation for many, are no longer inevitably intertwined. However, although there are people in the elderly community who are able use these technologies, no doubt that to many, such platforms are completely inaccessible, thereby heightening their relative social isolation even further.

I admire the British public for the recent outreach to the elderly in our communities, and others who face difficulties leaving their homes. But I hope that this support continues beyond Covid-19. This is a time of adaptation for us all. Can we adapt as a society going forward to meet the needs of this silent population? Studies have showed benefits of implementing video calls among residents of nursing homes on depressive symptoms and loneliness(2,3) – would there be scope to extend this support to people at home?

1. Menec et al. (2019) Examining individual and geographic factors associated with social isolation and loneliness using Canadian Longitudinal Study on Aging (CLSA) data. Plos One 14(2): e0211143.

2. Zamir et al. (2018) Video-calls to reduce loneliness and social isolation within care environments for older people: an implementation study using collaborative action research. BMC Geriatrics 18 (62).

3. Tsai HH et al. (2010) Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health. 14(8):947–54.

Ellie Watkins, medical student, 2020

Isolation - a familiar issue, disguised differently

I was inspired to create this piece following a clinical interaction I had 2 years ago during a hospital placement where I saw a non-physical barrier of language become significantly more dominant than any other physical barrier. It made me realise that patients and doctors are not only isolated by a physical barrier of a wall (as presented in the image) or PPE (since that is more pertinent during the current climate). It is the psychological barrier that profoundly impacts the doctor-patient relationship and the quality of the healthcare provided. This particular barrier has been prevalent and pertinent for a much longer duration than the transient and temporary barrier of PPE and self-isolation that exists globally now.

The current pandemic has only perpetuated and exacerbated the already increasing distance between the doctor and their patient. Before, the doctor would only be disconnected to the patient psychologically or emotionally, however, an increasing physical distance and a constant fear of seeing every patient as a potential source of morbidity and mortality means doctors want to spend as little possible time with their patients from the farthest distance possible.

The “clinical interaction” I mentioned earlier involved a patient with a likely diagnosis of cancer and no healthcare professional was able to translate that to her, the patient did not have any friends, family or any other social support network around her and I (a third year medical student) was the only person able to translate the diagnosis and the management plan for her. The patient mentioned it was the first incident of her understanding any communication since her admission, and the nonchalant behaviour of the lead consultant regarding the diagnosis further exhibited the issue of the concrete emotional barrier between doctor and patient that has laid firm for years now.

In the light of the recent pandemic, it made me reflect on what would had happened to a patient like her if she was admitted during the current crisis. Imagine you are a patient with a significant language barrier, you are clinically vulnerable due to the underlying cancer, the healthcare professionals are forming a physical barrier against you on top of the emotional barrier that they have already built, and the usual calm of the ward is practically non-existent, the emotional impact that such a circumambience can imprint on a person’s brain is incomprehensible therefore, as we walk out of this “biological warfare” on to the other side, we as healthcare professionals and medical students must do a lot more to emotionally connect with our patients and understand and interact with them as a fellow human being rather than another cancer or another stroke. Only then, we can truly fulfil our duties as doctors and as humans.

Umer, medical student

2018-19 Theme:

Compassionate caring in general practice

Within this title you can think about compassion for patients, compassion for carers, compassion for colleagues and compassion for ourselves (GPs/medical students)…you can draw on a situation that you have witnessed, a culture you have experienced, what you imagine might be possible or what you hope for…

Here are some thoughts to get you started around compassion…

Prof Michael West, Kings Fund https://www.kingsfund.org.uk/audio-video/michael-west-collaborative-compassionate-leadership#main-content

Collaborative and Compassionate Leadership

….So what is compassion? Compassion for me is the healthcare assistant I saw who stayed for an hour after her shift had ended, holding the hand of an elderly lady who was in distress and talking to her lovingly and caringly, until she was calm again. It was the GP who told me she danced in her surgery that day with an elderly lonely man when she discovered they had a shared interest in dancing.

And you might have heard of Schwartz rounds…. Please see this article which draws on Schwatrz’s life story behind the rounds:

Compassion, hard to define, impossible to mandate https://www.bmj.com/content/351/bmj.h3991

‘I cannot emphasise enough how meaningful it was to me when caregivers revealed something about themselves that made a personal connection to my plight,’ he wrote. ‘The rule books, I’m sure, frown on such intimate engagement between caregiver and patient. But maybe it’s time to rewrite them.’

2017-18 Themes:

a) The doctor – patient relationship

b) Treating disease: Engaging with the lived experience of illness

Title a) and b) are chosen for this prize in General Practice as they are both core to a GP’s clinical work.

Supporting your thinking about both titles and their importance to primary care, is the attached document (below, Appendix 1) with excerpts from a Professor of Family Medicine in Canada (Professor Wayne Weston). Also two quotes below might help orientate those thinking about ‘disease’ and ‘illness’.

Cassell (1978) uses illness to mean "what the patient feels when he goes to the doctor", and disease to mean "what he has on the way home from the doctor's office. Disease, then, is something an organ has; illness is something a man has." Illness refers to the subjective response of the patient to being unwell; how he, and those around him, perceive the origin and significance of this event; how it effects his behaviour or relationships with other people; and the steps he takes to remedy this situation (Eisenberg, 1977; Kleinman et al., 1978, 1980). It includes not only his experience of ill health, but the meaning he gives to that experience

HELMAN, C. G. 1981. Disease versus illness in general practice. J R Coll Gen Pract, 31, 548-52.

Doctors trained to diagnose and treat disease sometimes find it hard to cope with the individuality of illness. The crowded medical curriculum has little room for teaching anything other than disease; harassed junior doctors have little time for anything other than treating it.

O'DONNELL, M. 2007. Ultimate Achievement. BMJ Careers, 170.

Broken Time by William Hirst

Through this work, I would like to show that time is altered forever when a patient is diagnosed with a serious illness. Diagnosis with a chronic or terminal illness disrupts a patient’s life plan and changes how they view time. Chronic illness diagnosis is often associated with uncertainty in terms of prognosis and amount of time left in which a patient can be active. Patients lose control of how they want to spend their time, having to attend appointments at times that are convenient for the doctor and the health system but not for the patient. One example of this is cancer treatment which provides certainty in terms of a timeline, but patients on such a treatment plan must make many sacrifices to attend appointments and treatment. In a system where the patient is supposed to be central to everything we do, a patient’s time is no longer their own.

Patients losing control over their time is particularly true of hospitals. Being a patient in hospital leads to a loss of a sense of time and identity. Patients can no longer choose when to eat and often do not have any control over when they are seen by a consultant. This can also be frustrating for family members who feel left out of the decision-making process. In terms of identity, patients are identified by what is wrong with them rather than how they choose to spend their time or what clothing they wear. There is however another way, the national pyjama paralysis campaign is aiming to reduce the reinforcing effect wearing pyjamas has on feeling unwell (NHS England, 2018). By helping patients to wear their own clothes in hospital they will be able to identify as something other than their disease.

I have represented this patient experience as a mixed media piece made from a broken clock. I have created a piece of art from a broken clock face to symbolise how a patient’s experience of illness is closely entwined with time. This piece also represents how a patient’s life is disrupted when they receive a chronic diagnosis. The hole in the canvas signifies how a serious diagnosis tears a hole in their life plan. This hole also represents a loss of time left, as well as loss of having control over how patients can choose to spend their time. Another interpretation of this fissure is as the rift between a patient and their family, as relationships change due to the burden of illness. The clock face signifies the face of the patient who loses their identity and embodies their illness after diagnosis. The hands of the clock are held together to indicate a doctor’s attempt to reach out to a patient and offer them comfort and closeness. The cogs in the clock which have moved away from the middle, signify the machinery of life, which is no longer central to a patient who is experiencing illness. The numbers represent the hours of a patient’s life, which are no longer the patient’s own and are counting down until their last hour.

References:

NHS England (2018) 70 days to end pyjama paralysis, 2018. Available online: https://www.england.nhs.uk/2018/03/70-days-to-end-pyjama-paralysis/ [Accessed Feb 2018]

medical student, 2018

Mr X by Reya Srivastava

The importance of patient-centred care cannot be overstated. Treating each patient as an individual with a specific set of values and beliefs leads to greater trust, patient satisfaction, and better health outcomes. My painting depicts what happens when this is not recognised.

When creating my art piece, my aim was to portray the way many patients feel when they are subjected to a paternalistic approach. The blurred face in this portrait takes away the patient’s individual identity and replaces it with a generic form. The viewer is forced to see him the way a doctor might: simply as ‘young male.’ The use of a monochromatic palate again reinforces the lack of individuality.

Without the face serving as the focus of the piece, I wanted to draw attention to the patient’s hands. Clasped hands held over the abdomen are often associated with vulnerability, giving the viewer some insight into how he might be feeling. Medical consultations can be intimidating for some patients and detecting non-verbal clues can help doctors elicit and address the patient’s unresolved concerns.

Reya Srivastava, medical student

2016-17 Themes:

a) The patient examines the doctor

b) Medically unexplained symptoms

Title a) is taken from a title of a book chapter in ‘Intoxicated by my illness’ by Anatole Broyard.[1] He was literary critic and editor of the New York Times Book Review and died of prostate cancer in October 1990. The whole chapter is evocative and thought provoking, but here is a small quote:

‘…a doctor, like a writer, must have a voice of his own, something that conveys the timbre, the rhythm, the diction and the music of his humanity that compensates us for all the speechless machines…whether he wants to be or not, the doctor is a storyteller, and he can turn our lives into good or bad stories, regardless of the diagnosis…’

Title b) allows for consideration from patient or doctor/medical student perspective the challenges around medically unexplained symptoms which can account for up to 25-50% of all reasons to visit a GP. [2]

Engaging with the arts in reflection around medical practice may feel unfamiliar but allows, for example, engagement of imagination, emergence of alternative perspectives and the different languages of the arts to be used to convey ideas and experiences. You can use any creative medium – music, dance, painting, photography, prose, poetry, sculpture etc. The accompanying reflection may include references from the literature around your line of exploration, thoughts about the process of doing the creative work, interpretations of your symbolism and metaphors used, your thoughts on the finished piece and the significance of your work to you personally and/or as a medical student.

The marks will be allocated in these four categories: Impact, Perception, Aesthetics and Reflection.

[1] Broyard, A. 1992. Intoxicated by my illness. New York: Ballantine Books.

[2]Verhaak, P. F. M., S. A. Meijer, A. P. Visser & G. Wolters, 2006. Persistent presentation of medically unexplained symptoms in general practice. Family Practice, 23, 414-420.

The Patient Examines the Doctor by Freya Elliott

This painting is entitled ‘The patient examines the doctor’, which is also the title of a chapter in Intoxicated by my illness by Anatole Broyard (1). It is a moving and witty personal exploration of illness and mortality. In that chapter Broyard explores what he looks for in a doctor.

I have depicted the patient auscultating the doctor’s head as a metaphor for the patient wondering ‘what is the doctor thinking?’ ‘Who is this person?’ ‘Does he know what he is looking for?’ ‘if there is something to find, will he find it?’ And, as Broyard crucially adds, “How good is this man?”1

Patients share the intimacy of their body and mind with their doctor, possibly exposing thoughts and details that they wouldn’t even reveal to their own partner. Broyard’s book reminded me how important it is for doctors to make patients feel that they are respectful of the immense trust that is bestowed on them. There is a vulnerability in the basic act of taking your clothes off and letting someone examine you.

The two figures are squeezed into the composition to represent the intimacy of the interaction. I depicted the figures as the same person, to represent the idea that the doctor could easily be the patient, as we are all a patient at some point in our lives. I muted the colours, and faded out the outer part of the painting so that the viewer’s eye is drawn to the two central arms, which are almost entwined. I allowed drip marks towards the bottom, a metaphor for the impermanence of human life, and how our lives unravel in the face of illness. The patient is coming to the doctor because he is ill; once the doctor diagnoses what is wrong this resets the parameters of the patient’s life.

References:

1. Broyard, A. 1992. Intoxicated by my illness. New York: Ballantine Books. (pages 33-58)

Medical student, 2017

Oyster Shells by William Hirst

Doctors have a choice to make about the extent to which they connect with their patients. They can be open and compassionate and give part of themselves to a patient, or they can choose not to engage with a patient’s story. Broyard describes this dichotomy (Broyard, 1993). On the one hand doctors can be ‘professional’ and ‘scientific’, which he suggests is at the detriment to the doctor-patient relationship. On the other hand, doctors can open themselves up to patients and become part of the patient’s story (Broyard, 1993).

To represent these paths for medical practice, I sculpted two oyster shells, one showing the closed side of the shell and the other showing the open side. The oyster that is open has a pearl inside, representing the rewards that ensue from being open to patients. For the doctor, this is the reward of learning from the patient’s story, and for the patient this is the reward of shared decision making and understanding. The negative effect of being open is the emotion experienced by patient’s that gets loaded onto you as the doctor. This emotion must be managed, which can be exhausting for the doctor. Perhaps this is the price that must be paid for giving away part of oneself.

Oysters also have a hard outer shell, which signifies the resilience needed in medical practice to be able to be supportive to patients. This resilience is needed to face pain and suffering that cannot be healed. Oyster’s shells and pearls are made up from many layers, symbolising the layers of trust in a relationship between a patient and a doctor. These also symbolise the choice of how many layers of engagement to peel away.

medical student, 2017

The Doctors Office by Christine Carter

….This picture illustrates Georgina’s* story. It shows her on one of her various trips to the GP after he’s made a number of referrals and the investigations are all negative. The GP is at a loss. When he gets a nice clear result from a patient its easy; he can file that patient into one of the neat boxes on his shelves. A positive result for strep throat; excellent, that patient can be filed into infectious diseases and be given penicillin. Skip lesions and transmural inflammation found on histology after colonoscopy; a clear-cut case of Crohn’s. That patient can neatly be filed into gastroenterology. Chest pain, a STEMI and a blocked coronary artery; straightforward and treatable. A broken bone; easy.

But Georgina doesn’t fit into any one of these boxes. Defeated she slumps back in her chair and starts to slip through the crack that has opened up on the floor. Tired, unsupported and heavy. The GP, desperate to help puts his hands in the air, also defeated. Racing against the clock he thinks, “Why are so many patients I see like this?…this isn’t what I was taught in medical school.”

The rays of light in the picture edging towards the crack are symbolic of hope. In the past, after extensive fruitless investigation there was little more the doctor felt they could do. After the investigations for Georgina’s abdominal pain ... had come back clear, she had left the doctors office with no particular plan. Although she had been a frequent visitor up until that point she felt too embarrassed to go back. She felt like she wasn’t a ‘real’ patient. She learned to live with the ups and down of the pain.

This picture is made in mosaic style from cut out pieces of magazine, to illustrate that this is a ‘messy’ subject to deal with.

name and details changed

medical student, 2017

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