00:06 Our minds and body are intimately linked…

So, you may know this intuitively as a clinician, but your patient may not. There are a range of ways of talking about it…

00:19 Fear: the body gets ready to fight or flee…

·         If you or I were to hear a door slam right now, we’d jump. Our pulse would increase, our blood would flow to different parts of our body, some muscles would tense, our hairs might even stand on end

00:33 Flushing and sweating… 

·         We flush red when we’re hot, when we’re embarrassed, when we’re ill

·         We sweat when we’re anxious, when we’re hot, when we have too much or too little blood sugar

00:48 Breathlessness…

·         We are breathless after exercise, when we feel worried, when our chest is restricted

·         We feel differently about what breathlessness means based on what we’ve been through

01:03 Pain

·         We feel pain when we hurt ourselves, when we are tense and stiff, and when parts of our body swell due to a stress response

01:12 Eating

·         We eat differently when we lack energy, when we feel stressed and when we don’t have time to look after ourselves

01:22 Real changes in the body: emotion or illness?

·         Sometimes the body doesn’t know when to distinguish between when a bacteria or virus is threatening it or when a loss, shock, stress, or change in the environment is threatening it

·         In both cases the immune system can kick in, leading to swelling, pain, tenderness

What’s most worrying is when there are changes in our body and we’re not sure why – sometimes the default is to think the feeling of threat, vigilance and attack, means an illness is present. This might be the case, but it might also mean the body is stressed in different ways – what’s key here is the fact the dizziness, swelling, ringing, pain, chest ache, tightness, is real. The body is moving and changing in response to a threat, but this threat might not be what you think

Our emotions also happen in the body, where else would they occur? And, if we’ve also got arthritis or diabetes symptoms happening there, or if we’ve recently had frightening surgery, then we’re told by one person do more, one person do less. Before we know it, we’re more overwhelmed and anxious and then everything gets on top and feels too much and it’s hard to tell what sensation is coming from where. None of us can figure this out entirely alone

02:46 Cortisol and stress

The hormone cortisol is also a simple way of explaining the mind-body link. During times of stress, adrenalin and cortisol are released. In the short term, cortisol has anti-inflammatory properties, but in the long-term it can lead to stress responses. To fatigue, weakness, weight change, pain, loss of concentration, swelling, low libido, changes in the skin, impaired memory, insomnia, irritability, menstrual abnormalities, or blood sugar dysregulation, high blood sugar or high blood pressure

Throw in the fact that cortisol and adrenalin are usually signals for us that there is a threat, it is not surprising that any physical symptoms are felt to be very, very worrying – we are already in a state of high alert

Maybe the idea that stress could contribute is unsettling, but this is helpful to know, because we can target stress with a range of different approaches. So, psychological, social, dietary and physical

If you’re talking about cortisol and the stress response with patients, try to avoid doing so in a way that makes it sound like a potential disorder or condition. Instead it’s a natural response to stress that can be thought about further

Some consultations leave us feeling things that we don’t want to. Dread in the built up, frustration, ineffectiveness or guilt afterwards… they may challenge the hopes that drove us towards the profession in the first place. Where we may ordinarily by able to treat, cure or find a pathogen, here there’s often no satisfactory explanation, and the patient’s distress persists

This may be telling you what you already know: that these consultations are hard, and they can take their toll. But, such feelings are also signs that we are appropriately “tuned in” to our patients. They are a form of clinical information that can be looked at and thought about further

01:42 For example, “I never feel like I’m doing enough for this patient”

“Whenever I go on leave my patient ends up calling the practice daily”

“This patient says they don’t trust anyone in the practice except me”

“I always feel really unskilled with this patient, like I’m getting it wrong”

And, no matter how many tools or how much experience we have, these feelings are as central to certain consultations as prescriptions, examinations and the pleasure of helping others

This might be disappointing to hear, but accepting that distress, frustration and uncertainty are central to the work with persistent physical symptoms can be understood as a healthy starting place for patients and colleagues rather than a hopeless end-point

02:32 Unfortunately, when this distress cannot be discussed, unhealthy things can happen within teams

As you’ll know, clinicians can end up feeling weighed down if they’re not supported. This might be experienced tangibly in sickness, turnover and staff burnout. Or via tensions within the team, adding pressure to our existing struggle to meet more targets with fewer resources

By accepting the unavoidable emotional impact of the clinical work as a starting point, a number of robust practices can be put in place before a patient even gets into the room

03:23 Things such as, longer consultations, a planned break in your clinic after these consultations, and regular complex case meetings, for example

03:39 Whole practice patient plans (including admin and reception staff), utilising psychology resources for liaison and joint work, and thinking about releasing staff for training

These approaches obviously don’t make the complexity go away but research demonstrates that they can determine the health of your team

They can often be the first things to be dropped when the practice gets stressful or busy. But it’s only with a whole practice approach in place can we begin to think about individual encounters with patients

Patients with persistent physical symptoms don’t come to see us because of their symptoms. They come because they’re disturbed by changes in their body… a small but important difference

00:26 Try first meeting the patient where they are with their distress or concern

For example, “you seem to be worried about this , this might feel a bit too much to take…” or, “you think we’re missing something. That must be hard”.

Clinical research shows that offering reassurance before acknowledging distress does not work… It is perceived as dismissive

00:53 Try ascertaining whether there are any underlying fears

For example, “what do you worry this pain might indicate?”

Patients also come because nobody else they know has alleviated their distress

01:15 Try acknowledging a potential lack of support

For example, “Who is around for you? Are you getting much support at the moment?”

Any potential offers of psychological support have now been framed as somewhere to share the distress of living with the symptoms… rather than because you think, its “all in their head”

The patient will likely place a lot of hope in further investigations

01:59 Try preparing for negative results from the outset

For example, “we can try this investigation, but I think it might come out negative”

This might avoid a more upsetting consultation later

02:23 Try to be honest when discussing the potential harm caused by excessive examination

A patient might say, “well, you can’t be certain”.

02:37 Try acknowledging that there is uncertainty, which is difficult

Something like, “you’re right, and uncertainty is hard, but my team and I are monitoring this”.

02:53 Try backing up your statement of care with the offer of intermittent appointments

Once these appointments are in place, you have a robust care plan. And, you can be firmer in asking the patient to either wait for their next planned appointment or use crisis services in the interim (though this can make us all feel guilty as clinicians)

00:24 Try ensuring any treatment plan is shared among all of your colleagues to avoid team divisions

And, finally, with all of this in place, you are still left with a patient who is suffering. If you notice yourself struggling to acknowledge this, it might be helpful to bring the case for discussion with your colleagues.