I’ve now taken my place at my London training practice; hung up my coat, adorned the wall with the world map I carry from one job to the next and filled the drawers with a variety of snacks that will hopefully get me through those trickier sessions. I will be here for a year and, all being well, will exit this very building as a fully-fledged GP in a matter of months.
My first few days back down the mines have been daunting; with numerous computer systems to re-learn and referral pathways to memorise before I begin to even contemplate the actual medical stuff…
It’s an exciting time, full of surprises, and the biggest of those has undoubtedly been just how large an impact the past year has had on my own perspective, both as a doctor and as a person. Of course, through the patient’s voice project, I have been and continue to seek, among other things, influences that might change my own views and practice. However, it has only been during these last few days, through the observation and interaction with London patients again that I have really gained a sense of the journey I have traveled so far. Nearly every scenario I have encountered over the past week has triggered a memory and connection to something I experienced abroad and therefore, as I continue to document my findings and work through the data I have collected, I want to use these points in the blog, as they arise, as platforms from which I can share patients’ stories from around the globe and draw comparisons to the UK in a way that might resonate.
Having spent years racking my brains for ‘interesting patients’ to reflect on as yet another appraisal date loomed, I’ve found over the last few days that since coming back, I seem to notice people more and am generally more curious. I’ve always been interested in people; I’d say it’s pretty essential to be a decent medic and certainly to take on such a project, but perhaps after a year of delving far deeper than the ‘presenting complaint’, details that would have passed me by before now stop me in my tracks and make me think.
So, let's start in a Kensington basement flat, on a sunny day that didn't quite reach the subterranean rooms or inhabitant: a 90 year old gentleman, our patient. Having coped relatively independently for many years he had begun to complain of increasing unsteadiness on his feet and with that in mind alongside the fear of how such an affliction might jeopardise his mobility and freedom he had requested a meeting with his GP. I, the keen and eager new registrar, was taken along for the ride.
Our journey to the home visit entailed a 20 minute walk through some of West London's finest postcodes; after a year of the most varied landscapes ranging from rice paddies to fjords, I'm still finding returning to the spectacle of London's red brick mansion blocks a novelty.
On arriving, the grandeur continued through the door of our destination as we were let in to the flat by a small and very smartly-dressed man using a zimmer frame and I was struck immediately by how large the room was and yet how little furniture it contained. The encounter began to feel more and more like I was settling down for an interview as, not wanting to dwell on the banalities of medical complaints, our patient launched into a series of anecdotes on life, travel, his hobbies..he was charismatic, an excellent conversationalist and I knew instantly that we would get on.
It's easy in such a scenario to lose track of time and after what seemed like only a few minutes I could sense that my supervising GP felt we should get down to business, aware that we had only a further 30 minutes before afternoon clinic began.
After the relevant checks were done and examinations performed my supervisor closed by asking the gentleman how often he left the house and with whom. He replied that he tried to get out to Sainsbury's once a day, he liked to see people, and mostly managed the journey himself. However in recent weeks it had become more of a struggle, he'd had a few near misses with traffic and relied now on the odd occasion that the doorman could take him across the road. There didn't appear to be anyone else. As a man who had never married, family members were few and far away.
In an effort to help, we focused on his needs; how did he get food if he couldn't go out? Would a district nurse visit help in assessing his mobility? But the truth is he, like so many, falls between the cracks of what we, as medical professionals, can offer him. He is not yet incapacitated enough to require carers but what he really requires is company.
As we left his building I couldn't help but think of how many people would look at such a place and envy him. Yet to exist in any setting and go days without a conversation or to live with the fear that one day soon getting out might prove impossible, surely that constitutes a prison of sorts, regardless of the size of the rooms or wallpaper adorning them.
Since starting this entry, I have spoken to the gentleman twice more on the telephone. I was told by the reception staff that he calls 'often', 'seeking reassurance' and after two short conversations with him both triggered by a physical complaint that dissipates within minutes and both ending with the query of when I would visit or call again, I see that they are right.
I wanted to write about him not only because, having somewhat taken over his care, he will likely be a frequently recurring character in my coming year, but because sadly his story illustrates so well the ever growing problem of social isolation among elderly people in our country.
Loneliness can occur at any age, as documented so superbly in Sue Bourne's film 'the age of loneliness'; a big inspiration for the patient's voice project, but we know as doctors and as a society that as people begin to live longer, spending our twilight years in a single-person household with 'the television or a pet as our main form of company' is increasingly becoming the norm (1). We also know that loneliness or social isolation is not only an epidemic in itself but also negatively impacts our physical health, as is true of all mental health issues, with the acknowledgement that loneliness can be as harmful for our health as smoking 15 cigarettes a day and people with a high degree of loneliness are twice as likely to develop Alzheimer’s as people with a low degree of loneliness(1).
We know all of this and yet the solutions are difficult and still somewhat unclear. Efforts are being made on both small and large scales; the continued work of the charity Age UK is quite staggering as an example. Yet, currently, it's just not quite enough and often where it comes to lie, the last net that seems to catch it, is General Practice in those lunchtime phone calls and those requests for visits. Efforts in our arena are equally being made, our empathy in that basement room was real and our desire to help genuine, but as ever we are restricted by time, by the need of others and by the question of how far should and indeed can our role really extend?
But to get to the real point of this blurb, the crux, the reason why I personally feel affected by this story is that over the past year I've seen it done differently. I've seen a number of 90 year olds who whilst sharing their year of birth with our protagonist, in every other way live completely different lives, largely due to the cultures and communities in which they exist.
Let me take you back to Orkney and to a story that I shared early on in my journey. Those paying attention will recall the tale of an elderly man living alone on the island of Hoy in the basic surroundings of a historical military tower. Hospitalised for physical deterioration, a deep depression had set in at the acknowledgement that he might not be able to cope anymore and that he might not be able to return to the place he loved. You might remember the community's reaction to this, their actions triggered by the thought of losing him: an island with very little social care and support from outside services facilitated their neighbour's discharge within three weeks, overhauled his living accommodation and arranged a rota of people who would care for him on his return. As medics we visited frequently, but with the luxury of knowing he was receiving company from others, were able to fulfill a role that was manageable. I was moved by this episode back then, now in the context of the last week, I am even more amazed.
Now let me take you forward to my time in Japan, to a town of 4500 people, 47% of whom are over the age of 65. Japan is home to the oldest citizenry in the world, with 26.3% of its population in total being 65 years of age or older and whilst there are undoubtedly multiple reasons for this; diet, and a high level of medical investigation to name a few, I am convinced after observing small town Japanese society for a month, that the connection between community cohesiveness and social stimulation and good health do play a part.
Social structures are slowly changing in Japan with more and more young people moving away for study and employment with fewer returning to rural areas. However, traditionally, multiple generations of the same family would have lived in the same place and shared accommodation and as a result would have provided interaction and support for elderly relatives. Despite the move towards the western trend of single person living, this cultural pattern remains in places and certainly a feeling of responsibility for one's elders is dominant. I witnessed this several times during my stay in Tadami and through the care and compassion of families often supporting challenging situations such as dementia, elderly people were able to live much fuller lives.
However, of equal importance to the often strong familial support networks, is the attitude towards ageing and the value given to elder members of the community. Ageing in Japan is not seen as a barrier unless it has to be and staying active is not a health trend but a normality. The image of elderly people, some undoubtedly in their 80s and 90s, working their gardens and vegetable patches late into the evening is one that became so familiar to me during my time there. There is no question to most of what they might do on a Saturday or wednesday morning, they work as they have always done. Whilst obviously positively impacting their physical health, this level of activity also provides a sense of purpose, an occupation and a feeling of being useful that can be so essential in maintaining good mental health.
Through interviews with both elderly people and their families on this subject I was also able to explore the expectations both parties had of each other and found an almost unanimous respect shown towards older members of families. Their skills and experiences seemed to be valued, their stories listened to. Through the support and interest of those below them the grandparents of the community were empowered to keep going.
Could I honestly say the same for the gentleman in the Kensington flat? I hardly yet know him at all, I hope he has spent his life having experiences and passing them on, but I worry that, these days at least, he is not getting the opportunity. I worry about what impact that might have on his own feelings of self worth and as a consequence on both his mental and physical health.
I don't have the answer but I do have ideas..if I've learnt anything from my year spent in global communities about loneliness in the elderly, it's that it doesn't always have to be that way. Whilst I'm not naive enough to think an 'Orkney-type' community could be transplanted into central London, I do think we have to be open-minded enough to explore other ways of doing things. I think it's the only way forward.
And exploring those different ways is exactly what I'll be doing for some time…watch this space.
1. Read some staggering statistics on loneliness in the elderly provided by Age UK- https://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/Age%20UK%20Evidence%20Review%20on%20Loneliness%20July%202014.pdf?dtrk=true
2. Watch Sue Bourne's incredible 'the age of loneliness'- https://www.youtube.com/watch?v=2d9kzhIidOU