My name is Dr David Beales. I’m a retired GP with an interest in mind-body medicine. I share stories from medical practice and my own experiences to improve doctor-patient relationships. Following my diagnosis of Parkinson’s disease in August 2017, I wish to break down barriers to create more constructive partnerships.
I continue to live a full life, and write about my lived experience. I would like to share some of these thoughts with you, as well as hear your experiences.
I perceive a society in which intuitive knowledge is not necessarily balanced by rational analysis. Albert Einstein once spoke of intuition as a sacred gift and likened rationality to a faithful servant. I would like to combine rationality and intuition in writing about medicine and its impact on ALL OUR LIVES.
My aim here on this Dr David Beales website is to provide an interactive communication platform. I have spent a lifetime in medicine from 1967 to semi-retirement last year. My life experiences have been rich and challenging. They are filtered through hospital medicine – five years leading to Membership and Fellowship of the Royal College of Physicians specialising in Rheumatology – and GP partnerships in East Dulwich (1, Forest Hill Road) and Cirencester (Phoenix Surgery) until retiring from the NHS in 2000. I then moved into independent practice. During this time in Cirencester, at the local hospital, I was able to combine, whilst a full-time partner in general practice, six hospital practitioner sessions, 18 months as consultant geriatrician, and low risk inpatient obstetrics as clinical assistant – with a full list in general practice of about 1800 patients.
Continuity of care. Is this important?
I learnt as a busy London GP that, without continuity of contact, in a shared list of 11,000 people, that major life problems were often missed because an in-depth conversation had not occurred. Pressure on appointments and follow up was often not by the same doctor. It is very difficult to learn whether your diagnosis was right or appropriate if you are not followed up by the same doctor or health professional.
Have you had an experience where fragmented follow-up led to you receiving unnecessary treatment or a misdiagnosis?
NHS policy is now to offer a named GP of continuity for each older person over the age of 75 years. Does this happen in your experience? Do you think this is important and why?
I eventually started to keep a list of people, particularly with mental health problems, who I thought needed an in-depth review and appropriate treatment by a trained mental health professional. Difficulties for people related to conditions such as psychosexual problems, obsessive compulsive disorder, and stress-related work issues with anxiety and depression. I approached Prof Marks at The Maudsley and was fortunate enough to enable these people to work with a nurse practitioner in the practice for these patients with good effect.
I also learnt that trust and confidence build up over continuing contact and helped people respond to advice. As a practice we took part in Professor Russell’s pioneer research factors that aided stopping smoking. This was more likely to occur when the doctor connected patients presenting symptoms with the smoking habit. Advice to stop was then more likely to be followed. The percentage stopping increased when follow-up was agreed and took place.
Stress and unexplained symptoms: The impact of sustained stress
My key job as a primary care general practitioner was to diagnose disease in the early stages and treat appropriately. As a GP I needed to be an expert in the early symptoms of serious illness. However up to 50% of my consultations were with people living with life stressors and at the limit of their tolerance for the situation they were in. Each person I believe knows how their bodies and mind react when overloaded. If no disease I explained that symptoms of stress (distress) are real and are explainable because of disturbed physiology and the resulting body mind protest symptoms. There is a call for action triggered by the stress response.
For me this takes the form of fatigue, irritability, poor sleep and stiffness around the shoulders. My brain doesn’t work as well and there is a form of brain fog. I know I need to sleep and calm my wound up/uptight body mind state called hyperarousal. For me the remedy is do less, walk in nature, play tennis, enjoy my creative hobbies such as pottery, check my breathing so that I’m not breathing in my upper chest and practice 10 minutes of a slow breathing meditation each day (Dr David Beales Mindful Meditation). Take more time with partner and family. My enjoyment of life comes back and I have reset my protest symptoms with more calm, enjoyment and self-esteem.
My personal story of overload and poor performance – needing time off work one Christmas where I had looked after two terminally ill people, who died at home comfortably with full home support and care. The frequent home visits combined with a busy practice. In 26 years of medical practice I had not missed work before. I was emotionally overloaded because one of my patients had terminal breast cancer. Pattern matching to times of distress is often distressing. My own wife had died at home with breast cancer. I became overloaded and exhausted but soldiered on regardless of my own stress signals. A week after New Year I went down with a flu-like illness. I was profoundly fatigued. I knew I couldn’t work but had a policy with a medical insurance company cover for locums to cover for me during illness. My usual general practitioner was on holiday. When I explained my extreme fatigue and asked for a recovery period the locum put ‘fatigue’ on my sick certificate. When this diagnosis and certificate was received by the medical insurance company, they refused my locum cover. If depression had been written, rather than fatigue or in my predicament vital exhaustion, all would have been well. I was fortunate to know the CEO of the insurance company and when I explained my situation, he sanctioned my locums. I recovered completely in four weeks with prolonged sleep, walking in nature and eventually planting a hedge, quiet, music, and family and friends support.
Do you have stress symptoms when overloaded?
What do they prompt you to do?
Is it helpful to know them so you can take avoiding action?
Has your own intuition of what is needed to self-care, following a stress-related illness, been difficult to achieve? And why?
In my next general practice when I joined Dr Hugh Coleridge in Dyer Street – later called Phoenix surgery in Cirencester I/We were able to develop, as research and development lead, a full practice team. Each of the partners had a personal list to provide continuity of care. I began in my consultations to actively seek out symptoms that were stress-related. I explained that they were the body mind sensations and signals of overload. Underneath in response to threat the action arm of the sympathetic nervous system was too active without enough inner calm. The immune system changed to an inflammatory type (TH1 to TH2) and the hormonal system of cortisol production was too active or after prolonged stress underactive.
I offered a prolonged consultation of 30 minutes to see what the stress triggers were in their life. Sometimes this was enough to define what changes needed to be made. For more detailed support and insight I offered signposting to recovery programmes. Counselling, meditation to quieten the mind, stress management, art therapy, osteopathy, and acupuncture. These therapies were provided in the practice by the Phoenix Charitable Trust – (Cirencester and District) that I founded in 1991. It is still active. The charity also responds to urgent social needs. Stop gap provided aids such as special beds for home use where there was a delay in provision by the hospital and a delayed discharge. Initial start-up costs were provided by local businesses and the patient contributed to the cost of the service according to their means. The contribution is left to the individual, after being told what the service costs, the trust to provide. The trust receives approximately 70% of the cost for most of the services provided.
Further experience in mind body medicine
I left the NHS in 2000 because I did not wish to take part in the quality assurance framework, where my style of practice which is conversational and person centred I felt would not have been possible. I became chief medical officer at the Bristol Cancer Help Centre – now The Penny Brohn Centre.
I took a fuller training in mind-body/behavioural medicine and the physiology of sustained stress. I saw and reviewed case notes that included people who had made recoveries from disseminated cancer. I wrote the chapter on Science and the Holistic Approach in The Bristol Approach to Living with Cancer – a step-by-step guide to help you take control of your life and well-being (edited by Helen Cook and published by Robinson). I later became Medical Adviser to CNELM and taught PNIE (psycho- neuro- immune- endocrine studies) at the British School of Osteopathy. I became a tutor for the Whole Person Medicine course at Bristol University Medical School.
Within independent practice I gave numerous lectures and a full course for GPs on psychosomatic medicine with Confer and its director Jane Ryan.
My special interest became functional somatic disorders such as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, chronic pelvic pain, and the hyperventilation syndrome. I had published a further two books including Community Care of Older People with Alistair Tulloch and Michael Denman (Radcliffe) and in 2010 Emotional Healing for Dummies, with my partner Helen Whitten, published by Wiley.
The interweaving of life experience and medical practice
I am the eldest of four children and married aged 21 whilst still a medical student at Guy’s. My father was furious and said, ‘you will only become a general practitioner now’. The powerful pull of parental dis-approval led me through vital exhaustion, as I moved away from parental approval to what I loved, which is the specialism of general practice. In Cirencester I was finally able to practice personalised medicine where we all had personal lists. As research and development lead, I/we prioritised and added a full practice team. This included a psychologist as well as counselling, practice attached health visiting, obstetrics and attached midwife together with specialised elder care health visiting and district nursing. We grew from just over 2000 patients to over 10,000.
I founded the Phoenix Charitable Trust which created the vehicle for the relief of stress-related ill-health and social prescribing. Following a cooperative enquiry with Peter Reason in 1991 we added acupuncture and osteopathy within the surgery.
Whilst happy and fulfilled my first wife Rachael died of secondary breast cancer in 1988 – the conditioned was first diagnosed five years earlier. Our marriage had been blessed with four children. I now enjoy the emerging lives of seven grandchildren! Two failed marriages followed, where during the first, I became a battered husband, leading to the second marriage and sustained stress during the long illness of a loved one – now recovered. Ten years ago, I think now that I laid the foundation for Parkinson’s disease. I will blog separately about what I have discovered that might have led up to this condition. Ten years ago I also re-discovered my love for my partner Helen Whitten, now sharing our life in Kew.
In August 2017 I was diagnosed with Parkinson’s disease. This led me to discover not only a first-class research team with Sylvia and John Dobbs at Kings/Maudsley running the microbiota unit, but the influence of gut brain dysfunction in this disease. Treating a gut infection with Helicobacter pylori stabilised the condition with the ability to retain enjoyment of tennis, yoga, vigorous walking and a variety of hobbies has become a priority.
Passions and values
My passions and values were shaped by family, school and work: and evolved by observation within medicine, and within the confidence and trust of the doctor-patient relationship.
Medically unexplained and functional conditions explained
I saw how about 40-50% of presentations to us as general practitioners occurred, when people had moved beyond their limit of their tolerance and anxiety, to the situation they were in. I learnt how the PNIE system – psycho- neuro- immune- endocrine – became reactive, leaving the body mind spirit system out of balance, and producing symptoms of dis-stress.
Continuity and enough time – 10-minute routine appointments and two half-hour sessions a week – teased out these underlying life stories including prolonged stressors. Once symptoms of body mind stress could be attributed to these causes and disease excluded, signposting followed to support, counselling, stress management, complementary therapies such as osteopathy and acupuncture within the Phoenix Trust and elsewhere. My weekly consultation rate halved.
This integrated approach created the time to become a trainer, attend a Balint group, three years as a research associate for the Southwest region and six sessions of hospital practitioner work in elderly care and obstetrics. Tennis, pottery, family life thrived. As well as writing books and articles.
Anticipatory care and preventative medicine
Anticipatory care and preventative medicine are where my heart lies. I think so much waste of medicine, as time and money goes into spurious diagnosis and in treating medically unexplained and functional dis-ease. With colleagues Gina Johnson, Janice Benning, Helen Whitten and Julia MacDonald we are in the process of completing an online book that follows a protocol tried and tested with a grant from the National Institute of Health Research. We anticipate that the booklet will be launched in the spring of 2019. (Reclaim Health).
I also saw, through my hospital work, that timely comprehensive elderly care assessment (CGA), when symptoms of frailty develop, prevent dependency and hospital admission. Social support is paramount in old age as well and this led to Stay Well 75+ where our health visitor Liz Hicks worked with trained volunteers. We showed, in a randomised controlled trial, that those people with social support from trained volunteers, required four times less health visitor follow up than the control group. We developed a program that won Beacon award in three successive years. This led to a practice Stay Well 75+ coordinator and the birthday questionnaire that allowed practice to detect frailty sooner than it would otherwise do. This work was stimulated by Professor John Pathy and Dr Alistair Tulloch.
Whilst seconded for a year in 1995, to the Clinical Standards Advisory Group study on elderly care, I had seen how disconnected the needs of the patient were, in the fragmented budget driven system that developed from the 1990 Conservative health reforms. The Resulting purchaser provider split prevented joined up medical, functional and re-enablement care.
Politics and the NHS
I am concerned about the state of the NHS and the erosion of personal care and continuity. I think that offering comprehensive geriatric assessment, taking 30 minutes for medical functional and social review, as people show signs of frailty, is a necessity. It calls for trained general practitioners to take the lead in promoting good elderly care within their practices. As already mentioned, we pioneered at Phoenix the introduction of a birthday card reminder and review of physical emotional and functional health by a practice-based stay well 75+ coordinator. The paper Cause for Concern with Alistair Tulloch, published in the journal of the Royal College of general practitioners, summarises this approach.
I have learnt a great deal following my contact with the health service after the diagnosis of Parkinson’s Disease in August 2017.
I would like to share with you and hear your experiences of treatment within our National Health Service. Often good but sometimes failing when it comes to collaboration and information sharing.
How do we feedback what we as patients want and need including doing our part to speed recovery and sometimes acceptance of ill-health?
Please join with me in feeding back and following through with constructive suggestions, for improved care and support for each other?
Member of the Royal Colleges of GPs – MRCGP; Fellow of the Royal College of physicians FRCP and of the Royal Society of Medicine; Diplomas in Childcare (DCH); Obstetrics (DRCOG); Psychotherapy and Hypnosis (DPsych/Hyp).