Wellbeing for Real Life: what is resilience and how do we build it?

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I was recently asked to write a module on resilience for clients of a healthy lifestyle service provider. We had previously put together modules on anxiety, depression and stress management. The feedback that we were getting from some team members delivering the modules was that they found the subjects rather complex and difficult to discuss and there was a risk of ending up focussing on the negative. We therefore decided to simplify the modules, fuse them together where appropriate, and to take a more positive tone discussing fitness rather than illness. As I put the module together I was reminded that teaching something is a great way of learning something , and so thought I would share what I have learnt in the hope that it is useful to you.

Let’s start with some questions people commonly ask. What is resilience? Do I have it? How do I know? Can I measure it? If I don’t have it, can I get it, or improve it? How can I help my kids to have it?

Defining resilience

A very basic definition of resilience is the ability of a substance or object to spring back into shape after trauma. To make it more human, we could describe it as the ability to cope with setbacks, or the ability to overcome difficult experiences and to be shaped positively by them. It might be described very simplistically as physical or mental strength or fitness.

Resilient people are not just born, they can be made

As my wife pointed out to me during the writing of this post, anyone who has had a few children can tell you that we are all in different places on the scale of natural resilience. It’s undeniable. However, where we end up is not inevitable. Nurture has at least as important a role as nature. I used to be a bit daunted by the people in the weights section at the gym, heavily muscled and confident specimens stalking around the equipment as if they owned the place, occasionally grabbing hold of some colossal bits of metal and wrestling them into submission before grunting and moving on to the next unsuspecting piece of apparatus. This was until I realised that they hadn’t become like this spontaneously but had developed themselves over time, with regular practice and commitment and maybe some pain. I’ve heard physios encouraging people to keep doing their exercises, advising them that they should be aiming to stretch their muscles and cause them to ache because that’s the only way they will ever strengthen them. When you exercise, you need to get your heart rate up for it to do you some good, which isn’t always comfortable.

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So it’s good news for all of us, particularly if we are feeling life’s challenges. The route to resilience is adversity – getting through it, and learning from it. Machine parts are tested before they leave the factory, to ensure they are strong enough. In the same way that a person who never makes a mistake never learns anything, you can’t be resilient if you have never suffered any setbacks. I’m not suggesting you go seeking adversity, or deliberately make decisions that are likely to have a bad outcome, but its ok and indeed necessary to endure traumas to build resilience. In the same way however that an athlete would prepare to compete, there are of course things that we can do to prepare ourselves for life’s challenges.

My top tips for developing resilience, based on my own life and what I have learnt from others, include:

  1. Self nurture. Sleeping well, being physically active and eating a healthy varied diet will mean that we are physically and mentally in as good a place as possible to take on whatever comes our way each day. Relaxation is an important part of this too, setting aside some regular time that is just for you. That could include reading, listening to music or meditating.
  2. Good connections. With friends, family and other people that you have a shared interest with. Prioritise the positive relationships with people that encourage and support you, and who you can do the same for. Put dates in the diary to make sure it happens, or it won’t. If you have kids, make sure that they have positive, nurturing relationships in their life. These could be with friends, teachers, relatives, health care practitioners and of course…parents! It can be vital to be able to ask others for help when we feel we don’t have the strength for ourselves.
  3. Positive action. Take a positive attitude towards your abilities and encourage yourself, especially in difficult situations. Be assertive and open in your relationships, whether personal or professional. Set goals in the short, medium and long term and make a plan for how you are going to achieve them, breaking it down day by day and moment by moment if need be.
  4. Develop new skills and hobbies. You could learn a new language or take up an instrument. This is good for your brain, encourages further social networking and helps with practising delayed gratification. This is particularly important for children who have been born into this era of instant gratification and rarely having to wait for anything for any significant length of time.
  5. Learn from challenges. Whether it’s a mistake that you made, or something beyond your control that happened, take time to reflect on how it made you feel and what you can learn from it or do differently next time. If you have kids, it’s important to let them make decisions and live with the consequences. Obviously you have to pick and choose depending on the stakes for their immediate health and wellbeing. Resist being a helicopter parent. It’s understandable but rubbish preparation for life and not in your child’s long term interests. If you wrap them up in cotton wool, they will just break later in life when you may not be around to support and encourage them. Better to let them make mistakes at a younger age and be stronger and wiser for it.
  6. Practice gratitude. This is such a simple and yet profound thing to do. I would be willing to bet that if you are reading this blog you have at least one thing in your life to feel grateful for, no matter how bad today or this week or month has been. You can start with the very basic stuff (like being born!), narrow it down a bit (like living in a democratic society in here in the UK where you are allowed to express and practice your beliefs) and then focus on the more personal and specific things you are thankful for like the place where you live, your friends and family…maybe even your job!

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I hope you have found some of these tips helpful. Remember – we should not and cannot avoid adversity in life. It’s the route to resilience and can make us stronger.

The Weekly Wellbeing Round-Up #20: a miracle cure!

Good morning and welcome to another edition of the Weekly Wellbeing Round-Up.  This week I thought I would get your monday morning off to a great start by offering you…a miracle cure.  The ultimate tonic with guaranteed improvement to your health and wellbeing.  It has  been shown to improve physical and mental health and cognition as well as reducing the risk of cancer, heart disease, diabetes and other long-term conditions.  It works as well as if not better than many drugs and unlike drugs there are no side effects as long as it is taken in the appropriate dose.  Best of all, it’s free and available to every person on the planet.  You don’t need a prescription from a doctor, and you don’t need any special training or expensive kit.  You can start treating yourself with this wonder drug whenever and wherever you like.   I am, of course, referring to the medicine of movement: physical activity.  People are, I hope, used to health professionals banging on endlessly about this.  I thought it was worth reminding ourselves why  this is such an important issue, before we explore the benefits of it and then take a pragmatic approach to moving more.

The bad news about physical activity

Let’s start with looking at the scale of the challenge that we face in terms of physical activity being a part of our daily lives.   Once upon a time, it was.  We were hunter-gatherers, often chasing our prey over long distances.  If we sat still, we perished.   Nowadays, our day-to-day existence is much more sedentary.   We have enjoyed the benefits of tremendous technological advances and the associated convenience, but there are also tremendous downsides that are gradually becoming more and more apparent. The nearest we get to hunting our food may be tapping our password into our device when doing our online food shop from the couch.   Being inactive has roughly the same health risks as smoking 15 cigarettes a day and the overall risk of mortality due to inactivity may be double that of obesity. .  This is worth thinking about for a minute:  most people would clearly not choose to take up smoking, but by default we risk choosing inactivity.  The irony of all of this is that by sitting still we still perish (sooner) but for now for entirely different reasons.

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I used to think, a long time ago, that by default we were probably active enough and that to stay healthy all people needed to do was to avoid eating too much unhealthy food.   I have come to the realisation that this is nowhere near enough.  The default, the baseline that we operate from in today’s world, is not just inadequate but actually toxic.   In 1949, 34% of all journeys travelled by a mechanical mode were by bicycle.  Nowadays it’s less than 2%.  The design of our homes and our cities, our patterns of working, our use of technology and all the associated infrastructure have all contributed unwittingly to the making us less physically active. The consequence of all of this is that almost half of adults over 65 years of age are inactive, and most working adults spend at least 5 hours of their day entirely sedentary.   To overcome this requires thought, planning and effort.

The good news about physical activity

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Before you sink into despondency,  there is good news.  These problems did not appear overnight with a bang.  A lot of it has been incremental.   The good news is therefore that we can take the same approach to addressing the balance.  Let’s leave aside the need to lobby government about how we build communities and transport links in future, how we make cities safe for cycling and encourage working lives that are more physically active.  These things are important but you and I can’t do anything about them right now, whereas there are other changes that you can start with today to help you and, if you are a medical professional, your patients.

My top tips for physical activity

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  1. Make the first few steps.  The really good news about becoming more physically active is that the greatest reduction in risk of cardiovascular disease (heart attacks, stroke and diabetes) occurs in those who go from being completely inactive to mildly active.   If you break into a sweat at the thought of breaking into a sweat and are put off by images in your head of lycra-clad latte-sipping gym bunnies in a spinning class or ex-military personnel with personality disorders barking instructions to groups of miserable looking people dragging mud-covered tractor tires across the park in the rain – never fear.  The journey of a thousand miles literally begins with a single step.  If you don’t do anything that gets your heart rate up at present, try starting with just 5 minutes a day of brisk walking round your garden or down the street and back.  All you need are shoes on your feet.   Public Health England have a nice app which you can download onto your smartphone called Active 10.   You can get it for iOS devices from the app store, or for android devices from Google Play.
  2. Make it rational, routine and relevant.  For us to face the challenges of inactivity individually and collectively, it’s only going to work if physical activity becomes a simple, meaningful and sustainable part of our lives.   If a gym subscription works for you because you will feel motivated by parting with your hard-earned cash, you like the idea of being able to work out in all weathers and at any time of day, or you just like sitting in the cafe and chatting afterwards, then great.   If you have a dog, make the walks a bit longer and for part of each walk push yourself a bit harder to get your heart rate up.   If you don’t have a dog, think about getting one.  They provide people with company, keep their owners fitter than non-dog walkers, and encourage socialisation.  I love chatting with other dog walkers when I’m out and about.   If your job involves walking, whether it be commuting or delivering the post, use the opportunity to do likewise.  Try getting off the bus, tube or train a stop or two earlier.   Use the stairs at work rather than the lift.  Consider getting a standing desk.  You could suggest standing or walking meetings when appropriate – just think how much quicker they would go without people distracted by their laptops and phones!  T4YactPmS1KcJ4xRvSwLCA
  3. Make a plan.  I posted about this a few weeks ago.  Whatever you do, plan how it’s going to happen.  In my personal experience, if I don’t make a plan then nothing changes.  Once you have a regular slot and you’ve done it often enough then it becomes a habit and so more likely to stick. mdHKUVBWR9yqCTjy2IjpKQ
  4. Make it social.  Behaviour change is more likely to occur if it is socialised.  Taking part in physical activity with others is beneficial for a number of reasons.  Firstly most of us are social animals to one degree or another, so it’s a good way of connecting for our mental wellbeing.  Secondly, we are in effect making ourselves accountable to others or even allowing them to be our “referee”.  Your friend/spouse/cycling club/fellow dog walkers will encourage and check up on you.   If you aren’t sure what you would like to do, check out what information is available from your local council, community centre, library or GP surgery.  QMt5W8BPQq2F68v5UBFttg5. Make it pleasurable.  Pick something that you enjoy.  Don’t think of it as “exercise”, which sounds like something you have been told to do and probably won’t enjoy.  Instead think of it as something that gives you pleasure, makes you feel good and helps you connect with others.  Just getting out of the house and enjoying some fresh air and daylight is good for your wellbeing.  Two of my most favourite things are going for a bike ride on a sunday morning with my friend Al and taking my dog Prince for walk in the afternoon.The fact that the my sunday morning bike ride includes breakfast and a cuppa and that my afternoon walk involves a pint in my local is not a coincidence and a great example of “temptation bundling” – having a reward which is associated with a specific activity.

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Real life examples of the benefits of physical activity

I thought I would finish with two stories from this week.  The first was from a patient that I reviewed as part of teaching our medical students about mental health.  They had seen one of my colleagues previously with a longstanding history of depression.  They were physically inactive and presenting with a lot of physical symptoms which were really manifestations of how they felt in themselves.   They had been consulting about these physical symptoms frequently and eventually were persuaded by my colleague that the root cause of their symptoms was their depression.  They were encouraged to start being more physically active.  When I reviewed them with our medical students, they were transformed.   I asked them what they felt the reason was for the improvement and they told me that they had started to walk every day for half an hour, either in the park or up and down in their garden.  Their mood was better.  They had more energy, were sleeping better and were much less bothered by the occasional aches and pains that previously had preoccupied them.  They also had a much better understanding of how their mood might influence physical symptoms as a result.

The other story I really enjoyed listening to this week was that of Vassos Alexander, sports presenter, formerly of Radio 5 Live and now Virgin radio.   He was interviewed by Dr Rangan Chatterjee in Episode 31 of the Feel Better Live More podcast.  He described himself as being overweight, unfit and a smoker in his early 30’s.  He decided he wanted to make some changes.  He decided to go for a run.  His first run lasted just a few minutes.  He describes being out of breath and having to pretend to some of his neighbours that he had just finished a run, to avoid embarrassment.  Vassos didn’t give up, however.   To cut a long story short,  in 2017 he completed the Spartathlon, an endurance event run over 153 miles.  His enthusiasm for running, it’s benefits and his encouraging other people just to get out there and do something is infectious.  Well worth a listen.

We’re almost done.  I wanted to finish off with something to challenge and encourage you, your family,  friends or patients.  There is a great video available on YouTube called “Twenty three and a half hours“.  It’s got a fantastic punch line at the end and is well worth 5 minutes of your time.

That’s it for this week.  I hope that you have found this week’s wellbeing round-up helpful.  As ever, I would appreciate your feedback and you sharing it with others if you have enjoyed it.  You can subscribe to the blog to automatically receive email updates in future.  Until next week, take care of yourselves!

Dr Richard Pile.

 

 

The Weekly Wellbeing Round-Up #18: a weekend of wellbeing in Valencia.

When I was a medical student our favourite lecturer was Dr Andy Sparrow. Not because of his subject (which was anatomy) but because at random points throughout his slides he would show us pictures of his holidays – a bit of light relief in the midst of gruesome detail.

I am currently at around 30,000 feet as I write this blog post , returning from a weekend in Valencia with my friends. We are all part of a GP learning set and this was the group’s 19th annual trip. It’s been a great weekend in a fantastic city that I will definitely return to.

During our time away we each prepare a topic to discuss. We do these throughout the weekend, combining continuing professional development with eating, moving, (some) sleeping and plenty of relaxing. My topic this year was Lifestyle Medicine and Wellbeing. I shared my journey thus far and how learning about the importance of this has transformed how I feel about my job and purpose. We discussed models of wellbeing including the four pillars that I have already mentioned.  I had recommended to the group that we try to all read Dr Rangan Chatterjee’s Four Pillar Plan before the trip. We also added another pillar: connection. So for this week’s blog I hope you will indulge me as I share some of our experience how it relates to wellbeing for real life. With a few holiday snaps thrown in.

Eat

One of the pleasures of the trip is finding nice places to eat good food. We like to go on local recommendation, backed up by Trip Advisor. The highlight for me this year was a day spent on a farm learning how to make proper valencian paella and sangria. It was of course terribly gruelling but we did end up with a certificate which I will show to my appraiser next year. Learning about the origin of the dish and what the correct ingredients are (apparently if there’s sea food or chorizo in it then it’s not paella, just rice with things in it) was interesting but the best part was how paella is served up and eaten. First of all everyone makes a point of thanking the cook (whether it tastes good or not!) and then everyone sits round the table with a spoon (not a fork) and eats from their segment of the paella dish. If you want a bit in someone else’s segment you negotiate for it. You can put bits you don’t want in the centre for anyone to take. And you never, ever turn the dish round to take something you want, not unless you enjoy getting stabbed in the hand with a fork by one of your neighbours.

Connect

What struck me is how important this is for a key pillar of wellbeing: connection. The food is cooked from local, seasonal ingredients. The meal is communal. Everyone shows their gratitude. Food is shared together over what will doubtless be good conversation, helped perhaps by a little sangria. It was a wonderful experience that our hosts were very happy to share with us, and send us away as paella ambassadors! Interestingly, the valencians consider paella to be a dish that you only eat at lunch, and as it can be quite heavy then they enjoy their siesta afterwards and tend to have a light evening meal around 10pm, often with tapas dishes. In Valencia, anyone eating paella for dinner is definitely a tourist.

Sleep

In the interests of full disclosure, sleep was a bit of a mixed bag. There is time-stamped photographic evidence on our WhatsApp group of some deep and meaningful discussions taking place in a bar in the early hours of friday morning. However, we were quite sensible for the other nights. What is always striking when going to Spain is the siesta. In his book Why We Sleep, Matt Walker explains how we naturally have a biphasic sleep pattern as humans (i.e. we do best if we sleep twice a day) and so to have a siesta is consistent with this. In the UK we have forced a monophasic sleep pattern on ourselves with a masochistic long working day…which results in less productivity, not more. When Greeks stopped their siesta at the height of the financial crisis, cardiovascular deaths increased significantly as a result. We also get a surge in these events when the clocks go forward and we lose an hour’s sleep every year. The EU will stop the twice yearly changing of the clocks in 2019. It will be interesting to see if population health benefits can be demonstrated. After Brexit (the only topic we banned for the whole weekend) the UK could be the control arm of this large-scale population experiment!

Move

Walking from cafe to bar to restaurant was, as you can imagine, absolutely exhausting. Somehow we managed. We did take in the sights as well, hitting 10,000 steps most days. There are beautiful museums, markets and churches in Valencia

Having to walk up and down four flights of stairs due to a broken lift was very helpful in this respect. We must write a note of thanks to the hotel. On our last morning I went for a run with my friend through the park that runs along a dry river bed in Valencia. It’s a lovely setting and despite being early it was practically rush hour with the locals in running clubs, walking dogs and riding their bikes…Valencia’s equivalent of Park Run. Running with someone who is a better runner than me really helped me go further and faster than I would normally. I made a point of thanking them for this through only slightly gritted teeth. Incidentally, did you know that Park Run is a global thing? Apparently some people do the Park Run Alphabet challenge finding cities all round the world where it takes place. It takes place in both Mile End and Milan. I suspect the starting letter and hosting Park Run are the only thing they have in common. There’s also a UK version.

Relax

We are not usually short on relaxation during one of our trips. The key idea that underpins very trip is the idea of “me time”…that as human beings we all need and deserve some me time. Our group is very fortunate in being able to do this for a whole weekend once a year. What was interesting is that sitting round the dinner table and talking about which pillars we find easier and which we need to work on, the commonest area for improvement was in relaxing. One of our group described their child had complaining to them that they couldn’t sit in their lap if there was a lap top already there.

It’s great to have an opportunity like this once a year, but probably more important, if you had to choose, to have five minutes every day. We talked about what we found relaxing: reading, listening to music, walking the dog, eating a meal as a family or watching our favourite TV show with them. We discussed practising mindfulness, being present and limiting screen time and I showed some of our group how to use Do Not Disturb and night-shift functions on their phones, before we finally turned in for the night.

By the time this post is published I will be at my desk in the surgery on a cold, busy monday morning. I will feel a bit sad that our trip is over for another year. However, I have got more CPD points for my appraisal, a new background photo on my desktop, more fond memories to add to the nineteen year collection, and a date already in the diary for next year.

Thank you for allowing me to share this with you. I hope that making it personal has been useful. Like James Bond, the weekly Wellbeing round-up will return. Until next week, take care of yourselves!

Dr Richard Pile

The Weekly Wellbeing Round-Up #15: making a plan to improve your wellbeing.

When I first became a GP, I decided that many of my patients who needed to make lifestyle changes also had undiagnosed conditions that resulted in problems with their understanding,  memory and planning processes.  There must be something wrong with them, so my reasoning went, because they left my consulting room chastened by me about their lifestyle choices,  concerned about their impending doom, and clearly intent on turning their lives around….but when I saw them again they hadn’t done anything.   In fact, some of them were even more unhealthy than before.   Some cases stood out, like the man who was still popping out for fag breaks in between ward rounds on the coronary care unit after he’d had his heart attack.  Or the elderly lady with furred up arteries in her legs who looked me straight in the eye and told me that she was more scared by the thought of life without cigarettes than she was by the below knee amputation that she was heading relentlessly towards.   Surely the only explanation was stupidity or a death wish?  Or so I thought.

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Years have gone by and I have learnt a lot about people, which is an inevitable and highly desirable side effect of working in primary care.  I have spent time talking these things through with patients.  I have read round the subject of behavioural psychology (I highly recommend Nudge, Inside the Nudge Unit, and Think Small for a good grounding in this area), met with people from the Nudge Unit (or Behavioural Insights team, to give them their proper name)  and spent time discussing these issues with psychologists and other colleagues.   At Thrive Tribe, we are working with the Centre for Behavioural Change to ensure that all our practitioners are appropriately skilled in this area to help their clients, offering a service that is more than just education about giving up smoking or losing weight.

For the purpose of today’s blog post, I am going to share with you a small but important part of what I have learnt over the years.  It’s not very clever or surprising.   Neither is it difficult.  Everyone can do it.  It’s about having a plan.

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Why do we need a plan?

Humans are not rational creatures.  We assume that because we have been well in the past we will be so in the future.  We cleverly avoid joining the dots with all that we know about what is likely to happen as we get older.  We know that there are theoretical risks of things happening, like heart attacks and cancer and road accidents, but we assume that somehow we as individuals are exempt from this risk,  unlike everybody else in the world around us.   I’m sure you can see the potential flaws in this reasoning.  When things unravel, they can unravel quickly.  Even when things are not yet seriously unravelling health-wise, people are often still aware of their wellbeing issues.  When people fail to make changes that are needed, it isn’t because they don’t know what to do.  It’s beause they either don’t know how to do it, or they do know how to but have no plan in place to make it happen.   I know that I would like to catch up with my brother for breakfast over the next few weeks.  I also know based on the endless games of message-tag we play that via text, facebook messenger, what’s app and email unless we actually make a plan, it will  never happen.   It’s better to have a plan.  It could be written on paper, or stored electronically – just as long as you can refer to it and review it whenever you need.

Do wellbeing plans work?

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Plans are not foolproof.  Otherwise we wouldn’t refer to the best-laid ones or talk what the road to hell is paved with.  They do, however, increase our chances of making and sustaining the changes that we want to.   There are various reasons for this.

Accepting the need to make changes

Firstly, making a plan to change means that we have generally (perhaps grudgingly!) accepted that there is a change that needs to be made.  Maybe you’ve been along to see your GP, practice nurse or health care assistant and a few issues have been raised that you concede might be worth a look at – that weight you’ve been meaning to lose for years, your need to quit smoking or reduce your drinking because of the effect it’s having on your health,  or perhaps your worries about getting a bit fitter as you move into middle age.

Being specific about the changes

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Vague plans are not much good.  “I will lose weight/eat fewer biscuits/do more exercise” might work for a small minority, but for more people it will never translate into anything.  Why? Because they have leapt straight to the desired outcome and are too vague.  We need to be clear about what we are going differently that will result in those outcomes.   Each step in the process needs to be considered, broken down into even smaller steps if required, to see how realistic it is and what needs to be done in what order.  A plan makes it easier to achieve than a one-off mental note to self or vague intention.

A plan makes us accountable for the changes

If we have a plan, it means that we are accountable.  Not just to ourselves, which helps a bit, but potentially to others, which significantly increases our chances of success. Letting other people know what you are doing and even asking one or more of them to be a referee and hold you accountable means you are more likely to follow through.

A plan helps us to measure success as well as failure

If we have been specific in terms of what we want to achieve, how we will achieve it and how we will measure our success, then this will help us by encouraging us when we achieve what we have planned (which increases the chances of making further changes and sustaining what we have already done) as well as maybe challenging us with the areas where it hasn’t quite worked out yet.   The plan can always be changed when we learn as we go.   Putting rewards into the plan for when we achieve each stage of success can be quite motivating as well.

My top tips for making your wellbeing plan

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  1. Make it for yourself and only if you really mean it.  Not to make your GP happy.  If you’re not ready to make changes, let them down gently as early as possible and perhaps keep an open mind for the next time you have a wellbeing conversation.
  2. Make it simple.  The more complicated it gets, the more likely you are not to achieve bits of it, which can be disheartening.  Better to have simple success and build on it.
  3. Make it specific.  Losing weight might be the overall desired outcome, but break it down into smaller chunks e.g. cycling or walking to work, cutting out snacks, shopping for and preparing more of your own meals, not eating after a certain time of day.
  4. Make it achievable.  If you are inactive at present and break into a sweat at the thought of breaking into a sweat,  don’t aim for 150 mins of exercise a week from the outset.  Start with 5-10 mins a day every other day.  If you want to learn about mindfulness, start with 5 minutes a day on your smartphone app or just spend the time reading a book or listening to music.  I know a lot of people who say “I tried that” by which they mean they gave it a go a couple of times and gave up because it was too difficult or not immediately rewarding.  Changes are more likely to be made if they are easy, accessible, social and timely.
  5. Make it rational.  Think about what changes you can implement that are compatible with every day life and easy to sustain.  It needn’t involve hours of your time every day or expensive kit, diet plans or gym memberships.  It could be walking more briskly to the shops or whilst out with your dog, taking the stairs at work or working in the garden.
  6. Make it measurable.  It might be weight lost, minutes of activity completed, amount of sleep you have obtained or personal goals achieved (e.g. taking part in a social activity with your friends or playing football with your children or grandchildren)
  7. Make yourself accountable.  Tell people what you are doing e.g. work colleagues, friends and family, social media groups.  Consider asking someone to be a referee who will check in with you regularly.  Some people might ask their spouse.  Some might prefer a friend or colleague depending on how much they enjoy being nagged!
  8.  Make it a work in progress.  Your objectives are likely to change over time.  You will succeed in some areas and maybe not others.  That might simply mean not giving up and then trying again, or it might mean learning from what has worked well and not so well, and coming up with a better plan for the future.

Wellbeing planning in the real world.

I thought I would finished with some real life examples.

  1. Last year, all the GP practices in my area took part in a local Cardiac Prehab scheme which I had designed with some of my colleagues for our CCG.  Part of the service included identifying patients at higher risk of having a heart attack, stroke or developing diabetes and inviting them to an educational event at their GP practice.  The evening included a presentation on wellbeing and finished with each patient signing up to their own personal wellbeing plan.   These plans were collected and scanned into each patient’s records.  When they were reviewed a few months later, the doctor or nurse they saw reviewed their plans with them and discussed what had worked well or not so well.  The majority of the patients I reviewed had achieved at least one of their intended outcomes and were really pleased to see how well they had done, which encouraged them further.  This year the scheme has been rolled out across our entire clinical commissioning group, with a patient population of over 600,000 people.
  2. Those of you that are kind/enlightened/fortunate enough (delete as applicable) to read my blog posts regularly will know that I talk a lot about Rangan Chatterjee’s Four Pillar Plan.  Inspired by this, I have started to develop a welbeing plan template for EMIS (our computer system) which is based on this.  I have shared it with my practice colleagues and am now using it to enter data into the patient’s record and give them a printed copy after our consultation, so they have something to remind them of what we have agreed and to document their progress. Rangan Chatterjee and Ayan Panja did an excellent presentation on Prescribing Lifestyle Medicine at last week’s Emis National User Group conference at which they showcased an early version of their own lifestyle medicine template which is currently in development and  which will no doubt be snazzier than mine when it’s finished!

And finally, my own personal wellbeing plan

It is only right, of course, that I practice what I preach.  For years I have meant to lose a bit of weight.  For years I have surveyed my profile in the mirror in the morning, disappointed in myself for not having achieved anything and disappointed in the Six-Pack Fairy for not having visited overnight as I had hoped.  So in the end, I made a plan.  This included eating a lower carb diet (specifically changes to what I make for breakfast, making salads for lunch and cutting back on biscuits), exercising more regularly (getting up early to walk before work, doing HIIT workouts when I didn’t have time to ride or run), and doing press-ups as strengthening exercises each morning).   I am also much better at getting enough sleep, although there is always room for improvement.  I told my wife about this as I knew full well she would remind me if/when I lost track.   The results?  I have lost just over half a stone without feeling that I am depriving myself.   I feel fitter and have more energy.  I still don’t have a six pack and have decided that I was probably born without one, so maybe I will leave that out of the next version of the plan.

That’s all for this week from me.  Weekly Wellbeing Round Up #10 will be out next week.

Please do make a comment on the blog if you have enjoyed it, if you feel it could be improved, or to suggest future topics for me to work on.  I want to make it as useful as possible for all of you.  Please feel free to share the blog with your friends/colleagues/pateints/family members and sign up to it to receive updates automatically if you haven’t already.

Until next week, take care of yourself!

Dr Richard Pile

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The Weekly Wellbeing Round-Up #14

Welcome back to the Weekly Wellbeing Round Up.  We’ve taken a couple of weeks off to focus on the low down on low carb diets, and digital wellbeing.  I’m pleased to say that this week normal service is resumed.   Topics for today include calorie counts in menus,veganism, probiotics, the cost of eating health food, heart age and heart disease.  Let’s tuck in….

Counting the cost of counting calories

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The department of health and social care is to launch a consultation on its plans to require calorie counts on menus as part of its childhood obesity strategy.  The BBC reported this week that concerns had been raised by the treasury about the cost to small businesses, and the risk of distressing people with eating disorders. recommended this week that.   Whilst I have sympathy for both potentially affected groups, I think we should ask ourselves what our priorities should be for the health of our nation and particularly our nation’s children.  I seriously doubt that my local greasy spoon cafe will go out of business because they have to work out the calories in their full english breakfast.

Is being vegan good for your health?

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The BBC reported this week on the experience of Dr Giles Yeo going vegan for a month, in an episode of Trust Me I’m A Doctor.  During his trial, Giles lost weight, reduced his body fat and his cholesterol.  He required dietary advice to avoid becoming deficient in certain nutrients such as iron, vitamins B &D, omega 3 fatty acids, calcium, iodine and protein.  Some of this can be sourced from plants, but some probably requires supplementation.

This meta-analysis found that people on a vegetarian (including vegan) diet had an overall descreased risk of dying from heart disease and cancer but that there was no overall decrease in cardiovascular deaths or all cause mortality compared to non-vegetarians.

Take home message?  You might be slightly less likely to die of heart disease and cancer but overall vegetarians don’t live longer.  It is sensible to consider going meat free for some of your meals each week…maybe replacing them with oily fish.  Whilst my quality of life might be improved in some respects, I could no longer have a sausage, egg & bacon bap with my buddy Al on a sunday morning after our bike ride.  That would be a No then.

Children in food poverty

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On a more serious note, the Food Foundation issued a report stating that “a healthy diet is beyond the reach of 3.7 million children in the UK“.  It’s a shocking statistic.  There isn’t an easy answer to this one.  It’s easy to glibly state that an apple costs less than a mars bar (which is generally true, in fairness), but it is a fact that crap food is cheap, and good food either costs more or (and I think this is part of the problem) takes more time and knowledge to prepare.

The answer for me has to be pragmatic.  Whilst influencing national policy and financial instruments is beyond the ability of most of us, we can take simple steps to improve the situation even if we can’t achieve perfection.  There are plenty of books and websites out there about cooking on a budget.  Some examples include:

BBC Good Food Seven Days of Cheap Healthy Meals

Jamie Oliver’s cheap and cheerful recipes

Jack Monroe’s Cooking On A Bootstrap

Some providers of lifestyle services including cooking lessons, not just lectures about healthy eating.   If you really want to be challenged and inspired in this area, I heartily recommend Dr Rangan Chatterjee’s interview with Jamie Oliver in Episode 16  of his Feel Better Live More podcast.   Jamie’s passion for this subject shines through.  I particularly like his ideas about using his recipes like a jukebox for types of meal and associated costs, to come out with some realistic options for families struggling in this area.   If you are a health professional talking to a family about this, just remember that even if they eat one or two healthier family meals per week, and their kids have maybe one or two healthier lunches at school, that is making a difference and it’s a start.

Probiotics…the sage continues.

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Finally  for our food section this week, the BBC reported on this study in the journal Cell which reported on the use of probiotics and whether they have a meaningful impact on our gut flora.  It’s a very long paper and to summarise very simply…they don’t have much effect if taken in a one-size fits all approach.  If you think about it logically, introducing a tiny amount of unsuspecting friendly bacteria into a person’s entire gut flora or “microbiome” is going to have very little impact in terms of relative numbers.

Take home message?  Our understanding of the gut microbiome is still at a very basic stage and there is very little available to us so far in terms of evidence that has immediate practical applications.  In the future we will look back and realise how little we knew.  Probiotics might work better if it is possible to take a personalised, individual approach to treatment.  For now, if a patient asks me whether they should take some “friendly bacteria”, I advise them that they won’t do any harm but in the average person they won’t do much good either.

Physical Activity

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The World Health Organisation has recently produced a report on global levels of activity.  It was a self reported study based in 168 countries with 1.9 million participants from 2001 to 2016.   The BMJ reported on the findings this week.  Sufficient activity was defined as 150 mins of moderate intensity activity per week.  36% of UK adults were insufficiently active, with Kuwait winning the wooden spoon at a whopping 67%.  Women were generally less active than men.   Inactivity was a worse problem in high income activities.  Over the study period, levels of physical activity did not rise.  The solutions are large scale and up to governments when it comes to decisions about transport and infrastructure etc.  Personally, I think 36% of UK adults being insufficiently active is a massive under-estimate and a reflection of a lot of people kidding themselves when they filled int the report.  My take home message is that health professionals should bear this in mind and drill down a bit more into a person’s history when asking about how active they are.  Physical activity is a miracle cure, a wonder drug.   If you haven’t seen it, I recommend you take five minutes to view Twenty Three and a Half Hours on YouTube.  It ends with an excellent challenge that puts all our excuses about physical activity into perspective.

My dog Prince has offered to be share, with anyone who wants to know, how he feels about exercise.  All you need to do is to come round to our house, look him in the eyes and ask him if he would like a walk.   You may wish to consider wearing body armour with an anti-slobber coating for this exercise.  Don’t say I didn’t warn you.  Here is the presentation he has put together.

Heart health and disease

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In a collaboration between Public Health England have released a Heart Age online tool that allows you to calculate what your heart age is compared to your actual age.  When it comes to risk, people often struggle to get their heads around risk scores as percentages over a number of years and scoring tools are increasingly calculating the age of the relevant organs in your body (heart, brain, lungs) as it is felt that this is a more powerful motivator for people to make changes.   You can take the test online.   If your heart appears to be significantly older (according to Public Health England!) then you actually are, it may be worth booking a phone call with your GP to talk things through.  If you haven’t already done so and are between the ages of 40 and 74, I recommend you take up the offer of a free NHS health check.

Lifestyle Medicine

As a new user of EMIS (a GP computer system), I attended the national user group conference in Birmingham this year.   It was a great event and both I and the rest of my surgery team learnt a lot and came away with loads of ideas for how we can provide better and more efficient care for our patients.  One of the highlights of the conference was the Lifestyle Medicine presentation by Dr Rangan Chatterjee and Dr Ayan Panja. Excellent, inspiring stuff.  The real time roleplay between Rangan and Ayan of a GP consulting with a stressed, sleep deprived patient was particularly good and could have taken place in any GP surgery in the land.  I was able to catch up with both of them afterwards and we talked about the difference that this approach can make to our lives as patients and healthcare professionals.  I have already seen a positive impact on the lives of some of my patients.   I am definitely going to sign up for their highly rated, RCGP-approved Prescribing Lifestyle Medicine course in January 2019.  If you can’t wait that long, I recommend you get a copy of Rangan’s Four Pillar Plan in the meantime.  I recommend it to all my patients who need to make changes in their life, as it has helped me to make changes in my mine.

That’s it for this week.  I hope you have enjoyed the blog.  Your comments and feedback would be really helpful.  If there are particular topics you would like me to cover, please let me know and I will do my best to keep it real.    Until next week, take care of yourself!

Dr Richard Pile

The Weekly Wellbeing Round-Up #6

Welcome back to the Weekly Wellbeing Round Up!   I hope you have had a good weekend, enjoying the weather and the world cup final.  Having overcome the disappointment of England not getting to the final,  I made the decision not to watch the entirely meaningless 3rd/4th place playoff , and so missed watching England lose to Belgium (again)…which was probably much better for my overall wellbeing!  Let’s start off today with…

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Cardiovascular disease 

Today instead of watching the final, I spent the afternoon with my wife.  This is partly because I am a very caring and considerate husband (hopefully she won’t read this or at least will have the good grace not to contradict me in the comments) but also because I am an evidence based husband as well and had read this systematic review and meta-analysis in Heart concerning marital status and the risk of cardiovascular disease (subscription required for full article).  Being married was associated with a decreased rate of death from heart disease and stroke.  Being divorced was associated with increased CHD mortality, being widowed with increased risk of stroke, and never being married with an increase in mortality in the event of a heart attack.  The article points out the obvious that association does not mean causation, but does raise the idea that marital status could be considered as part of CVD risk calculation in future.  I have shared this with my wife.  She says she needs more evidence before she is convinced.

Whilst I would like to spend all my time helping patients not to get premature cardiovascular disease (such as heart attacks and strokes), clearly a part of a GP’s workload is helping people who have developed it look after themselves as well as possible.  Again, I like to focus on lifestyle measures such as food, physical activity and sleep but inevitably most if not all people in this situation will also be taking a number of medications to reduce the risk of their conditions worsening.  The world health organisation stats for adherence or compliance (i.e. people taking their tablets as prescribed) are truly shocking.  Take for example hypertension or raised blood pressure:  it is estimated that only half of people diagnosed with hypertension are taking their meds regularly (80% or more of the time) within a year of being diagnosed.  Clearly I must have the best patients in the world, because they all look me in the eye and reassure me that they take their drugs every day.  But for doctors out there whose patients are not as well behaved, this systematic review, also published in Heart, may make useful reading.  Three interventions were found to improve adherence and clinical outcomes:  SMS (text) reminders to take medication, a fixed dose combination pill (interesting to consider as these drugs may be more expensive and less flexible in dosing but if the outcomes are better maybe doctors should be prescribing more of them) and a community health worker-based intervention.  It is worth noting that these demonstrated relatively short term improvements so we need longer term outcome data to confirm this.

Instead of talking about cardiovascular risk, the focus of this article is about calculating Cardiovascular Health.  CVH is a concept developed by the American Heart Association.  It takes into account 4 ideal health behaviours: non-smoking, body mass index < 25, regular physical activity and adopting a healthy diet.  It also factors in cholesterol, blood pressure and blood sugar level.   It has been suggested that CVH could be a proxy for wellbeing.  Of course that leaves the question as to what comes first..wellbeing or health.?   What are the practical implications of this for me?  The next time that a patient comes into my consulting room and says that they would just like a bit of an MOT, this is perhaps where I could start, rather than asking them a lot of questions about their bodily functions and sending them off for a load of blood tests.

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Hypertension

Speaking rather less positively about the American Heart Association, I was deeply troubled by their suggestions about changing the threshold for diagnosing and treating hypertension.  The guidelines suggest that a blood pressure of greater than 120 (systolic) and/or 80 (diastolic) should be considered “elevated”.   This would result in a huge increase in numbers of patients diagnosed with a disease and then potentially medicalised by offering them drugs…with the associated risks of this.  The author of this article in the BMJ estimates that this would result in half of the adult population over 45 being diagnosed with hypertension.  My view?  Utterly bonkers.  We should be sticking to identifying people who already have undiagnosed hypertension (>140/90, as defined by the European Society of Cardiology), giving appropriate lifestyle advice as first line management where appropriate, and offering a personalised approach to risk reduction based on an individual person’s risk factors.  I would be very interested to learn more about the individuals and organisations who had input into the AHA guidelines, and where they might have potential conflicts of interest…big pharma, anyone?

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Food 

The low carb debate continues and I for one am more than a bit fed up of the unedifying content and behaviours on social media, particularly twitter.  Yes, it may well be that it’s hard to prove that there is something intrinsically good about eating a diet low in carbohydrates because it is almost inevitably associated with also reducing calories, but then again this is a food group that, plant based carbohydrates aside, we have largely manufactured for ourselves (often with a lot of processing involved) has very little if any nutritional value, and the increased consumption of which (particularly in the US) has been associated with sky rocketing obesity levels.   So its nice to see this article in the BMJ on the role of carbohydrates , quality and quantity, in chronic disease.  It takes a  fairly measured approach to the subject.  It’s well worth a read as it’s too detailed to really summarise, but the key messages are:

  • Human populations have thrived on diets with widely varying carbohydrate content
  • Carbohydrate quality has a major influence on risk for numerous chronic diseases
  • Replacing processed carbohydrates with unprocessed carbohydrates or healthy fats would greatly benefit public health
  • The benefit of replacing fructose containing sugars with other processed carbohydrates is unclear
  • People with severe insulin resistance or diabetes may benefit from reduction of total carbohydrate intake

My view on this is that there might be a number of reasons why a lower carbohydrate diet is of potential benefit for some patients, but really…who cares if the end result is better health outcomes and wellbeing?  It’s particularly worth considering in people who are diabetic, pre-diabetic, or need to lose a significant amount of weight…especially if they have struggled with weight loss in the past.

Staying with diabetes and pre-diabetes, this Cochrane review found that  in order to delay or to prevent the onset of Type 2 Diabetes, there wasn’t sufficient evidence in the meta analysis it carried out for diet or physical activity alone…but both combined together produced results.   Patients who have been told by their doctors that they are pre-diabetic should have be advised accordingly.  I used to talk mainly to patients about their diet and weight loss and say that physical activity didn’t contribute particularly to the latter…but we now know that physical activity is protective in itself and has favourable effects on the way that your body deals with both sugar and cholesterol.  The greatest benefits in reducing the risk of disease and death are seen in patients who go from being inactive to moderately active.   It doesn’t require a gym membership, donning lycra, or dragging a tyre round your local park whilst someone in combat fatigues with anger management issues barks instructions at you.   Just ten minutes a day of heart raising exercise, such as brisk walking, is enough to get you going in the right direction.

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Sleep

Last week I confessed that sleep is one of the areas of my life that I have struggled with.  Not because I can’t get to sleep but because I choose not to get what I really need.  I have done better this last week, inspired by having started to read Why We Sleep by Matthew Walker.  My favourite podcast this week has therefore been Episode 26 (Part 1) of Feel Better Live More podcast by Dr Rangan Chatterjee, who interviews Professor Walker, on this subject.     There’s a quote early on in the book which makes the point (and I’m paraphrasing) that if sleep does not serve a purpose and yet almost all animals spend a third of their life in this state, then it’s the biggest mistake that the evolutionary process ever made. Thought provoking stuff.

That’s it from me for this week.  Until next week…look after yourself!

Dr Richard Pile

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The Weekly Wellbeing Round-Up #3: My Weekend Wellbeing Clinic

How was your weekend?  Maybe like me on sunday afternoon you found yourself in a glorious alternative reality, as the match commentator stated that it was 5-0 to England.  At half time.   It doesn’t get much better than that!  My weekend had started less positively, as I found myself getting up (a little resentfully, if I’m honest) earlier than desired to go into work and do a three hour surgery.   I decided that for both my patients and I to get the most out of the surgery,  I would make a note of how many of the consultations were rooted in wellbeing and lifestyle issues, and to dig a little deeper with those patients to help them get the most out of the consultation.  After all, if I’m going to blog about wellbeing I need to make sure I’m practising what I preach, not just summarising the theory.  The results genuinely blew me away…so today’s blog contains the summarised highlights and learning points of my experience.  In case you’re worried about GDPR (that’s General Data Protection Regulations to those of you fortunate enough not to have to know this), there is no patient identifiable data contained in this blog. For those of you desperately disappointed that this isn’t the Weekly Wellbeing Round #3, I promise that it will be back next week!

So what did I learn?

  1. There’s a lot of it about.  Two third of the consultations were primarily about an underlying wellbeing or lifestyle issue.  I was expecting it to be high, but not that high!   Of those two thirds it was about a fifty fifty split between those that openly acknowledged this was the problem and those that either weren’t aware of it, or chose not to acknowledge it.
  2. It’s easy to take the path of least resistance with a prescription and do your patient a disservice.  At least two of the patients that I saw presented with one simple symptom, for which they were asking for a quick fix, usually a prescription.  One patient had a rash.  They just wanted some cream for it, having tried nothing at all so far.  I could have just prescribed steroids.  I’ll be honest – depending on how late I’m running and what sort of day I’m having, I have historically taken the easy way out, gained myself five minutes of catch up time and breathed a sigh of relief. However, the reason they had this rash was because of chronically swollen and inflamed legs, which in turn was due to their weight.   I did give them some cream, but only after we had spoken about their weight, what they felt about it, what they had previously tried in terms of weight loss etc.  They left not just with their prescription but with a weight management referral.  I could have spent time talking to them about a low carb diet but they gave me the very clear steer that they really wanted to be told what to eat and to be held accountable and would prefer a weight management programme.
  3. Social history is important, particularly occupation.  Doctors are taught to take a social history.  This is particularly pertinent in primary care.  However, as the years have gone by and the time pressures have increased, I find myself sometimes taking shortcuts.  That may well be okay in the case of minor illness and discussing blood results, but it’s an important part of the picture as a determinant of wellbeing.  Of the cases that I identified as related to wellbeing and lifestyle, half were at least partly occupation related.  They were either the primary cause of stress and multiple symptoms, or contributing significantly to the problems.   I may not be a career advisor, but what’s the point of repeatedly consulting for mental health issues, signing prescriptions and sick notes to address the symptoms, without challenging a person to consider addressing the cause?
  4. Ideas, concerns and expectations.  Oh how we love them.  Anyone who is a GP reading this will be familiar with these terms.  They are all about the importance of establishing a patient’s understanding, their fears and what they want to get out of the consultation.  Having been a GP for almost eighteen years now,  I sometimes end up feeling that all a lot of patients want is a referral for a fancy test or to see a specialist who will fix the problem that I can’t (or that they don’t believe I can).  What was really interesting about my wellbeing surgery experience was that my assumptions were often incorrrect.  When we began to explore the issues and the options for dealing with them, a significant number of the patients did not want a blood test, or a drug, or a referral.  They were actually very happy with advice about lifestyle medicine and even expressed relief that it was something they could be in control of.
  5. It’s okay to be honest and you don’t have to “fix it”.  The consultation that I found the most challenging was with a patient who was actually very up front about the reasons for their wellbeing concerns and clearly identified work and relationship issues that were causing them a lot of stress.  They had adopted some unhealthy coping mechanisms as a result and , in my opinion, their situation was clearly unsustainable in the long term without serious consequences for their health.  The problem for me was that they made it very clear they weren’t immediately planning on taking personal responsibility for the situation and making any of the vital changes that they needed to improve things.  They also made it very clear that that felt it was up to me to sort them out, and requested various medications to this end.  When I was younger and less experienced, I would have felt pressured into prescribing because it was the only thing that I could do.  It would have also made the consultation much shorter.  Now that I recognise this is actually not serving the patient well at all, I pushed back and (having checked they were safe from a mental health perspective) challenged them about expecting medical solutions to a problem that they should be dealing with themselves.   We agreed to a further consultation to discuss this some more and I also gave them our wellbeing team phone number so they have someone else to talk things through with.
  6. Wellbeing and lifestyle medicine is increasingly on the patient agenda.   A lot of patients are very well informed, even if they don’t have my obsessional podcast/blog reading habit.  Wellbeing is increasingly on the political agenda and in the media.   Some of the patients who identified lifestyle issues were already well on the way and we talked about a number of concepts and resources such as Public Health England’s Active Ten campaign and app, Dr Rangan Chatterjee’s excellent 4 Pillar plan,  the concepts of a low (or low-ish!) carb diet, time restricted eating and weight management programs.   It’s very rewarding to see people making changes and just to touch base with them occasionally or give them a gentle nudge here and there as they work their way through managing their own wellbeing.
  7. It does take a bit longer.  Case selection is key!   My clinic did finish on time, thanks to the one third of people who came with minor and easily addressible problems.  I’m not going to lie to you…to do this properly does take a little longer.  My belief is that if health professionals invest just a little extra time with the right people, the benefits in the long term will be significant.  A very small proportion of people genuinely have no insight and are not willing to take any responsibility for their own wellbeing and may not respond to this approach.   However, if a doctor would offer a double appointment to a patient with serious mental illness, a complex long term condition or a newly diagnosed cancer, why would we not do the same for someone who could make huge, lifelong gains in wellbeing as a result of a little extra time?  A GP can sometimes feel a bit of a lightweight if they book too many extra long appointments.  Patients may feel they are taking up too much of the doctor’s time with “minor” issues.  I would argue that of all the things we spend more time on, this is one of the most potentially beneficial areas for patients and health professionals alike.

I hope that you have found my sharing this helpful, whether you are a patient or a health professional.  Weekly Wellbeing Round Up service resumes next week

Until next week, look after yourself!

Dr Richard Pile