MSKMag OutLoud
Who is Responsible?
Descripción
I look around the waiting room. There’s an average BMI of about 40. I observe oedematous ankles and a variety of walking aids (some flowery so you know they’re not a temporary feature). I can almost smell the inflammatory soup. A young person sits glued to an iPad, headphones shielding them from the world. No doubt an ADHD diagnosis inbound. The health of the nation has changed, and not for the better. And I wonder, when did MSK care become less about sprained ankles and bad backs, and more about metabolic disease and mental health? But who is responsible for this decline? Scanning the room, my instinct is to lay responsibility at the door of the individual. The media will have us believe that our beloved health service is failing the nation but is it in fact the nation who is failing the health service? As someone who works hard to maintain a healthy, balanced lifestyle, I am of the belief that I need to be accountable for my own health. Not every condition is avoidable or preventable, but I feel that I need to at least do my bit. I’m no teetotal, clean-living vegan, but nor am I held together with statins and gabapentin. Don’t misunderstand me, as a healthcare professional, of course I believe that access to healthcare is important, but with such a high incidence of people living in poor health (89% of deaths in the UK are attributed to non-communicable diseases) surely, we all need to step up and do our bit? I am not, however, optimistic. ‘The Spectrum’, overwhelm, body positivity, and food noise are just some of the reasons one can choose to justify an external locus of control. But these are avoidance tactics. Avoidance of the difficult, the uncomfortable. Avoidance of Responsibility. I hear the food noise; I can hear the packet of biscuits seductively calling me but I’m not a labrador and am able to exercise a degree of self control. Is it always easy? No. The same way that curling up on the sofa might feel more appealing than heading out for a run. We all have choices, and we are all capable of autonomous thought (even if these days we seem not to exercise that particular skill). Before judgement completely takes over however, and I am able to reach the lofty heights of the moral high ground, I am pulled back by the sight of a physiotherapist escorting a patient with magnetic knees back to the waiting room (if you aren’t familiar with magnetic knees, they are the kind that due to years of deconditioning and lack of proper use, are drawn to each other as if the medial femoral condyles are polar opposites!). The patient has just undergone a steroid injection and the physio gives them some instructions about a couple of days rest, then hands them a sheet of exercises. Patient and physio part company like a couple of England football fans*; both hopeful for success, both expecting disappointment. And my judgement shifts, from the patient to the physio. Like a warning light on the dashboard of your car, the focus here seems to be on turning the light off, rather than addressing what triggered the alert in the first place. Corticosteroid and a few clam shells aren’t going to address years of deconditioning, poor diet and social isolation. And I ask myself again, who is responsible? While I still stand by the importance of taking care of our own health, we can only do so if we are educated - if we understand what is going on in our bodies and are aware of our choices. With so much access to information and misinformation it can be a minefield for an individual to navigate. But I see MSK services stuck in the past. Clinicians still treating knees and backs in isolation and failing to treat people. Failing to acknowledge the complexity, and failing to have honest, albeit difficult, conversations. And clinicians have their own set of excuses. Their own reasons for absolving responsibility. No time; out of scope; it only says ‘knee’ on the referral. The system is s**t. Now I do agree that time pressures in MSK services are a limiting factor, and services need a redesign, and I hear clinicians complain, but I don’t see them upskilling to meet this new demographic head on. If time is such a precious commodity, why are we wasting it trying to identify dysfunction rather than discussing dysregulation., Why are we not prioritising conversations about the impact of weight, stress, hormones and sleep on pain and MSK health? I see a dramatically changed patient population, but MSK clinicians failing to acknowledge or keep pace with these changes. Many pay lip service to a biopsychosocial model, remaining entrenched in a ‘lets fix it’ biomedical model, not because they are lazy or ignorant, but because they lack the skills to challenge the status quo in a meaningful way. Why should patients change, if clinicians are not prepared to do so? I do worry that if MSK professionals fail to upskill to meet the shifting demands of health, if they are not willing to take on the responsibility of helping patients to navigate these health challenges, they will become obsolete. But I digress, as this piece is about the responsibility of health and not a debate about the future of MSK services. That is perhaps for another day. I scan the room once again, and wonder if I am being unfair to my MSK colleagues. Why should they take on the nation’s ills, simply because pain is the thing that demands most attention? Shouldn’t the proverbial buck stop with primary care? As the first and most consistent point of healthcare for most patients, they are best placed to provide holistic, ongoing support. Patients might spend several years, sometimes a lifetime, with the same GP practice. Responsibility should surely start here as the best place to effect sustainable change?? True that GP practices are under pressure, but maybe this is being perpetuated by referring away to specialist services with the promise of a solution, only to find patients boomerang back when the problem persists. There is some good news! There is a small, but growing number of GPs who are upskilling in the field of lifestyle medicine. Finally, some responsibility! But just as I begin to fantasise about a world in which all GPs are as skilled in promoting health as they are at treating illness, I look round the waiting room once more. Lifestyle medicine is still the exception, and far from the norm. Once again, I think about responsibility. What caused this epidemic in the first place? Several people sit scrolling on phones, someone opens a packet of crisps, another an energy drink…I’m not sure that the thumb movement involved in scrolling through Instagram requires that level of sugar and caffeine! My heart sinks with the realisation that what we are facing isn’t just about helping people make healthier choices. This is full scale addiction. Smart phones keep our sympathetic nervous system fired up, keeping us in fight or flight for sustained periods. And we now know these things aren’t addictive by default, they were designed that way. Add this to food-like substances, developed to leave you craving more, failing to nourish, creating inflammation and a heightened sense of threat in our nervous systems. The nation needs a detox! So, who is responsible now? The tech companies? Food conglomerates? The Government? Are we fighting a losing battle here, or does this bring us back to the beginning and individual responsibility? The addict can blame their dealer, but it’s supply and demand. We want life to be easy, convenient, and comfortable, but the easy choices in the short term don’t always serve us well in the long term. The important thing to realise is that there is choice. Clinicians can help a person on their health journey, but change will only happen off the back of individual effort. Health isn’t something that can be fixed, and recovery is hard. Our health is the most valuable and precious commodity we will ever possess; how can we not take responsibility for that? *Just to clarify, this is a reference to the men’s game This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe [https://mskmag.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]
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