Trauma and the art of medicine

‘As we absorb the stories that shape our patients’ lives, we feel their full impact.’¹

Being human means that we have lives shaped by trauma that may be physical, emotional, or even spiritual (loss of faith) or professional (did I spend all those years studying just to do this?). Always disturbing, trauma indelibly alters lives for better and for worse. For better, it can build positive attributes like resilience, resourcefulness, humility, and appreciation of life in the present. For worse, disability, dependency, risk aversion and distrust can follow in its wake. Trauma may never completely resolve. Healthcare providers may have more vicarious experience of trauma than almost anyone else in society as they support their patients in their journeys of recovery from trauma. In this issue our lead article comes from an analysis of the Midland Trauma Registry, a registry of trauma presentations to the Waikato hospital.² From this paper we learn some important epidemiology about the mental health, physical pain, alcohol use and quality of life of adult survivors of major physical trauma. The numbers are important: they give an idea of the scope and risk of trauma consequences within the first year after a traumatic event. The numbers are certainly not sufficient however, if healthcare providers are to understand how best to support such people. Our guest editor writes of trauma experiences that will resonate with many of our readers:³ experiences that take patients by surprise, like loss of identity, and experiences that dull compassion when they are repeated over and over again. Numbers fail to capture all the lessons for doctors, nurses, physiotherapists and others caring for people who are in the grips of a trauma journey. We need stories.

A recent issue of the New England Journal of Medicine published some important stories that serve as a reminder that being a practitioner of the medical arts is not an optional extra. It is, if anything, more important now than ever for doctors and other healthcare providers to embrace the medical arts in this age of sophisticated technological developments, computer templates that enable systematic recording of patients’ medical histories, and clinical practice guidelines that check that patients are treated according to the latest scientific evidence.^1,4 Novick worries that new generations of doctors will have been so carefully trained in modern health technology that their clinical practices will be bounded by them: she worries they will not have learned in their training enough about the art of medicine to provide the professional medical care patients expect and deserve. That is why this Journal, like many other medical journals, is reserving a special place for publishing stories, poems and drawings or paintings that encourage reflections about medicine, so that our readers can be assured that we have not forgotten the importance of the medical arts in our focus on publishing scientific research. Our first offering in this section is a very short story (a genre called ‘flash fiction’) that we hope will encourage readers’ reflections.⁵

Non-fiction case studies are another type of story. We have an increasing number of case studies submitted to the Journal and we consider their publication as carefully as for other types of manuscript. The main criterion for case studies, and all our papers, is that they should hold a message of relevance to our readership. The case studies in this issue were written by a general practitioner, cardiologist and student,⁶ and an allied health professional team.⁷ The importance of teamwork was an overarching message of both these case studies, but every reader will probably take from these stories something a little different.

We have two papers reporting clinical research.^8,9 One is a systematic review of diagnosis and treatments for idiopathic mastalgia.⁸ Epidemiological research has found that up to 68% of women aged 18–44 years may experience mastalgia and although it is mostly transient and benign, that is not always the case:¹⁰ an update on the condition is warranted. In the other clinical research paper, Simpson et al. report their analysis of data from New Zealand’s Pharmaceutical Collection regarding the anticoagulant dabigatran etexilate.⁹ As this is now the most commonly prescribed anticoagulant in New Zealand an examination of its impact is timely. We are increasingly seeing research based on routine collections of health data – a great way to put them to practical use, in my opinion. However, there are ethical considerations that have still not been completely worked through when these databases are not publicly held, such as the databases formed by general practice records and held in privately owned centres. Wallis and her colleagues explore these issues.¹¹

‘Thinking about health care differently’ is the provocative title of one of our health services research papers.¹² Almost by definition, health services research is about thinking about health care differently. For Kirkman ‘differently’ means finding out whether Nurse Practitioners working in primary care can be considered social entrepreneurs, and if they can, what might this mean for primary care business models, healthcare politics, and healthcare reorientation.¹² We are always pleased to publish not only thoughts of doing things differently, but evaluations of different things being done. In deviating from established clinical practice, evaluation is necessary to see if different is also better. In the previous issue of this Journal Nixon’s team described the scope and effect of Point of Care Ultrasound used by rural hospital doctors.¹³ In this issue they present in-depth analysis of the effect and quality of kidney and bladder Point of Care Ultrasounds.¹⁴ Rural hospital use of Point of Care Ultrasound represents an important step in health system reorientation that is receiving the careful evaluation in New Zealand that it needs.

Finally, we have a short report about why patients choose treatment with acupuncture¹⁵ and our complementary medicine and evidence-based care columns.^16,17