What matters most?

Dan

Dr Dan Muckle-Jones has worked as a general practitioner in Mold for nearly 30 years. Through his time as a GP, he was at the centre of the local community and saw various generations of families come through his care.

He decided to retire nearly 10 years ago, and although he felt it difficult to leave his patients behind, he felt it was the right time for him to move on.

“The truth is, I miss it. I don't miss all the pressure, but I really miss the people. I do often have feelings of guilt about leaving the profession because I sometimes think that I have more to give. Interestingly, I think I still have that caring need in me and I'm glad I retired because that caring role has been fulfilled to a large degree by my family. My mother-in-law has Alzheimer's, and we've been supporting my brother who has mental health issues; plus now, we have a seven-month-old little rescue dog, who takes up a lot of my energy at times.”

Dan’s mother was a nurse and his father was a doctor, so the family had an ethos of caring for others. His ‘Nain’ (grandmother) was a district midwife who covered much of Caernarfonshire, cycling around on a bike. With the medical profession being a big part of his life from a young age, Dan went into medicine at Cambridge and then St. Thomas's in London. He particularly enjoyed his clinical training.

“As a child growing up with my father as a GP in Harrogate, in the 1960s, we would have people knocking on the back door with nails stuck in their fingers and all sorts of minor injuries and traumas. My father would be getting up in the middle of the night to drive off to Pateley Bridge to see patients. I think if my father had a fault, it was caring too much. As my medical career progressed, I became far more interested in people rather than diseases. I became interested in the whole holistic sense of caring which led me to be drawn to training in general practice.”

Through his time in general practice, he soon realised that the closer you get to people, the more pain you absorb. Certain situations became emotional as a lot of the patients were Dan’s friends, not just people with illnesses.

“I can say that general practice did, to some degree, chew me up and spit me out in that it became all-consuming, because that relationship with the patient was so fundamental. It could be overwhelming. It led to something of a paradox because I realised that unless you get close to people, you don't get near their problems. My experience was that people, by and large, came to see me only when they needed to. Every consultation was a building block in my relationship with that person. They were all important because that's where the trust was built. Patients would come with something relatively minor and have their hand on the door handle about to leave when they would suddenly turn around and say, ‘Whilst I'm here, doctor, what do you think about this?’ and a great number of times that that was actually the most important thing.”

Seeing that within his profession building a rapport with patients was important, and finding himself being lots of things to lots of different people, he always saw it as his responsibility to be sincere and genuine. He would often encourage patients to write down their ailments in a list that Dan would then work through with the patient. They would identify which things that could be addressed that day and which ailments were most important. Through logical and engaging techniques, the individuals often would relax into talking about what was worrying them most. The most important thing for Dan, every day during his surgery, was to build up trust with those who came to see him.

“If you have a rare condition, my job as GP would be to say, ‘we’ve got a problem here, we're going to have to deal with this. Not only is the condition rare, but we're going to have to deal with it maybe for a long time. Knowing I’m not an expert on this I will read up on it and we will become experts in this disease together. We will make sure we know who to ask for advice, we will make sure that we communicate with the right people, and I will try to negotiate the system with you. I will help you to understand what's going on. I will learn about this with you on our journey and will be with you along the way’. I learned a lot from my patients.”

Working as a GP for so long, Dan was constantly busy with around 2000 patients. He had to learn how to manage his time and learnt that as a practitioner he didn’t have unlimited resources. Through the years he saw a lot of friends and patients reach the end of their lives and it was always an emotional experience for him. By offering what care and expertise he could, he would try to make each patient’s journey as comfortable and easy as he could for them in their unique situation.

“Every individual and every terminal care situation is going to be different. In midwifery, every lady is thought of as an individual and gets a care plan. We need to approach palliative care similarly, recognising that not only is every person different, but every terminal illness is different. The importance of medical training and continuing education is to know what particular sets of problems a particular terminal disease might present, and then know what tools are in the toolbox to deal with it. In palliative care, the focus, I think, must move towards anticipatory care.”

Losing his mum to pancreatic cancer, he has also seen palliative care from the point of view of a loved one. “Pancreatic cancer is a rotten disease. It has very high mortality rates, you must be extremely fortunate to pick it up early enough for surgery to be curative. At least that was the experience that I had all those years ago when my mother died of it. We talk a lot about managing symptoms in palliative care, for instance with painkillers and anti-nausea drugs etc., but there are other treatment modalities that not everybody's always aware of. One of the modalities for the treatment of pancreatic cancer that I was always keen to keep at the back of my mind was a Celiac plexus nerve block. Sometimes the pain of pancreatic cancer can be quite difficult to control. Every district general hospital should have access to a specialist who can give a nerve block to the nerve supply to the pancreas. That can be remarkably effective at relieving pain. Morphine is a fantastic drug but that's not the only available thing.”

Over the years he has learned that not all painkillers and anti-nausea drugs can have the same effects on different people. In terms of palliative care, sometimes alternatives to drug treatments, including surgery and radiotherapy, can be appropriate to treat pain. He believes that working as a team during end-of-life care is essential and thinks GPs have an important role to play in helping to coordinate services.

“GPs are not consultants, we're not specialists, we must recognise the limits of our competence and abilities. My experience as a general practitioner was that it was vital to discuss with the local palliative care team even if it's just to phone them up and give an overview of the patient. The local district nurses are absolutely invaluable in the support that they give to patients in terminal care, as are also the palliative care nurses. They are highly skilled people. I tried to get them involved early on, so they knew about the patient.”

The importance of communication and a handover of information within the surgery is so important to Dan and he believes that all partners who are involved with the care of that patient should know fully about them. For continued care, the significance of things like pain management self assessment scales can be very important. These help a patient to measure their pain regularly so the care team can assess the response to any interventions.

Through his role as a general practitioner, he talked regularly to families about their experiences during bereavement. “I think that general practitioners have an incredibly important role to play in helping people with bereavement, in terms of recognizing the loss. It can help to signpost people to services and where relevant, the spiritual aspects are important as well. I'm not talking about any specific religion, but people have different understandings of what death is. My experience was that patients who had some structured belief system about what happens after death and families that shared that often coped with bereavement better.”

As a GP during palliative care with a patient he didn’t see his role just as doctor-patient “I think that the role of a general practitioner is like a conductor. You have an orchestra at your command, but you need to know what instruments are at your disposal and how to get the best out of them. I’ve talked about trust between patient and doctor but there must be trust between all members of a palliative care team. The district nurses need to know that when they ring you up as a GP and say ‘I need you to come and see this patient, I’m really worried about them’, you will go. The palliative care nurses need to know that when they say ‘I think this patient would really do well with a trial of a certain drug for a certain symptom’, you're going to put that into practice. You need to trust each other based on evidence of previously working together.”

Reflecting on the times he spent with patients in palliative situations, he believes it to be a privilege to be there with the patients and families, but not easy. “It's an incredible honour that someone would be willing to put their trust in you to be with them on that journey. To me, it was always important not to be obtrusive. Respecting the family is more important than you and they need time together without you. It’s a great honour and often very emotional, but you need to keep your emotion in check, because part of the trust in you as a doctor is trusting your objectivity and professionalism. Inevitably, it's at a personal cost.”

What matters most to Dan is the patient and always has been. “For me, the most important thing was getting all the people who could make that death better and more somehow palatable for all involved. That the patient's wishes had to have been respected.”

Dan now enjoys his retirement with his wife of over 40 years, Sandra. Their house is always busy with family and guests and their young rescue dog. Dan follows his passions in life which include photography, art and creating music. There is still the doctor’s caring deep in his soul that will never retire.

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