Integrating Everything

Front matter

THE INTEGRATED PRACTITIONER

A CRC Press J u st | n A m e ry (2) Taylor & Francis Group

THE INTEGRATED PRACTITIONER Integrating Everything

Section Two: Having a Go Chapter 5: This is it Chapter 6: Clearing

e Clearing the ring

® Getting perspective

® Health practice as ‘being’ not ‘trying’

Chapter 7: Awakening

® Committing

e An example

® Dissolving

® Jumping

® Waking up (flying, not falling)

Chapter 8: Connecting

® The golden minute e Introducing the patient into the infinite ring e The flood ® Deep listening (and watching)

® Don't interrupt. Really don't. Really. Don't.

e The very useful miracle

Chapter 9: Trust your intuition (but check it too)

® Thinking: fast and slow e The practical application of convergent and divergent thinking ® Problems with divergent and convergent thinking e Factors that may affect the way we think e Ebbing and flowing

® integrating and harmonically balancing our thinking in practice

Chapter 10: Mapping

e What maps of health are there?

® Don't fall into the health beliefs trap ® Creating and merging different maps

® Consonance and dissonance in practice

® Integrating maps into practice

46 47

56 57 59

63 64 64 66 67 68

71 72 74 76 76 77

80 81 82 82 84 85

89 91 92 94 97

Chapter 11: Negotiating e Co-creation can only be done in partnership e Negotiating agendas

® Negotiating routes, waypoints and end-points e A worked example

e The road taken

® A good enough journey plan

Chapter 12: Letting go

e The absolute importance of letting go e (Re)Creating ourselves

e A brief meditation on death

e Health practice as self-practice

Chapter 13: Models and reality

@ The model as a tool

e The model as a tyrant

® Models as tools or tyrants?

® Integrating and balancing models and practice e The realities of practice

Chapter 14: Creating better health

® Creating in your own practice

Chapter 15: Integrating everything

e Cycling on the road to nowhere

e The messiness of life

® Beginner's mind: meta-competence

® Including but transcending our expertise

® Integrated practice as a ‘meta-level’ of reflective practice ® Zen and the art of health practice

Conclusion: power, beauty and love

Contents

99 101 102 104 107 108

112 113 114 116

119 120 121 122 123 125

129 130

136 138 138 141 142 143

149 168

“Ver

These books are dedicated to my Dad, Tony Amery, who was a wonderful doctor and who is still my inspiration.

About the author

I am a full-time practising family practitioner and children's palliative care specialist doctor working in the UK. I have also spent some years working in Uganda and other sub-Saharan African countries.

I enjoy teaching, writing and mentoring. | am a medical student tutor at the University of Oxford, a trainer in general practice, and I have designed and set up children's palliative care courses for health professionals in the UK and Africa. I have worked with ‘failing practices’ to help them turn round; and also with health professionals who are struggling (as we all do from time to time).

I have always had an interest in philosophy and spirituality, and have studied this at postgraduate level. I have carried out some research into education and training of health professionals around the world and I continue to explore that interest.

I have previously written two books: Children's Palliative Care in Africa (Oxford: Oxford University Press, 2009) and the Association for Children's Palliative Care (ACT) Handbook of Children's Palliative Care for GPs (Bristol: ACT, 2011). I particularly enjoy reading and writing poetry.

At heart, though, I am a practitioner and a generalist. What is more, as you can probably see, I am rather a jack of all trades, and a master of none.

I have been motivated to write this book as I am hoping to explore practical ways of practising health that help us all, patients and practitioners alike, to become a little more healthy, and a little more whole.

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Acknowledgements

These books have been brewing up over many vears and so there have been very, very many influences upon them. There are far too many people to mention and thank without risking leaving someone out, so I shall just mention those who have been immediately involved.

I would also particularly like to mention Chris Smith, who not only gave very useful feedback on these books, but who also helped me to develop a lot of the ideas in them through his leadership of the Oxford Advanced Consultation Skills Course that I help him with, and over a few pints in the pub as well.

Thanks as well to Gillian Nineham of Radcliffe Publishing, who was brave (or daft) enough to put her faith in these rather unconventional offerings; suggest numerous areas for improvement and offer tremendous support and encouragement in their publication. Thanks also to Jamie Etherington and Camille Lowe for all their help in putting them together.

I would like to thank my colleagues at Bury Knowle Health Centre in Oxford, Helen House Hospice in Oxford, Hospice Africa in Kampala, Uganda, and Keech Hospice in Luton. They have all shown utmost patience and perseverance as | have led them on various merry dances, contortions and deviations in the name of ‘good ideas’, rarely reminding me of the 99% which failed, and always supportive of the 1% that, miraculously, did.

Of course | cant forget Karen Bateman (the doctor) and Karen Amery (the missus) who has been a continuous and never-ending source of sound advice, support and wisdom.

Finally, | would like to offer a huge thank you to Polly who, on a cliff top in Spain, gave me the courage to risk writing this stuff down and making it public.

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Introduction to the series

Hello and welcome! This is me. You and | will be sharing a journey through this book, so you may wish to know what | look like. Because practice can't happen without practitioners, | will be popping up now and again, to test-drive some of the ideas that we will be discussing.

WHY ARE THESE WORKBOOKS NEEDED?

If you are, like me, a modern-day practitioner, you are probably still dedicated to the idea of good practice, but feeling rather buffeted by many and various winds of change that are sweeping through. You are also probably feeling (like me) that it would be good to have two minutes to sit back and reflect a little: to think about what's working and what's not; and maybe even to find a little balance.

If this is how you feel, you have come to the right place. So welcome!

In this series of workbooks we will be doing exactly that, taking a little time out, thinking about what we are doing, looking at things from different perspectives and using different lenses, and trying out some practical ways of making our practice more effective, more efficient, and (above all) more satisfying.

On the other hand...

If you are, like me, a modern-day practitioner, you will probably also be moving far too quickly to have any time for doing anything except what you need to be doing. In other words, you probably don't feel you have time for luxuries like sitting back and thinking. Frustrating though it may be, you probably have time to do only what you have to do, rather than what you want to do.

If this is how you feel, you are still in the right place, so welcome again!

In this series of workbooks, we will be working under the clock, recognising that there are boxes to tick and targets to hit. No doubt you dont just need to keep up to date, you need to prove you are keeping up to date too, for appraisal, or for review,

. 1.

or for revalidation. So, as we go along, we will be providing practical examples that will help you not just to reflect upon but actually to develop your practice.

What's more, we will even be providing appraisal certificates, so our appraisers, line managers and bosses will stay happy too!

But you're gonna have to serve somebody, yes indeed You're gonna have to serve somebody, Well, it may be the devil or it may be the Lord But you're gonna have to serve somebody.

— Bob Dylan

WHY DID | WRITE THEM?

I have written these workbooks because there doesn't seem to be anything out there that scratches my itch. Our experience of real-life health practice is messy, complex and often chaotic. It doesn't seem to bear much resemblance to the practice we read about, or even the practice we try to teach our students and trainees.

Modern scientific and philosophical understandings of the universe are complex, messy and relational too. But our models of health and health practice often seem to be built on glib and simplistic models, or they fall into dualistic discussions (for example, about ‘patient-centred or ‘practitioner-centred’ care; or about ‘traditional’ or ‘alternative’ practice; or even about ‘disease’ and ‘health’). Is the world really like that?

I have also written these books as I am worried about the levels of demoralisation and burnout among students, trainees and colleagues that I meet, right across the globe. Of course we can all get a bit tired, burnt out, and maybe even ill. If we are honest, we are often sceptical and occasionally a little cynical about what we do. But if we are even more honest than that, at heart we believe in what we do, because we think it is important.

Its not that we want to turn the clock back. We can feel a considerable (if quiet) sense of pride in how far health practice has developed. But perhaps we'd also like to think that, in the 21st century, there is a way for our practice to include and yet somehow to transcend what has gone before. It’s not that we want to reject the practicalities, the science, the technology and the politics. On the contrary, I think most of us wish to accept and value them. But we also want to do what evolution always does: including, building upon and then transcending what has gone before. In so doing, maybe we can also rediscover the art of what we do, and perhaps even find a way of expressing ourselves with a little more poetry.

.2+ introduction to the series

WHAT WILL BE IN THEM?

The answer to that is simple really. We are hoping to look at practice from different perspectives, and using different lenses, so each book takes a different view.

Workbook 1 — Surviving and Thriving in Health Practice. We are the foundation of everything we do. Without us there would be no health practice. We are our own most useful tools. So, in the first book, we will look at how we can keep ourselves sharp, surviving and thriving in practice.

Workbook 2 — Co-creating in Health Practice. As practitioners, whenever we come into contact with our patients, we create something very familiar but also very strange: a relationship. This relationship is neither me nor the patient, but some sort of third entity, which has an existence of its own, partly from me, and partly from the patient. This 'co-creation is arguably our most powerful tool, but it is a tricky one to use. So we will focus on that in the second workbook, considering how we might practise in a way that co-creates healthier and happier existences, for both our patients and ourselves.

Workbook 3 — Turning Tyrants into Tools in Health Practice. As practitioners we have a vast array of tools that we can use: time, computers, money, information, colleagues, equipment, targets, our workplaces and so on. If they get out of balance, however, each of these tools can become a tyrant, so that it has control of us, rather than the other way round. So in workbook 3 we will be looking at some of the most important tools (and tyrants), considering how we can stay in control of them (and not vice versa).

Workbook 4 — Integrating Everything. Health practice is, ultimately, a single integrated thing. While workbooks 1-3 have been looking at the different ‘bits’ of this ‘whole’, workbook 4 is where the rubber hits the road, because it is here that we try to put it all together and come up with ways that we can integrate everything into a happier, healthier and more skilful whole within the real-life, complex and messy world of health practice.

Workbook 5 — Food for Thought. We are practitioners, so we are practical, and interested in practice. So we will leave the theory until last. But most of us like a little bit of theoretical background to give context to, and to underpin our practice.! So workbook 5 tries to provide that. Everything that exists does so against a background. Indeed the word ‘exist’ means to ‘stand out’. All of our experiences, beliefs and understandings of health practice derive from a living, organic and constantly moving context: whether scientific, philosophical, cultural, aesthetic, biological or spiritual. It is useful therefore to spend a little time understanding and reflecting on these building blocks of who we are. As practitioners, we dont always have time to do this, so we will leave this book until last. It will be a little luxury for those with a little more time, not essential, but hopefully a bit nourishing. Like a fireside cup of cocoa.

The Integrated Background Whole (Book 5) (Book 4) You and me other (Book 2) (Book 3)

WHAT PERSPECTIVES AND APPROACHES WILL THEY USE?

In the 21st century we practise healthcare in a strange tension.

Science has taught us that we live in a highly relational, messy, multidimensional, complex, blurry and even chaotic universe. The humanities and philosophy have taught us that much of what we hold to be ‘true’ is relational and cultural and socially constructed. The arts teach us the value of creativity and expression in all walks of life. Spirituality teaches us about perspective, the value of awareness, and the fundamental interconnectedness of all things.

However, despite this relationality, creativity and complexity, we seem to be practising in a world that seems ever more bound and codified, with ever more targets and tick boxes, according to models that seem unrealistically geometric and two-dimensional, and with ever less room to breathe and to express ourselves.

So, in these workbooks, we will try to be practical and pragmatic. While we may not necessarily like the rules, regulations, guidelines, laws and targets that have nosed into our practice, we recognise that they have their uses. We know that health is a political football, and we are used to being kicked around a bit.

As practitioners in the 21st century we also value (and sometimes worry about) the advances that science and technology have brought. As practitioners, we are scientists, and we have a duty to do our best to ensure that what we do is as safe and effective as possible. We recognise that finding an evidence base for what we do is important not just for safety, but for development too.

So in these workbooks, we will start from the premise that we should, wherever possible, look for empirical evidence for what we are suggesting. On the other hand, ode

Introduction to the series we will remain vigilant to the blind spots of the empirical and technological approach, and look for alternatives to fill any gaps that we find.

Wherever possible we will look for empirical evidence for what we are suggesting.

As modern practitioners we are scientists, and also technicians, but we are artists too. There is an art to being a practitioner, and in fact practice is an art. We might lose sight of it sometimes, but we are in the business (and busy-ness) of trying to create healthier and happier existences for our patients, and hopefully for ourselves too.

So in these workbooks we will be using plenty of imagery, art and illustration to engage the more creative sides of our brains, and to remind us that integrated practitioners need to be able to find balance between creative and practical.

These days, we dont tend to talk much about spirituality. Many of us would not think of ourselves as ‘religious’, and some of us might be horrified at the idea that modern-day practice should have anything to do with spirituality.

But most of us perhaps like to feel that there is some purpose or meaning behind what we do. We may hope that our practice connects with and somehow reflects the values and traditions of our families as well as of our broader societies and cultures. We deal with life and death, and so with the many existential and spiritual questions that arise as a consequence. If we are to be integrated practitioners, we need to have a handle on these too.

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So, in these workbooks we will try to look around the edges and to peer through the gaps, asking not just: ‘What should we do? but also ‘Why should we do it? and "What does it all mean anyway?

Finally, we dont have to practise long to realise that there are some things that make no sense, and from which no sense can be made. Random and chaotic events, reactions and emotions may arise, surprisingly. These can be both deeply troubling but also deeply wonderful, in that they can give expression to the inexpressible. We practitioners are practical people. We like to 'do' things. But sometimes there is nothing we can do, because there is nothing to be done. At these times, we have to just ‘be’. For just ‘being’, for making sense of nonsense, and for making nonsense of sense, there is nothing better than poetry. So we will be seeing a fair bit of that too.

Symbols and rituals are fascinating things that in some way speak to

us at a ‘level beyond’. It is not often easy to make sense of them, and yet we may be surprised to find that our practice is full of them.

Ars Poetica

A poem should be palpable and mute

As a globed fruit,

Dumb

As old medallions to the thumb,

Silent as the sleeve-worn stone

Of casement ledges where the moss has grow — A poem should be wordless

As the flight of birds.

*

A poem should be motionless in time As the moon climbs, Leaving, as the moon releases Twig by twig the night-entangled trees, Leaving, as the moon behind the winter leaves.

Memory by memory the mind— A poem should be motionless in time As the moon climbs. * A poem should be equal to: Not true.

For all the history of grief An empty doorway and a maple leaf.

For love The leaning grasses and two lights above the sea— A poem should not mean But be.

— Archibald MacLeish?

Introduction to the series

POINTS AND PRIZES: SOMETHING FOR NOTHING

In the initial stages of this book, my publisher explained that medical publishing is at a turning point. Whereas before practitioners might choose a book that they would enjoy reading, nowadays they are too busy for that. So the upshot is that we only read books we need to read, rather than those we want to read.

A bit like Nanny McPhee...

The good news about adopting an integrated approach is we dont need to judge, we just need to adapt. If that is the way of the world, so be it, and so we have.

The particular way of the current world of health practice (at least where | currently work in the UK) appears to be a focus on objectives, outcomes, points and prizes. So the initial book has been adapted to match. Each chapter will contain activities and reflections that will meet common curriculum areas for medical and nursing practice. At the end of each book is a link to the Radcliffe Continuing Professional Development site, www.radcliffehealth.com/cpd, where you can download certificates that you can use for your CPD, appraisal or revalidation requirements.

OK, | admit it's a bit tongue in cheek, but there's no rule to say that we cant have fun while toeing the line, is there?

PROVISOS

| am, at heart, a practitioner, and a general practitioner at that. That means I am a bit of a jack of all trades, but master of none. | am partial, biased and subjective. The book is intended for all health practitioners but, inevitably, and despite my best efforts, no doubt the ‘male’, ‘medical’ and ‘Western’ nature of my experiences and thoughts will peep through. I hope you feel able to forgive them and look past them.

Also, I can quite honestly say that there is nothing new in this book, and I doubt there is anything in it that you could not find better argued and more coherently evidenced in other places. There is some philosophy, science, spirituality, art and poetry, but | am not a philosopher, scientist, guru, artist or poet. I am a health practitioner who dabbles.

So I have referenced those sources I can remember and can find. Others may be lost in the mists. But 1 do not claim any of the basic ideas in this book as my own. I have simply looked at them from my personal perspective and tried to put them together in a way that | have found useful in my own practice and in my own teaching. | hope you can enjoy them, and that you will forgive the numerous mistakes and omissions that you will undoubtedly find.

Section One Creating in Practice

Chapter 7

“The Integrated Practitioner’: it has a nice ring to it, doesn’t it?

Who wouldn't want to feel integrated, to be integrated? In modern health practice it sometimes seems that things are going the opposite way, with increasing specialisation, compartmentalisation and regulation. With added time and work pressures we often feel pulled in every direction at once, with increasing stress, burnout and exhaustion.

The Disintegrated Practitioner’: that sounds more like it, doesn't it?

Well, yes and no. It depends on which perspective we take.

If you are a practitioner, you will be familiar with something like the record on page 15, either in paper or computer form. It’s a patient record. But it is much more than just a record. Prompts appear everywhere, reminding me to check this and that, encouraging me to use drug A rather than drug B for budgetary reasons, giving me lots of boxes to tick and tasks to achieve. All useful stuff, you would think.

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Me Background

Integrating everything - our practice is the integration of all relationships: with ourselves, with our patients and with everything else.

Other Wwe

But often it doesnt feel useful. Indeed, seeing my patients pile up on my appointment screen, knowing | will only be able to spend a few minutes with each at most: feeling under regulatory, financial and contractual pressures to hit targets and achieve goals: all this often makes me lose sight of my patient, of myself, of what we are actually trying to do together — to create better health.

How on earth can 1 try to achieve any sort of integrity with all of this? Is being an integrated practitioner in any way still possible?

Well, it all depends on how you look at it.

In this series of books we have suggested that health practice can be ‘seen as’ many different things, and from many different perspectives. In the previous workbooks we have looked at it from the ‘me’ perspective (Surviving and Thriving in Health Practice), from the ‘we’ perspective (Co-creating in Health Practice) and from the ‘other’ perspective (Turning Tyrants into Tools in Health Practice).

In this particular workbook we recognise the fact that health practice can be many things, with many constraints and pressures. But we will also try to take a different perspective. Health practice has always been many things, with many constraints and pressures. These constraints and pressures may have changed over time and still vary from place to place, but health-practice constraints and pressures of some kind have always existed and will always exist.

Being a practitioner here and now is, from one perspective, no different to the way it has always been. It involves integration. It involves weaving together many threads into one whole tapestry. It involves taking a constrained and limited palate and painting freely. It may be a science, it may be technical, it may be psychological,

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Computerised patient record from my own practice (anonymised)

it may be spiritual, but it is always an art, because it integrates everything in order to create something better.

And what we hope to create is better health.

THE ART OF PRACTICE

In practice, we create and co-create better health in an infinite number of ways, using every bit of ourselves. It is not just a technical process, though it is a technical process. It is not just a scientific process, though it is a scientific process.

It is always a complete expression in which we can choose to touch, see, hear, think, feel, sing, narrate, transfer, model, ritualise, dance, and even play.

As we dance (or sing, or play . . .) together, we pull all these various threads of information together within our imagination, and using that imagination we co-create an actual, new and healthier existence for our patients, and hopefully for ourselves too.

If we are practising in an integrated way, we can heal ourselves as we heal others.

All works of art start in the imagination. We imagine what we want to create, and then we go about trying to create it.

. 15.

It's the same in health practice. Without the imagination to put ourselves in the shoes of our patients, to see the world from their perspectives, and to imagine how their life and health could be ‘better’, we will not be able to use all the tools we have discussed to this point constructively, we will not be able to integrate them effectively, and the ‘health’ that we create will be less perfect.

Without imagination we are simply computers. We can analyse the data but we cant use it to create and construct new realities.

Can health be contained in a tick box?

A QUICK RECAP If you've not read workbooks 1, 2 and 3 (and maybe even if you have), all of this might come as a bit of a surprise. If so, here is a quick recap.

If it's not new to you, please skip on to the next section.

The universe is fundamentally relational, complex and infinite. As part of that universe, we should not be too surprised to find that we are fundamentally relational, complex and infinite too. The fact that we are self-conscious beings makes our relationality, complexity and infinity even more relational, complex and infinite. Actually, strictly speaking, you can’t get more infinite than infinite.

Fine, but you get my point. The key thing is that despite all this, and despite the fact that we exist on two levels (both as physical beings within the physical universe and also as conscious beings within our conscious minds) we also exist as one integrated whole.

So, how can we exist at two levels at once, as complex, relational, infinite entities and also as simple, single, integrated wholes?

The answer is that, unlike most other things in the universe, we are conscious. Our consciousness has an extremely rare, if not unique, quality. It is self-creating. We are never not conscious of being conscious. We can only ever be conscious of being conscious (of being conscious, of being conscious etc. etc.).

Self Self Perception Creation

Self-consciousness is a product of our self-perception, which is experienced through our self-consciousness

Our experience of life, of our existence, is therefore something we create within our own consciousness. Consider the riddle of the red rose: are the qualities of being red, and a rose, qualities that exist within the rose, or within our consciousness, or somehow both? What happens when the lights go out?

Question: Is a rose red at night?

What we create depends on what we perceive. In a relational universe, things look different depending on your perspective. What one person sees as ‘health’ and ‘practice’ may be quite different to another. So our job as health practitioners will vary depending on the perspectives we take, and the perspectives our patients take.

Rather than try to define the undefinable, or to pin down the ineffable, we have suggested that a useful perspective might be to see ‘health’ as a form of integration and harmonic balance between all the relationalities of ‘existence’. It then follows that ‘health practice’ may be seen as the attempt to help patients to achieve this integrated, harmonic balance.

As we have seen in the previous workbooks, we can only experience the relationalities of existence from one of three perspectives — as an individual experience of ‘me’, as a shared and co-created experience of ‘we’, and as an external and remote

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Can we arrive at health by algorithm?

It’s not experience of the ‘other’. These three perspectives give us three different sets of tools

that we can use for our creation.

1. The most important tool that each of us has is ourselves. Without us there would be no health practitioners and so no health practice.

2. But there are many, many 'other tools. These others can become tyrannical if we attach too much importance to them but, if we can keep perspective, we can use them skilfully to add texture, depth and quality to our creation.

3. Finally, because we can only create health in partnership with our patients, they are our tools too (just as we are their tools). We have to work skilfully together with our patients not just to create, but to co-create, better health.