This transcript has been edited for clarity.
Eric J. Topol, MD: Hello. I'm Eric Topol for Medicine and the Machine. I'm with my friend and co-host, Abraham Verghese. This is actually the last Medicine and the Machine podcast. For that 5-year run we're especially grateful to all our listeners. Our guest today is Dr Gavin Francis, who is a prolific author as well as a physician in Scotland. Welcome, Gavin.
Gavin Francis, MBChB (Hons), BSc (Hons): Thank you for having me on the podcast.
Abraham Verghese, MD: Welcome, Gavin. It's been a while since I've seen you. You've had an extraordinary career as an explorer, a traveler, a writer, a general practitioner, and someone at the forefront of the COVID response in your community. We're delighted to have you on. This is a fitting last show for us, Eric, to talk about issues like this.
Topol: Absolutely. Gavin, you're a prolific writer but also a keen observer. I wonder, because you travel around the world, if you're particularly astute. I know you have a book in the hopper about the National Health Service (NHS) — Free For All — but the one we have our hands on, Recovery: The Lost Art of Convalescence, is a pithy book full of wisdom. Tell us a bit about it.
Francis: I am a general practitioner in Scotland. I work in the city of Edinburgh and also in the rural Highlands of Scotland for part of my time. I had just finished writing an account of primary care responses to COVID in the United Kingdom, but in 2021 into 2022, I realized that as a primary care physician, I was spending more and more of my time talking to patients about recovery — from COVID itself, of course, because most people with COVID never go near hospital, they stay in their own homes; but also recovery from the damaging mental health effects of the lockdowns. I realized that I was having the same conversations, again and again, about principles of convalescence that I take for granted but that many of my patients did not.
So, I decided to distill all these conversations, and reflections, and observations, and the wisdom of my own mentors over the years into this one short, accessible book. That's the origin story for the book.
Verghese: I found it quite delightful because, at least in America, we're focused on acute illness or on rehabilitation, but not in the sense that you made it. Here in the United States, it's much more about physical rehabilitation and nothing else. Is this something unique to the British sensibility, the idea of convalescence and the receptivity toward such a notion?
Francis: I hope it's not uniquely British. I was trained very much in the Western tradition, the biomedical model of illness. As in the United States, most physicians' training takes place in hospitals. The majority of patients, as soon as they can walk back and forth to the toilet and dress themselves, are discharged from hospital. It's only once they're back at home that the journey of recovery really begins. It's a journey that can take many months with all kinds of conditions, and general practitioners are much more closely involved in this.
So, it wasn't until I became a primary care physician out in the community that I realized what a big part of my job involves guiding people through recovery. The word doctor comes from a root meaning "guide," and I often feel that I am a guide for my patients through these stormy waters and challenging landscapes of recovery. I suppose I wanted to offer this book as a way to help guide others through that journey.
Topol: I see a common thread, Gavin, with you and Abraham, where you have the human-human bond. You cue into that in a special way. A lot of the wisdom you impart in this book is about that: the sensitivity, the presence, the things that Abraham has been working on for the past many decades. Would you agree with that?
Francis: I'd love to hear what Abraham thinks. Certainly my own journey as a doctor has made me realize, first of all, what a wonderful job it is. It's a rewarding, satisfying job. Can you ask for any better occupation than to take scientific knowledge and use it and dispense it in small doses every day to make people feel better? I mean, it's a wonderfully rewarding thing to spend your time doing.
But as I've gone on in my career, I've realized more and more that different kinds of patients respond better to different kinds of doctors, and different kinds of situations respond to different kinds of doctors. I wanted to write a book that was aware of that sensitivity. Some situations call for a paternalistic, science-based approach. Some situations call for a much more collaborative, warm approach, with an arm around the shoulder of your patient.
My own sense is that the very best doctors, such as yourself and Abraham, the very best doctors modify and adjust their consulting style according to the kinds of patients they encounter. It was lovely to write a book that dug down and explored the magic that happens between a doctor and a patient when the consultation is going well — the truly therapeutic encounter.
Verghese: I marveled at the book. It's full of wonderful background on the history of convalescence and lots of pithy pearls to offer patients. It was a wonderful, quick, and enlightening read.
I want to pick up on one aspect of this, which I hadn't thought about until I read it in your book, and that is travel or pilgrimage as a form of recovery. I know many friends who've made pilgrimages to the famous churches in Spain, doing that famous trail. It was in part a physical effort, but it was also a kind of spiritual recovery exercise. It's interesting to make that prescription to patients. Take a journey. Make a pilgrimage and find your soul. I think that today we're hesitant to say these kinds of things. But I must say, you've given me some courage.
Francis: That's good to hear. If you go all the way back to the origins of the English language, to Chaucer and The Canterbury Tales, it's a pilgrimage. Some of the characters on the Canterbury pilgrimage frame it explicitly as a healing pilgrimage. I think before we had modern medicine, people would often make journeys to shrines or to healing water, wells, and springs.
Sometimes it must have been the journey that helped. It must have been the act of preparing yourself and girding yourself for what might have been a bit of an ordeal, but then placing yourself in a new set of contexts with new people, thinking about your illness in a very different way. And then we can't discount the tremendous power that we're only beginning to understand on top of that: the power of the placebo.
I can't think of a more powerful placebo than making a long and difficult journey to behold a magical object about which you've already heard many testimonials of cure. That may have been part of it too. I sometimes wish I could prescribe a holiday or a pilgrimage for my patients. Maybe I should start trying.
Topol: You mentioned COVID, Gavin. For the past 4 years, Abraham and I have been covering COVID pretty intensely. I suspect that some of your patients are suffering from long COVID. What do you do when hopes are not particularly sanguine, when we don't have a treatment or much to offer these folks? It's a challenging situation.
Francis: Absolutely. I'm aware that for a lot of medicine we don't have good cures. Modern medicine is good at mitigating and palliating, and at softening and blunting the effects of disease. But many of our conditions hold disease in abeyance rather than cure it.
I'm aware as a general practitioner that much of my job is about that and also about trying to help patients purely by telling them what has helped others. So, with a condition like long COVID, which is so poorly understood at the moment, I'm not able to fall back on that biomedical reassurance of telling them exactly what's going on in terms of molecules and chemistry.
But I can tell them, "Well, this is what the physiotherapists in the rehabilitation department say. This is what they have found is most helpful." I can tell them stories of other patients. I can tell them stories about recovery from other kinds of chronic fatigue or chronic breathlessness, because one of the principles of this book is that we gain when we think about medicine as more than just pharmaceuticals.
We gain when we realize that, for some people with chronic lung disease, joining a choir may be an effective therapy or, for some people with Parkinson's disease, joining a dance class may be effective therapy. If we broaden our awareness of what constitutes a therapy, we gain, and we can explore whole other ranges of options for our patients.
Rather than seeing ourselves sitting opposite the patient, shrugging and saying, "Sorry, we don't understand this condition, I've got nothing to give," instead we can come around the desk, sit beside the patient, and say, "Let's go on this journey together. I'll tell you what some other people have told me."
Verghese: Related to COVID, you quote the Indian poet Rabindranath Tagore, who says that in the rhythm of life there must be pauses for renewal. One thing that struck me about COVID — especially in America — was that many of us professionals have been on this treadmill, this rat race, where it was just work, work, show up every day, renew on the weekends.
And suddenly came this moment, an extended moment, when people were at home for a long time, and they began to rediscover their families, rediscover their purpose. And as a result, we are now struggling to bring people back to the workplace. Maybe we shouldn't expect it at all because everybody has sort of decided that was a crazy kind of life, that there's a better way to do this that's more holistic.
So, I'm struck with what COVID did for many of us who never got COVID. It made us reassess what we were doing. Would you agree with that, Eric?
Topol: Absolutely. I think we're still processing this. Gavin, I'm sure you have some ideas as well.
Francis: I find that a lot of my patients reconfigured their priorities during COVID and realized that they wanted to build a life with more time for their families, more time back home. As a general practitioner, about one third of my workload in a normal day concerns mental health. But during the worst of the lockdowns, it became more like two thirds. Huge numbers of people were struggling with panic attacks and insomnia. People were becoming quite paranoid because of so much public messaging of danger outside. A huge amount of negative mental health effects was caused by the lockdowns.
But within that, I saw real transformations of life, too — people who had never stopped in their whole lives suddenly were taking time to "dig their gardens," both metaphorically and literally. Adolescents are another good example. Some adolescents find school very challenging, and suddenly, when the schools closed, they flourished.
What I've tried to do with those conversations is to encourage people to listen to that, act on it, and try to build a life that includes more of what they found positive. Most people work too much. Most people work too hard. Wouldn't it be better to drop the intensity of work? Then you may well find that you can work longer.
Topol: Speaking of working hard, you have written nine books and you're not even 50 years old. Help us understand how you balance your life as a physician. How do you achieve balance in your life?
Francis: I love practicing as a physician. I love my medical work. I became a general practitioner in the community because I love the diversity of that work. I was lucky enough to realize early on in medical school that I was more interested in people than in diseases. I was never going to find an organ or a disease that would satisfy me or that could sustain my interest over a 40-year career. The diversity I see in the community clinic extends now as I divide my time. Three weeks out of four, I work in Edinburgh. I work in a deprived area of the city with a lot of immigrants who don't speak English and who often have multiple deprivations.
One week out of four, I work in a remote part of the Scottish Highlands, where the population is extremely thinly dispersed. I cover about 1000 square miles, with a population of just 1500 within the 1000 square miles. So, I get to practice medicine up there, but I also have a lot of time to write.
I'm eminently interruptible when I'm on call up there. I find that rhythm helps me, and the writing helps me too. I don't know how it is for you, Abraham, or for you, Eric. But for me, writing uses such a different part of my brain that to write is to refresh myself.
I find that after a couple of days of spending a lot of time writing, I need to go to clinic. Clinic refreshes me. Then I become quite exhausted by the demands of the other people and then I find that a day's writing refreshes me. The two are mutually refreshing.
Verghese: I would completely agree with that, except I think our temporal frame is slightly different. It took me 14 years to write my last book. So, I need to take some lessons from you.
I want to turn to something else that struck me in the book. You talked about a personal experience: You were having a lot of headaches and an MRI indicated that you needed surgery. But then you had to wait months for the surgery, so you were forced into a convalescence on your own.
I know this is not the topic of our discussion, but I'm curious about the difficulties you face in the NHS, especially of late. We seem to hear from this end about increasing difficulties. How does that translate to your own experience as a general practitioner? What is it you're seeing? What are the challenges?
Francis: The challenges are mostly about accessing secondary care. In the clinics where I work, I'm well able to look after patients who only need primary care. But as you know, the UK's NHS is an extremely cheap way of running a national health service. It costs less than 9% of GDP, whereas your figures in the United States are double or even more than double that in terms of amount of GDP spent on health. So, it's a budget service here. Our politicians have managed this by trying to prevent the amount of money going into it from increasing.
What's happened is that the waiting lists to see the specialists have gotten longer and longer. So, right now, at the end of 13 years of our current governmental administration, we're facing a 2-year wait sometimes to see a specialist in clinic for some of the specialties — vascular surgery, for example. Routine colorectal surgeries take a year. It can take up to 2 years to see a dermatologist.
That is frustrating as a general practitioner because I can manage eczema, for example, or peripheral vascular disease up to a point. But when I refer my patient to a dermatologist or to a vascular surgeon, it's because I've reached the limit of what I'm able to do as a primary care physician. Now I need a specialist to take over, and then to find that a specialist is going to take a year or so until they see my patient is very frustrating.
That's the main challenge I see on the ground. But I should point out that the job remains immensely rewarding because I can manage most of my patients without having to involve secondary or tertiary care. Most of the problems I can manage fine myself. That's as satisfying as it's always been.
Topol: Has the change in the length of time for secondary care been more sudden in the past few years? Or has this been a steady problem throughout?
Francis: It has lengthened since 2010 because there was a change in government in 2010. The new government that came into power saw the spiraling costs of the health service caused by the aging population and didn't want to increase the funding to the NHS in the way the prior administration had. So, they chalked off increases to funding.
The funding hasn't kept pace with the demand on it, so much so that the CEO of NHS England in 2017 said that the NHS is no longer funded adequately to meet the demands that are being placed on it. That was 6 years ago now and 3 years before COVID.
The huge stress of the pandemic flipped us into a new paradigm. Things were getting quite bad in 2020, after 10 years of this underfunding. Then COVID flipped us into a new paradigm, where wait times have suddenly lengthened quite dramatically since 2021.
And now, of course, the junior doctors are out on strike in England because they've seen a drop in pay in real terms since 2010. When the doctors go on strike, that makes the waiting lists even longer. So, the NHS in the UK is in a bit of a pickle right now. I would argue that it's purely because it's always been a very cheap service when compared with other developed countries. It's been obliged to become even cheaper over the past 13 years, and the demand isn't able to cope.
Verghese: Has this driven more people to private medical care? Will that be a stimulus to put more of the cost burden onto the patients to seek private care for things to become expedient?
Francis: Definitely. It depends on which part of the country you're in. I've heard it said that in London, over 30% of healthcare is in the commercial sector anyway. Whereas in Scotland, where I live, it's traditionally been a small part; I think it's less than 5%.
When I started my career — I qualified in 1999 and became a GP in 2005 — it was rare that patients would go into the private or commercial sector for a procedure. Usually only the very wealthy would do that. Now it's quite common. Anyone who has any savings will do that, particularly for straightforward procedures such as cataract surgery or a hip replacement. They'll just go into their savings and go straight for it, not through insurance — just paying outright through their savings.
Topol: When I was asked to write the review of the NHS and the future of technology, artificial intelligence (AI), genomics, and a digital NHS for the workforce, it was just before the pandemic. The people I got to work with were upbeat, and yes, there were things in the background, as you described, Gavin.
But interestingly, the NHS in the UK is a world leader in genomics and intends to be the world leader in AI. So what's interesting is that the care of patients is underfunded, and they're still putting whatever resources they have into trying to find ways to restrain the growth in the workforce, which is stressing the costs of healthcare. But it's kind of interesting that they have set priorities in the country to maintain their reputation and contributions.
We have this All of Us program in the United States. It's taken 7 years to enroll 500,000, whereas Our Future Health in the UK has enrolled over a million people in less than a year and it's doing gene sequencing on everybody. It's interesting how the UK strives to be research-dominant but is not necessarily using some of those funds to deal with the day-to-day medical problems. What are your thoughts about that?
Francis: When the NHS was created in 1948, it was with idealistic — some would say utopian — post-war thinking. Famously, the minister for health who brought in the NHS in 1948 was a former miner. He said that illness is not an indulgence for which people should be punished. It's a misfortune, the cost of which should be borne by the community, which is a lovely kind of distillation of an idea that illness is bad luck. So if you're going to offer good healthcare only to wealthy people, that's even worse luck. It was an idea of collectivizing healthcare and collectivizing bad luck.
That philosophy of cradle-to-grave healthcare — that's how it was sold to the population; this service will look after you from cradle to grave — means that pretty much everyone in the UK is registered with a primary care physician. Everybody's registered as part of the same system, and we have the most extraordinary data as a consequence.
There are 67 million people in the UK, and they are all registered with the same healthcare system. So once we start talking about genomics or even incredible work that's being done in the UK on diabetes management, it is because the datasets are absolutely extraordinarily vast to manage these things.
I would hope that's one of the reasons the UK has remained a world leader, because it's one of the benefits of having a truly national health service that everybody is signed up for. The sadness of the past few years is that people don't trust it as much because its funding hasn't kept pace with the expectations. That starts to shatter it into different kinds of providers, which means that we don't have such a big uniform dataset of everybody being part of the same system.
Verghese: I want to mention the tradition of physician writers bringing about social changes. It's quite impressive, beginning with The Citadel, the book by A.J. Cronin, a fellow Scot. Many people credit that book with capturing the nation's attention and making the idea of the NHS palatable. It took the country by storm.
I won't say it resulted in the NHS, but it certainly sowed the seeds for people to be receptive to that idea. With that sentiment, I want to compliment you on managing to wed a wonderful, meaningful career as a physician with this ability to comment on medicine and aspects of medicine in such a beautiful way. It's been our privilege to get to chat with you. We're looking forward to many more books in the years to come.
Topol: Gavin, you're a unique force because you not only have written books about your travels around the world, but also — and I don't think anyone else has done this — you've written all these books about medicine. I first got to know your work through Adventures in Human Being. It was around 2015 when you wrote that. It was an amazing book.
Before we close, I want to comment about something that is maybe a thread between your advocacy for patients in recovery and for our physicians and clinician listeners who are struggling because of burnout. It seems as though you found a solution for the balance of writing, just as you mentioned dance and pilgrimages and other things that you recommend to patients. Can you comment about that as we close — how to deal with burnout, how to come up with things that will preserve clinicians' mental health?
Francis: I combat burnout, first of all, by trying to keep my clinical workload manageable. I realize that I'm a better doctor when I'm rested and refreshed. My patients get better faster. And I enjoy the job. It's about managing my clinical workload.
Once my clinical workload is managed, it's about finding plenty of the things that refresh me, like building a team, because one of the great pleasures of healthcare is the teams we work in — the most extraordinary colleagues, wonderful people to work with. That goes all the way from the receptionists at the front door to the clinic right up to the professor.
When I think about how much I love this work, and I'm asked about burnout and preventing burnout, I try to encourage all my colleagues to connect again with what they love most about medicine. It's an amazing profession. It's an ancient profession. People have been doing it for thousands of years, and they'll do it for thousands of years to come.
You get to do this wonderful thing of meeting people, using all your scientific knowledge and training to make them feel better. If you can connect to the joy of that exchange, that encounter, that engagement of using your skills and knowledge to make people feel better all day, then I believe you'll enjoy your work and you'll be much less likely to burn out.
Verghese: Beautiful.
Topol: Thank you, Gavin. This is such an apropos closing of Medicine and the Machine. I think what we've learned in the past 5 years is about medicine and the human-human bond and the machine. You exemplify that. We're lucky to have you on our closing podcast. Thank you so much for joining. And we'll be reading your work and following you for years to come.
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