DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance.
Date of interview: 5th October 2020
Number of confirmed cases at time of interview: 78,247
Number of deaths at time of interview: 1995
Population: 10.28 million
Our interviewee this week is Dr Nina Monteiro, a family physician from Portugal and the former Exchange officer of our WONCA VdGM Executive Board. She is currently doing a PhD in family violence and is also a member of the WONCA family violence special interest group (SIGs) and lead for the VdGM family violence SIG. For the uninitiated, WONCA has a series of SIGS and Networks depending on your interest and I recommend that you email them to find out more about how to get involved. I was keen to interview her for because we have heard worldwide of the increase in domestic violence and child abuse during the pandemic and I knew her insights would be valuable as a working family physician.
So where do we start? We, in the UK, are facing a second wave as is Portugal and we start by talking about whether you can truly call it a second wave when the prevalence of the virus hadn’t really been suppressed sufficiently during the trough. When we share our experiences, it seems so painfully similar. During the initial stages, the elderly were affected and now it’s the younger members of our population but, when I compare our death rates, I’m rather surprised to see that we have 20 times more deaths in the UK. Admittedly we have six times the population but our deaths per capita seem to be much higher. Not that I am a big believer in being able to directly compare statistics but I couldn’t help wondering what their “secret” was – as if there was a magic formula to minimise deaths and hospital admissions.
A huge difference (and a possible contributing factor) is the level of government messaging that they are receiving. In Portugal, there are still have daily messaging by the Health Minister and the Head of the organisation managing the health system (I wonder if this is like NHS England). Further to this, the GP is tasked to call patients who have tested positive every day to remind them of the isolation rules until they test negative again. She is quite clear that the work that she does calling the patients is separate to public health who try to find links and clusters. We know that, in the UK, compliance is poor – possibly due to confusing government messaging – and I wonder if a daily call from their friendly family doctor is a way to hold individuals accountable? I find this really interesting because I’ve heard that this is also done in Turkey and just cannot imagine how much extra work that this is for the average family physician. What does Nina think of it? She says that the benefits are that people can stay at home with confidence and do not go to hospitals unnecessarily but she does describe it as clinically boring and it can get slightly awkward when it’s the eighth consecutive day that you’ve called them. Much like the UK, Portuguese primary care is trying to catch up with the backlog whilst managing covid which means more tasks, more targets and more work. In many ways, we agree that the initial lockdown was easier when we were all acting like covid was the only disease in the world. Now general practice, in both countries, is facing difficult times since being squeezed by rising covid numbers and mental health crises, ongoing chronic disease work, and minimal investment from the authorities.
The Portuguese Minister of Health has urged patients to see their doctors since the healthcare system is now “back to normal” which has left a dissonance between patient expectation (i.e. able to get an appointment) and the resources (underfunded with extra workload). We know that managing patient expectation is so important and when we don’t reach this mark, this will undoubtedly lead to disappointment and negative feedback. This worries me about the doctor wellbeing across the world since most of us have worked flat out for eight months without respite. Nina says that it would be fine if we had an end-date – we could pace ourselves and suck it up if we knew when it would end. We both look at each other and sigh, only reflecting the mood of our nations.
Fascinatingly, we talk about our different experiences of remote consultations. In Portugal, they are seeing all children, pregnant women, family planning and poorly controlled chronic illnesses. Nina finds that telephone consultations are leading to more investigations because we can’t examine them as easily. We are no different in the UK and I find this transition hard to swallow. I’ve always loved our judicious use of investigations in the NHS and cherrypicking the right investigations that would change my management. However, needs must and I’m interested to see what the long-term consequences of this will be in terms of resource use and patient satisfaction. I also wonder about the reassurance that we offer patients by touch – a ‘thorough’ examination almost acting as well as a placebo. One of the things I am finding a lot easier, however, are the mental health consultations. Maybe it’s because of our indirectness of British culture but I find people are much happier talking about their mental health on the phone- perhaps because of the anonymity and the fact that they can’t see my expression. I wonder if this is what confession at the Church feels like! But Nina finds the opposite. Her patients prefer to come in face-to-face to talk about their anxiety and depression and, on occasion, have refused to speak on the phone about it. I love hearing about these small cultural differences because, as family physicians, when our ethos and our principles are the same, the way we practice varies only by the culture of the population that we serve and reminds me how adaptable our profession is.
We move onto the topic of family violence – what I’ve wanted to talk to her for ages about. Being 24 hours with one’s abuser in times of stress and uncertainty can lead to arising conflict between couples. We have seen a huge rise in child safeguarding cases in the UK and I’m sure this is only the tip of the iceberg. With the reduced socialisation and the difficulty accessing healthcare, a rise in intimate partner violence can only be expected.
I ask Nina what we can do as family doctors. She says that even calling the victims to remind them that you’re still there and give them contacts to stay in touch can be enough. She warns us about paying attention to red flags. If a person is making a lot of complaints that don’t add up or the dots just don’t connect, just think what can be behind this – the hidden agenda. “How are things at home”, “How has it been during lockdown?” A common reason a victim gives for not leaving an abuser is the lack of economic independence and this may become more of an issue as we face the ensuing economic and social crisis. She says that don’t be afraid to ask. Stressful situations increase the risk – alcohol abuse, economic instability, disability (either victim or abuser). There is a fear of asking because we don’t know what to do next so she advises us to learn how to manage it as much as you would chronic diseases. She describes a cycle of abuse. The first stage is when tensions are rising. There are stresses in life and the abuser can feel ignored or threatened. The victim may choose to be docile to avoid provocation or even provoke the abuser in order to get the abuse over with. The second stage is the incident – the violence, whether psychological or physical. Once this negative energy is expunged, the abuser may feel guilty or even feel remorse and the pair enter the reconciliation phase – promises to change, gifts, expression of remorse. The final stage is the phase of calm when the relationship can feel relatively normal before interpersonal difficulties arise again and thus brings us back to the first stage of the cycle. Nina explains that victims are most likely to walk away after the second stage and we must be ready to support when they choose to do so.
It’s important to check what local services are and what your local laws state. In the UK, the victim is seen as a consenting adult, so we can give support but we cannot do much more. If there are children involved, we are obliged to refer to social services but we can’t do this if there is only the couple involved or if the children are adults. I always found this a little frustrating but Nina explains that this isn’t a bad thing. In Portugal, family violence is a public crime which means that everyone is obliged to report it including doctors. But it gets complicated because if you’re going to report an abuser and the victim is still living with them, it can lead to an escalation of violence. What I find interesting is Nina’s approach to autonomy in these cases. Following a risk assessment – whether to report or not to report- she prefers to allow the victim to make their own decision. Being in a relationship where everything is often dictated for the victim, she encourages the doctor-patient one to be collaborative and not to mirror the one of the victim-perpetrator. I hadn’t quite seen this parallel and the violence we, as doctors, can cause by being directive which would lead to a breakdown of the relationship with the only ally the victim may have.
I’m also interested to know about whether there are cultural differences to family violence. I was particularly struck by this several years ago when I was in my home country, Japan, and I was watching an interview of a Japanese celebrity after his wife very publicly left him. “I didn’t cheat on her, I didn’t hit her, and I don’t drink…” as an explanation to why he was a model husband. Through my European lens, this phrase really stood out for me because this would have been met with outrage in my other home country, the UK. Nina explains that family violence occurs all over the world but there are cultural differences in the perceptions as what constitutes violence. Nordic countries famously have higher numbers of reporting but only because they have a lower threshold to what is counted as unacceptable. We know that cultural and social norms are so important in shaping individual behaviour and I wonder if one of the things that we can do is to remind our victims that any form of violence, provoked or unprovoked, is not ok.
Thank you to Nina for the time she gave this interview. The work that you do on family violence is inspirational and I’ve really enjoyed working with you on the VdGM exec. Sending all my love to my Portuguese colleagues as we face this second wave.
WHO guidance on changing cultural and social norms that support violence