Dr Catherine Calderwood on the need to treat people, not patients
It has been just over a year since Dr Catherine Calderwood stepped into the role of Scotland’s Chief Medical Officer (CMO).
“I tell people who ask me I’m ‘getting used to it’. That’s probably the easiest way to sum it up,” she says.
There is no sense of missing her former life as an obstetrician, however, as she is still practising.
“I still see pregnant women when I can. It’s not my clinic anymore, but I still have it once a fortnight, on a Friday.”
Introducing the Holyrood baby - a letter from the editor
Her chances, your choices - Introducing Kirsty, the Holyrood baby
She tells Holyrood she believes she is the only CMO in the UK to have continued clinical practice after being appointed. It allows her to see first-hand and experience the frustrations of front-line NHS staff.
“I was so frustrated trying to get somebody seen in a timely way and I got moved from department to department. That was me, the obstetrician, I suppose, if it was me in here, they’d get it sorted. But I did it the same as any doctor would have done, and you know, was passed on, ‘sorry, I don’t have the right rota’, ‘it’s this extension number’ then the number was wrong.”
Keeping the two jobs going allows her to experience that frustration, she says.
“The obstetrician bit is who I am.”
In both her roles, then, Calderwood is the perfect person to be introduced to Kirsty, the Holyrood baby. As an obstetrician, she expresses frustration that Kirsty has already been born. Already, she says, Kirsty is “programmed” by her mother, Caley, whether it be smoking, breastfeeding or other choices.
“If I can give you an example of a woman who is obese when she’s pregnant, then what happens in the utero environment changes the child’s response to a bad environment. So that child, once born, will have a worse response to all the different risk factors.
“A child whose mother has a BMI of 40 when she’s pregnant has five times the risk of dying of a heart attack at the age of 50, so the mother’s womb programmes the child. So even if the child doesn’t smoke or do any of these things, it is still born with the risk, and if the child does go on to smoke etc, those risks are compounded.”
Caley is pregnant with Kirsty while the Scottish Government is reviewing its maternity services. Calderwood says it is “a very interesting time”.
“If Kirsty has been born into this deprived part of Scotland, then her mother is in deprived circumstances, and therefore all the effects that has on the baby, by the time she is born, they are already affecting her.”
Even if Caley has avoided smoking and alcohol, and isn’t obese, she is far more likely to have a poor diet and low levels of physical activity, she says.
“The simple way to put it is it pre-programmes the baby. If the teeth are worse, there’s a link between teeth and pre-term delivery, she probably has a low-level infection. If all the things you think about deprived communities and the risks, the baby isn’t born ‘new’ from scratch.”
The aim would be to get Caley into maternity services as early as possible, says Calderwood; a midwife would advise on nutrition, cutting out alcohol and smoking cessation – something Calderwood says maternity services are “getting much better” at supporting.
Physical activity, too is becoming a major recommendation. “Even if you’re not used to doing any, we know it can make you feel better, it makes them fitter. And if you look at labour, it potentially is quite a stressful exercise. People being fit actually have better labour outcomes, generally.”
If Caley was to become a “late booker” – someone who doesn’t engage with maternity services by week 16, it carries its own risks, warns Calderwood. These tend to be people who are quite young, don’t have support from their family and may be in denial about their pregnancy.
“What I would say about that is we don’t make it easy for people to access us, sometimes,” she says, remembering cases she had when she ran a clinic in West Lothian, who had to get two buses to attend appointments.
“I had a woman who couldn’t read as one of my very complicated patients, her partner was her carer and so he had to come with her. Two buses, and because she couldn’t read, she didn’t know what bus was coming.
“They had three other children, and that was an absolute drama for them. She often didn’t come, and it wasn’t her fault. She wasn’t being bad or uncaring or anything, it was just with three other kids and all the other stuff going on, and no money coming in apart from the carer’s allowance.”
Efforts are being made to remove such barriers, Calderwood insists, pointing to the way ‘deep-end’ GP practices and community midwifery have broken down barriers with the use of extra resource to support the time to take an asset-based approach.
Calderwood’s first annual report, published in January, stimulated a national discussion on what she calls ‘realistic medicine’ – where doctors are encouraged to use fewer treatments and listen more to the wishes of patients, or as Calderwood prefers to call them, people. She says she has been satisfied by how the idea has taken off, and has spent a lot of time going round the country talking about the concept with various professionals.
Social media has pushed the conversation beyond Scotland too, she says, with her report still being retweeted 50 to 60 times a week four months on.
“The patient has this whole other life, and if you call them a patient, you narrow them down into that little box. Actually, it’s far better to think of them as the person they are the rest of the time. I think there’s a shift, we’re starting to shift conversations.”
What does realistic medicine look like for Kirsty’s mum? Calderwood says it is about balancing service needs with the needs of vulnerable people. Health literacy is also a factor, she says.
“Forty-three per cent of working-age adults can’t work out the dose of paracetamol for a child from the side of a bottle. We talk to people, I think, without necessarily recognising what level their understanding is.”
And for somebody in their first pregnancy, like Caley, it is about remembering how unfamiliar the experience is.
“I know myself when I was in labour for the first time, everybody said, ‘why were you scared? Why was it scary? You’ve seen it every day.’ Yeah, but it’s never happened to me before.
“I was much less scared, actually, because at least the people were familiar faces, the people I worked with, but imagine feeling like that in a completely alien environment. I knew where the stairs were, I knew who was coming to see me, I said ‘hi’, I knew what the rooms looked like, and I was still scared. That’s a familiarity, not putting yourself in the shoes of Kirsty’s mum.”
But at a time when many professions in both health and social care are expressing concerns about workload and the length of time they get for appointments, is it possible? Calderwood acknowledges these have been brought up in the ‘realistic medicine’ conversations.
“Kirsty’s mum’s midwife will have far more work than midwives used to have, because we’ve added in screening, smoking cessation, all of these things, and the midwife’s role has changed.”
This, she offers, is why the Scottish Government is investing in more midwives and health visitors.
The other aspect to come up in approaches to realistic medicine is mental health. If Caley had anxiety during pregnancy or post-natal depression, it would have a direct impact on Kirsty’s chances of suffering from mental illness. With twelve per cent of pregnant women experiencing postnatal depression, it is the most common complication in pregnancy.
“And we’re not good, we talk about having a clot in your leg, pre-eclampsia, we talk about diabetes, but postnatal depression is more common than all of those. It’s disproportionate,” says Calderwood.
Mental health feeds directly into understanding the person rather than the patient, according to the CMO. She describes a survey which revealed “the same disconnect”, a gap between what medical professionals thought people wanted and the reality, particularly at the end of life.
“The doctor was saying, ‘yes, we’re giving them all this treatment so they can live longer’ and then they asked the actual people they were treating and they said two things: they wanted to be symptom free, and wanted to spend time with their family. None of them mentioned living longer,” Calderwood remembers.
She says health and social integration is currently focused on “delayed discharge, and at the end of people’s lives”, and should be starting to look at how it can help people like Caley by linking maternity, social services and mental health support.
As preventative spend, maternity services can stop many problems in the health service in the future, she suggests.
“Investing in the mothers means investing in the children and the teenagers.
“It keeps going back and back and back. I’m always talking about the midwives and the obstetricians and preconception – that’s the future health of the nation. Nobody recognises that. It’s the downstream preventative investment.”
And as for the maternity review, Calderwood hopes it will not just change outcomes for mothers and babies, but listen to them too.