Dignity

Let's try and keep it dignified.

Please, no wailing and gnashing of teeth at this news.

Bwah ha ha ha ha ha haar!

Sorry.

I'm composed again, now. A clinician stops meddling in GP processes and making ill informed decisions on health systems he isn't informed about and returns to clinical practice. Huzzah!

Narcissism

I've good GPs in my corner. Sensible folk, with too much to do and not enough time to do it in, genuinely devoting themselves to their patients' care. I know this because not only do I write to them, a lot, and receive letters from them, a lot, but patients talk about them.

When we meet I habitually explain who I am and why we're meeting, which invariably involves a comment that Dr X felt Blah was going on and we could meet up to think that through, is that a fair comment, what's the truth of it, what're your thoughts on what's going on? The patient then can chatter about either the matter they've been referred with, or the GPs framing of it.

Sometimes it's helpful because they can talk through a another person, such as "The GP says I'm losing my memory, but I'm not, I'm fine," which then can lead on to why would the GP/spouse/daughter reckon your memory's not so good, and so on.

The last way I know anything of the GPs is through meeting them. Rarely I meet them formally, in monthly training they do, if I'm doing teaching with them. Sometimes I meet them in their surgery, popping in after I've seen one of their patients, just to talk it through with them. More frequently I see them in practice meetings when a nurse and I'll meet with the GPs, practice manager and their nursing staff to talk through both operational/service stuff as well as clinical stuff (such as updates on management of different conditions, since without that patients were sometimes getting inaccurate and unhelpful details).

The written contact, formal contact, informal popping in, episodic practice visits and patient dialogue means I get a fair feel for different GPs in my corner. Mostly, they're very good indeed. Some are fantastic.

But it gets me thinking. Who are the good doctors? Which GP would I want for my kith and kin?

And that's where I come a little unstuck. I want a good doctor to generate a service that is accessible. To have no waiting list, at all. I want them to see folk where ever they may be, that's appropriate. I want them to have a motivated, passionate team of relevant disciplines working with them, to work with the doctor to orchestrate exceptional care (synergy, not parallel working). I want few prescriptive protocols since I want care for each patient to be person centred, individual, appropriate care. I want the doctor to have capacity in their service, so all health needs they determine can then be met by their service. I want the doctors/their team to be friendly and work helpfully and collaboratively with others in Primary and Secondary Care. I want the doctor to temper policy and guidance with huge doses of common sense.

And at that stage it kind of struck me, what I want in a good doctor is really what I'd be wanting from myself. Burst my bubble there, as it really is an act of supreme narcissism to think like that. Which helpfully has got me looking at colleagues who work differently, or construct a different service, to try and see the positive in what they're doing.

Plenty of ways to skin a cat, eh?

Cause and Effect

There's been a scheme of late, in an adjacent county, to promote breast feeding. It's been praised as a success. This is because the PCT and midwives and health visitors all have seen that more people have attended or had contact with breast feeding promotion, so more women have had the right information and support. More, patient feedback forms were used. They’re not ill, they’re not even under health services, but they’re still patients and not service users. Hmmm, odd, that. Ho hum.

Anyway, the patient feedback was embarrassingly good. Gushing praise ‘bout dedicated, passionate, informed breast feeding counsellors and peer support counselling and breast feeding cafes and baby bistros where mums could meet for advice and support from other mums and from informed/expert resources too. Mums love it, see it all as a great success and really value it.

Everyone wins.

The PCT wins, they commission a great community programme for young mums and babies, ticking the box for a national agenda (promoting breast feeding) in a locality where breastfeeding rates are low, at under 1/3 of the national average.

The acute Trust wins, saying they’re generating a great patient centred valuable service, through investing in staff and developing projects to invest in mums and babies, getting young babies off to the best start in life.

The local community/patient population wins, with mums saying it’s all great and generating oodles of feedback forms saying so.

A year on, a keen midwife and health visitor evaluated the impact of this combination of successful projects. Everyone was still optimistic, dedicated, enthused and happy. All was as popular as ever. Everyone saying what a fantastic development it is. The midwife and health visitor looked at breast feeding rates now, compared to the years gone by.

They’re no different.

A good idea is had. Good, passionate, competent staff develop the idea. Managers in the PCT fund the idea. The idea’s delivered and the patient love the service. Ticks lots of boxes ‘bout addressing a local failing in low breastfeeding rates, improving patient choice and community services and peer support and Local Extension of Services and whatnots.

But the service isn’t effective.

It costs a lot of money. The staff time (daytime and evenings), the ongoing staff training, the cost of the use of the properties it’s delivered in, all adds up. Adds up to quite a lot, actually. Massive investment (in time and money) to improve breast feeding, for no improvement in breast feeding uptake or mums maintaining breast feeding.

Should the health service continue to fund this?

We’ve an identical scenario in mental health services locally, that’s popular and well received and highly valued by patients, but doesn’t deliver any beneficial outcomes that patients or staff can see. But it’s just as hard to say that we’ll stop that and use the money in a different and better way, to be more useful. Both commissioners in both situations and flapping about “patient choice” and saying they like the “service” even though it isn’t an effective service.

Is seeing something and liking it and believing it’s doing something else a valid use of taxpayers’ money? Or a valid use of NHS staff and patients’ time? It’s a bit like reckoning that, statistically speaking, those people who have more birthdays live longer, thus I must eat more cake with candles on top. It’s all gone a bit peculiar.

Girl on Girl Action

We reviewed a lady in a care home. She was, "causing a disturbance."

She was holding hands with other ladies, talking suggestively, then at times cuddling, stroking and kissing them. She and the other ladies all have advanced dementia.

The care home sought advice on how to manage this.

Knowing my foibles, they'd already looked for delirium, considered diet and fluids and constipation, arranged for a district nurse to do bloods to exclude infection and common physical causes for acute on chronic confusion and sussed out and documented what the circumstances of this behaviour were.

A life long heterosexual woman, with an active libido throughout her life, she sought companionship and intimacy with accessible men.

Her dementia cued her in to selecting men through one principle determinant, which of a fashion makes sense. She'd progress amorous overtures to anyone in trousers.

I don't have a pill to stop that one.

Continuity of Care

Do patients like continuity of care? Or is it that folk favour a fresh pair of eyes and a new team looking at things?

There's been an irritating practice of late, in my corner, that as soon as someone turns 65 years old, they're referred from their existing working age adult mental health services, to mental health services for older people, and to me. It's flagrantly outwith our Trust's graduation policy, they're all read, shredded and filed carefully in the bin with a succinct letter back to the referrer, but it got me thinking.

Locally, patients we asked favour staying within existing services and didn't want to move on the basis of age alone.

Happily, 2 local audits of working age adult patients (well, they were called audits, but they were surveys) found that patients feel the same way that I do. If they've clinical reasons for being under my care, with stuff that I can do better, I'm keen to snaffle them on over to my corner. If they've no reason to transfer care, I'm keen for them to stay with their existing team.

Surely transfer of care on basis of age alone, not clinical need, is flirting dangerously with age discrimination, no?

Complementary Therapy

I work as a psychiatrist. Having trained as a GP and delivering all liaison psychiatry, I've a bent towards folk presenting with physical comorbidity. In my patch if you're physically unwell and have mental health problems, it's common that someone refers you to my door, or invites me to a case conference to throw in my 2p worth.

It was at just such a fortnightly meeting at the local district general hospital that I was delighted by the succinct, acerbic quip 'bout local independent practitioners.

A young lady had long term back pain, with a degree of sacroiliac and hip pain. Practical treatment had been of some benefit, but the crunch was that she'd knackered joints and a frenetic lifestyle/busy family so couldn't pace herself at a comfortable level. She'd seen a someone about her back between appointments (a chiropracter) who I'd not known, so when the Consultant was describing her care over the last month and mentioned this name, and I asked who this clinician was, it was with great candor that a physio chirped up, "Oh, he's the local quack. Rub you anywhere if you cross his palm with silver."
The lady was no better from seeing him. Apparently, few folk ever are. Ho hum.

The very next patient had problems after a below knee amputation after trauma. Again, discussion on practical and psychosocial and pharmacological management of his care. Young bloke, bad motor bike accident, loss of job and self esteem and social life, not doing too well. He'd also seen someone to help him, an osteopath to, "get him moving again" and sort out, "back spasm" that was, "stopping him walking." The name of the osteopath was not known to me. I asked who he was. It went quiet as medical collegaues tried to think how to frame it, but a physio who knew him well interjected helpfully that he was, "A charlatan."

Clarity of information, I love it. One of the perks of working in old pit villages, people call a spade a spade. As one old man said to me today, when I was asking about diagnosis and how much he sought to know of his dementia, "Tell it like it is, lad. Just tell it like it is." Complementary therapy better deliver meaningful outcomes, because if it doesn't, local folk sure get the measure of it pretty sharpish. And to date, results in my corner are woefully shabby . . .

Fiddling

I trained as a GP, after going to med school. I sought the continuity of care, of looking after folk over the long haul, rather than fiddling for a day then passing them on. I sought the clinical freedom to work as I felt best within my own practice, rather than as I was told to do by hospital managers. I sought work that was biomedical and psychosocial, that was complex and meaningful.

Through this, I found myself spending rather a lot of time in care homes. Most lunch times, in fact. I liked it. Meant I rarely got lunch (a habit that persists to this day) but meant that I could while away time with elderly folk, talking through what was meaningful to them (notionally the "patient agenda") and what was meaningful to me (reviewing their chronic health problems and drug regimens) whilst passing the time of day with what was invariably engaging conversation with interesting folk.

I knew I wanted to work with older adults early on.

Oh, the child health surveillance clinics were good enough. I enjoyed my paediatric SHO job, and obsterics as an SHO and in Primary Care. But rather than kids or young adults, it's always been the older adults I've gravitated towards. So often they ask for nothing, you want to give them everything.

I knew I wanted to be a psychiatrist before I'd even finished my VTS. Somehow I managed to get through all my psychiatry training with just 12 weeks of pure General Adult psychiatry (of which hospital induction, annual leave and study leave wiped out over half of it). I've nothing against General Adult psych, it's just not for me, I knew it never would be, so I didn't want to do it as an SHO. I didn't do any, after being an SHO. I knew I sought to work with Older Adults, so for me it was old age psychiatry all the way. Oh, I did my CAMHS and forensic and rehab and a few specialist posts as an SHO, but thought I may as well focus on what was useful to me rather than fiddle with working age adult psychiatry when I knew my enthusiasm lay elsewhere.

Overall I'm very grateful for all the training posts I've had. Life in A&E and in Primary Care teaches you a lot about triage, consultations, decision making and safety netting. Every post I've had has given me useful training that's shaped me into the clinician I now am. Even though I'm not a physician, there're translatable skills gleaned from that post.

I'm in the habit of visiting all GPs in my patch. Some don't want to meet and over years the only contact we've had is through letters. Some want to but are too busy to. Mostly, though, meeting GPs is a good thing that's welcomed. Firstly so we can wrangle over how we can collectively iron out any wrangles. Secondly so we can share news on patient care (what the guidance released in March 2009 says about schizophrenia, how we should manage vascular dementia vs what stroke outreach do, how acetylcholinesterase inhibitors and memantine's used locally). Thirdy so we can form better relationships, with fewer barriers and more common sense.

One problem GPs have is what's happening in care homes. Out of hours, when struggling, especially if poorly staffed, care homes call the out of hours doctors. The doctors are presented with skewed information by the care home, of an unmanageable patient in profound distress who's generating risk to themselves and to others so needs something doing right away. Dementia typically progresses over months and doesn't typically get worse over minutes/hours - if they were settled at 4.00pm why are they now unsettled at 7.00pm? Their dementia's not warranting hospital in-patient care, suddenly, so what can the on-call doctors do? The deterioration could be delirium, so could be managed medically in Primary or Secondary Care. Usually the care home's just after some medication "to calm them down." The on-call GP has few options. The on-call GP invariably isn't in a position to effect changes in care plans generating person centred dementia care that addresses the causes and consequences of the person's presentation with nonpharmacological strategies. You need to know the staff, the care home, the environment, the patient, the resources and the context before you have a hope of that. The on-call GP is left with the stark choice of effectively do nothing or prescribe a tranquilliser, most often the antipsychotic, haloperidol. The care home reports a need for this to continue so it's added to a repeat prescription at low dose.

A local "audit" by the PCT has shown that invariably it isn't reviewed. The sampling wasn't perfect so I went through all care homes in my patch and reviewed every MARS and it was true - most psychotropics were initiated in Primary Care and most weren't reviewed. Was it audit? What was the gold standard being espoused, what was the GP and Consultant Psychiatrist's variance from this? No, it wasn't formal clinical audit. More a PCT survey, really. But the PCT pharmacist has at least got the discussion going. Scared the willies out of me, for a start.

Lots of elderly incapacitated folk, on psychotropic meds, without review.

Over the last year or two the amount of psychotropic medication used in care homes has plummeted. Care homes know that I'll pop in promptly, as will our CPNs, so there's little excuse for hassling a GP out of hours for mental health problems. Although I regularly go through every care home, it's a time consuming business. Most folk in care homes aren't known to our Trust. To suss out what's going on, why they're on medication, what the effect of the medication is, isn't straightforward. A lot of unpicking to be done. Usually the care home manager sits with a CPN and me as we review all their residents, sometimes it's the RMN if it's a nursing home, but someone has to be there to explain the consequences of medication and presentation of their residents. It's a good learning opportunity for all parties, too. Thus, as well as popping in to sort specific patient problems, we also review the drug regimen and mental health of all residents in care homes, which takes roughly 6 months to do. With current resourcing, that means we review everyone in a care home in my patch twice each year. Could be better, could be worse, I guess.

Usually we stop the medication and review this. Mostly they're better off the drugs.

Milo has suggested that, "I don't think that there are many psychiatrists out there (i haven't been able to find any!) who would not be judgmental towards someone who has paranoid schizophrenia and chooses not to take anti-psychotic medication!"

Dementia, schizophrenia, depression, anxiety . . . if you're taking medication there should be rational prescribing practice. I'm not judgmental towards someone not taking medication. I think GPs and Consultants simply need to evidence sound, rational prescribing.

Increasingly I'm of the view that Voltaire had the truth of it in saying, "The art of medicine consists in amusing the patient while nature cures the disease." Medication has a place. A very important place. Mental illness can be ghastly and can cause permanent structural damage. Medication therefore matters. Whether palliation, whether prophylaxis, whether effecting a cure, medication can be key in reducing/removing symptom burden and ensuring restoration of decent mental health. But it's often just part of the answer, a way to improve things so that "the proper treatment" can then work. And when the non drug treatment's working, often the medication's withdrawl is then useful.

I guess all this is a long way of saying I'd challenge Milo's view. I think mental health is better at reviewing patient's medication, offering choices and considering rational prescribing practice. I do think we fiddle less.

Therapy

After twelve years of therapy my psychiatrist said something that brought tears to my eyes. He said, ‘No hablo ingles.’

Thirst

I've a lady who has a mood disorder who I've been seeing for a few years, now. As time's ticked by, she's also developed dementia. She recently had an acute admission, onto a medical ward that's busy, rather like this.

Staff are largely well meaning but care's not as you'd wish since the wards don't have enough staff to optimally support the patients' needs.

This was rather brought home when, last week, I was in their hospital seeing other folk but had heard my lady with dementia had been admitted. I popped on to her ward, to see how she was being cared for and to let the ward team know what support we'd be able to put in place on discharge. I saw her, she didn't look good. She was thirsty. She was very thirsty.

Her bedside looked like this. I've not moved a thing, this is exactly as I found it :



This was all well outside of her reach.

5 drinks, if you count them. There was water there from the morning. Orange juice that came with lunch. Then coffee. Then a dietary supplement. Finally, some more water from the afternoon.

5 drinks, all on the tray of a lady with dementia, all still there for hours and not drunk as drink after drink is added.

She was discharged back home that afternoon, on antibiotics for her exacerbation of COPD, where she's getting a couple hours of home care and 2 visits a day from daughters to support her. Tragically, this episodic care 4 to 6 times a day results in far better care for her than being on an in-patient unit where there are staff there continuously, 24 hours a day.

As Nurse Anne says, something's very wrong on our acute medical wards . . .

Care Planning

Yesterday I described a lady who had schizophrenia, but had been managing fairly well.

She had emerging deficits and had historically reacted to command hallucinations and delusional ideation that, to a modest degree, adversely affected her (e.g. in employment opportunities, where to live, who to be around and in personal relationships) but, since she could talk to so many friends psychically, she'd always got by well enough. Effectively, she'd her own support network.

Calling 999 and presenting with breathlessness unsettles me. When I did my time in GP land, before jumping over to mental health, we'd reflect in Balint groups. Oddly, I've no reflective practice or peer support now I'm doing more complex and risky and distressing work in mental health, but that's another story and I digress. Again. When reflecting, one of the recurring questions was, "Why now?"
Most people pitching up in Primary Care weren't there with true emergencies. So the dry, pink, itchy skin rash you've had on and off at times for 6 months or so, why'd you come to see me about it today? Why not yesterday? Why not next week? The headaches you've had and put down to stress, for 2 years or so, what brought you to consult me, "just to get things checked out," right now? That indigestion you've managed for a couple months with over the counter antacids, what brought you to discuss your fears of stomach cancer now, in this moment?

Timing matters. To a degree it's pragmatism. It's about when we can get time off work, when an appointment's available. But more often it's about what we want. We want reassaurance since things haven't settled down as swiftly as we'd wish. We want an intervention early on, just in case we need to stop something getting worse. We're now worried enough to make changes or do something about it, so consult. A friend died with similar symptoms, giving us impetus to act. The media say that a condition we think we might have now has a miraculous treatment. Our family's worried and nags us into going because the symptoms grumble on and they're worried it's something sinister.

We're creatures of purpose. We don't take time out to fret over things, make an active decision to seek help, 'phone for that, take time out of our week, travel, wait, talk, be examined, discuss ideas, consider investigations, weigh treatments, arrange follow up, travel to chemists, wait, pay for pills and do all the other gubbins that seeing a medic involves, just on whim.

Shall I read a novel in the park as the cherry blossom cascades down around me, shall I whimsically whisk my wife off to a fantastic new restaurant, shall I weigh up the merits of a rather splendid 24 year old Port Ellen vs a bottle of Shiraz I've been gifted and partake of the winner, shall I lavish time on my children who're enthused with a new playground, or shall I go to the doctor and discuss indigestion I've had on and off for a few months?

To seek medical advice, even when free at the point of delivery, we need something that's motivated us to do it then, at that point in time, at that moment, rather than do whatever else we'd otherwise wish to do. There's no cash cost, but there's always an opportunity cost.

For a lady to be silent 'bout her mental wellbeing for 30 years then now choose to urgently disclose what's going on, in rich and exhaustive detail, surely is relevant.

The experiences had mostly been positive, now she's having more unpleasant thoughts about conspiracies and her role in surveillance. She's being told what to do more. They're affecting her physically, once causing pain and recently making her breathless.

Symptom burden seems perhaps to be increasing.

She's sought contact with mental health services after so long, having feared psychiatry for decades. There are no high risks. There're no risks that are serious/significant but unlikely or are moderate but likely to arise, to either herself or property or others.

She's adamant she ain't taking tablets, so medication's not an option. We talked through different medication options, considering what could help her feel more in control of her thoughts and feel more resilient, what could help her feel more relaxed and less distraught, affording her more fortitude, but she was firm in her view that medication simply wasn't going to happen.

Diagnostically her symptoms, negative impact (on career, residence, social behaviour, relationships) and mental state undeniably attract a diagnosis of F20.0 paranoid schizophrenia. It's not a diagnosis I often make, but if I could share all details it'd be evident that it's really not contentious.

A nurse (band 6 on an acute medical ward) felt she was mentally ill. The nurse is correct. She has a mental disorder, within the meaning of the Mental Health Act 1983.
The nurse felt she was psychotic. The nurse is correct. She has hallucinations and delusions and lacks insight into the nature of these and, critically, into the impact and consequences of these.
The nurse felt she needed mental health input. The nurse is correct. She has had increased symptoms which recently have been more distressing and wanted to talk to a psychiatrist and wanted to share her narrative at length, at this point in time. She's not known to us so the nurse felt her mental health and risks, "needed monitoring."
The nurse felt she needed medication. I'd say the nurse was wrong, here. Medication might help some symptoms some of the time, but abolishing all psychopathology would surely be a futile and unhelpful endeavour. The amount of medication necessary would no doubt be stratospheric. The fact she's refusing means she'd need detaining under the Mental Health Act 1983 so medication would be undertaken as a depot administered under Part IV of the Act. Not the best way to forge a therapeutic relationship, for certain. Probably not the best way to manage her mental health, either. The nurse disagreed, vehemently. "You're saying she's ill, she's got schizophrenia, she's hallucinating and deluded, she's hearing voices telling her to do stuff, she's got things making her feel pain and become breathless, she's wasting ambulance time and she's been in A&E and a medical bed when she's not ill, so we can't let her go and not treat her!" She went on to state how my lady's mentally ill, we don't know anything about her, she's refusing treatment, so we need to "section" her.

Talking glibly of "section her" was what finally did it for me. Pedantic, I know, but one of my many foibles is we don't "section" people, I make recommendations for detention and treatment. We don't do punishment, we do therapy, we do care. The glib presumption that somehow I can lock folk up on whim and stick needles in 'em as, "a section," always, always riles me. A lot.

I documented the interview at length, since it had been a lengthy consultation and she was such an interesting soul. I concluded that she was psychiatrically fit for discharge. She went home that afternoon.

I'm seeing her next week, at her home, so she doesn't feel threatened and doesn't need to come to a hospital. I'm sure there'll be no change in risk. I'm sure there's little benefit from ongoing surveillance. I'm sure she'll again decline social support, CPN input, out-patient follow up, CBT, day hospital, psychological work, in-patient admission and our functional community group that's just a couple minutes up the road from her. I'm sure she'll want no drug treatment. But maybe Balint had it right. Maybe sometimes the doctor's the drug.