Tuesday, 22 April 2008

Tea and Cake

I expect Dr Crippen will not countenance such activity, but I found myself doing tea and cake this week.

I saw a lady in her mid 60's with a diagnosis of F20.0 Paranoid schizophrenia who's not been seen for years by General Adult psychiatry, by her choice. She'd become unwell, believing people were peering through her window and watching her at night. Her window was 9 feet up with no way this could easily happen, her partner said she'd often seen people when he was there and he couldn't, she'd called police and said the person was at her door right then, when the police answered it, but they couldn't see anyone.

So, it seemed most likely she was experiencing more illness, having elected to stop her medication a few months prior to this. We looked at coping and reality orientation but the answer, in part, was to start medication again.

She started medication enthusiastically, 2 months later she was completely well.

I reviewed her last year and found she'd remained well, her partner thought she was totally well, all was good. She was very happy with her medication, adamant she didn't want it changed and it kept her well. Her diagnosis was clear. Her treatment was clear. She was happy and asymptomatic (with no symptoms either of illness or of side effects from medication). She was again stable and remained so over 6 months. My work done, I had no more to fiddle with.

Not wishing to leave her high and dry, but equally not wishing to drag her back in x months for no purpose, I made an open appointment for her. If she, her partner, her GP, whoever, thought it would be a good idea for me to see her in clinic again they could just 'phone up and book in, without a need for referral. Excellent service, no? Get seen when you need to be seen, not at some arbitary time for no real reason.

She booked herself in to my out-patient clinic. I spoke with her GP before seeing her, in case there were any issues I needed to be aware of or that I could support the GP with, but he thought all was well. She came in to see me with her partner, I asked her what I could help her with. "Oh, just a check up, doctor."
I went through her mood, her thoughts, her general health, her medication, her functional level.

All perfect.

We discussed her medication, the role, benefits, consequences, dose regimen. She's perfectly happy, please don't change it, it's perfect.

So, why did she book in and spend almost 2 hours travelling to see me for half an hour with her partner, then almost 2 hours travelling back? "I just like you to keep an eye on things, doctor." I ask her if I should arrange another open appointment so she can book in if or when she wishes to. She looks crestfallen. She wants another appointment now. I offer to see her in 6 months time. She is very happy. Between now and then, she may become ill. When I see her in 6 months, she may be well. I shall see her any way.

For now, at least, I have very very few patients like this. Thus, for half an hour of my time twice a year, I capitulate and I do tea and cake. A misuse of precious Consultant time, or patient centred care?


BenefitScroungingScum said...

Although a different area of medicine I think this kind of appointment is particularly important for those with long term conditions and unfortunately one that seems most neglected as it's not 'quantifiable'
I see one of my consultants every 6 months, alternating with his registrars to allow them to see someone with a 'rare' condition There's no real reason, except without that support, input and ability to discuss condition management with a doctor I would really struggle. Having seen nurse practitioners, however nice they may be, I've found it to be a complete waste of time for both parties. Invariably they need to ask advice from the consultant anyway, and are just not able to provide the kind of support provided by a doctor. The way of thinking is just too different, and in my experience it takes that medical rather than nursing training to be able think outside the box and come up with the kind of solutions required.
I personally feel the loss of such access to general medical consultants must be impacting on the benefits system too, so overall it probably reduces costs where this access is available.
Bendy Girl

Jobbing Doctor said...

I sometimes have medical students sitting in my practice, and quite often they look at me after a consultation and say "what was all that about?". Tea and sympathy, I say. This is a valuable role where you don't need to, or are expected to do anything: just be there for them - it really matters.

This is quite common in GP land.

marcella said...

Having suffered the abject terror of being left high and dry with no clear path of treatment of a loved one who was becoming increasingly unwell, no one with whom the buck stopped, I'd say good on your patient for realising that she needs a check up every now and then. Shame on the system for not making them available to all patients before they become unwell.

Disillusioned said...

Patient centred care, in my opinion. I know when I am feeling fragile (even when objectively I am "well") it really helps to know i have an appointment coming up. Although the offer has been made ot me of an "open appointment" my experiences tell me that this is not always as easily accessed as it should be. Thus, having a clear appointment is helpful. It's a safety net, a reassurance, a barrier against things going disastrously wrong. It also enables me to feel that I have a "reason" to make contact earlier if things suddenly deteriorate. I would call it "proactive care".

marcella said...

By the way, during that near fatal time of fear and lack of support we did, in theory, have open access to the specialist team.

A sick patient is often not able to wade through the system to make an appointment with someone within a system of which they are afraid. A carer may try, but issues of confidentiality and patient choice will usually stop them actually sorting anything out. GPs often don't see their patients that regularly. In a group practice a patient fishing round for help but unsure of what he or she needs and frightened of the system could be seen by three or four clinicians within a month. All of them might be concerned, but not enough to make a formal referral.

A simple, "come and see me on 26th June at 10am" by the professional in whom the patient has some faith can save a fortune in admissions and appointments later, even if that person is the consultant and the task technically somewhat beneath him.

dr Xerxes said...

I love this type of patient care. You can't do this for all your patients, but this sounds as patient-centered care. Doctors who are able to do this, will be feeling better and will have lower burn-out rates. It's very healty to see sometimes healthy patients. Maybe we can audit this, or are doctors even without audit being allowed to be humans?

Anonymous said...

definatley the patient centred care that the NHS is missing.

The Shrink said...

Thanks for all the comments.

Bendy Girl, I agree that medics offer a different perspective and different service from non-medics. Nurses are better at some things than me, I'm better at complex medical stuff (and different approaches to these) than them. Vive la difference!

Jobbing Doctor, wholly agree. I trained as a GP before finding my way to mental health so am wholly sold on the doctor as the drug notion. And Law 13 of the House of God. Being there rather than fiddling can be A Good Thing.

Marcella, access to teams can be difficult. An open appointemtn with me is with me, not the team. Thus there's one 'phone call to my secretary and I see them in the next available clinic slot. Over the last 12 months for routine reviews this typically has been within 7 days and never more than the week after.

Dr Xerxes, I agree, working with the latitude to work as you feel is "the right thing to do" makes for a much less stressful job. And yes, it's nice to have perspective and see that folk can have successful car eplans and remain in excellent health over the long haul!

Jobbing Doctor said...

Dear Shrink,

Thanks for the advice on Law 13. Never come across it till now, but I will go away and order the House of God right away.