Sunday, 6 April 2008

What do doctors do?

"Other than the aforementioned [the specific ability to include/exclude organic disorder], do our learned colleagues (cue the doc) uphold any other aspects of the medical training that supports their (purely) mental health skills?"
- Mr Ian's comment at Mental Nurse.

This piqued my interest.

In addition to dealing with organic disease, which I guess we'd all agree only doctors are trained to do, there are a few things that support mental health skills.

Diagnosis. We're the only group of professionals trained in broad diagnosis. I recognise that psychologists can diagnose mental retardation. Some can make formulations around personality disorders with credibility, too. But beyond this, the clustering of symptoms, the weighting and interplay of intensity, pervasive nature, impact on function, chronicity and associated features is something that medics are trained to sleuth out. Trained specifically in mental health, sure, but that training can happen readily since our background of 7 years training before this (minimum of 5 years medical school then foundation training) before mental health training means doing diagnosis is what we live and breathe. I still maintain that only psychiatrists have the competence to ascribe significance to psychopathology and generate diagnosis from this. Some are rubbish at it, I've met woeful psychiatrists who are ghastly at this. But for those who are up to speed, good medicine with competent psychiatrists allows good diagnosis that nobody else is trained to do.

Therapeutics. I work with a pharmacist in my team. She knows a lot about drugs. She knows a fair bit about physiology and mental health, a bit about anatomy and a bit about clinical work. If I want to know about drug interactions or if Symptom X could be from Drug Y she's the woman who knows. She's great at medicines reconciliation and all the governance gubbins we need to do. She frankly states, despite her extensive training and vast pharamcological knowledge, she's not the one to guide on treatment. Clinical outcomes, what's tolerated well and what's not, peripheral consequences to taking medication all is learned from follow up (which CPNs or I do) so she doesn't have her finger on the pulse to make as informed decisions on therapeutics as I do. In most cases, medics have a better, more contextual and richer awareness of therapeutics than other professions.

Legal awareness. We're all trained in the Medicines Act, Mental Health Act and Mental Capacity Act. Last week I was quoting the 1861 Offences Against the Person Act to a care home manager. Then I was quoting section 4 (7) (b) of the Mental Capacity Act 2005 on Best Interests because she was acting unlawfully. I liaise with the DVLA on a weekly basis re fitness to drive. I'm section 12 approved to do Mental Health Act admissions which no other profession can do (even come October, only medics can make recommendations for admission). We all do what is right, medics historically have had responsibility stop with them, thus an awareness and obligation to have intimate familiarity with statutory instruments is ingrained.

Expertise. We're trained extensively, over ludicrous numbers of hours, over stupidly stupidly obsessive and obscure levels of detail. A local Nonmedical Prescribing course leader (who is a nurse) said to a district nurse on the course never to consider meningitis when treating kids with infection, since if she did she'd end up referring everything to a doctor and never treat anyone. Medics do the opposite, we are trained to think of everything. When one of my patients returned from a holiday in Asia feeling very tired and more depressed and losing weight I considered psychosocial factors but also looked for hypothyroidism and common causes for "tired all the time." One exclusion was diphyllobothrium latum the fish tape worm, since she'd been eating raw fish. Rare as hens teeth, but it's that kind of obscure taking what's said and sifting for patterns that medics are trained in, having greater levels of expertise than non-medical colleagues.

I don't think doctors are better than nurses or psychologists. The question posed was what aspects of training gave us noteworthy skills, which is what I've waffled on about. This gives a different approach from medics which isn't necessarily better, it's just different. Nurses are far far better at many areas of patient care in mental health than I am. Equally, I'd argue medics have strengths that others don't have. So, as usual, I'm banging on saying medics should do medical stuff, nurses should do nursing stuff, and we can all be happy together.

15 comments:

Tainted_Halo said...

And of course, knowing how to spell "diphyllobothrium latum" must take years!
Thanks for the post Shrink. I would disagree somewhat with the limitations you ascribe to psychology as there are more and more psychometric tests being used in psychiatry. Many psychological screening tools have existed for years (Becks Depression Inventory; Symptoms Checklist) as well as the BPRS. I foresee, arguably, that psychology will take the lead diagnostician role also in time based on 'testing' over subjective clinical opinion formulation.

Since general psychiatry is more art than science and is measured in observable behavioural functioning; once a diagnosis is made, can the psychiatrist's role revert to medicinal expert as they are trained - or perhaps even rely on their learned pharmacist for this - and possibly trust in collegial experts to manage care? This is the area I believe mental health care (possibly other specialties?) would serve itself well - once the 'target' is acquired, the pathways can be pretty straightforward and easily within the remit of experienced nurses to implement, adapt and evaluate; even possibly titrating drugs (as I believe some of those other staff already do in your team). Such extended skills then (ought) reduce the amount of hours required by medical team.

In reality I hold onto the traditional framework as any change would be more significant than I think people are aware - particularly with litigation and accountability. Put bluntly, nurses can still rely on 'blame the doc' - but when you're the RMO (or RC?) - who do you blame"?.

To paraphrase "llama" on Crippen's site many weeks ago - what we seek is a cadillac service on a mondeo budget.

I'm pretty biased anti psychiatrist at the moment in my forensic field as we do not have section 12 medical training and certainly no real (meaningful) understanding on assessing capacity and frustratingly no grasp on personality disorder - tho I do rhetorically debate there are some secondary gains in psychiatry to 'avoiding' getting into PD and merely treating any co-morbid mental illness - (tho there are issues that there's no-one else to refer them to for a functionally disabling PD 'treatment' as you would with say gall-stones). On balance I've worked with some great psychiatrists who have managed the holistic care extremely well but this seems more by chance than design. If it were so designed then I would probably happily sit back and stick to "nursing".

Ian

Dragonfly said...

Yes!!! And enough of the politically correct-doctor slagging. Aren't we all sposed to be working together for the good of the patient?

Hospital Wallpaper said...

A very interesting post. When I was on my psych rotation what my consultant told me was that one of the most important things the Consultant Psychiatrist needed to do is to look as the patient as a whole. As many psych patients have co-morbities which may need care/affect their psychiatric illness, the psychiatrist has the background to include this into his perspective, which none of the other members of the team has the training to do.

Oliver Smith said...

Interesting post as always.

mandy lifeboats appeal said...

Hmmmm...and more hmmm

My experience of psychiatrists is that they hide their learning under a bushell of ecomonic time use (to the point of not really giving much or listening properly when they do) and over prescribing.

As in everything a good psychiatrist is worth their weight in gold. But what makes a good psychiatrist.

Well the good psychiatrists I have come across have replaced poncing about and looking all important with common sense.

I don't think it takes an ology to prescribe. And certainly when it appears that the same medications seem to be prescribed en mass...due to fashion trends (or more so what is being hailed for whatever reasons as the latest sort it out tablet).

Talking Olanzapine right now. But a few years back it was Prozac.

I appreciate that a shrink's time is much needed but what point 15 minute meetings? Nothing much can be got from those. Except the obvious "Are you taking your meds?" type questions.

And the ward round meetings are the same. Little time to go into any depth but maybe that is why they are so short because the shrinks don't want to go into depth. considering they make the key decisions about their patients (as in treatment), I see it all as botch it and go.

And yep, I am highly biased but i think a little more conversation and a little more action would be good.

Paul said...

"Some (psychologists) can make formulations around personality disorders with credibility, too. But beyond this, the clustering of symptoms, the weighting and interplay of intensity, pervasive nature, impact on function, chronicity and associated features is something that medics are trained to sleuth out."

I often find myself defending psychiatrists from attacks by clinical psychologists, and question the idea that case formulation is unique to clinical psychology - as it clearly isn't.

But I'm disappointed you imply "the clustering of symptoms, the weighting and interplay of intensity, pervasive nature, impact on function, chronicity and associated features" is the reserve of psychiatry.

I'm shocked you can ignore the vast strides made in developing the assessment and psychological treatment of depression (e.g., Paul Gilbert), anxiety (e.g., Wells, 1997), psychosis (e.g., Tarrier, Garety, Freeman, Morrison, Birchwood, Chadwick, Bentall etc.), 'personality disorder' (e.g., Fonagy, Linehan), dementia, head injury and neuropsychological functioning (e.g., Lezak) and many many more. All of these practitioners are clinical psychologists who are acknowledged experts in their chosen field with respect to "clustering of symptoms, the weighting and interplay of intensity, pervasive nature, impact on function, chronicity and associated features".

I certainly wouldn't claim professional ground from psychiatry as I don't see you as a homogenous group.

There are bad mental health professionals and good ones; this cuts across professional boundaries.

For a fair assessment of the difference see; http://frontierpsychiatrist.co.uk/psychiatrist-vs-psychologist/

Competing interest: I'm a trainee clinical psychologist.

The MSILF said...

I remember one time we had a classic borderline patient - manipulative, a million and one psych symptoms that didn't match up, like someone who spent time on a psych ward but didn't really know the ins and outs of psychosis. Drug seeking. Lots of malingering. And they had me call her psychologist. And it was tremendously surprising to hear her interpretation of everything, "Oh, she's just one of those very fragile, quiet patients." The attending told me to ask very specifically if she had made a personality diagnosis, and the psychologist was so surprised and said not at all. That was when I realized how very differently trained they are. And, for the purposes of doing a medical report, she couldn't contribute much.

Now, she's the one working with the patient all the time. She certainly knew her better than any of us. But she couldn't pick out a set of pathology at all. Not saying she wasn't good, or useful or anything. It really is a totally different field. Like you said: the clustering of symptoms, the weighting and interplay of intensity, pervasive nature, impact on function, chronicity and associated features is something that medics are trained to sleuth out.

Paul said...

Msilf

But how does one example of one psychologist reflect on the entire profession? Unless you believe your example to be representative or illustrative? In that case, I refer you to my post above.

I think it would be highly unfair of me if I were to limit my view of psychiatry to the particular psychiatrists I have met. It seems to me that all professionals have stories of the (in)competence or (in)effectiveness of people from other professions, and our own. Hardly grounds for making generalisations though - although good grounds for prejudice I expect.

Zarathustra said...

Thank you for this thoughtful and comprehensive answer, Shrink.


If only certain other blogging doctors would give their (often equally valid) insights without either condescending people to death (Dr Crippen) or enveloping them in a torrent of gibbering abuse (Dr Rant) then possibly more people might be willing to listen to their concerns.

izzywizzy said...

Really interesting post. In my GP placement, the GP often talked about how nurses and other professionals are taking on more and more roles which traditionally a doctor would have done. But in the end I remember him saying the responsibility was often still left to the doctor. I guess until other healthcare professionals are willing to take full responsiblity for a patient, it will lie with the doctor. It's important that everyone realises everyonelse's contribution to the team and I feel that the doctor has a major role in coordinating a patient's care.

Dr Andrew Brown said...

Thanks for another rigorous posting, Shrink. I can tell you're a specialist by the clarity of your thought. As a GP my thoughts and assessments are more woolly. I don't know if all GPs are like me (indeed, heaven help us all if they are!) but we are more at the "open question" end of the playing field. Having said which, I am frequently impressed by how widely specialists think, including your good self of course.

There is a lot of emotional baggage around the doctors and nurses thing. I came across a useful idea in the RCGP Journal - that nurses work well in the oases of clearly defined knowledge, whereas doctors thrive while roaming the plains of conjecture and partial information. Problems may arise when they try to do each other's jobs.

Tainted_Halo said...

Doc Brown said: "I came across a useful idea in the RCGP Journal - that nurses work well in the oases of clearly defined knowledge, whereas doctors thrive while roaming the plains of conjecture and partial information. Problems may arise when they try to do each other's jobs"

[Shhh... you'll ruin the debate when you bring sensible notions like that]

Polly said...

Thanks for an interesting post Shrink :)

Calavera said...

A well written post, I agree with Zarathustra.

The Shrink said...

"I appreciate that a shrink's time is much needed but what point 15 minute meetings?"

Agreed. I've no appointments for anything under half an hour. All new patients get at least an hour. Patient and I need time to work as I work. Some things I don't compromise readily over, duration of contact is one of those.


"I'm shocked you can ignore the vast strides made in developing the assessment and psychological treatment of depression"

I don't ignore those, no no no. However, I really really feel that diagnosis is something medics are ruthlessly battered in to doing so it's an intuitive and high competency skill we possess. Psychologists, as I said, can do some diagnosis. Let's discount that and assume psychologists are less holistic than nurses and become disease and symptom focussed and diagnosis oriented like medics. Even then, psychologists simply don't see the volume of patients medics do so generally can't get the exposure and familiarity woith pattern recognition and clustering that medics gain. A Consultant Psychologist interview I did 3 months ago had candidates who were undertaking a fraction of the patient care I do (as in, about a tenth) and in training it transpired they'd seen about 100 times fewer patients than I had.

To claim psychologists can do diagnosis as well as medics, then, seems a bold claim to make. I agree that psychologists can unertake objective assessments very well indeed and can undertake interventions better often than anyone else can. They can diagnose much as well or better than psychiatrists. But I still maintain that for many disorders, although others can try to diagnose, psychiatrists should be able to do it better!