Baggage

Patients, it is oft times said on American and American-esque daytime chat shows, have "emotional baggage" and need "closure" of things. Closure is still not a mainstream European concept (with "mindfullness" and acceptance being more avant garde in Cognitive Behaviour Therapy circles) but baggage is something that we all possess.

Many folk have recently seen me with baggage. And I use baggage in the sense of what they bring to the meeting with them.

One junior doctor (who's thankfully got a job) popped in with a bottle of wine to say thanks for all the supervision and support she's had from me over the last 6 months which have been particularly trying for all junior doctors.

One lady brought a bunch of flowers for my wife.

One chap brought in laminated cards he'd made of amusing cartoons he'd drawn to "cheer us all up" with.

One chap and his wife brought in a card to me simply to say "thank you."

My favourite was in my last outpatient clinic. A lady who I've known for a few years (with F31.7 bipolar affective disorder, currently in remission) who's on a complex drug regimen including lithium visited me for her quarterly review. She was well. She has been well for a while, now. She was delighted. Not hypomanic, not elated, simply happy, she came in beaming. What she brought to me was her smile.

Priceless :-)

UK Healthcare

The World Health Organisation published the report, "The World Health Report 2000 - Health Systems : Improving Performance"

This lists 190 countries in order of countries with the best to countries with the worst health.

Any guesses where the UK came?

Go on, have a guess. Pick a number from 1 to 190. Got it? Good. Now, have a rummage around at the rankings and see how you fared.

I was pleasantly surprised.

Much goodness.

More obsession

A quickie - is it wrong that this appeals to me? Someone's been obsessive enough to make the domain name and content for a web page just to highlight how one word is spelt.

Probably it's just part of my obsessive disposition now :-)

Happiness

It is not uncommon for folks to lament over how much woe has befallen them. It's not uncommon to read how stressed and fraught and frazzled folk are.

Is this all just a good old cathartic moan, or are most medics miserable?

Most GPs I know go through ups and downs but, overall, like their jobs. Last week one was saying how privileged he felt (even so many years in to his career) to be able to share in patients' confidences and try and improve things with them. Some GPs write very eloquently about work in Primary Care now, some rant about the environment they have to work in, very few slate the work with patients.

Most psychiatrists I know are happy, or at least satisfied and content most of the time, with good patches of happiness and levity. Sure, some are more frazzled. But looking around at GPs and psychiatrists and talking with them, most seem to be doing okay.

Looking in to this, it should not be surprising.

A longditudinal study in 2005 found most doctors were happy with higher levels of job satisfaction than folk working in comparable professional groups.

Any subgroups standing out? Glad you asked. Why, yes there were, ". . . psychiatrists and primary care doctors reported a higher level of job satisfaction than the average."

So it's not just me . . . there can be a reason for optomism, the nature of our work lending itself nicely towards high job satisfaction and personal happiness.

Huzzah!

Being bad

When I was a junior doctor a sage Consultant Psychiatrist said to me that he reckoned the difference between a great service and a dismal service was about 2%.

If referral rates got a little bit more then you were seeing more people than you had capacity to see, which is disastrous . . . you'll develop waiting lists and never catch up.

If funding is reduced and you lose 2% of your ward staff's time, 2% your annual bed base, 2% of your hours of community nursing input, 2% less medication for patients . . . whatever.

It wasn't a scientific or validated number, although it did hold true locally (where a dismal service had 2% less than a fantastic service). 2% is irrelevant, his point remains sound . . . it's just a small difference in resources between stunning success and catastrophic failure.

As an SHO (when they existed and training was thankfully exhaustive) another Consultant Psychiatrist told me that there shouldn't be a waiting time in NHS services.
- maybe you've enough capacity to see you patients (you can see 50 patients a week, you have up to 50 booked in every week).
- maybe you've not enough capacity to see you patients (you can see 50 patients a week, you have 60 booked in every week).
If you've not enough capacity you'll grow a waiting list and never catch up, having a extra 10 patients a week growing and growing until, ultimately, they've no realistic chance of being seen within a helpful amount of time.

Simple maths.

If you've got a service that's got greater demands on it than it can cope with you need to fix things or it'll implode and fail. If you've a service that's matching capacity and demand then (other than natural peaks and troughs) you'll have a responsive service that doesn't need to have a waiting list since everyone who should get seen can get seen.

More simple maths.

It's disheartening to see Dr Rant's appraisal of the state of the NHS. Disheartening because most of it is true. Outside the NHS 'cross the pond some folk remain cheerily positive about their work.

Do most people in failing services go to work thinking, "Right then, who or what can I really screw up today?" Surely most folk don't pitch up to work wanting to do a bad job. The systems around them and the edicts imposed upon them force a way of working, which is why it happens that way. Evolution. Services evolve because of the pressures on them pushing them in certain ways. It's not hard for systems of management to push a service 'til it breaks.

Equally, one sage voice felt that it wasn't hard to make it better, needing just a small amount. 2%.

Ethics

In my neck of the woods, people who developed dementia used to readily get help. Crucially, the patients with Alzheimer's Disease also got medication. All of them could.

The National Institute for Health and Clinical Excellence (NICE) has determined that antidementia medication is now just for those with moderate dementia only.

This puts me in a peculiar position.

I see a patient and diagnose Alzheimer's Disease causing their dementia. This will progress, robbing them of their memory, thoughts and function, then kill them. This is not nice. In many ways, it's a worse diagnosis than cancer. But there's a silver lining . . . we have medication which can help, which doesn't change the underlying course but can delay symptoms for an average of a couple years. And it works. Numerous trials confirm this. NICE say the evidence is that it works in Mild dementia. But the benefit is pretty modest, so it should only be prescribed when dementia is of Moderate severity, not Mild.

Can we tell patients to go away and come back when they've deteriorated so much that we can then start treatment to maintain them at that lower level of function?

I can't. My colleagues can't. Our local GPs don't want us to. Our patient's don't want us to. Their families don't want us to. Our PCT is surprisingly supporting of my practice and is ambivalent about this NICE guidance.

So what do we do?

Everyone who could profit from the medication is given a trial of the medication and reviewed. If they have been assessed as having Mild dementia and the odd person queries prescribing, well, let's say they've got Moderate dementia then. Just that they're in the fortuitous position of faring rather well in a few domains to bump up their score. Hurrah.

It's grim that medics are bending the truth, but if it's necessary for our patients to get the care they deserve, is this the right thing to do?

Containment

I'm a doctor. The professionals I work with with most are nurses. We're part of the local health community, improving health through helping patients and supporting GP colleagues.

We try to help patients a lot, seeing every new referral within days, sorting out usually at least half a dozen (and up to 15, recently) helpful interventions to improve things with them. We invariably work with them rather than passively doing things to them. Last year I had a ward for several months with no inpatients at all . . . if we can help folk cope in the community (even with significant risk present) then we do.

Last year I managed 11 months without any use of the Mental Health Act at all, but in December had to recommend admission under a section of the Mental Health Act 1983 (MHA 1983) for one individual.

Overall we admit seldom and compulsory admission is pretty rare. Patients trust us, and rightly so.

Zarathustra has provoked discussion about assessment for treatment. Rather than derailing his thread with rambling comments I wanted really to take it away from the discussion on legislation and Code of Practice and towards implications arising from a shift in culture.

At the moment patients who have mental health problems and present criminal risk (of harming others) have their health needs treated. This is done mostly in psychiatric hospitals (and sometimes in the community) and what can't be treated isn't treated. Obviously. Because it can't be treated. When such an individual then makes threats to harm others they're then managed through the Criminal Justice route, being locked up in prison if necessary.

This makes sense to me.

If you're being bad 'cause you're ill, society believes we should treat the illness, get the person well and all is good.

If you're being bad 'cause you're choosing to be bad (and you're not ill), you go to the courts.

If you're being bad and it's all a bit of as muddle then section 35 of the MHA 1983 means that instead of remanding the person in prison they're admitted to a psychiatric hospital for preparation of reports for the court (initially for 28 days then renewed by the court for up to 12 weeks).

Courts can then make sensible decisions as to how much a person's actions are their own elective choices and how much arises through mental illness.

At present, even with mental illness being present, most folk go to prison not hospital. If you've a violently explosive personality and hit people a lot, you've tried to "get help" but that's just how you are, what can a hospital do for you? It can contain you. Keep you locked up so you don't hit people. It's not improving you, it's not helping you in any meaningful way, it's simply reducing risk to people at large through containing you. Since this role is served better by prisons, unsurprisingly most violent individuals with F60.2 Dissocial Personality Disorder (also called psychopathic) who can't be improved/cured are in prison. They're contained.

There's a fashionable idea in the corridors of power that these folk should be in hospitals. In fact, anyone who's a risk to the public and is mentally ill should be locked up in psychiatric hospitals. Given we can't cure these people and we've no way of evidencing a reduction in risk at some point in the future, they've no easy way of getting out. Ever.

Do we want psychiatric units which currently serve vulnerable, distressed individuals who are unwell to be awash with folk who are violent and essentially untreatable? If patients see mental health work not as collaborative partnership but as a scary unsafe world with folk locking people away for ever "just in case" I'd see the essence of care being thoroughly undermined and the positive culture (that we're finally coming to experience) will be lost.

Health care should do the caring for the peoples' health. Prisons and specialist forensic units should do containment. I can't see how else folk with mental health problems would ever be tempted to enthusiastically seek out and engage with mental health services.

Obsession

It occurs to me, having seen a lot of colleagues and students over the years with a similar trait, that I am not alone in being a touch obsessive.

Just a touch. I'm not talking about obsession that meets the World Health Organisation's rather splendid Internaional Classification of Diseases (ICD-10) diagnosis for F60.5 Anankastic Personality Disorder or for F42.0 Obsessive Compulsive Disorder with Predominantly Obsessive Thoughts or Ruminations. I'm talking 'bout just a touch of being more meticulous and fussy and obsessive than necessary.

And this trait is surprisingly common in medics.

It can be annoying. I knew a scrub nurse who'd bemoan a surgeon who always has things set out "his way" and another who does it differently for the same procedure. She gave him the instruments, what did it matter how it was set out on her tray? It mattered to the surgeon. It had to be done just so in order to be right. I've work with an anaethetist who aligns stationery in out patient clinics (and will re-align pencils and paper if it's not all in place).

Small things. People wanting to have influence over their working environment. Nothing too neurotic or compulsive.

But I don't tend to see the same in the local supermarket, in my local garage, or even from one of the three solicitors I was recently paying when moving house. And I've sadly had to spent a lot of hours in all three locales!

Medicine maybe attracts those with obsessive traits. But since we enter medical school at a relatively young age, I'm not sure that people are self selecting for a career in medicine because it will suit their temprement.

I think it's more likely that medicine inculcates obsessive traits.

It's a good thing.

When a patient is wondering what's wrong with them you want a medic who's thinking, "What were the results of Test X and do we now need to do Test Y and Scan Z to exclude conditions A, B and C?" You want someone thinking, "It is unlikely, with only 3 cases reported in the UK ever, but it could fit so we better exclude Condition Blah." When a referral gets lost in the internal post, when a result isn't 'phoned through, when a GP's not been told of interventions isn't it great that medics are obsessive enough to check out and 'phone up to "sort things out" and make sure all is well?

I think so.

Not being meticulous, not making sure everything is done, not checking . . . being very relaxed and cavalier about it all is not reassuring to me.

Which is why I think being a touch obsessive, although potentially quirky or eccentric, is healthy. It means checking, it means getting things done thoroughly and getting them done right. If my wife or kids need to see a doctor I'd rather they saw someone who was also a touch obsessive!

Diagnosis

Dr Crippen has strong views on the role of senior nursing staff in specialist areas. His views are widely shared. In fairness, there are also folk who have opposite views. I'm not opening up the Nurse Consultant/Specialist role is good/bad here, I'm wanting to touch on just one specific area . . . diagnosis.

I couldn't do my job the way I do without my senior nurse colleagues who are the most important members of the team. What they do, they do exceptionally well and do expediently. Patients and GPs love 'em, and rightly so.

What nursing staff are weaker at is diagnosis. Diagnosing things that are the bread and butter of a speciality is fairly straight forward. Diagnosing the obscure is harder. Diagnosing the exception that looks commonplace, presenting largely with commonplace symptoms, is exceptionally tricky.

I used to believe that only medics could robustly diagnose problems. I've changed my view. Nursing Staff can diagnose common problems effectively, most of the time. They can not diagnose atypical and obscure problems and should not be expected to do so since they've not had the training to do so.

The endless and involved teaching of anatomical structures, physiological function, pathological processes and outcomes from this necessitated years at medical school that nurse training rightly does not include.

The training process means a doctor may not know exactly what the condition he's looking at is, but can make sensible considerations of anatomy, physiology and pathological processes on these to ellucidate causes and generate diagnostic formulations. Nurse training precludes this process.

Worse, there's an implict and explicit acceptance amongst many senior nursing staff that getting it right enough of the time is good enough, so missing the odd wrong diagnosis isn't something to fret over. This was brought home when senior G and H grade nurses (erm, band 7 and band 8 in new speak) have undertaken the nurse prescribing courses over the last couple years. I've mentored many nurses (and physios) through this and been staggered by the attitude of the course lecturers and course organisers. Just one example. When talking through managing an unwell child with fever and sore throat there was anxiety from (these very senior) nurses over missing meningitis and what should be done to address this. They were told that nurse prescribers need to be confident in managing what's common, viral infection and bacterial throat infection would account for almost all presentations so manage the child as that. But what if it is meningitis, they persisted. Their lecturer explained that meningitis is so rare, viral/bacterial infection so common, if they worry about meningitis they'll be referring everything and never treating anything so it's best to ignore the rare diagnosis of meningitis altogether and focus on treating what it's almost certainly going to be.

I've worked in paediatrics. I saw children with proven meningitis. I've trained and worked in General Practice. When I worked in A&E I saw a child with meningitis who died.

Meningitis is not common. But it is present. To ignore it as a diagnostic possibility is madness. But it is what Practice Nurses, A&E Nurses, District Nurses and ward staff (all at the most senior level) have been told to do. They were not told this in "the bad old days" they were directed to do it this year. Let us hope none ever treat my children.

Diagnostic formulation is based on the probability of Diagnosis X accounting for the problems your patient's presenting with. Always listing obscure causes for a patient's common problem and referring on to exclude these is not helpful. The opposite, of only considering common causes, is equally unhelpful (yet it is what most nurses are being asked to do).

For nursing staff to be asked to do more than triage, to ask them to start to diagnose, is fraught with problems since it is manifestly outwith their training. They can be excellent at assessing what's common but I really believe that ignoring (knowingly or unknowingly) the uncommon and rare conditions is a grave disservice to our patients.

It is neither how I would wish to treat patients nor how I would want my nearest and dearest treated.

My nurses are exceptional at what they do. But let's not collude with managers and the Department of Health that cheaper nursing staff gives better outcomes. It gives decent outcomes for most patients most of the time. It gives disastrous outcomes for others.

Child abuse

A 4 year old died from iatrogenic drug overdose . . . she was medicated on major antipsychotics (quetiapine) and 3, 3 other drugs to treat her Bipolar Mood Disorder which had been diagnosed at age 2.5.

And the medics thought she was the mad one?!

Much badness.

Too much medicine

After posting 'bout how oft times I find myself reducing medication, I chanced upon a blog by an American psychiatrist saying they're largely pushed to do the opposite.

Apparently they're practising in a less critically rigorous culture and dish out antidepressants, antipsycholtics, anxiolytics and mood stablisers largely according to symptoms rather than to address the underlying condition provoking symptoms of distress.

So today I'm happy that I'm not practising mental health across the pond.

Medication

I'm a doctor. I've been trained to select, evaluate and prescribe medicines. I have an FP10 prescription pad which I carry around with me so I can provide medication to people I see where so ever I chance upon them.

It may seem curious, then, that the most frequent change I make to medication regimens is to stop a medicine rather than to start one.


Old medicines

Often folk have been prescribed a medicine that usually was wholly appropriate at that point, in the past, when it was initiated. Then when I see them the drug's causing side effects or it's working in unhelpful ways.

It's done it's job but it's now run it's course and can be stopped.

A common example would be antidepressants. Someone has something bad happen (like being told they have cancer) and their mood, naturally, drops. It stays low. An antidepressants is started to help them cope (and sometimes it's indicated, other times the person isn't depressed they're simply very sad 'cause life's awful). In any case, the medicine's used and time passes. When they're still feeling low and referred to me they're often at a stage where they're accepting that life's not peachy and they're coping well enough, but feel appropriately sad. Being sad because life's awful is a normal human emotion, it's not an illness and isn't depression. Antidepressants like fluoxetine are often started to "pep people up" with a bit of vim and vigour but the alerting qualities can make people restless. Having energy, but not purposeful, directed energy, makes people feel ill at ease and unable to relax. Stopping the antidepressant and giving explanation and support is usually more helpful than prescribing more.


Physical medicines

Often folks may be on medicine for other problems that start to affect their mental well being. If physically frail and losing health, losing energy, losing mobility so losing independence mood can, understandably, drop. Some medicines, like atenolol for blood pressure/heart problems, can not uncommonly lower mood. Opiate analgesics can cause mood disturbance. Often, stopping these medicines (and swapping to another if still needed) can help moods strikingly, along with other support.


I'm struck of late by how prescribing really isn't necessary for many folk much of the time.

Lazy or Busy?

I was musing over Shiny Happy Person's post conveying thoughts that psychiatrists are lazy and do nothing.

Hmmm. Methinks not.

Every week I have a slew of patients I enjoy seeing in their homes, with colleagues, in day hospital, in day respite, on wards, in out patient clinic, on medical and surgical wards and occasionally in police cells or a section 136 assessment suite.
I would guess that most medical and surgical Consultant colleagues would also be busy with clinical contact (as well as the teaching, admin and management work Consultants do).

Last week I had, at very short notice, to dash off to peoples' homes and assess them with a view to admission under the Mental Health Act 1983. How many other Consultants in other specialities drop everything to go and see patients at their homes urgently?

Most GPs have opted out of being "on call" at night. Most medical Consultants who do "on call" don't have quiet nights "on call" they have completely silent nights with no interruptions at all. When was the last time a dermatologist or rheumatologist or gastroenterologist had to get up at 3.00am? Not a common event at all, in my neighbourhood. And by "not a common event" I mean it's never happened in living memory.

Psychiatrists are busy when "on call" on nights and weekends. We get calls from medical and surgical wards, from GPs, from families, from distraught patients, from social workers, from homeless teams, from crisis teams, from probation, from adult protection teams and from the police. You'd be surprised how often police detain someone under section 136 (of the Mental Health Act 1983) and bring them in for a Consultant to assess (well, a specialist with section 12 approval which in my patch is solely Consultants). Mostly people act "a bit odd" and are picked up by police in the streets in the wee hours. Many assessments are in the early hours of the morning.

Working full days and being genuinely busy with 'phone advice and patient assessments when "on call" makes psychiatrists far from lazy. I can't think of other Consultant colleagues in other specialities who have it busier.

Time for us to eschew this image of genteel bimbling about . . .

Teaching

I enjoy teaching medical students. Mostly, they're bright eyed and bushy tailed, keen to learn what they can from their short time in their placement. Last week I was pleasantly surprised at how much reading around the subjects they'd done. For undergraduate students their level of knowledge was good, their understanding was good, their questions were sensible.
Much goodness.

Last week I also taught the new cohort of junior doctors. Years ahead of the medical students, in terms of postgraduate training and experience, they were less bright eyed and bushy tailed. I'll forgive them that since they'd had inane lectures about lifting and fire extinguishers and the like that had driven them to catatonic states.

What surprised me was their understanding of assessment of capacity to consent to treatment. It was less than ideal. This was somewhat disheartening. Making sure that your patient can consent to what you're proposing is, obviously, a key task that doctors have to be adept at and use many many times every day. It's so central to our work it's seen as a Core Skill that medical students must know (and, indeed, they did). Many junior doctors were not adept at this process.
Much badness.

Just to summarise what the process is, for those who may be curious, the British Medical Association and the Law Society in 2004 generated a document clarifying standards for determining if a patient could consent to treatment. It's simple and surprisingly common sense :
• Understand in simple language what the medical (or other) treatment is, its nature and purpose, and why it is being proposed.
• Understand its principal benefits, risks and alternatives.
• Understand in broad terms the consequences of not receiving the proposed treatment.
• Retain the information long enough to use it and weigh it in the balance in order to arrive at a decision.
• Make a free choice.

I'm pleased that medical students are up to speed with this. I'm less pleased that some practising medics aren't.

I wonder of GP Registrars fair better, with more reflective practice? Non-medical prescribers I've mentored through their courses over the last few years (nurses and recently physio's too) have had mixed understanding of determining consent. If folks wishing to become prescribers can have a lack of clarity on this, I wondered how what Dr Crippen calls Nurse Quacktitioners make of this. All my senior nurse colleagues in the community were very clued up on determining consent.

Phew.

I am happy once again.

Dementia

I concede that dementia subtyping is my role, not the role of medical colleagues. To sleuth out whether someone's got Alzheimer's disease and merits drug treatment, or has vascular dementia, Lewy Body dementia, or something obscure, sits firmly in Old Age Psychiatry. This I am happy with.

A local neurologist who I respect enormously (and has a brain the size of Saturn) also diagnoses dementia subtypes in her patch and does so incredibly well. Referrals from her are a joy. This too makes me happy.

Most of the GPs in my corner are very good indeed. They are committed, receptive to ideas, often doing what's best for their patients even if that does fall a touch outside protocols, guidelines and edits of What Thou Shalt Do. GPs with common sense, this makes me happy.

Although a diagnosis of dementia can be made by a GP or Consultant colleague, then referred on to me for dementia subtyping and appropriate treatment, some GPs aren't sure and refer patients who may or may not have dementia and don't make the diagnosis themselves. I'm fine with this, too. At best we're picking up dementia early, at worst I'm reassuring the GP and his patient that all is well. I don't have to be always treating and intervening. Supporting GPs in areas they're not sure about is, to my mind, a valid use of Consultant time.

It's good that local GPs can query concerns with me and express themselves frankly.

Still, there are some basics I would hope all clinicians have an appreciation of.

What surprised me in chatter with a local GP about our services was his honest question, "What's dementia?"