Monday 6 August 2007

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 . . .


Spirit of 1976 said...

As a mental health nurse, I suspect that my fellow RMNs probably do rather a lot to propagate the "psychiatrists are lazy" myth. Often it just seems to boil down to the assumption that if the consultant isn't right there on the ward, then he must be on the golf course. People should be a tad less presumptuous than that.

The Shrink said...

Hi there Zarathustra and thanks for the comment.

I have the opposite problem, to a degree.

Because I cover my own sector and have district wide responsibilities and management responsibilities, I'm visibly busy. Also i work in out patients, in patients, day hospital, memory clinic, day respite, care home and crisis teams so they all know I'm running around covering all those corners. I do all the formal medical student teaching. I'm the only Consultant who attends the management meetings to keep things nice and settled for our corner. I do all the liaison visits in the district. I do a fair number of home visits. When I'm not busy I'm in the CMHT office to discuss patients with them or do joint visits and even have the odd cup of tea!

My office is just a few doors along from my CMHT and next to my secretary so they know just how busy I am (and they all see me arrive early and leave late) so my problem's the converse. Some CPNs are more hesitant to trouble me than I'd wish, assuming I am being Busy And Important somewhere so they'd rather spare me the hassle!
No matter how many times I harp on about the CPNs being more important than even my junior doctor they're still a little precious with my time.
As such my CPNs propogate the rumour that Consultants are too busy!

As I'm over in the CMHT every day I guess they know they'll be able to catch me fairly often anyway.

In fairness (but not in my hospital, thankfully) I do know of Consultant Psychiatrists who are lazy and who I'd not want treating my nearest and dearest. So it goes.

I think it's critical that Consultant staff are visible and accessible so as well as decision making and direct clinical contact, we can genuinely be consulted. Then, after all, RMNs and medics can work at their best.

Shiny Happy Person said...

Hang on, hang on, HANG ON.

I really hope I've misunderstood completely and you weren't under the impression that I think psychiatrists are lazy and do nothing. The title of my post was sarcastic - intended to convey the erroneous impression that seems to be held of psychiatrists when in fact the majority of us, very much myself included, work INCREDIBLY hard. My point is that junior psychiatrists are being trained out of this. Of course you, as a consultant, work hard. I, as a conscientious junior, also work hard. But I would be willing to bet my house that I have less to do when on call than you did when you were an SHO, and when I am a consultant, I will have received less training and less experience than you. Whether you believe it or not (and part of the problem, in my opinion, is our seniors burying their heads in the sand and refusing to acknowledge the slow destruction of our training), juniors' experience is being taken over by liaison nurses. A recent study in the Bulletin of psych SHOs in a DGH revealed that in a six-month period, each SHO saw an average of two self-harm cases. TWO!!! How many did you deal with per six months when you were an SHO?

I'm afraid psychiatrists DO have a reputation for being thick and lazy, which is mostly undeserved. But when juniors are being trained to believe that most of the acute cases should be dealt with by a nurse, they ARE going to start perpetuating the stereotype. I DO know juniors who get irate with being asked to see patients, because they have become used to nurses doing most of the work.

Some of us work our butts off trying to dispell the myths about psychiatrists. I would FAR rather be approached directly and come to visit a patient at night than get involved ONLY if the nurse can't sort it out, a) because I think ill patients should see doctors, and b) because I want to gain more experience and therefore become a better psychiatrist, but plenty of my colleagues will be sure to make sure the caller knows they offically need to go through the liaison nurse first. Hence, we get a reputation for being obstructive. I try so hard to debunk the myths, but it is terribly difficult when that is essentially how we are being trained now. Trained to believe that our emergency duties can just as easily be done by nurses - hence we are 'superfluous'.

I'm sure you do see a lot of patients, most consultants do, and I don't know where you work, but I've yet to experience a system (I've worked primarily in London teaching hospitals) where the majority of patients presenting as emergencies are not seen by a doctor. Ask Dr Crippen how many of his psychiatric patients get seen by doctors. Nobody is denying that psych consultants work hard, but are you not aware of how many patients AREN'T getting to see you? And if all psychiatric patients see a doctor, can I come and work there, please?

The Shrink said...

Hi there SHP :)

I really hope I've misunderstood completely . . . The title of my post was sarcastic
- yup, I got that :) No misunderstanding . . . I wasn't rebuffing what you were saying, I agree with you and was just adding my musings!

My point is that junior psychiatrists are being trained out of this
- agreed. Your house is safe :) Junior training is a heck of a lot less involved than when I was an SHO and SpR. This is bad, as I said, when you're in the hot seat you should have had oodles of clinical exposure, not been overly protected and under trained.

Some of us work our butts off trying to dispell the myths about psychiatrists.
- yup, which is why I'm open about my work and everyone can know and see exactly what I do (both through the working week as well as colleagues and members of the MDT having copies of my Job Plan and the ludicrous number of extra PAs I squeeze in).

I agree that junior doctors need to see patients presenting with deliberate self harm (DSH), acutely, at night, and make sense of how to manage such things collaboratively and reasonably safely. Nursing staff doing it all, or junior medics admitting everyone, isn't honing the clinical skills of our future Consultants. As you say, SHOs (erm, ST docs) needs to see DSH our of hours.

Hence, we get a reputation for being obstructive.
- true, which is why those of us keen to rid ourselves of this (Consultants and future Consultants alike) have to be accessible 24 hours a day to contribute directly to patient care.

And if all psychiatric patients see a doctor, can I come and work there, please?
In Old Age Psychiatry (where I work, mostly) all patients with memory problems see a Consultant psychiatrist. Every single one. There are, obviously, a lot of them . . . but it's important to pick out the treatable causes and as we're giving effectively a progressive and terminal diagnosis a medic really should get involved in each and every case.

I see everyone with major mood disorder, everyone on a mood stabliser (some people have lithium clinics, I see them all myself whether ther're on lithium or olanzapine or whatever).

Some patients do see a CPN and don't see me, such as those with a simple bereavement. But we talk through every element so I know what the tale is, what the biological features are, what psychopathology was asked about and what interventions have been. Often I'll do joint visits to the patient after this, too. If things don't go smoothly to resolution then I do see them myself.

I do rely a lot on CPNs and nurses in day hospital, memory clinic etc seeing patients and getting a lot of information for me, but I firmly believe that a mix of medical, nursing and social intervention's the best way to go most of the time, so we all should be involved directly in their care.

Of course this has implications for workload so we've local agreements with GPs to help them sort out in Primary Care problems that, with their input, will resolve nicely without CMHT input.

But for major mental illness, no patient comes through my service without seeing me.

The Shrink said...

. . . but are you not aware of how many patients AREN'T getting to see you?
- I go through every referral to the service, every Monday morning, so I know exactly how many patients I'm seeing or not seeing.

Even those I apparently may not see (e.g. referred to us and sent on to a nurse in memory clinic) I am in fact destined to see after the half day's cognitive testing in memory clinic. The letter from there's typed up with all the information and they're seen by me in out patient clinic.

Annual appraisal requires me to specify the exact number of patients I see (and this information is shared), so it's apparent to one and all that patients I should be seeing, I am seeing :)

Unknown said...

Where i work, the Psychiatry SHO's seem to do enough to proprogate "the Psychiatrist are lasy myth/fact". With out doubt there are a large number of hard working psychiatric SHO's, in fact where i work there is almost always one picking up the slack for everyone else.

Over the last 4 week in A+E i have had psyciatric SHO's asking me to refer patients "in a few hours" so that it gets refered to the one taking over the shift and, presumably, that the incomming doctor isnt made aware that work is being shifted. I've had a child psychiatric specialist, when covering A+E admissions, deny any knoledge of psyciatric services for children; i find out the next morning that he runs/ sees patients in the child psychiatric clinic. House mates rotating through an F2 psychiatric rotation, we're incesently seeing Overdoses at 3.00 4.00 in the afternoon and later as the morning SHO's couldnt be arsed/ were only capable to see one person in 4 hours.

And a whole load more.

Psychiatrists are not lazy, and in fact the majority of consultants i have came accross are nothing but hardworking and helpful. The junior staff however seem to spend most of their time trying to turf work. Sadly this isnt just in my area, i've hear the same from liasion psychiatry SHO's in 2 other major hospitals around my area.