Thursday 27 September 2007


An update on my lady who's been having sex.

Although we've directed him not to, the man who's been whisking her off to his place for nights of intimacy continues to do so.

Yesterday she turned up at her day centre. Staff were concerned. They 'phoned to say she was smelly and found he'd packed her off wearing no knickers and she had semen dripping from her. Worse, she had extensive bruising on her upper legs and perineum.

Police have finally agreed to look in to this . . .

Wednesday 26 September 2007

Mental Health

Mousie has kindly shared thoughts in comments here that an explanation of good mental health services was necessary.

I work in a mental health Trust that delivers, I believe, good mental health care. I've an appraisal in a couple months (a subject to blog about at another time) and part of the information gathering that managers undertake for this, generating an entire lever arch file full of objective evidence, shows exactly what I do and what the sector I work in as a whole is like.

- In the last 12 months every urgent referral from a GP has been seen within 4 hours.
- In the last 12 months every routine referral from a GP has been seen within 10 days.
- My access time for my next out patient clinic slot is under one week.
- In the last 12 months every patient of mine needing a hospital bed has been admitted immediately (with no wait time from blocked beds).
- In the last 12 months every routine liaison referral from medical/surgical wards has been dealt with within 5 days (some within an hour, most by the next day).
- In the last 12 months the number of patient clinics cancelled at short notice (defined as within 6 weeks of their appointment) : 0
- Average number of professionals involved : 3 (eyeballing it it's averaging a community nurse and me for most folk, with a social worker or occupational therapist or support worker or psychologist or memory clinic nurse too).
- In the last 12 months every patient discharged has had a letter written by me with summary including a diagnosis and risks and medication and interventions and follow up completed and signed before the patient leaves the ward, to be mailed to the GP.
- In the last 12 months every patient discharged has had a full discharge letter sent to the GP within 2 weeks.
- In the last 12 months every patient needing Mental Health Act 1983 assessment has been seen by me within 2 hours of the request (and only 2 of my patients have been detained).
- I've had letters of gratitude and praise, which of course is always welcome.
- I've had no complaints (verbal or written) about me or the service which in mental health seems amazing.
- Our Primary Care Trust gave extra cash to us this year (to offset the 2.5% "efficiency saving" the DoH forces on every hospital every year) because the PCT loves us. They let me prescribe what I want and aren't trying to limit drugs even when NICE are.
- meeting with GPs in the sector, they're strangely enthusiastic about our service and haven't had any axes to grind.

So everyone is seen within 2 weeks (urgent problems are seen that day), everyone can access a Consultant within 1 week (urgent problems are seen that day), all communication is prompt and there's good support from GPs and the PCT. The wards are new, every patient has their own room with ensuite, their own space and privacy.

It's not magical, it's just the sort of service I'd want for me, or my nearest and dearest. So that's the service we try and deliver. After all, who pitches up to work wanting to give a bad service? It's more satisfying for us this way as well as being responsive for our patients.

It's just to say that it is possible to have what I'd see as good mental health provision in the NHS.

Private Practice

I have never worked in private practice and have no intention to do so. When my wife needed to see an orthopaedic surgeon a few years ago we waited 18 months to see one on the NHS. I like the NHS and think when it gets it right it can be fantastic. It's nice when it all just works.

I've nothing against private healthcare, I just am sufficiently naieve and idealistic to see the NHS as the laudable preferred option.

What piques me is the pervasive whispering that episodically surfaces, insinuating itself into speech and media stories, that "going private" is, of course, going for a better service.

It isn't.

It's going for a different service.

I worked with an SHO (ST2 junior doctor in new speak) who moonlighted and covered a huge private hospital for a huge city on nights and weekends. Maybe he still does. He was the resident medical officer. He was the medic on the site. When ever there was a need for medical care, he did it (as he was the only one there).

When I was "on call" working on NHS medical wards I'd spend hours on Coronary Care and on the Haematology ward and covering scarily ill patients, but my medical Registrar and her Senior Registrar would do scary things (like cardiac pacing). It would happen almost instantly, we'd get bleeped, we'd dash to Coronary Care, we'd get pacing wires and run them in to the person's heart, fiddle with dials to capture pacing, exciting but scary stuff. I'm so glad there were House Officers, Registrars and Senior Registrars as well as my good self. Once we were busy through the night and at 8.00am the Cardiology Consulant arrived to meet us in Coronary Care. When his patient had (another) cardiac arrest the Consultant let us crack on and manage the event . . . the "junior" medical staff were much more familiar with such emergencies than the senior Consultant staff, thankfully the Consultant wasn't too proud to show that. An NHS hospital. Lots of staff, all doing lots of emergency work (we worked like Egyptian slaves) so got pretty proficient at what we did. If I had a heart attack and arrested, I'd want that sort of team managing me.

Cut to a private hospital. There's a SHO/ST2 junior doctor there. He's an SHO in psychiatry. He's never even seen cardiac pacing. He vaguely remembers how to resuscitate someone since he's got to attend an update every year or so, but it's not somthing he's seen or done for years. As a psychiatrist his knowledge of surgical and medical problems is modest. He was the only doctor in that hospital.

Now, in the private hospital, the surgery was done by a Consultant not by a trainee junior doctor. The food was excellent. The rooms were sumptuous. Flat screen TVs on the walls. Great selections of books and magazines.

Routine and elective care was excellent.

But in an emergency, would I rather be in an NHS hospital with a horde of experienced junior/senior trainees who could capably sort the problem out, or would I rather be in a private hospital with a psychiatrist who could ask me how I feel about it?

Tuesday 25 September 2007


Who should do psychiatry?

A mature and sensible anaesthetist (she was a physiologist before training to be a medic) believes that psychiatry is just very complicated neurology. If you're a proponent of biomedical psychiatry it becomes quite a compelling argument.

A psychiatrist who taught me when I was a junior doctor believes that many psychiatric conditions, like severe depression, are too serious to leave to psychiatrists to treat. Although truly biopsychsocial in outlook, the "bio" bit was important enough for him to feel that "social psychiatrists" focussing on psychosocial problems were mistreating many of their patients by ignoring pathological neuroendocrine biological processes. "In 10 years time," he said, "physicians will be the ones treating depression, not psychiatrists . . . it's too serious a condition for us to play with."

Taking this views on, who should treat them? Their points both suggest that "sitting down and talking about it" is wrong and a more active management is warranted. And in many ways they're right.

We know that depression is bad.

The consequences of depression are serious. We know research shows that being stressed for protracted periods of time is damaging since the hormones released aren't meant to be sustained at high levels for any length of time. A "fight or flight" response is great if a lion is chasing you but to have surges of catecholamines like adrenaline is, we know, neurotoxic.

This means each and every day that someone's being there, fraught and frazzled, stressed and depressed, they're poisoning their brain and killing off brain cells. Much badness.

The original comments referred to this, meaning that patients deserved prompt and effective treatment to address the neuroendocrine elements of their distress. They felt that depression was too serious an illness for "social psychiatry" to treat and physicians (or maybe neurologists) should be treating such folk. My mentor said this over 10 years ago; his vision hasn't come to pass.

I think this is a good thing.

I believe that good mental health services can address the biochemical elements of illness expediently but, critically, can generate a holistic and cohesive careplan that's broader (and better) than simply getting the right drugs prescribed at the right time.

Wednesday 19 September 2007


I've said earlier this week that a key trait in mental health work is an interest in the patient's experience. It's from this that we can sleuth out both meaning and management plans.

Often it's assumed we're in the business of making people "normal" or curing "pathology" which are goals largley abandoned long ago in favour of helping people understand and cope with their experiences.

What's important then shifts so the emphasis is not to be reaching stratospheric doses of multiple psychotropics simply to abolish one specific symptom.

Imagine we've a patient who was in their kitchen hears footsteps walking upstairs when nobody's there. They also smell aftershave when no man's been in their house for ages. At night they feel someone lying next to them.

Auditory, olfactory and haptic hallucinations, mostly in clear consciousness (I'll concede feeling a body in bed with you could be a hypnagogic or hypnopompic experience as they drift in or out of sleep). Not illusions, not misperceptions whilst in a dreamy oneiroid state, these is crisp fully formed hallucinations.

Solid evidence of psychosis?

Not necessarily. I remember reading a paper from 1971 by a GP in Wales who looked back at 293 bereaved patients seen near the end of a life long career in General Practice and found that hallucinations were common. 46.7% experienced the presence of their departed spouse at some point, 13.3% had auditory hallucinations and 2.7% had tactile hallucinations such as feeling a loved one still in bed next to them, for example. In 1985 another paper found 61% of the 52 widowers they interviewed experienced hallucinations.

Hallucinations are typically seen as the hallmark of major mental illness. These papers and a wealth of evidence suggests that hallucinations can arise in folk who are not mentally ill. It's not simply the presence or absence of psychopathology that's key (even important psychopathology like hallucinations). Even in specialist mental health work what's key is the patient's narrative, their experience and the context.

Citations :
1) Dewi Rees W: British Medical Journal, 1971 Oct 2; 4 (5778): 37-41
2) Olson PR, Suddeth JA, Peterson PJ, Egelhoff C: J Am Geriatr Soc. 1985 Aug;33(8):543-7

PS : Isn't it great that good quality enduring research, informing and educating psychiatrists decades later, was done by a rural GP in Wales?

Tuesday 18 September 2007


Rarely (about once a year or so) one of my patients needs Electro Convulsive Therapy (ECT). It's a contentious topic to some folk that I'll whitter about another time. When folk have ECT they're asleep. An anaesthetist (a doctor with decades of training and experience) gives them an anaesthetic, they drift off, they have ECT for however many seconds then they wake up and life's getting better for them.

This preamble is simply to introduce what anaesthetists (the gasmen) do since this is the funniest thing I've seen for ages and simply has to be shared :


Psychiatrists talk about sex a lot, apprently, so it's about time it was blogged.

The Mental Capacity Act 2005 has had explanation on it's implementation through the Code of Practice which presents helpful guidance.

I have a lady who has dementia. She enjoyed frequent intimate relations with a longstanding friend who has had a turn for the worse and been admitted to hospital. When his name is mentioned her face lights up.

Since he was admitted months ago, another man has started seeing my patient who is an affable old dear and opens her door to anyone. He has started having intimate relations with her. She has repeatedly told nursing staff she doesn't like him but then on other occasions is confused and is more ambivalent. When his name is mentioned she recoils. Her daughter is mortified the man who her mum hardly knows has no relationship with mum except for sex and wants the man to go away and never see mum again.

Within the meaning of the Mental Capacity Act 2005 she is an incapacitated adult. She can not consent to sex. The Code of Practice says in 1.10 that there are ". . . specific decisions which can never be made . . . by family members, carers, professionals, attorneys or the Court of Protection." The subsequent list includes, "consenting to have sexual relations."

She can not consent to having sexual relations and the Mental Capacity Act 2005 makes it clear that nobody can consent on her behalf.

Is it that incapacitated adults can't have sex? Can the issue be ignored? Is it that a man, having sex with a woman without consent, should be charged as a sex offender?

Monday 17 September 2007


I recently was talking to junior doctors about career options. They've been sharply curtailed and the freedom to explore specialities as active doctors in one speciality (rather than as a more passive student) has largely been lost. Speaking with one doctor it dawned on me how much even early clinical contact can have formative influences that resonate with how I work now.

My first clinical attachment as a 2nd year medical student was General Surgery. I loved being on the wards and seeing patients and finally getting "stuck in" to proper medicine.

The quirks (having to illicit Boas sign on a ward round), the theatre of it all (ward rounds with an entourage whirling around the deific Consultant at the epicentre), the needles (learning to take take blood and cannulating) . . .

. . . the patients were the thing, though. Finally doing history taking and examining folk, being proper medics, then clever folk sussing out what was going on, it was being a part of magic!

For me, over time I loved the patient work up on the wards, the sleuthing out why a patient had jaundice, then what could be done to sort it.

Sadly, the "sorting it" didn't interest me. Surgery as a speciality was great, 'cept I didn't enjoy the cutting which kind of wrote it off for me :-)

Still, that attachment was fantastic both for teaching a wealth of skills and for learning from surgical folk who were interested in their patients. At variance with the sterotype back then, good modern surgeons would delight that even way back then there were surgical teams that valued undergraduate medical education and were essentially patient centred (but never would have called it that). The patient focus stayed with me, drawing me to train as a GP before back to hospital medicine and mental health.

What was my conclusion with my trainee? It was that the sum of my training and experiences means that for me the heart of good medicine and the quiddity* of psychiatry is a genuine interest in the patient narrative.

* A great word I really must try and use more :-)

Edit : Milk & Two Sugars just blogged about surgical training this morning, too. Snap! Her more lucid medical student perspective is here.

Thursday 13 September 2007

Deliberate Self Harm

We know Deliberate Self Harm (DSH) is common. One study talking to over 350 interested parties found about 1 in 15 children doing it from age 12 upwards. Other studies quote up to 1 in 7 in certain subgroups. So it matters. We know DSH invariably is nothing to do with suicide. We know that in younger folk (12 to early 20's) it's usually concealed (e.g. cutting arms then hiding the cuts under clothes) and is not about overt attention seeking.

Some groups seem at higher risk than others.

The National Institute of Health and Clinical Excellence has guidelines about this.

One key issue is that the self harm is a way for the young person to cope. They've often no better way to cope, which is why they cut. Stopping the cutting is stopping them coping. Thus, guidance is (sensibly) directed at looking at the causes of the DSH and addressing these rather than simply abolishing the self harm behaviour.

All well and good.

But, the crunch . . . just how do you explain to a terrified parent that we're going to accept their 19 year old teenager is still cutting themselves?

We'll offer alternatives (many distraction techniques work brilliantly) and CBT (which has established benefits after just a couple sessions) and medication (lorazepam can give similar relief that cutting does and works quickly to de-escalate distress) to try and reduce cutting and we'll give advice on cutting safely, but it's the loneliness and college pressure he's put himself under that needs sorting out then (invariably) the DSH diminishes and stops.

A difficult management plan to sell . . .

Wednesday 12 September 2007


I've spoken with a gentleman who's been to another planet, visited Heaven and divined the future. Through "revealed truth" this will be shared. He's seen that I shall write a book which will bring great rejoicing. On this other planet he visits he has great standing and has been promoted to the top of four tiers.

Travel to a far off planet where you have import, a future of happiness and rejoicings, it's not a bad way to journey.

If only his travels hadn't also led him down a rather more mundane route, crashing his car and abandoning it in oncoming traffic . . .

Monday 10 September 2007

Primary Care

Most poor mental health isn't anything to do with illness and disease and being sick.

Most mental health is to do with feeling rubbish, transiently, as life's given you a good kicking.

The severe problems (psychotic breakdowns) are few compared to the large number of folk with difficulty coping for a while (but not quite having an anxiety disorder or depressive disorder or whatever).

Thus, as we all know, most mental health work happens in the community and mostly in Primary Care.

It's of interest to me, then, that today it's reported that the Government is keen to whip GPs back in to working nights and weekends.

Will this generate better patient care?

Friday 7 September 2007


There is no "me" in "team" unless you're dyslexic or a savant. Modernising Medical Careers and New Ways of Working threatens to undermine a lot of established good practice.

I work with several teams. There's one team, for example, consisting of two nurses, a social worker, a bit of an occupational therapist, a support worker, part of a secretary and me. We all spend a lot of time in the same office.

But what is teamwork? What's the difference between collaborative work, parallel working and genuinely working as a multi-disciplinary team?

Thursday 6 September 2007


Our Directorate is fine, all our patients are seen within 2 weeks, patients and GPs love us, outcomes are consistantly above average and we've run without finincial overspend for over a decade. All is good.

And then . . .

. . . 10.00am, meeting with hospital managers and a number of Directors explain the "vision" for our Trust.

I have of late, but wherefore I know not, lost all my mirth and indeed it goes so heavily with my disposition that this goodly frame the earth seems to me a sterile promotory.

Being British

I often have doubts over a word's appearance and fret over the spelling or meaning of a word that seemed right but looks dodgy when typed out. Thankfully there are online dictionaries, huzzah.

Recently I was tempted to use the word "gaol" in one discussion, but typed out it looked odd and I wondered if I was being a tad too anachronistic and if the American "jail" or the term "prison" would be better. I learnt that "jail" and "gaol" are synonymous but that "prison" has a different meaning.

What tickled me was one online dictionary's definitions of "gaol" that simply has to be shared.

Rummage around here and read down to find what presumably an American has written 'bout British folk using the term "gaol" :

see jail, you tea-sodden football hooligan.

Online Etymology Dictionary, © 2001 Douglas Harper

Tea-sodden, well, quite possibly :-)

Wednesday 5 September 2007


Psychiatrists diagnose mental health problems.

We have been trained to sift through symptoms and signs in order to ellucidate relevant psychopathology and ascribe significance to this, then weigh the constellation of relevant symptoms and signs and intensity and duration to generate a robust diagnosis.

One comment from my ST1 doctor (Specialist Trainee year 1 doctor, what used to be an SHO) stirred my thoughts. He's just finished his Foundation training which included a stint in GP land.

He was surprised at the diagnostic rigour in psychiatry.

A lot of diagnosis in Primary Care is based on clinical impression formed from history, examination and occasionally relevant investigations to confirm or refute a diagnosis. Many diagnoses are formulations made with the best evidence available before the GP, which can be a bit thin. Diagnosis of, say, Irritable Bowel Syndrome or a Chronic Fatigue Syndrome can be difficult to make in a robust fashion. Even before diagnosis, symptoms can be hard to quantify (such as dysmenorrhoea that means different things to different people).

My junior doctor was surprised that in Primary Care most GPs diagnosed problems intuitively through each consultation, seemingly at whim. Psychiatric diagnoses are determined within the World Health Organisation's International Classification of Diseases, 10th Edition, ICD-10.

In psychiatry we need to tick many boxes before we can say, "This patient has a diagnosis of F33.11 Recurrent depressive disorder, current episode moderate, with somatic syndrome."

It was interesting to see a young doctor realise that determining diagnosis of mental health problems is oft times more considered and robust than diagnosis of physical health problems.

We're not just musing and making stuff up!

Monday 3 September 2007


This weekend I had to go to A&E, son had a broken bone.

Unlike Shiny Happy Person's recent forray into patient experiences, I was pleasantly surprised.

My local A&E is in a hospital that doesn't know me. I've never worked there (and work in a different county) so they didn't know I was a medic. I didn't tell anyone and avoided "doctor" and "consultant" and "clinical director" and such, pitching up just as someone helping their son.

We had a wait, half an hour. Other folk before us had similar waits.

We were seen and triaged and had another wait, half an hour. Folk around us said they'd waited a similar time.

We had an x-ray (undertaken promptly with no wait) then we were seen promptly by a medic who said it was a broken bone which I'd already surmised but it was good that it had been clarified one way or the other.

The limb was promptly treated and dressed and we went on our way.

Isn't it nice when a system just works?


Extra chocolate rations for recognising this quote :

"Look at that, look at that. "Accident black spot." These aren't accidents. They're throwing themselves into the road, gladly. Throwing themselves into the road to escape all this hideousness. [To a pedestrian] Throw yourself into the road, darling, you haven't got a chance!"

Watched it, yet again, and love it more and more each time.

Some days, I'm easily pleased!