Tuesday 30 December 2008

Side effects

Drugs have side effects. Heck, even placebo has side effects.

Some arise almost instantly (the one sticking in my mind was when, as a House Officer, I injected an IV penicillin on a weekend on-call to a surgical patient, who then went grey and collapsed). Some more typically arise after longer term use (especially in mental health, e.g. with lithium knackering kidneys/thyroid/parathyroid and antgipsychotics causing the movement disorder of tardive dyskinesia which lasts forever, even/especially when the offending drug is stopped). Some are serious (like neuroleptic malignant syndrome which unfortunately I've seen twice, now).

This has instilled a healthy scepticism of drugs. I like them, if they're used appropriately. But they're not a free lunch. Rational prescribing practice has to be central to use of medication.

But what about me? The Northern Doctor has posted about how busy life is in GP land at this time of year. He's a better man the me, hacking it in Primary Care. His last paragraph comments on the proportion of health care professionals who've used the 'flu vaccine.

Got me thinking. What're the bad medicines I've taken? A relatively short list, since I've not been to see my current GP ever (and last saw a GP some 20 years ago) on the premise that many doctors like to meddle/do stuff/fix things/intervene so are best avoided unless necessary. I delude myself into believing that not seeing a GP is fine because I can suss out myself if/when I need medical attention and, if that ever happens, that's when I'll darken their doors. But I know in my heart of hearts that mostly doctors are awful at looking after themselves.

Anyway, it means my exposure to prescribed medication has been modest. The last time I had a 'flu jab was when I worked in General Practice and, after that jab, I felt awful. It wasn't as bad as 'flu, I'm sure. But it was worse than any cold I'd ever had. So, for me, it seemed that the 'flu jab an a medication to take when well, to reduce risk of a possible infection, wasn't a smart idea for me. If I had health problems so the risk/benefit was different I'd think again, but for now, for me, it's nto something I'm keen on.

Rabies jabs were worse. I was abroad in a third world country, fiddling around in patients brains and spinal cords, so needed rabies jabs before going. They hurt. A lot. And made me feel really grotty.

The worst medication I've ever taken has been an antimalarial. I'm almost never nauseous/vomitting but my wife and I were so sick on them we were hurling up daily. Urgh. Felt so wretched on them we had to stop taking them, which made us much more paranoid about netting and safety so overall worked out well enough for us.

All this no doubt has coloured my conceptions of a medication's risk, benefit and role, which is why I'm wont to stop medication more often than I am to start it.

PS : Zealots in "proper" English, do tell . . . should a full stop go before or after the brackets in the opening sentences of the second paragraph?
I could write (with comments like this.)
Or, I could write (with comments like this).

Monday 29 December 2008


They say that absence makes the heart go fonder. I don't know which "they" said this, and in all my cardiology lectures at med school I can't recall anything 'bout separation from meaningful folk being good for it, but it's said a lot so it must be true.

I've seen a couple of folk of late who've been with relatives over the Christmas period, having not seen them for a year.

On meeting up, one year on, it struck the family how their parent seemed less able to concentrate, a bit slower in their thinking and a bit worse in their memory.

To a one, they're all normal.

We know that as we get older (Primary Ageing) that memory does get worse, when assessed objectively using different scales and rating instruments. This intuitively makes sense, too. As we're older, memory gets a bit ropy, okay, I'll buy that, it fits with what we all see and kind of makes sense. This is different to a disease process affecting brain structure and function (Secondary Ageing) when, in dementia, the brain literally physically shrinks as bits of it are lost, so brain function gets worse.

It can be hard to tell the two apart. Memory is getting worse, is it just old age or is it a neurodegenerative disorder needing assessment and interventions? Sometimes a lot of investigation, radiological and radionucleotide imaging is needed along with longditudinal data over time before it's valid to say it's normal ageing or Mild Cognitive Impairement rather than saying it's definitely dementia.

The key difference between Primary Ageing and Secondary Ageing changes, though, is one of impact. In normal ageing, although neuropsychiatric testing shows memory getting worse, function is preserved. You can still find your way to the shops and back. When in the shops, you can still remember most of what you went for. When paying, if short changed from a £20 note, you'll notice.

We have less than perfect memory all the time. A friend who's a school teacher says normal kids, with perfectly young and healthy brains, have appalling memories. Lunches forgotten, pencil cases left, PE stuff not taken home and washed, coats and cardigans left on chairs. She has loads of stuff every day that evidence how the childrens' poor concentration, attention span and memory result in forgetfulness.

Yet they're normal.

Too, when my wife asks me to go to the shops for one thing, I'm usually fine. If she asks for a dozen, I'll make a list. If she asks for 5 or 6 things, I'll remember most of them most of the time but often will forget something. My memory's not bad, but I forget things.

We can edit out this background forgetfulness when seeing our family. It's easy to identify memory's not great, but harder to frame it as not great long term and a little bit worse, not great long term and worse with impact meaning they're not coping, not great long term and a lot worse recently and so on.

Which interested me, since it's odd how we look at things, then what we see (or what we see as important) isn't based wholly on the reality of what's before us.

Families spotted their parents' memories changed and sought help for them, which was all wholly appropriate. What was heartening was that their parents' memories were changing through physiological Primary Ageing but none of the folk of late have had clinical, neuropsychiatric or radiological evidence to support a diagnosis of dementia. Now that's a reason for seasonal good cheer!


Christmas snuck up on me, this year.

I know, I know, it's still on December 25th this year so I could still have planned for it all in good time, but I didn't. Somehow it was upon me rather more swiftly than planned (erm, because it wasn't planned) so has all been a bit of a flurry. Ho hum. Or ho ho ho.

It's been healthy blogging for a year then taking some time out, but now I'm bored so it's time to start waffling on again, as is my wont. Thank you kindly for the comments and emails, which were surprisingly positive.

Just a brief aside. As folks will have gathered, I'm more than happy to be challenged on clinical opinions, indeed it's welcomed. What I think is a reasonable plan of action someone else may quibble with, the discourse that ensues is helpful and either helps me feel that my view is rational and sound, or that it isn't and helps me shift. When to give ECT, how long to be on an antidepressant for, what section 5 of the Mental Capacity Act 2005 should be used for, at what age to formally diagnose personality disorder, when to use a Supervised Community Treatment order . . . I'm happy to have offered views and chew the cud 'til the cows come home. What unsettled me wasn't when what I was saying was being challenged, but how I said things was being challenged.

Tricky one, that.

It's something I'm not easily going to change. Also, even if I stopped just posting on whim, and thought through and edited stuff, no matter how assiduously I tried I'd still cause affront to someone, somewhere, some of the time. One author of another blog rightly pointed out that a goodly number of their readers are patients (so things need to be framed in a suitably benign and universal way, presumably because patients are too fragile to exist in the really real world) which gave me food for thought. It'd be wrong for me to be saying things on other sites that could be taken as unhelpful.

I'm not a politician. I'm often wrong. Thus, I've never aspired to be "politically correct."

Medical blogs and medical student blogs I frequent seem to be liberal minded and haven't had issue with how things are said, so it seems sound to largely confine myself to such waters. And what better place to start than my own icy waters of Lake Cocytus . . .

. . . time to start blogging again.

Thursday 30 October 2008


After a run of poor communication on my part 'pon various blogs, it's got me rattled.

T'interweb is a great resource but happen my banter on mental health matters, without explanation or context, is too easily misconstrued. Or maybe it's just that I'm better at talking things through rather than writing things down.

Happy to chatter through emails with folk who've got my address.

Anyways, time for a blogging break and a bit of reflective practice.

Safe roads, one and all!


Over the last few months I've had a rather significant number of folk who've had insight but haven't wanted it.

Several people with dementia have been on treatment for this which has maintained their thinking, memory, concentration and function for a goodly length of time.

As time's marched on, their deficits have progressed. They know they're losing their memory. They know they're losing their attention span. They know they're losing their orientation. They know they're losing their organisational skills. They know their decisions are less considered. They know their function is deteriorating (e.g. no longer being able to dress themselves since they can't manage shirt/blouse buttons). They know they're losing weight since they don't appreciate feelings of hunger/satiety so much now. They know their mood's got worse, being pretty glum and anxious. They know they can't recognise friends they see less frequently now.

Their dementia is progressing. They know.

This insight causes feelings of disquiet, of anxiety, of frustration, of dismay.

This has resulted in a slew of folk wishing to stop their medication, since it was holding them in an unhelpful place, where they had memory problems yet had insight and couldn't forget the woe. The burden was unpleasant. They sought to be relieved of that, to be allowed to forget.

To a one, they've all faired better from stopping their medication. Of course, their cognition and Mini Mental State Examination scores are significantly worse, but they're all, all much more relaxed and less distraught. The knowing is less.

Just sometimes, the loss of memory can be a blessing.

Tuesday 21 October 2008

The tail wags the dog?

Having established that all those doctors are evil, wicked, tyrannical baby eating terrorists who drop gum, talk loudly in cinemas, fail to prevent earthquakes, park in disabled spaces, caused global warming and, through their salaries, have caused a global financial disaster and credit crunch, I set out to see just how ghastly these 'orrible medical folk are.

In November 2006 the BMJ published details of a MORI poll showing what 2000 random adults thought of different professions :
- 92 per cent of the public trust doctors to tell the truth. This is higher than the rating for any other professional group included in the poll.
- teachers 88 per cent
- professors 80 per cent
- judges 75 per cent
- clergymen/priests 75 per cent
- politicians and government ministers 20 per cent

"Doctors will be incredibly heartened to hear that they continue to earn their patients’ trust. These figures once again demonstrate the importance of the doctor-patient relationship and patients will find this trust of enormous value when they attempt to navigate the many changes affecting their health care."

Hats off to the BBC who reported this, but also reported the bottom of the poll which before today I'd not been aware of :
- Business leaders, 31% of the public trust the, they're actively not trusted by 56%
- Politicians Trust, 20% of the public trust the, they're actively not trusted by 72%
- Journalists Trust, 19% of the public trust the, they're actively not trusted by 72%


MORI do the poll every year and the BMA share results this year, which are good :
- Doctors, 90% of the public said they trusted them to tell the truth
- Teachers, 86% of the public said they trusted them to tell the truth
- Professors, 78% of the public said they trusted them to tell the truth
- Judges, 78% of the public said they trusted them to tell the truth
- Clergymen/priests, 73% of the public said they trusted them to tell the truth
- Politicians, 18% of the public said they trusted them to tell the truth

In 2003 MORI conducted a separate survey of politicians’ attitudes to doctors. It found that three quarters of MPs (74 per cent) believe doctors are patient-focused, as opposed to self-centred (18 per cent). Most MPs have a positive view of doctors working in the NHS. They see them as committed (92 per cent), hard-working (87 per cent), and vocationally driven (74 per cent). As well as believing they work effectively (82 per cent) the majority view doctors as helpful (83 per cent). Almost as many MPs as members of the public trust doctors to tell the truth (89 per cent compared to 92 per cent).


Right then. Doctors think they're concientious and have their patients' best interests at heart and know what's best for their patients. MPs agree. Lord Darzi and the DoH reckon we should have a "clinically driven" service. The public reckon politicians and business and journalists can't be trusted but doctors can.
Pretty clear to me who should be deciding how health care's implemented and delivered then, isn't it?

Friday 17 October 2008


My nursing colleagues are underpaid. I know this. I don't see medical colleagues as over paid. Compared to peers, some psychologists seem overpaid for the work they do. OTs seem better paid than nurses, for what they do (since nurses do more, see more patients, put in more hours, carry more responsibility and have more to achieve). But this kind of "they get too much money" isn't a helpful position to hold.

I don't often read The Times, but after clicking a link on Jobbing Doctor's site I started rummaging around The Times online, by mistake.

It has annoyed me. The Times says that CEOs typically earn £212,910 and, ". . . are the head of the business . . . will answer to a board of directors."
Useful information, okay. Leadership but accountability, a fair comment to account for their salary and balance this with this comment of the framework they work within.

They move on to City Brokers, average pay is £94,293. "The City broker is usually portrayed by the media as a scary man screaming and gesticulating manically. They are in fact qualified professionals who buy and sell shares on behalf of investors. To become one, a person is required to pass the Certificate in Securities from the Securities and Investment Institute."
Great! Challenging stigma and negative media portrayal, they frame the broker as a qualified and professional responsible soul.

Then they move on to doctors. Average earnings £81,744. A group who've been savaged by the Government for reluctantly accepting the deal the Government imposed upon the profession. So it goes.
What is The Times view on this? Like City Brokers, do they redress this negative portrayal with some sensible perspective or comment?
"The salary of doctors has been high up the political agenda lately after the Government introduced new contracts that many outside observers regarded as overly generous."

Many see it as overly generous.

Maybe I should give up and just join the massed throngs and throw rotten tomatoes too. Bastard doctors.

Tuesday 14 October 2008


One of my nursing colleagues was discussing with me how she'd seen a lady in a care home who was distraught. The lady would often shout out, incoherently. When family were with her, she was settled and fine.

The nurse worked with the home to understand why the behaviour was arising and if there was unmet need.

She worked with the care home to look at if she was hungry or thirsty or needing assistance in mobilising or toileting, addressing practical elements of care.

The nurse sorted out analgesia for her, four times a day, over one week, to see if pain was causing her distress. It wasn't, so she suggest stopping the analgesia and things were neither better nor worse.

She arranged with District Nurses to have blood tests undertaken to exclude common causes of delirium.

She visited when the lady was distraught and told me, "Her blood pressure and respiratory rate and pulse were all normal."

In order to ensure the patient was communicating and not anxious, she'd thought to look for signs of autonomic overactivity consistent with an anxiety state, checking pulse etc.

I'd never have thought of doing that.

Some people are so clever. Very impressed.

Saturday 11 October 2008


The Jobbing Doctor has been musing over 50 folk who've been said to shape the NHS in recent times. I thought I'd share my thoughts of a woman. Fear not, I'm not about to wax lyrical 'bout affairs of the heart. Mental health I do, agony aunt I do not. But to flirt (ha!) with affairs of the heart for one moment, if I wasn't married and Nadine Schofield didn't have a partner, I could whisk her up and hug her.


Well, she says all the right things that get me excited.

She's passionate about older adults getting exceptionally good care. She's not just feeling strongly about it, she's vocal and active in effecting change too, with tangible results for the better. She challenges, without compromising and capitulating at every turn, yet without being stroppy and unreasonable and unrealistic. Over the last couple years we've crossed paths at a number of conferences and I've always been stunningly impressed by her. She speaks enthusiastically and with has real insight . . . a woman who can present well and who's got sensible, salient, contentious and vital content to deliver. Vital in the true sense of the word (i.e. in maintaining vital signs, reducing mortality) rather than in a management "this is what I think is awfully important this month" sort of vital.

She collaboratively developed the Lets Respect campaign which is just starting to gain prominence in some acute Trusts as more of us bang on about it. Particularly those doing a lot of liaison psychiatry for them. John Holmes should also get an honourable mention here, promoting older adults mental health needs within a mental health Foundation Trust that's providing liaison psychiatry input to another Foundation Trust that's historically had a somewhat modest mental health agenda.

What's been pertinent of late are her views that services hould be equal. Fine, that makes sense, is hard to argue against and sounds fair. Nadine's point is that we need to develop services that are appropriate, which means that equal does not mean the same.

To explain, if younger adults have a service to deliver mental health care if they present to A&E, then older adults should, too. If younger adults have services to support them in crisis, then older adults should too. Of note, this doesn't mean that younger and older adults all get the same service.

Why not?

Because just as "equal" does not mean "the same" so "the same" is not "equal."

Say I change my practice such that I could honestly say that I give the same service to all my patients. Every single patient is seen in the same location. Every single patient is given the same amount of time. Every single patient is seen by me. Is this an equal and a fair service? If everyone has to be seen in out-patient clinic and folk can't get there, that's not fair. It's an un-equal service already. Everyone's seen for the same duration, but what of the people who need more time to grasp and explore and understand? I see everyone so there's Consultant input into all care, but I'm British and speak English. So everyone gets an equal, same service, but if managers were to prvocatively say you choose not to speak or understand English then though you're getting the same service regrettably you'll not understand a thing, so is it a fair service? Not good, huh? Giving the same service to everyone isn't patient centred and doesn't address individuals needs.

This is why I like her awfully compelling argument that services should be equal so whatever your age or ethnicity or social class or gender or whatever you get the right care for your needs. Which through necessity means that services will have to be different in order to optimally meet needs, since different groups will have different clinical needs. Patients I work with typically have very different mental health problems, physical health problems and social adversity compared to child & adolescent or learning difficulty or forensic or general adult or rehabilitation psychiatry patient populations.

Thus, older adult services should be discreet and different from other mental health provision.

The DoH mantra of "cradle to grave" psychiatry and "needs based" services (so if you're depressed at 16, 46 or 86 you get the same team sorting out your mood problems) is flawed.

Thank goodness there're sensible and effective folk like Nadine telling them so.

Friday 10 October 2008

Age concern

Why isn't this publicised more?

Wednesday 8 October 2008


The Girl with the Blue Stethoscope has posed an interesting comment.

"What kind of proportion of your work is made up of patients with dementia and related conditions?"
Probably about a third to a half of my work is dementia related.

"What can you do for them if (as in this case) medications won't help?"
Ah, now that's what is of interest.

My starting point would be that lots can be done by a great many people. What can I do, well that's a much more modest thing.

As a doctor, when medication won't help, and I can't change the underlying process at all, my role is mostly explanation and psychoeducation, with a touch of patient and carer support thrown in too. The biggest thing I do, typically, is to involve the right colleagues.

When someone has dementia they need advice on a lot of things (initial assessment letters often run to over a dozen points for various folk to act on). After this, input is provided according to need.

My stab at the simple answer of what's done could be that, "appropriate patient centred health care and social welfare is provided with dignity and respect."

The complicated answer is that we need to understand the person, we need to understand them very well indeed.

It's easy in mental health to see a behaviour and attribute this to mental illness. Normal behaviour can become pathology all to readily. The way to challenge this is to understand the behaviour. The behaviour may be wrong (e.g. taking food from someone elses plate) or may be unacceptable (e.g. pushing people to the floor when they're in your way) but this isn't about moral judgement it's about understanding. Why did the behaviour arise? Was it the situation that made the event almost destined to happen? Was it the interaction with staff or residents that escalated frustration? Was it that the person had tried to communicate and now couldn't see any other way of behaving? Was it to do with the person's beliefs or experiences that cause a certain reaction? We have to spend a lot of time in care homes and a lot of time with family and carers to then be able to suggest interventions that form appropriate person centred care.

All a bit abstract, so here're two real examples.

One patient with Alzheimer's disease in an EMI residential home was settled almost all the time, but occasionally would wander and occasionally would pack clothes at 4.30am (when he'd always woken up and had to get up all his working life as a miner, to get to the pit on time). None of this was problematic. What was difficult was meal times. In the dining room every breakfast, lunch and dinner he'd throw things. Food, crockery, cutlery, whatever. He'd shout and moan. He was too demented to express himself lucidly when distraught. His wife gave us the answer. He hated sitting with his back to people walking behind him, with him not knowing who they were or what they were doing. All his life in cafes or meals out, he hated being in the middle of a room. When he was seated with his back to a wall, almost all his frustration and challenging behaviour evaporated.
Through knowing him, he got better care.

One lady with Alzheimer's disease was wandering a lot in the corridors and grounds of a large EMI nursing home. She often (twice a day or so) would get upset and sometimes cry but with frustration and anger rather than sorrow. She'd shout repetitively, she'd rail against carers and repeatedly slap furniture and walls. This would last anything up to an hour and a half, with her shouting and tap tap tapping the wall.
Solution : understand what works for her, to help her feel calm and relaxed.

How was this done? We spoke with her and her family and the care staff in the EMI unit. This was documented within a diary, detailing an increasingly richer picture of her and her world.
So from this, should the answer in her care plan be : "When distressed, people around make a difference. This can help de-escalate her distress and associated behaviours."
No. Not good enough. What do people do that makes a difference, is it that she needs one to one time with her hand held and close contact and eye contact and talk and reality orientation? Or is that proximity winding her up, is she best left and given space and encouraged to pace and discharge her emotion through walking, walking, walking around the grounds?
So from this, should the answer in her care plan be : "When distressed, she responds well to having one to one care, through someone being with her."
No. Not good enough. What do they do that makes a difference? We still don't understand what the person does.
So from this, should the answer in her care plan be : "When distressed, a person needs to sit with her for 20 minutes, sitting near to her but not within her immediate personal space."
No. Still not good enough. We understand what the person does, but we still don't understand the quality of the interaction so can't yet understand how to help her.

What is culminated to was that she was relaxed when someone was with her but there was no pressure or expectations placed upon her. She didn't do well when people tried to talk with her, she didn't have the concentration and attention span to engage in a 10 minute conversation so became more frustrated and distraught. Equally she didn't want to be ignored. She wanted human contact and company so did better if people were around her rather than being left on her own. A lot of eye contact and sitting facing her and a lot of questions, especially open questions, were bewildering and threatening to her, making things worse. She didn't want to be asked how she was or how she felt or what she fancied for supper or how she'd like to fill time through the sunny afternoon. This gave us a solution for her.
Her care plan read along the lines of, "When distraught, she benefits from staff input. This needs to be one to one, sitting at the side of her, doing a passive activity shared together. This shared contact should continue for 20 minutes in order to be therapeutic. Her preferred activity at the moment is watching old black and white films, sitting with someone as a shared experience of something familiar to her but in a situation where she doesn't have to respond or react to other people. After 20 minutes of sitting and watching it with her, staff can leave her to continue watching her film alone."

Knowing how a shared human contact impacts upon that lady, so understanding the detail of what key elements need to be in place, that's what my team and I do for folk with dementia when medication's not the answer.

Tuesday 7 October 2008

Low mood

I've a lady with Alzheimer's disease, let's call her Gladys.

She's living on her own but has frequent support from family who live nearby (very near, it's about 2 to 3 minutes walk from their house to hers) so has folk around her much of the time.

Still, they have their own lives so are busy and aren't with Gladys all the time.

Much of the time Gladys is low in mood. She's down, feeling miserable and glum. She doesn't cry, but feels as if she could. She doesn't see much of a future for herself, with nothing to look forward to. She eats what family cook or bring, but doesn't enjoy food, has no interest in it and no appetite. She has no guilt, no initial insomnia, no early morning wakening, no broken sleep, no significant weight loss, no diurnal variation in mood. She's never self harmed and has never had suicidal thoughts or feelings or impulses.

Gladys has tried different antidepressants. She's tried them at the maximum doses, so she's tried them at a therapeutic dose. She's tried them for a minimum of 6 weeks, so she's tried them for a therapeutic duration. She's no better on them. She has no evidence of a chemical mood disorder (endogenous depression) so it's no surprise that fiddling with the chemistry (i.e. taking tablets) has made no difference.

Still, it's hardly a cheery scenario. Alzheimer's disease damages your mood before it damages memory (with changes in the limbic system being the first changes in Alzheimer's disease) so she's structural changes in her brain that mean her mood's likely to be different. Changing or low mood is likely, then.

She sees herself becoming a burden to her family (they already invest huge amounts of time caring for her rather than just being with her), they won't entertain social services home care since they believe they can do it better and are happy to do so.
Gladys is miserable because she has a terminal condition that's getting worse by the month, robbing her of her memory and speech and personality then will kill her.
Unlike cancer, there's no hope of surgery, no hope of chemotherapy, it's destined to march on and take its toll.

She's low in mood because she should be.

Not an easy scenario to manage.

Wednesday 1 October 2008

Deadly doctors

Dr Shipman's actions have had a lasting impact on the medical workforce.

Training, regulation and scrutiny have all explicitly changed as a result of this. I'm sure there are other issues around trust and confidence and probity that have also been challenged through this.

Nowadays I have to go through an annual appraisal with a Medical Director at a neighbouring hospital, once a year. This is a significant and laborious process. I've said before how it ties up a full week of my time and a full week of secretarial/clerical time to do this. Unlike Dr Bacon's spurious website to rate doctors, I'm anonymously rated by patients, doctors, receptionists, clerical staff, nursing staff, physiotherapists, OTs, social workers, healthcare assistants, secretaries and managers in a structured and rigorous fashion, collated by the Royal College who then illustrate my ratings against a national benchmark, to see how I compare.

Masses of time, effort and expense is therefore invested in to annual appraisal. This is a subject dear to my heart at the moment since I've to generate my appraisal folder over the next couple months, a folder that will fill a lever arch file.

By unhappy chance, in the past I have been involved in the investigation of a number of complaints. One was around the practice of a Consultant Psychiatrist in another hospital. Looking at her case notes, standards of care seemed poor. Speaking with staff, standards of care seemed poor. Speaking with patients, standards of care seemed poor. Speaking with carers, standards of care were poor and their fury towards this doctor was palpable. Speaking with the service manager, standards of care, organisation, service delivery and teamwork seemed poor. Lots of complaints had been generated. 360 degree appraisal suggested the doctor was not good. Yet, this Consultant Psychiatrist had signed off annual appraisals.

Annual appraisal can only realistically appraise the evidence that is brought to the meeting. Even with a lever arch file of evidence, it's perfectly possible for a bad doctor to limp through it, presenting their practice as good enough.

I am quite certain that the current systems would not pick up or spot a doctor like Dr Shipman. Clinical audit could. Investing massive effort and confidence in appraisal seems to be missing the point.

Monday 29 September 2008


I've good working relations with our PCT and Area Prescribing Committee (APC) who let me prescribe any acetylcholinesterase inhibitor (antidementia drug) that I'd care to use, for any number of patients, at any dose, for whatever duration I wish. It's glorious to have the trust and clinical freedom to do what seems best for my patients without having constraints.

The compromise is that a fourth drug called memantine (which NICE say should only be prescribed on the NHS as part of well designed clinical trials) isn't prescribed much at all. Since NICE say not too. All well and good, I've got 3 others to play with and can deliver excellent care with them.

Too, the PCT and APC are happy for me to use memantine, just not much. So every now and again I find someone with a clinical presentation that suggests memantine could be useful, the other drugs aren't, so memantine's prescribed.

My nursing colleagues and Clinical Effectiveness lead were reviewing our practice to make sure that despite our belief we use little that we really weren't giving memantine out like smarties. We're not. We also looked at MMSE and outcomes from memantine use, to ensure that it continues to be useful for patients. We struggled at this bit, since we'd stopped it in almost every patient, because it hadn't worked.
I know the drug company's got efficacy data to show it's better than placebo, but I'm really after some good effectiveness data to show that in the really real world (outside of clinical trials) it does something useful, much of the time.

The number of folk who gained benefit on memantine and remain on it can be counted on one hand.

Hardly glorious results, then.

I'm starting to feel memantine's not quite as effective as it's said to be . . .

Thursday 25 September 2008


How we are impacts 'pon who we are.

I didn't make this up, this statement was deduced by keener minds than mine. It's a concept that's gained credence over time and has been embraced in psychological therapies to effect change. Cognitive Behavioural Psychotherapy (CBT) has a rich evidence base showing that changes in behaviour and thoughts effect changes in our feelings and disposition. From being stressed when driving around a particular roundabout after a bad accident, from feeling panic when having to look after the grandchildren for a Saturday morning, from staying at home since you feel you're poor company instead of popping over to a friends for your usual Tuesday morning coffee and a natter, you work through CBT and move towards being able to manage these things. We're no longer anxious, or having panic attacks, or constricting our behavioural repetoire through thoughts of ourself/the world/others.

Thus, what we do has changed who we are.

This is a good thing. We can take positive action to make positive changes.

I was speaking with a lady from Sweden. Although this is anonymous, the number of Swedish ladies who have had this care will be modest, but her insight was such that I wished to share it. I spoke with her and she was more than happy for this to be shared here, so here goes. She had experienced a period of depression after her husband died which we managed with input from the CMHT and successfully improved things without medication. CBT over just a few sessions was very useful for her.

She has been well for a length of time so I visited her to review things, ensuring she wasn't being too brave (and wasn't depressed), that medication still wasn't necessary and whether discharge from our service should be entertained.

When I saw her in her home I was struck by how well she seemed. Often folk in my corner can be stoical, but struggling to manage beneath the veneer of coping. Not so here, she really was well. She wasn't as cheery as she felt she once was, still seeming a little weary, but was doing everything she used to, visiting friends, managing her garden every day which looked lush (the mixed sunshine and rain of this Summer helping make it a riot of colour), helping more frail neighbours with shopping, visiting a friend down South last week for a couple days, really doing well.

I talked through with her how life was for her now, how she'd been low in mood, how she'd recovered and what had been helpful in this process. Talking with friends and family had helped her, but what had been most useful was a CBT session with a CPN who had been promoting mindfulness and acceptance therapy ideas with her, to frame things she can't change in a fashion that she could accept and cope with.
This had switched on a lightbulb moment for her.

She was very animated and excited on telling me this, recounting how she'd had this conversation with the nurse. "I know this," she beamed, "this is how I am."
She explained that she had always felt you need a little of everything. She had experienced disbelief, she had felt wronged, she had felt sorrow, she had experienced warmth and friendship. "This is how it should be, this is how I am."
She explained to me how in Sweden they have a concept with they call Lagom, a word which has no direct equivalent in English. It's apparently used to mean things being in balance, good enough, sufficient, suitable, as it should be.

Rather than perfection, or excess (of wealth, success, happiness, anything), she espoused the view that "Lagom är bäst," meaning Lagom is best.

Having good and bad, but no excesses, wishing for things being just so, being simply appropriately good enough, is apparently a strongly rooted Swedish cultural value.


Here we are in our CMHT thinking we're being clever, when Sweden really did have it worked out ages ago. I always find myself taking something away from my contact with my patients but on this occasion I felt I'd learnt far more from her than she had from me.

Lagom, a simple, elegant and intuitively brilliant notion.

Tuesday 23 September 2008

One doctor

I saw a lady at her home on the way in to work this morning, since her home's on the route in. She's a lady who has had episodes of depression over decades but thankfully has been stable for a good few years now through a mix of interventions.

She's had problems with her physical health, was admitted for investigations and was discharged last week so I thought I'd best pop in to review how she was and if her medication was still appropriate.

Driving in to work, my mind was busy. I've several patients to review later today on the wards. I was seeing this lady and thinking through how she'd been in the past, how before coming to older adult services she's had several admissions and courses of ECT, how she'd been on her medication over the last 5 years I've known her and whether they were now safe. I was thinking through the content of a presentation I'm doing later this week, doing teaching within a neighbouring Trust, structuring what I need to get over to them and what key take home messages I want to stick. I was thinking through 2 formal complaints in a nearby unit I'm investigating and what information I'm going to have to go through this week to substantiate what I already know of how 2 staff really have acted woefully. I was thinking of the patient visits I have this afternoon.

So I visited my kindly lady, who as always methodically made a superb pot of tea, then talked things through with her.

She wasn't having problems of hypotension or risks or treatment emergent adverse events necessitating a change of medication. Phew.

She did make a point that I've heard a few times before but forgotten. As I'd been driving in, thinking of lots of patients and lots of work, she'd been thinking of me arriving. She knew of the appointment that the ward staff told her of so had been fixing on this, as an important event in her week, her chance to meet with her Consultant. And then she said it, "I know you have lots of patients, but I have only one psychiatrist, I'm really glad it's you."

A sobering thought and a pleasure to hear, it really has been the best of ways to start my day.

Monday 22 September 2008


I am no philosopher. I have no great insights. Big questions like, "What is mental illness?" are for greater minds than mine to ponder. But, as a clinician seeing folk day to day, it does fall to me to arbitrate over the implications of what's the business of mental healthcare. Simply put, what do my team and I do?
Other than eating biscuits (liaison nurses have the best ones at the moment), we need to define what work we'll do. We need something more workable than, "make things better, make it good enough, help folk cope," even if that's the reality of it.

So I started musing over what the concept of what mental illness means from a healthcare perspective and what we do and don't see as mental illness.

Comments were very interesting. One specific point was made. Also, two general themes that emerged were :
- what's psychiatric mental illness in contrast to other changes of mental wellbeing?
- what's the relevance of mental disorder and the Mental Health Act 1983 in managing mental health problems, now we've got the Mental Capacity Act 2005?
Those two themes merit a post in their own right, so I'll post about those another day since the comments have started stirring my thoughts in a bit of a whirl and I haven't quite got my head around all the implications yet.

The specific point was on diagnosis. I believe diagnosis, done openly and honestly, can serve a useful purpose (with patients and carers and me finding it useful, as I use it). One suggestion was that treatment (drug and psychological therapy) is guided by symptom clusters rather than a diagnostic label. I'd take that further and think that if you have a symptom cluster that has significance, when the presence of those particular symptoms and the intensity of them are all taken together, then this forms a definition of a clinical syndrome. Which is a diagnostic label. As such, I'm still wedded to the belief that attention to symptoms and the impact of symptoms is the key, but I'd then encapsulate the summary of symptoms (and signs) in a diagnosis.

Does diagnois matter, is it useful, or conversely is it unhelpful? When I was in General Practice diagnosis was managed differently by different GPs. Some were firmly wedded to diagnosis, saw it as a critical role of a GP to diagnose what was wrong, share it with the patient so they had an understanding of what the medical perspective was of their collection of symptoms they presented with, then enabled appropriate treatment for that condition. Other GPs were fuzzy in using diagnosis, they were great clinicians and adeptly sleuthed out what was going on but wouldn't share formal diagnostic terms with patients. Their patients would say, "I see Dr X for my heart condition," or "Dr Y looks after my breathing problems, she keeps my lungs cleared up," and so forth. Mostly this worked well, patients had confidence that their GP was managing their problems, knew what was going on, explained to the patient what was being done but didn't harp on about blah blah blah syndrome which had no meaning to the patient.


Apart from when patients got worse.

"Dr Z is treating my stomach complaint but now I've pain, nausea and am totally off my food, I'm vomiting, I've weight loss, my skin's yellow and I'm really tired all the time." That's because you have stomach cancer with widespread malignancy and liver metastases, you're getting worse, you're going to die, but the diagnosis of "cancer" has never been raised so management of consequences of this have never really been discussed since you can't have that kind of talk for, "a stomach ulcer that's gone a bit nasty," which Dr Z is treating.

Ducking diagnosis, with the issues of problems progressing, yet everyone colluding not to look it in the eye and call it what it is, has generated so much poor clinical care for patients I've seen that I'm really, really wary of treading this path now.

Diagnosis and honesty in what's going on means you can then have meaningful dialogue about what's going on, what the future may hold, what choices are before you and what choices you may want to consider for the future. A disadvantage of discussing symptoms in the here and now (instead of diagnosis) is that it doesn't lend itself to that kind of discussion as readily. It does have the advantage that it can focus on symptom management which can be more positive, presuming that improvement of symptoms and coping so all's good enough is restoration to a state of relative health, so all's good (in contrast to a diagnosis that can linger on forever).

Over the last few weeks I've seen many patients.

One lady had poor concentration and poor attention span, poor organisational skills, poor memory of recent events and low mood with mild anxiety. She had dementia (F00.131 dementia in Alzheimer's disease, late onset, with predominantly depressive symptoms, of moderate severity). She could benefit from an antidementia drug.

One lady had poor concentration and poor attention span, poor organisational skills, poor memory of recent events and low mood with mild anxiety. She had depression (F32.11 moderate depressive episode, with somatic syndrome). She could benefit from CBT and an antidepressant drug.

One lady had poor concentration and poor attention span, poor organisational skills, poor memory of recent events and low mood with mild anxiety. She had a bereavement (F43.22 adjustment disorder, mixed anxiety and depressive reaction). She could benefit from nursing or chaplaincy support.

Symptoms of poor concentration and poor attention span, poor organisational skills, poor memory of recent events and low mood with mild anxiety don't determine the treatment, it's the clinical syndrome (and thus the diagnosis) which frames how we can conceptualise the patients' experiences and generate appropriate interventions to then offer.

Diagnosis can be exceptionally unhelpful, but most of the time I do think it's useful since it can guide more widely on the management of the symptoms and on the likely future course.

Given as a helpful handle and explanation, with specific detail that has meaning, a diagnosis can be important. For example, one type of dementia needs different drugs to other types of dementia, and will run a different course, so rather than "memory problems" or "dementia" being discussed, a diagnosis can be useful in helping us discuss drug treatment, Council Tax exemption, psychological interventions (which are at least as important as drug treatment in maintaining cognition), formally making Advance Decisions, driving and the DVLA, Direct Payments, Lasting Power of Attorney for financial decisions and for health/social welfare decisions and so on.

I'm sold that it's the patients' experience that is at the heart of what we do. As such, symptoms matter. They're what our patient is grappling with, what they're telling us they find hard to manage, they're what impact upon their ability to function/to crack on and do what they would wish to do. The number and the intensity of symptoms (the symptoms burden) is key to understanding. But although this informs our assessment, formulation, interventions and carer support, I truly believe that diagnosis still has some use in adding to this process.

Wednesday 17 September 2008

Good enough

"Be ye therefore perfect, as your Father who is in heaven is perfect."
- Mat 5:48

Now that's a tough standard to live by, and no mistake. Charged by our Lord himself to "be perfect" is a lofty aspiration to strive towards. How achievable is perfection?

One issue in mental health is of illness, medical models and diagnosis framing a whole person's experiences (and potential health and social care) in a couple words.
Mental health is undoubtably about "health" so of course has to concern itself with illness and affording approriate care and treatment to our illest patients.
Mental health is also about mental wellbeing, about health in the broader sense.

The World Health Organisation define health as :
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
The WHO also say a lot about mental health, but little of their assertions seem to filter through into healthcare provision.

My last post was about a patient who had no mental health problems in the recent past (but had self harmed when unable to cope in the more distant past) who presented with great mental health until his relationship ended which he said caused him to behave in a suicidal manner. He wasn't mentally ill, he was stressed/frazzled and wanted to show his partner what she had driven him to.

Letting him go and act as he wished to act provoked different views, from thoughts that this was great to allow his responsibility and autonomy to views that he had a personality disorder and needed care but had been inappropriately left with nothing. He was given offers of social care and CPN input and Consultant follow up, so did have some health and social care proffered but the discussion over at Mental Nurse around a comment "Isn’t this just pathologising behaviour?" is similar.

What's mental illness? At what stage do we say that problems aren't necessitating input from specialist professional services?

As a doctor the easy option is to treat illness, thus if someone doesn't have a psychiatric disorder I don't see them and they're discharged from the service. This would be overly harsh, since it then helps manage all formal psychiatric illness but doesn't help address psychological upset (rather than psychiatric illness).

If moving to help folk manage psychological upset then that opens up options for helping folk with relatively minor problems through to relatively serious ones and everything inbetween. Someone who really likes sex and spends more than they should on this, is that a mental illness? Should they be seen within mental health services to "get help" with this? If it's a choice they're making, is it an illness or a disorder? What if they don't like the impact it has but they like to keep doing it so their motivation for change is almost zero, so there's no enthusiasm for treatment?

Anger falls in to this. Often someone's angry but not mentally ill. Anger's just an emotion that's part of all of us, managing it is something we all have to do. Without formal psychiatric illness, is anger a mental illness? Should mental health services help people manage anger? If they don't get better, is it because mental health services haven't tried hard enough, or is it because we've got it wrong and the "treatment" hasn't not worked 'cause there's no "illness" to treat and we're just conceptualising it in this false fashion?

Personality disorder can fall in to this too. Some people will see it as a disorder. This can be helpful, folk can then receive support and care. This can be unhelpful. People with personality disorder (especially F60.31 emotionally unstable personality disorder, borderline type) can receive malign care. Such a person behaves in a fashion that causes concern. Rather than this being their choice (arising in someone who's not psychotic) it's seen to arise through mental disorder (personality disorder). To manage risk, the concern necessitates appropriate management, so compulsory admission and compulsory treatment follows. No better? Then better add in more medication. Doesn't work? Can't stop it, there's a mental illness there, it's causing risks, we need to be seen to be managing it, best keep on with the drugs. The evidence is that personality disorder can be improved through psychological work, if it's intense and there's a high motivation for change. Some work suggests that if motivation to change is sufficiently high, the person effects change without contact from formal mental health services, anyway (using their own resources and support networks).
What can mental health services do for folk with personality disorder? What should mental health services do for folk with personality disorder?

One problems of pathologising behaviour is then the follow on from this. It's not just a behaviour someone's chosen, it's pathology. So needs treatment. Admission, drugs, ECT, whatever. Not cured, well, more treatment, then. Still not improved? Then it's treatment resistant so needs even more drugs, at high dose, in combination. I like diagnosis, it guides care, but diagnosing something as an illness when it isn't can be really, really unhelpful.

In my corner I'm very keen on assessment that looks at all domains. Psychiatry is obviously a big part of it, but physical health and social stressors and the person's past life experience all contribute to what's going on in the here and now, why we're meeting up right this moment, this day, to look at this issue. As such I see diagnosis as important (so people get the right care) but equally there are those without formal psychiatric disorder who can still profit from mental health input.

This work then can help folk improve to a state where things perhaps aren't cured, aren't brilliant, but the person's coping and things are good enough. We may seek perfection but, within mental health services, it's a happy day when this is achieved. Usually we'll have to settle for helping make situations good enough.

Thursday 11 September 2008


"Certainty? In this world nothing is certain but death and taxes."
- Benjamin Franklin

Well, he has a point.

This week's been frantic. A lot of folk have been unwell and (as is my wont) a nurse and I've been doing a large number of joint visits. One referral from A&E resulted in a section 136 assessment. What's that? It's when police arrest someone in a public place and convey them to a place of safety (erm, that'll be my hospital, then) for an assessment of mental disorder. In theory a section 136 is applied because the person presents as mentally disordered and is in immediate need of control and restraint. In practice it can be used 'cause someone is acting, "a bit odd," but the police would find it hard (and bureacratic) to arrest the man then go through their custody officer to get him into the cells. Oodles of paper work. Best just cart him off to health, then he's their problem. But on this occasion an assessment was indeed appropriate.

Thus, I was asked to see a retired gentleman who was detained because he wanted to kill himself and had flounced out of his partner's home and driven off (but was curiously found very swiftly after a number of mobile 'phone calls he made) yet notionally he wanted to be left alone and sought to kill himself. He'd injected himself with insulin. He could tell me, to the unit, how much. He had all his papers with him so he could relocate and settle in my patch. He'd brought suitcases and personal effects. But, erm, "I'm suicidal, I'm going to kill myself and going to end it all."

The approved social worker did some sleuthing. He's been assessed in 5 neighbouring hospitals with the same presentation. Euphemism : he's problems of anger management. Truth : he batters his partner and blames it on anger that doctors haven't cured. He feels no responsibility for this, he can be violent since, "It's not my fault." It's other people, "They wind me up, play head games, do my fucking head in, doc." So they deserve it? "Well no, but they're kind've askin' for it, really, aren't they? Kinda got it comin' with what they say." Who is responsible then? "Not me, it's them folk in [town blah 30 miles away] who never helped me. They know I fly off the handle dead easy, like, but don't treat me or anything. Nobody cares." Ah, my colleagues in a neighbouring county fail to control your anger, so you batter your partner, you're not responsible and they are, now I see.

Are there any delusions? No.
Are there any hallucinations? No.
Any cognitive impairement or confusion? No.
Any changes in physical health, medication, wellbeing? No.
Any obsessions, compulsions, odd thoughts? No.
Alcohol misuse, drug problems? No.

Erm, anything to affect your judgement at all? "Yes doc, it's her, she's done this to me."
Done what? "Said she can't live wi' me, asked me to go, so I have. But now I want to kill myself."

He's assessed. Usually a section 136 assessment takes an hour or so. The approved social worker (ASW) wants more details so it goes on a while. He's observed by nursing staff.

Before this event he's had no tiredness, no loss of pleasure, no initial insomnia, no broken sleep, no early morning wakening, no loss of libido, no diurnal variation, no low mood, no hopelessness, no worthlessness, no guilt, no tearfulness. So, no evidence of somatic features of depression a few hours ago, but suicidal now. Crikey.

He's chatty, enjoys watching the telly, talks with patients about his favourite football team and a match he's looking forward to (and how he might drive up to watch it live). He speaks of new things he's ordered and has to collect next month. He talks of accomodation he wants and support he'd need, "I can't cook, like, so I need looking after."

He's expressive, reactive, no psychomotor retardation, no restlessness, no tearfulness, no distress. He speaks fluently, normal rate, rhythm, volume. Spontaneous with neither poverty of speech nor poverty of content. No dysprosody. Mood subjectively "I'm going to kill myself" but objectively is euthymic. Thoughts are of normal form and content. No perceptual anomalies. No cognitive impairement.

The ASW gets a colleague to see him. Then 'phones another. We talk with 3 nurses who've been with him most of the day, now. Reassauringly, everyone feels the same.
Nobody sees any symptoms of mental illness. Nobody feels he's evidence of mental disorder. Nobody feels he's detainable under the Mental Health Act 1983. Everyone sees him as a capacitated adult, able to make his own choices.

He says, "If you let me go, I'm going to kill myself. Don't you have to detain me, don't you have to stop me killing myself?"
I explain that's not the case, I really hope he won't kill himself, but that's his choice.

We arrange a range of accomodation options for him, for today, in a range of locations. We arrange mental health followup from a CPN and Consultant in his own town but he says he won't go to it. "Your choice, we've offered social support, we've offered mental health follow up, if you want to choose to do something else, we can't stop you."

We send him on his way.

I really, really am not sure he'll live. He's impulsive and reckless. The Mental Capacity Act 2005 states that adults with capacity must be allowed to make unwise choices. He's likely to take overdoses and, intentionally or accidentally, at high risk of killing himself through this.

As Mr Vonnegut would say, "So it goes."

Friday 5 September 2008

Life and death

I had a letter informing me that I needed to reply to an invitation to attend a conference and it "was vital" that I replied by mid September. It was a meaningless conference put on by a drug company that I had no intention to ever attend so it was carefully filed in the bin.

But it got me thinking.

Lungs. Important things, lungs. Hearts, too. Wouldn't want to have those stop working, it all goes rather badly then. Knowing they're necessary to stay alive, when in receipt of health care it's common for symptoms and signs to be sought. Clinical indicators of cardiac function and ventilation are recorded, as pulse and respiratory rate. These are known as "vital signs" since in addition to symptoms, these signs help guide on severity.

If you have a pulse rate or respiratory rate of 0 and they've stopped, the prognosis is not good. These are signs necessary for life. Vital signs.

An online medical dictionary describes "vital" as meaning :
Pronunciation: 'vIt-&l
Function: adjective
1 a : existing as a manifestation of life b : concerned with or necessary to the maintenance of life vital fluids>
2 : characteristic of life or living beings
3 : recording data relating to lives
4 : of, relating to, or constituting the staining of living tissues —vi·tal·ly /-&l-E/ adverb
Merriam-Webster's Medical Dictionary, © 2002 Merriam-Webster, Inc.

Not writing to a drug rep about a spurious and somewhat tawdry conference where folk are trying to peddle their wares with a veneer of civility and propriety, hmmm, who's going to die as a result of this, then? No. It is not "vital" at all. To tell medics it is, well, that's a rather astonishing act of hubris that never fails to irritate me.

Having mused over the implications of "vital" and what this means to health, I've been thinking about causation, disease, consequence and interventions.

It's common, in medicine.

Cause (a virus), disease (a cold), consequences (knackered and can't work that day), interventions (rest in bed with paracetamol).
Cause (cigarettes), disease (lung cancer), consequences (knackered, breathlessness, weight loss), intervention (surgery, radiotherapy)
Cause (bereavement), disease (adjustment disorder), consequences (housebound, not seeing friends, not shopping or cooking), intervention (support)
Same process can be thought through with diabetes (pancreatic islet cells) or bladder or stomach cancer (analine dyes or nitrosamines in smoked foods) or most any condition you'd care to consider.

What of conditions that arise which could be prevented? Weight gain from antipsychotic medication can be an issue, but in older adults often isn't. Usually it's the other way around, with a gain in weight being positively beneficial. Obesity more generally is seen as an elective life choice. After all, we choose what we eat and how physically active we are.

This can lead, from past experience, to interesting conversations that GPs have with their patients :

Am I overweight, doctor? Why, yes I am.

Is this impacting adveserly 'pon my physical, mental and social wellbeing? Why, yes it is.

So this constitutes a situation where my physical state is impacting adversely upon my health? Evidently so.

Having now poled up for this health matter to be addressed, I'd therefore like appropriate clinical care to address my health problem.

What, no, you can't fix it? You say it's a lifestyle choice? So's skiing, but you treat sprained ankles. So's sex, but you manage contraception and abortion. So's going to work, but you treat occupational injuries and health problems. So's smoking, but you treat COPD and lung cancer.
So come on, over to you doc, treat me, make me better.

Simply because the causation wasn't a random event, should that impact on the condition, the consequences and the interventions (in terms of clinical care offered) at all?

A Nice Lady Doctor notes the medicalisation of ordinary and everyday life. GeePeeMum notes that a lady with end stage bronchitis is chided for past choices she made. The Ferret Fancier (and those commenting) recognise obesity is best addressed through social/public health measures rather than Primary Care.

Although my attendance at drug companies peddling pills for all ills is not "vital" I do think joined up thinking matters on management of health issues where lifestyle choices (cycling -> RTA, smoking -> Ca lung, eating -> obesity, sex -> teenage pregnancy, whatever) that impacts on health in the here and now doesn't result in different care because the aetiology of the disorder was within the patient's gift to influence. Addressing current clinical need can truly be "vital."

Wednesday 3 September 2008

Having a stab at it

When I was training, procedural skills were taught at the bedside by someone a touch more experienced (an SHO or Reg or SR) who would talk you through something like cannulation or siting a chest drain or lumbar puncture or whatever. You just had to crack on and do these things, they're practical tasks, you can't just read up on them. A skill you aquire through doing it, we got better at intubation at cardiac arrests and suprapubic aspiration of urine in kids and siting central lines through doing more and more of them.

As one SR quipped, placing a needle at the ready, "You just need to have a stab at it!"

The benefits of this system were that you got really immersed in the clinical work, your competence (and confidence) got better from aquisition of skills, it was you who were working intimately with patients so developed consultation/therapeutic skills and there was someone who knew what they were doing standing right next to you so if care wasn't right then they would do it (so there was no practising and playing, patients got the right care).

Nowadays, practical tasks can't be learnt "on the fly" like this.

No no no.

Our Deanery organises regular teaching on training, the current vogue for practical skills is of explanation, then showing someone the task talking it through for them, then you doing it silently, then showing them the task with them talking it through to you, then them doing it. Surely life's too short for this.

Worse, once a trainee has done something, it needs documenting. Not just documenting in clinical records what's been done, no, it needs documenting in the trainees logbook or portfolio that they've done whatever.

Worse still, it can't simply be a comment that the procedure was successfully undertaken and any positive/negative feedback noted, it has to also be documented online as a DoPS. DoPS, you don't know? It's unclear to you what a DoPS is?

Fear not, you're in good company.

The DoPS is undertaken on the Royal College of Psychiatrists own web site, entered online (since, of course, electronic information systems, especially online ones, are the safest and most robust methods of storing sensitive information on trainees successes and failures). The Royal College site describes DoPS as "DoPS Direct Observation of Procedural Procedures" one one page but then as "DOPS Directly Observed Procedural Skills" on another.

So, after a trainee successfully administered a depot antipsychotic injection under the auspices of a band 7 nurse, which was the work of moments, we then have to spend an age documenting it all for the trainee.

Is this better than when a nurse could toss the syringe over and say, "Have a stab at it!"

Monday 1 September 2008


In my time when I'm working with younger adults I recently saw a colleague from a nearby hospital.

She's in her 20's. We went through a neuropsychiatric assessment, discussion of changes at work and home, talked through her agenda (a couple of diagnoses she thought she had), undertook a neurological examination then mused over formulation and diagnosis.

She was well, she was simply worried and needed some time, space and objectivity to frame what was going on as understandable and normal, rather than her not coping and pathological.

I thought nothing further of it.

It was only on reading a Nice Lady Doctor's post on treating colleagues that I stopped and thought. What she's said resonated. I remember, when working in General Practice and when in hospitals, feeling exactly as she describes. What's changed? Although a couple years older, I guess what's changed is that it's simply I'm more comfortable recognising that as Donald Winnicott would say, I'm a "good enough" doctor.

Seeing myself as "good enough" I can have a stab at working with most anyone, comfortable that I can do a decent enough job, even if they are experienced or clinically very savvy or have a brain the size of Saturn and are far cleverer than me.

Sunday 31 August 2008

Continuity of care

Continuity of care. Does it matter?

In Primary Care, bloggers have been vocal for over a year, raising awareness that government policy is to shift Primary Care away from an established GP practice with GPs looking after you (and other staff supporting this) to a new style of clinic. In these (often private) clinics, access is easy but the consultation is usually not with a doctor. When medical input is necessary, it's with who ever is working in the clinic that day, so there's no continuity of care.

You speak with a doctor about your problems. Tests are arranged, there's uncertainty over diagnosis, there's sensible safety netting and a review is arranged for a month to see what the clinical course has been. But when you're reviewed it's by a different person. So how can they compare if things are better or worse? How can they tell if the chest auscultation is clearer, or the heart murmur is harsher, or the skin is more icthyotic, or the dyspnoea more intense?
Much badness.

Patient surveys have consistently shown that patients would prefer to see the same doctor. In psychiatry, surveys have shown that this is also true. Who wants to give a frank account of their life to a doctor, start to develop a relationship and perhaps feel some trust, to then see some random soul and pick up consultations with a stranger? Much better to work with someone who knows your medical history but more (and this to my mind is the crunch) with someone who knows something of you. You can't get that in medical notes. It's about rapport, about relationships, about a shared understanding and shared confidence and shared trust.

Patients will trust me and I will trust them. That develops over time, it's generated through honest dialogue and evidenced actions that we undertake together over a period of time. Then, if I'm suggesting something they're sceptical about, they know it's because I genuinely feel it's the right thing to offer, knowing and having experienced appropriate care over time, so having a degree of trust.

I know colleagues who work in other hospitals/mental health Trusts, in other regions. Mental health isn't a huge field. Some colleagues work in systems where patients see a different team for different stages of their illness.
First you see an Early Intervention team.
Then, if things aren't great, you see a Crisis Reolution or Home Treatment team.
Then, if you need support within a hospital, you are transferred to the Inpatient team.
You're then discharged to the Community team.
Not cured? Then let's transfer you to the Rehab team.
A patient has been bounced through 5 teams before they've even entertained specific teams that might add in to care pathways (lithium clinics, drug/alcohol services, clozapine services, early onset dementia teams).

5 different teams, 5 different Consultant Psychiatrists. What if one is very much a community psychosocial medic who likes holistic interventions and minimum use of medication and another is a very biomedical medic who like the medical model and drugs? Care is ghastly. You get no drugs in one part of the service, you're admitted and given oodles of drugs, then discharged to the community where you're picked up by someone who doesn't think you should be on lots of drugs, but now you are. What to do, what to do.

As well as a lack of consistency of approach, there's then the tension of boundaries. The community team feels risks are significant and treatment isn't working and the patient and family aren't coping, so arrange for a hospital admission. The inpatient Consultant hasn't experienced what it's like for the patient and family at home so can't see what's so bad that hospital in-patient care is necessary, so promptly discharges the patient back to the frazzled community team, bitter that community folk are always turfing work to the in-patient wards whenever they're stressed or busy or have real work to do. The community team is bitter that the in-patient team never sorts problems out and only's interested if a patient needs detaining or needs ECT and sees everything else as something the community team should manage outside of hospital.

Speaking with folk from 3 areas who do work in this way, this scenario sadly isn't fiction but is the world that some folk now live in. Mental health services are already like this, in some parts of the country.
Much badness.

I don't work in this system. I cover a geographical area and manage all the patient's care where ever they may be. There's no tension over what area should be doing what, it's still my work whether they're an in-patient or in the community or in a care home or whatever. There's no tension with me having one philosophy of care and another psychiatrist with different views giving conflicting care. There's no problems of patients and families seeing a different person each time (only I do an out-patient clinic, there isn't even a junior doctor's clinic list, so I see follow-up patients myself).

I would be driven to burn out if shackled to out-patient clinics all week. Or in-patient wards all week, without seeing the follow up and positive results in the community.

Polyclincs in Primary Care. Fragmented services in Secondary Care. It's worth speaking up about them, and speaking up about them now, before things change for the worse. It may not feel immediate or directly and personally relevant. It's still an issue that should be fervently opposed.

"When the Nazis came for the communists,
I remained silent;
I was not a communist.

When they locked up the social democrats,
I remained silent;
I was not a social democrat.

When they came for the trade unionists,
I did not speak out;
I was not a trade unionist.

When they came for the Jews,
I remained silent;
I wasn't a Jew.

When they came for me,
there was no one left to speak out."

- Pastor Martin Niemöller (1892–1984)

Thursday 28 August 2008

MDT Teaching

Like many better other folk, I am enthusiastic about teaching.

I teach medical students often, both on wards and in clinics and within the community as well as formal classroom teaching. I'm often asked to do some teaching outside our organisation, this month it's been within a GP surgery, two care homes and our hospice. But I also teach members of our teams.

Teaching small groups of nurses and social workers, student nurses, occupational therapists and support workers does give people the opportunity to ask about small things they would like to know about or clarify. It also means we can share new information. It's healthy for teams, I feel, since we can all get together and bat out our views on a topic and there's a sense of collective "buying in" or cohesion at the end of it.

This week I have been struck by just how much people learn within the working week :
- one nurse queried with me whether a patient we're seeing with atypical dementia (and still trying to formally diagnose what the problem is) could have Binswanger's disease.
And she's quite correct, it fits very well indeed, he may well do.
- one nurse student, on seeing a patient on an anticonvulsant who had recently been initiated on olanzapine, queried the dose. Starting at 5mg, she questioned whether the dose would be therapeutic because wouldn't the anticonvulsant mean that her cytochrome P450 would metabolise the olanzapine so there'd be less to work?
The answer was almost meaningless but it was the process, her thoughts on the medication and consequences of interactions, that was spot on . . . stunningly good thinking. We've titrated the dose up now but she was absolutely right that the patient was on an enzyme inducer.
- a social worker asked me if a younger patient who's been on donepezil for 4 years for Pick's disease should stay on it. It's working very well, but the patient's had a arthritis, has taken over the counter tablets since last year and now has heartburn and is being investigated for stomach ulcers.

An atypical diagnosis, impact of pharmacology on clinical care and knowing cautions of drugs we use. I'm really am blessed with such a good team.

Tuesday 26 August 2008


There's been a lot of talk in my corner about interests.

I was reading The Guardian this weekend which was saying that drug companies influence doctors through gifts and that this influence isn't adequately disclosed.

It's human nature that when someone is kind to you and gives you a gift you want to be kind to them. If they're wishing for you to prescribe more of Drug X and give you a gift, you're more likely to prescribe Drug X. There's research that shows this to be the case, even though most prescribers believe they're not suggestible and not influenced by drug reps or gifts. The evidence is that they are.

So how do prescribers deal with this? Are patients informed that the pharamceutical company of Drug Y has visited 17 times this year, left £300 worth of gifts and brought in food for a few team lunches but we don't think it affects our use of Drug Y?

In our Trust every 12 weeks we've got to sign a statement of all gifts and hospitality that drug reps provide. Increasingly it's easy. I've never yet had anything to sign for and as time passes that's the case for more and more of us.
The only way I can be certain I'm not influenced by drug companies is to not see them. So I don't. And all my study leave is paid for by the Trust, not by a drug company. I don't accept any gifts from drug reps, not even a biro.

So I'm not sure how representative The Guardian's piece is, nowadays. Drug Reps can no longer enter our premises unless invited to by a Consultant, so we simply don't have contact with them any more.

That way, when my colleagues or I'm talking with patients about their treatment, we can be wholly up front in knowing that our prescribing choices aren't influenced by pharmaceutical companies' machinations.

Monday 25 August 2008


The media portray madness in many ways. Okay, this is simply a shameless excuse to share what I think is a hillarious take of one archvillain, The Joker, who says, "Am I crazy here? Okay, I know I'm crazy . . ." :

Well I thought it was funny!


Burried deep within the comments of an interesting post on nurses' training experiences 'bout medication I found this gem.

FOFOY training.

Fuck Off and Find Out Yourself training.

I like being spoon fed. Undergraduate education seems to have swung too far away from this, though, with espoused "adult self directed learning" ideas.

FOFOY. It really is how far too much medical (doctors and nurses) training seems to be, nowadays.

Sunday 24 August 2008


I met with a 66 year old lady to tell her the results of her investigations.

She'd been referred a month ago, with a 2 year history of memory problems. She was widowed, having a bereavement when her husband died 2 years ago. She lives alone and can't see her daughter now that she's in hospital a lot with her child who's had 9 operations and needs more. She calls the police once a month or so because the kids outside throw things at her and her neighbours windows, so she no longer feels safe (and they really do throw quite hard, I saw the dents in her garage door and the marks on her walls).

Talking with her, she had no evidence of a neurodegenerative process like dementia.

She scored normally on MMSE, Camcog and DemTect. NPI was fine, BDI II and HAD were not.

Her lack of focus seemed more to do with psychosocial stresses than through structural brain changes.

Still, since this was new to her, I thought it was worth absolutely excluding any treatable dementia, such as Alzheimer's or Lewy Body disease. As well as the raft of blood tests the GP kindly did before referring, I requested a CT scan of her brain. It came back wholly normal.

I shared the good news with her. The history, clinical course, presentation, mental state, objective cognitive assessments and brain scan all suggested she didn't have dementia. Hurrah! But before being able to move on to address her stresses and how things could be improved, she frowned and asked, "Can't you do a deeper scan, doctor?"

I explained the CT again and why there was no "deeper" scan then moved on to managing her mood and helping her cope with packages of support being offered and gratefully received. She didn't think she may need all the home care support a social worker's arranged but she is awfully grateful that all the visits and 2 days at a day centre will get her out of the house, get her talking with others once again and help her loneliness.

It got me thinking, though. A "deeper" scan? Where does this notion come from, I wonder. A plain x-ray* goes all the way through the body. Lots of them, put together to form a CT scan, also penetrate all the way through the body. MRI scan shows everything. Looking at structure of a brain, CT and MRI are perfectly good at seeing absolutely everything, no matter how "deep" it may be. CT scans are generally better at showing cerebral atrophy (which happens in Alzheimer's disease and Lewy Body disease). MRI is generally better at showing vascular damage and tiny changes of other neurodegenerative processes.

As well as the CT and MRI scans showing how the brain looks (it's structure) we can do tests to see how the brain works (it's functioning). SPECT scans look at blood flow, showing areas of poor perfusion. DAT scans show dopaminergic pathways and abnormalities that arise in Lewy Body disease.

Therefore investigations are sought to confirm or refute a diagnosis based on what's being looked for.

There isn't a better or deeper investigation to do. Which is where I started. Where did this notion that there are "deeper" investigations come from? Next time I see my lady, I'll have to ask her!

* I don't usually talk of x-rays after a harrowing experience at medical school. "X-rays are part of the electromagnetic spectrum! You' can't see them! There is no such thing as a chest x-ray at all, it's a chest radiograph!"
Exams were failed on such pedantic whimsical details, so it's stuck. I talk of "a chest film" rather than "a chest x-ray" to this day. Ho hum.

Friday 22 August 2008


A lot of decision making I am asked to undertake involves an element of risk management. Whether it's risks of leaving mentally unwell folk in their own home or whether it's around timing of discharge planning (when folks aren't cured but are things "good enough" to go home?), or of course prescribing. Stopping or initiating medication has clinical consequences, and thus risks.

My team has, I believe, a healthy attitude of positive risk taking. External agencies, partner organisations, patient and carer groups and our own Trust Board agree, so hopefully my belief is reasonable.

There are scenarios when I'm twitchy and would see risks as unacceptable. Almost always, since these are discussed as a team with the patient/carers, concensus can be reached and a sensible management plan generated. With prescribing it's a little different since I do that in discussion with the team but prescribe independently. We do have nonmedical prescribers but they're not independent prescribers and I don't envisage a day when nonmedical prescribers will initiate or change medication without discussion with a Consultant Psychiatrist. Currently our clinical governance framework requires this and it's firmly entrenched in our Medicines Management structure, so although nonmedical prescribers support, review, titrate and advise, the initiation or withdrawl of medication always always involves a Consultant Psychiatrist. Almost always it's the Consultant Psychiatrist doing it, since nonmedical prescribing is a tiny proportion of our prescribing.

Prescribing practice is singularly unique in my corner in that the risks (unlike other risks) are almost wholly carried by the Consultant Psychiatrist. It's therefore of interest to me how my colleagues and I prescribe (and an area that's audited and reviewed).

One theme that's arisen has been of varied prescribing of anti-dementia drugs.

I prescribe widely almost wholly irrespective of severity of the dementia (i.e. whether it's mild, moderate or severe I'm keen to prescribe if the medication's of benefit) which is outside the NICE guidelines (technology apprasial TA 111) which directs us to prescribe just for moderate severity dementia. I feel uncomfortable waiting for someone to deteriorate before prescribing, so prescribe for mild dementia. One colleague does not, sticking pretty closely to NICE guidelines. It's hard to say they're doing the wrong thing, it's easier to say I'm doing the wrong thing. Either way, there's a difference in clinical care, depending which of us you see, which is determined by where you live.

So I prescribe a lot of anti-dementia medication. At the other end of the spectrum is a colleague who prescribes far less anti-dementia medication than I do. A potential risk of the medication is to slow the heart rate down (bradycardia). At some point the heart rate is normal and all's fine. At some point it's so slow it's hugely abnormal and you're unconscious. There's a range in between where it's not perfectly normal but it's having no clinical consequences, through to sometimes causing problems, to having ongoing minor problems, to being more serious. This gives a grey area then, at what stage should a doctor no longer offer medication because the possible risk of possibly getting bradycardia may possibly make the heart rate slower and possibly cause serious problems? Some doctors prescribe readily with a pulse rate of 60, some won't prescribe. Either way, again there's a difference in clinical care, depending which doctor you see, which is determined by where you live.

The drugs also ramp up risks of conduction abnormalities within the heart, a lot of elderly folk have ECGs that aren't perfect and aren't totally normal, which of these folk are excluded from having medication? Again, it's up to the doctor to decide what seems too risky, with different clinicians having different views of this.

Postcode prescribing. I really can't see a way around this.

Tuesday 19 August 2008


Some people are vibrant, cheery folk, come what may, most all the time.

Some are not.

Dr Brown acknowledged that he's not been full of smiles a lot of the time of late and says that, "It's true that my attitude to things tends to be serious and gloomy."

This got me thinking because it's the second time in the recent past that I've heard a medic say this. The last time was from someone (a physician, not a psychiatrist) who had embraced this in a very healthy fashion.

Imagine medics sitting around a table having dinner. They're all Consultants or senior GPs so are old enough not to be larking about throwing buns at each other or getting pissed on tequila slammers. Such is for the younger students to aspire to.

Through the chatter, folk who knew this particular Consultant well were talking about her persistent low mood and depression. She took it all in her stride (she's a formidable woman) and explained that she didn't think she was clinically depressed. She just was a glass half empty kind of person.

When it was suggested that maybe things could be different, maybe she could be happier, her take was interesting. Different? Maybe yes. But no, that wouldn't be better. "Why, then I wouldn't be me!"

She embraced and accepted how she was, was an essential bit of who she was. That makes for being a pretty grounded and content kind of soul. Thus, chasing permanent bliss or happiness isn't desirable for everyone, there's sense in having other dispositions also.

Sunday 10 August 2008


The folk over at Mental Nurse are discussing the art/science/craft of nursing and after baiting them (why do they never bite when I try and wind them up?) commented on the medics role of pushing drugs.

Got me thinking.

How many prescriptions for antipsychotics do I dish out and hope for the best. As Mr Zarathustra says :
"Writing a script for some olanzapine and hoping for the best is being a “highly trained professional” is it?"

So, having some time on my hands, I've been through my last weeks activity. I guess it's fairly representative of a typical working week in terms of activities, but with a change of junior doctor and inductions I was doing and teaching and PCT/other meetings and management stuff taking up several afternoons, the absolute numbers seen are lower than my weekly average. This week clinical activity included :
- meeting in-patients (of which I currently have about half a dozen) throughout the week on different occasions to talk with them
- a formal weekly review of in-patients, with ward staff, pharmacy, CMHT et al
- meeting daily with the CMHT to discuss their visits and day to day patient care (what's the point of having an MDT if we don't think through and have a voice in all patient care?)
- a formal weekly CMHT meeting
- an out-patient clinic seeing 4 follow-up patients (each for half an hour)
- 2 home visits (joint visits with with a CPN) to see new patients referred
- 1 home visit (joint visit with with a CPN) to see an urgent referral on an evening
- 1 case conference at a GP's surgery with a CPN, Consultant Physician and GP then a home visit by the CPN and me to convey outcomes
- 2 case conferences to discuss care with patients and families
- 5 early onset dementia patient reviews
- 2 formal Best Interest meetings with patients, families, social services, care staff, CPNs, care staff (and lengthy 'phone calls with the GPs who couldn't be there in person but being fair they knew the patients well and visited frequently)
- 3 home visits (joint visits with with a CPN) to follow up patients and discuss medication with them
- 1 home visit (joint visits with with a social worker) to follow up a patient
- 1 care home visit (joint visit with with a CPN) to see an urgent referral, one from police
- 1 care home visit (joint visit with with a CPN) to see an emergency referral from the police
- 3 care home visits (joint visits with with a CPN) to review care
- 4 liaison referrals from our neighbouring acute hospital Trust
- 1 section 136 assessment (joint visit with an ASW, ward nurse and a home treatment CPN)

Only 35-ish patients that I saw directly, with a similar number discussed. 70 patients whose care I influenced last week. That's a very different world from Primary Care.

Going through these patients, what prescribing decisions were made? Prescriptions :
- in-patients : 0 antipsychotics, 3 acetylcholinesterase inhibitors, 1 duloxetine, 4 lorazepam, 0 sedatives/sleeping tablets
- out-patients : 0 antipsychotics, 3 acetylcholinesterase inhibitors, 1 lorazepam, 0 sedatives/sleeping tablets
- community : 4 antipsychotics (trifuoperazine, amisulpiride, 2 olanzapine) continued, 1 atypical antipsychotic stopped (aripiprazole), 1 depot antipsychotic (fluphenazine) stopped, 5 acetylcholinesterase inhibitors, 1 citalopram continued and titrated to 40mg, 1 citalopram stopped, 1 mirtazepine, 3 lorazepam
- liaison : 3 haloperodol stopped, 2 acetylcholinesterase inhibitors, 1 mirtazepine, 1 lorazepam
- 136 assessment : 0 antipsychotics

Antipsychotics prescribed : 3
Antipsychotics stopped : 5

The 5 stopped were 3 inappropriate prescriptions for haloperidol, 1 depot that no longer seems necessary and 1 aripiprazole for BPSD that hasn't done anything tangible.

The trifluoperazine was continued in a lady who asked for it. She'd been on it since God was a lad, and after so many years and trying so many drugs she had confidence in it, wishing to take it 3 times a day. It's working for her, so we're running with it. No more hallucinations. Delusions that she's being spied on gone. No longer wanting to move house. All's good.

The amisulipride 300mg is a relatively low dose since it's for BPSD and is working, the husband can now take her to the shops with him and she's settled. All's good.

Olanzapine 20mg is for BPSD in someone who smokes. I know, I know, high risk (2% a year) of CVA. But smoking halves the amount of olanzapine available so effectively she's just on 10mg. And it's cured her symptoms of BPSD. No more wandering at night, no more physical hostility, no more paranoia about family that she's acting on. Still awfully muddled, still swears like a trooper. But family can manage her at home, now, and even after discussing risks are adamant that she's a new woman on this drug so wish to continue it. And I agree, it's in her best interests to be functioning better and less distraught. All's good.

The other olanzapine 20mg is for bipolar disorder and is working. From being on section 2 this Summer the lady's now back home, off lithium and off her depot and on just olanzapine. She's content/a touch high which is exactly where she likes to be. Lots of energy and motivation, lots of creativity, but insightful and able to manage her relationships with family (that're damaged when she's hypomanic). So she's stable and well. All's good.

So there we have it. In one week I've stopped more antipsychotics than I've prescribed, which is pretty typical. It's not too bad, is it?