Wednesday, 30 January 2008

New Ways of Working

"Noctors." I'm grateful to Dr Rant for this rather splendid neologism, used to mean a non-doctor doing a doctor's role.

This is a recurring theme that's deliberated 'pon Dr Crippen's comments forums by patients and GPs and NHS staff as well as by the good Dr Crippen himself.

"New Ways of Working" (NWW) is a movement that happily arose from psychiatrists, doctors working on the shop floor, who wanted to be able to do the psychiatry bit more and lose the non-doctory bits of work they'd got by mistake. Psychiatrists were a bit like rubbish bins, everything could get tossed their way when it got hard for someone else, they were the default container for all stress, risk and woes so accumulated roles and tasks that were nonmedical and nonsensical. Doctors felt they'd so much of this gubbins that they couldn't crack on and see their patients so dreamt up the NWW proposals. This makes NWW appealing 'cause it's medics driving it, not the Department of Health or whoever.

Dr Crippen commented that, "I have never seen a psychiatrist with a stethoscope but fortunately this one has one."

I find this worrying! If Old Age Psychiatrists aren't looking at physical comorbidity then :
- who will?
- why are they psychiatrists if they're not acting in a medical role?
- won't patients miss out through nobody else having the time to do so?
- won't medical care be poor?

Who will?

If psychiatrists don't consider their patient's physical health and undertake physical examinations then a "noctor" will. This would be A Bad Thing for patient care.

Medical Role

If psychiatrists aren't working as doctors, why have them? Prescribing guidance can be proffered by pharmacists, holistic care is the remit of nursing staff, optomising function falls to physios and occupational therapists, talking therapies go to CBT practitioners and psychologists . . . what do you need a psychiatrist for?
If we're not working as medics then rather than CSIPs helpful views of New Ways of Working in mental health (which has doctors doing doctor things and non-doctors doing non-doctor things and never the twain shall meet) we move to the unhealthy model of doctors doing less and "noctors" doing the doctors' work principally 'cause it's cheaper.

I like the notion CSIP advance of a psychiatrist being able to be a psychiatrist all the time and not do work that others can do just as capably/better, but that a psychiatrist is key to doing what psychiatrists do best.

Part of this is sleuthing out relevant physical comorbidity either causing or arising as a consequence of the patient's mental health problems. Part is looking at complex drug regimens. Part is looking at the biopsychosocial elements and formulating care balancing risk/benefit in all domains. Part is the diagnosis.

Nobody but nobody is trained to elicit symptoms of psychopathology, cluster these and ascribe significance to them except a psychiatrist. On this basis alone, a "noctor" can't replace what medics do.


When my GP colleagues see a patient with a new problem they've about 12 minutes to sort it all out. When I see a new patient, I've an hour at a minimum, if seen at home I can spend longer.

It's simply not possible for a GP to go through a history in the sort of detail I can, then undertake relevant physical examination, so psychiatrists surely should be examining patients since we've the resources (in terms of being medically trained and having the time) to do so.

Medical Care

If I examine a patient I find things. This is good. 1 in 12 causes of dementia are reversible. Unless I look for them, who will? I'd see looking for physical (treatable) conditions with neuropsychiatric sequelae as our remit, and if psychiatrists don't address these then it doesn't get done. Patient care would be the worse for that.

Delirium kills people. Crack your hip, go to hospital, get it fixed, all is well. If on the otherhand you have an episode of delirium (an acute confusional state) whilst having your hip sorted, your chance of death in the next 12 months is 40%. Which is high. 40% mortality is hard to ignore, especially given that delirium is commonly caused by treatable elements but orthopaedic wards miss it (failing to spot most or almost all of it, depending which study you believe). It's better to have psychiatrists addressing problems like delirium, since if we don't hordes of folk die. A "noctor" can't consider the breadth of conditions impacting on a confused patient simply because they've not been trained to do so.

As regular readers know, I'm slavishly devoted to multidisciplinary team working, I love my nursing colleagues, I'd not be able to do my job as I do without them and patient care would be worse. How I see it, though, is that medics and nurses both work differently through NWW. Nurses (or others) never take on the role of a doctor and doctors don't take on roles they don't need to.


Spirit of 1976 said...

I find this worrying! If Old Age Psychiatrists aren't looking at physical comorbidity then :
- who will?

Indeed, and not just in Old Age Psychiatry either.

Before my recent move to CAMHS, I was working as a staff nurse on a rehab ward. If a patient had a physical health problem we naturally referred it to the psychiatric SHO. After all, she's a qualified doctor.

Spirit of 1976 said...

Oh, and on a side note, have you noticed that there are now two "Zarathustra"s commenting on your blog?

Go to the comment by "Zarathustra" on the previous post, and look at the profile.

When I saw that comment, I assumed my account had been hacked, but it actually seems to be another entirely genuine account that just happens to have the same display name.

I'd be less suprised if my display name was "John" or something equally commonplace.

The Shrink said...

Zarathustra, the in-patient side is usually supported by junior doctors or Hospital Practitioner sessions in most Trusts.

I'm much, much more twitchy about the rest of our patients. For every in-patient under my care last year, I had a over 42 community patients.

The maths speaks for itself - it's folk outside the wards that need physical assessment that potentially are getting a raw deal if psychiatrists don't do it. Someone's referred with confusion or depression or memory problems. Who else will find and address the treatable comorbidity? It's got to be a core part of our job.

And yes, I'd assumed it was you posting. Now there are two Zarathustras? Being a soul who's easily muddled, this all is getting a bit too much for me :-)

XE said...

"Crack your hip, go to hospital, get it fixed, all is well. If on the otherhand you have an episode of delirium (an acute confusional state) whilst having your hip sorted, your chance of death in the next 12 months is 40%."

Pleas forgive my ignorance, but why would that be?

The Shrink said...

Good question.

The most rigorous work is from John Holmes showing mortality increases with delirium, with a paper here.

Unknown said...

Noctor is not a 'rather splendid neologism'. Noctor is an Irish surname. Do us a favor and find another clever word to express you concerns about current / future trends in the healthcare industry.