Monday 28 April 2008

Medical Care

I looked after a chap in his home, with his wife, through much of last year. Notionally he was depressed, but he seemed much more jaded and despondent than clinically depressed, to my reckoning. I saw him at intervals, roughly once every three weeks or so, throughout the Autumn and Winter. His GP asked for help, since the chap wasn't eating or drinking much, was largely bed bound and seemed to be fading away. He's got a good GP who works hard for his patients so I'm always happy to go the extra mile (or 6.8 miles in this case) to help out.

He refused all medication but I'm stubborn so a nurse and I visited every few weeks. He didn't want us to. We got him eating and drinking again. We got him more mobile. He no longer needed his frail wife to carry him to the toilet. He no longer wanted to die. He was no longer chain smoking in bed and burning his sheets/smouldering holes in the carpet. He still didn't want us to visit. By now, 6 months on, with him coping well enough and no evidence of mental illness and telling us to go away, I didn't feel we could keep intruding in to his home and persuade him How It Had To Be any more.

I knew it wouldn't go well.

Once when I saw him he was too breathless to finish sentences and his lips were a glorious shade of puce. Focal signs in his chest. GP tried to arrange admission but he'd not go in. The GP tried this a lot. He always said no.

Earlier this year things broke down. He became confused, wouldn't listen to his wife, didn't appreciate who she was or what she was trying to do, wouldn't accept help from his son or daughter, absolutely refused to go in to hospital. The GP was desperate. The GP asked if I could admit him. I visited the chap, saw a scene of woe, he was thoroughly confused which was just sufficient to persuade an Approved Social Worker to take the pink form the GP and I'd hastily penned and apply for him to be detained under section 2 of the Mental Health Act 1983 for admission and assessment on one of my wards.

Within a couple days on a cephalosporin he improved. Temperature, tachypnoea, dyspnoea, cyanosis, all better. Too, he was less confused. But still too frail to mobilise. Pretty infirm, really. Abdominal masses. Abnormal LFTs. Chest signs. Blood count that's halved in 6 months. Anorexia. Trophic changes of his skin with widespread pressure sores on admission (that are getting better now he's on the right sort of matress and nurses are attending to this). CT imaging is awaited. I suspect something sinister and have said exactly that to his family, along with words like "cancer" so we're all crystal clear we're looking for stuff that's not dysthymia or an adjustment disorder.

Meeting with family, we're all clear his mental health is the last thing that's concerning us now. But when his confusion's resolved and he's no longer detainable under the MHA 1983, he'll not accept informal admission. Saying that, he's too frail to self discharge and flounce out.

What to do, what to do . . .

Thursday 24 April 2008

What's in a name?

"What's in a name? That which we call a rose
By any other word would smell as sweet"
- Billy Shakespeare

Frontier Psychiatrist asked, "Whether I should describe people who use psychiatric services as 'patients' or 'clients'/'service users'."

We asked in-patients, day hospital patients, out-patients, home visits and day respite patients what they wanted to be called. We then did it all again, months later. We then did it across the entire district. We then asked a carer forum. We then asked another carer foruim. We then asked the local Alzheimer's Society branch. Locally MIND isn't that active with older adults, but we asked them anyway. The response was almost 100%, we should address them as "patients."

To stop stigmatising mental illness with different terminology, to stop them being called "clients" (which resonates with hairdressers, prostitutes and lawyers) or "users" or "service users" which our older adults associated with drugs, "patients" it was.

Locally, if a pregnant woman is going to her antenatal check up, or a bloke is going to see a surgeon for a vasectomy, or a mum is going to have her diabetes sorted out, they're all referred to as patients and all attend an out-patient clinic. The woman is well, undergoing a normal life event. The man is well, seeking an elective operation for a common life choice (on contraception). The mum is currently well but has a life long propensity for becoming unwell if she stops her medication or has physiological stressors. All are referred to as patients.

Why, if you're well but experiencing a common life event but wonder if all's normal (e.g. memory problems with age, is it just age or is it dementia), or seeking elective management and interventions (e.g. help with substance misue) or seeking assistance in the management of a long term problem but you're currently well (like schizophrenia) should you be overtly named and labelled differently from the pregnant lady, the bloke seeking a vasectomy or the diabetic mum?

That's stigmatisation.

Isn't that wrong?

Wednesday 23 April 2008

Refocussing the Care Programme Approach

I've just read through the document that came out last month, Refocussing the Care Programme Approach.

I'll try to resist saying that it's simply 55 pages which are soft, strong and thoroughly absorbent so arguably has some utility. Ooops, I didn't. Ho hum.

The 36 pages of "Making the CPA work for you" had me frothing because firstly it's front page is for "service users" not "patients" and secondly it's got the trite byline on the front page :
"It is not about how you fit into services
It is about how services fit with you

I have few folk on enhanced CPA. By few, I mean none. It's meaningless to their care so largely ignored. Okay, it's optional for older adults, so nobody hits me with a big stick, but this new guidance is aimed at one and all. What piqued me was the notion of who it's for and how they'll be helped.

To quote : "Individuals with a wide range of needs from a number of services, or who are most at risk, should recieve a higher level of care co-ordination support. From October 2008 the system of co-ordination and support for this group only will be called Care Programme Approach (CPA)."
Yes, they did underline "only" in the document.

Later on, ". . . the individuals needing the support of the (new) CPA should not be significantly different from those needing the support of enhanced CPA."

Erm, that's nobody, then.

Am I missing something here?


My work gets pulled in many different directions. I seem to have absorbed many roles and am often asked to pitch up and help out with stuff that's not really my core work. A post on this use of Consultant time is for another day. Last week, a Consultant Geriatrician and Consultant Anaesthetist were stuck on how to manage a chap of 66 with multiple health problems. Let's call him Arnold.

Arnold is profoundly deaf. He has a lot of aches and pains. He told his Consultant Geriatrician that he had leg, foot and chest pains that were severe and stopped him from sleeping. He also had cramps at night. He would like all pain abolished, thank you kindly. The Consultant sought advice from an Anaethetist who's an expert at this. The Consultant Anaesthetist had a number of clever suggestions (which were helpfully introduced) and Arnold's pain wasn't abolished but did reduce.

The Consultant Anaesthetist found Arnold to be unusual. He thought something was wrong and that Arnold was mentally unwell. When speaking with Arnold, Arnold didn't grasp everything that was said and became feisty with colourful language and wild gesticulations with his walking stick. I was asked to see him to determine if he had dementia or a mood disorder.

When Arnold was told something, he wanted it doing. Right away. He wanted a scan, wanted it in the hospital and wanted it that day. He didn't seem to grasp that this wasn't realistic.

I happily traipse on over and meet with Arnold and a senior nurse from the Geriatrician's unit. I go through his mood, checking symptoms and signs and biological features. I shout a lot since he's so deaf, I write some things down. After the near hour's consultation the staff outside said they could hear everything I said since I was shouting, so much for confidentiality and dignity on medical units. Pet peeve. At least I was given a private clinic room (rather than curtains around a bed) even if it wasn't sound proofed. They didn't hear his answers, so that's something.

Having gone through mood problems, I went through cognition. Orientation, attention, praxis, memory, sequencing, language, executive information processing, all of it. As is my wont, at one point I push Arnold with stressful questions which he handles appropriately but assertively, there's no hostility or impulsivity or loss of control or disinhibition.

When I'm older, I'd like to be like Arnold. I attended the Consultant Geriatrician's team's multidiscplinary meeting this week and fed back my findings. He's in perfect mental health. No mood disorder, no cognitive deficits, no dementia.

So why his feisty behaviour at times? Because Arnold's a quirky, idiosyncratic and curmudgeonly old chap who elects to be like that. Fantastic!

Tuesday 22 April 2008

Tea and Cake

I expect Dr Crippen will not countenance such activity, but I found myself doing tea and cake this week.

I saw a lady in her mid 60's with a diagnosis of F20.0 Paranoid schizophrenia who's not been seen for years by General Adult psychiatry, by her choice. She'd become unwell, believing people were peering through her window and watching her at night. Her window was 9 feet up with no way this could easily happen, her partner said she'd often seen people when he was there and he couldn't, she'd called police and said the person was at her door right then, when the police answered it, but they couldn't see anyone.

So, it seemed most likely she was experiencing more illness, having elected to stop her medication a few months prior to this. We looked at coping and reality orientation but the answer, in part, was to start medication again.

She started medication enthusiastically, 2 months later she was completely well.

I reviewed her last year and found she'd remained well, her partner thought she was totally well, all was good. She was very happy with her medication, adamant she didn't want it changed and it kept her well. Her diagnosis was clear. Her treatment was clear. She was happy and asymptomatic (with no symptoms either of illness or of side effects from medication). She was again stable and remained so over 6 months. My work done, I had no more to fiddle with.

Not wishing to leave her high and dry, but equally not wishing to drag her back in x months for no purpose, I made an open appointment for her. If she, her partner, her GP, whoever, thought it would be a good idea for me to see her in clinic again they could just 'phone up and book in, without a need for referral. Excellent service, no? Get seen when you need to be seen, not at some arbitary time for no real reason.

She booked herself in to my out-patient clinic. I spoke with her GP before seeing her, in case there were any issues I needed to be aware of or that I could support the GP with, but he thought all was well. She came in to see me with her partner, I asked her what I could help her with. "Oh, just a check up, doctor."
I went through her mood, her thoughts, her general health, her medication, her functional level.

All perfect.

We discussed her medication, the role, benefits, consequences, dose regimen. She's perfectly happy, please don't change it, it's perfect.

So, why did she book in and spend almost 2 hours travelling to see me for half an hour with her partner, then almost 2 hours travelling back? "I just like you to keep an eye on things, doctor." I ask her if I should arrange another open appointment so she can book in if or when she wishes to. She looks crestfallen. She wants another appointment now. I offer to see her in 6 months time. She is very happy. Between now and then, she may become ill. When I see her in 6 months, she may be well. I shall see her any way.

For now, at least, I have very very few patients like this. Thus, for half an hour of my time twice a year, I capitulate and I do tea and cake. A misuse of precious Consultant time, or patient centred care?

Thursday 17 April 2008

Occupational Therapy

A commissioner asked me, "What does an Occupational Therapist (OT) do in a mental health Trust that can't be done by generic community OTs?" His question was, in essence, why employ an OT in a community mental health team for older adults when you could employ a nurse (who can do generic mental health work but also do RNCC assessments, administer depots, undertake independent prescribing etcetera).

We have OTs in our teams and on our wards. Still, I had vague ramblings but when stopping to think, couldn't really give a compelling reply.


Wednesday 16 April 2008

Non-Medical Prescribing

"I haven't made up my mind yet whether I think nurses being able to prescribe is desirable.

This comment from Medically Brunette about prescribing got me thinking.

I work with non-medical prescribers and every year mentor more through the course. It should be a course based on aptitude and on the need of that person's role to prescribe in order to deliver better patient care. Really, it should be determined through a review of the Knowledge and Skills Framework (KSF) within the person's annual appraisal.

It doesn't work like that, in my corner.

Prescribing is something with such significant implication that the only folk I've mentored through the non-medical prescribing courses and continue to support are those who I work with closely who I've confidance in. I know, I know, it shouldn't be personal like this, but it is.

We've nurses, pharmacists and a physio who can prescribe. At the moment, legally, the nurses can be independent prescribers. I'm not comfortable with tossing them the BNF and sending them on their way, so we've quite constrained formularies they can use and they can only undertake supplementary prescribing. This means that I see a patient (usually with them), if a nurse wants to be involved in prescribing she suggests this then we all agree a clinical management plan (CMP), I type this up, the nurse actions it.

Benefits of this are :
- I still see every patient for diagnosis
- The nurse and patient and I agree a range of drug treatment options together, so I get to say what options are on the table and the patient gets to select from those what they want in the CMP
- It's typed up on a proforma so the CMP can be printed out and easily shared with one and all, making it clear to one and all what's being proposed
- The patient never then needs to see me just for a prescription
- When things change, the nurse has latitude to effect change with the patient (e.g. titrating dose as we've agreed) so things can be done quickly
- The nurses say they've become much more familiar with medications' benefits and consequences
- They're so cautious in prescribing that they collect massive amounts of information about what they do, so we've rich audit/clinical effectiveness data

Independent prescribing is on the horizon. What's the difference? Legally, in essence it means the nurse can prescribe what they wish, rather than what they've agreed with a doctor in a written CMP. Under supplementary prescribing if a nurse sees someone who's bereaved and could use some medication, they can't prescribe unless I see the patient and write a CMP with them. Under independent prescribing they could see the patient and start treatment, without me being involved at all.

Now, here's the rub.

Most nurses I work with, most of the time, are cautious and sensible enough that they'll work with what they know but won't touch anything that's outside their competencies. Nurse nurses, doctor doctors, we're all happy. Most senior nurses already guide on medication and I'm confrotable with this. A patient is on Drug X and stable with no side effects, things then slip, the nurse reviews this. I'd take issue with diagnosis but the nurse is certainly adept at triage (is the patient worse, yes/no) and if deteriorating can sensibly nudge up Drug X.

Initiating new medications can be a big thing, for various reasons. It's a tangible affirmation that a diagnosis is real (e.g. you can have quirky ideas or confused beliefs, fine, but when you're on your antipsychotic for schizophrenia for these, it's different). Medication often is long term. A year for antidepressants, often longer with antipsychotics and with mood stabilisers, usually lifelong for cognitive enhancers. It's not the same as a course of amoxycillin for an iffy chest. Psychiatric medications can have very significant side effects, so the risk benefit ratio often is in favour of not using medication. Critically, if the diagnosis is wrong then whatever you prescribe is inappropriate.

In my corner, independent prescribing that we're starting is paradoxically even more rigid than supplementary prescribing. In supplementary prescribing nurses have latitude to prescribe what they will within the agreed written CMP. In independent prescribing nurses can't put pen to paper on their FP10 without discussing it with me. For any script. For anything. The nurses wanted this, too. They can prescribe but 'phone me up to bat it out before doing so. The protocol for this is pages and pages long.

It's the only way I could work it - a robust clinical governance framework that ensures patients receive medication only when all relevant clinical implications have been thought through.

Monday 14 April 2008


I'm drawn back to the issue of diagnosis. Again. Sorry.

I've been referred a lady, let's call her Deborah, from Primary Care. Her mood is a bit low. She's a younger adult, in her early 40's. She 'phoned her GP surgery, complaining of tiredness and feeling drained and unwell, was given an appointment with a nurse there and started on treatment. The nurse (a prescriber) started her on citalopram 20mg once a day. The nurse spent time talking with her, documenting all her symptoms accurately and detailing all her past medical history. The nurse arranged review with Deborah to see how the citalopram was working and to look at supporting her, so saw Deborah again 2 weeks later. Things hadn't changed, so the nurse brought Deborah back again after a further 4 weeks, so she'd tried citalopram 20mg once a day for 6 weeks.

The nurse felt that the citalopram wasn't delivering as well as it should. She's a good nurse, she's attended teaching where I bang on about trying drugs at the right dose for the right duration before saying things ain't working, so after a few weeks she titrated the citalopram up to 40mg once a day. She felt this would help treat depressive and anxious symptoms, helping Deborah relax and helping her cope better. Then, as her hopefully depression lifts, her lethargy and lack of drive and loss of appetite would hopefully improve.

The nurse brought Deborah back after 2 weeks and found that the citalopram 40mg wasn't working well. Deborah was still, "feeling pretty rubbish" so the nurse continued the citalopram 40mg to give it more time to work. After a further 4 weeks, and 2 more reviews by the nurse, she felt that Deborah wasn't getting better. Deborah agreed. Having tried to sort out mild/moderate depression in Primary Care without success the nurse referred her on to me to look at treating this, since she felt it wasn't mild depression.

And she was right.

I saw Deborah and was struck by how languid and lethargic she appeared. She looked ill. The excellent history that the nurse included in the referral detailed past breast cancer with a mastectomy. I scanned her. She's developed metastases in her liver, brain and bone. Much badness. Her loss of energy, lower mood, loss of appetite was due to tumour burden and widespread, advanced cancer. I know Deborah's GP, I know he would have seen Deborah and, given her history of cancer, would have looked at this before referring on. I know this, because over time I've seen this with other patients the GP has.

The delays in Deborah's diagnosis caused by many reviews in Primary Care by the nurse haven't changed the outcome. It amounted to a bit over 3 months of treating her as having functional mental illness rather than diagnosing metastatic cancer. Even if the nurse had referred straight away, it's grim.

Deborah could have had a better understanding of what was going on, though. She could have had better palliation of symptoms. She might have chosen to use her time differently.

The practice nurse, diagnosing and treating, did things differently to the GP. I was reading The Observer yesterday. The front page story had a huge title of, "GPs warned over failure to diagnose cancers." The opening paragraph spoke of, "the government's top cancer expert" and "botched diagnoses." Obviously, GPs must be getting it wrong, no? Well, no. Reading on, the article quotes the experts words as, "'There are 250,000 new patients with cancer every year,' said Richards. 'It's probably only a small proportion who experience a missed or delayed diagnosis. It's a small minority of patients overall."
Curious how this is front page headline news and GPs are botching it up so badly then . . .

. . . like Deborah, I'd still be better served seeing a GP for diagnosis and formulation, despite what the press seem to be saying.

Sunday 6 April 2008

What do doctors do?

"Other than the aforementioned [the specific ability to include/exclude organic disorder], do our learned colleagues (cue the doc) uphold any other aspects of the medical training that supports their (purely) mental health skills?"
- Mr Ian's comment at Mental Nurse.

This piqued my interest.

In addition to dealing with organic disease, which I guess we'd all agree only doctors are trained to do, there are a few things that support mental health skills.

Diagnosis. We're the only group of professionals trained in broad diagnosis. I recognise that psychologists can diagnose mental retardation. Some can make formulations around personality disorders with credibility, too. But beyond this, the clustering of symptoms, the weighting and interplay of intensity, pervasive nature, impact on function, chronicity and associated features is something that medics are trained to sleuth out. Trained specifically in mental health, sure, but that training can happen readily since our background of 7 years training before this (minimum of 5 years medical school then foundation training) before mental health training means doing diagnosis is what we live and breathe. I still maintain that only psychiatrists have the competence to ascribe significance to psychopathology and generate diagnosis from this. Some are rubbish at it, I've met woeful psychiatrists who are ghastly at this. But for those who are up to speed, good medicine with competent psychiatrists allows good diagnosis that nobody else is trained to do.

Therapeutics. I work with a pharmacist in my team. She knows a lot about drugs. She knows a fair bit about physiology and mental health, a bit about anatomy and a bit about clinical work. If I want to know about drug interactions or if Symptom X could be from Drug Y she's the woman who knows. She's great at medicines reconciliation and all the governance gubbins we need to do. She frankly states, despite her extensive training and vast pharamcological knowledge, she's not the one to guide on treatment. Clinical outcomes, what's tolerated well and what's not, peripheral consequences to taking medication all is learned from follow up (which CPNs or I do) so she doesn't have her finger on the pulse to make as informed decisions on therapeutics as I do. In most cases, medics have a better, more contextual and richer awareness of therapeutics than other professions.

Legal awareness. We're all trained in the Medicines Act, Mental Health Act and Mental Capacity Act. Last week I was quoting the 1861 Offences Against the Person Act to a care home manager. Then I was quoting section 4 (7) (b) of the Mental Capacity Act 2005 on Best Interests because she was acting unlawfully. I liaise with the DVLA on a weekly basis re fitness to drive. I'm section 12 approved to do Mental Health Act admissions which no other profession can do (even come October, only medics can make recommendations for admission). We all do what is right, medics historically have had responsibility stop with them, thus an awareness and obligation to have intimate familiarity with statutory instruments is ingrained.

Expertise. We're trained extensively, over ludicrous numbers of hours, over stupidly stupidly obsessive and obscure levels of detail. A local Nonmedical Prescribing course leader (who is a nurse) said to a district nurse on the course never to consider meningitis when treating kids with infection, since if she did she'd end up referring everything to a doctor and never treat anyone. Medics do the opposite, we are trained to think of everything. When one of my patients returned from a holiday in Asia feeling very tired and more depressed and losing weight I considered psychosocial factors but also looked for hypothyroidism and common causes for "tired all the time." One exclusion was diphyllobothrium latum the fish tape worm, since she'd been eating raw fish. Rare as hens teeth, but it's that kind of obscure taking what's said and sifting for patterns that medics are trained in, having greater levels of expertise than non-medical colleagues.

I don't think doctors are better than nurses or psychologists. The question posed was what aspects of training gave us noteworthy skills, which is what I've waffled on about. This gives a different approach from medics which isn't necessarily better, it's just different. Nurses are far far better at many areas of patient care in mental health than I am. Equally, I'd argue medics have strengths that others don't have. So, as usual, I'm banging on saying medics should do medical stuff, nurses should do nursing stuff, and we can all be happy together.

Friday 4 April 2008

PRN medication

It's not uncommon for folks to be prescribed medication to take when it's needed, rather than regularly at the same time each day.

Such medicine is prescribed with the accepted abbreviation PRN (pro re nata), i.e. when required.

Doesn't this get you thinking?

If I prescribe a drug PRN for one of my in-patients, it's not there to be used regularly (or I'd write it up regularly, at specified times). It's then wholly up to the nurse to decide if or when it's given.

Usually if I want a nurse to decide if the patient has a particular problem, then formulate presentations to conclude that pharmacological treatment is indicated, then determine that a drug I've suggested is the right drug for that patient with that problem at that time, then ensure my patient gets that drug, the nurse is a Supplementary Prescriber. She's done courses on therapeutics, pharacokinetics and dynamics and (critically) has ongoing teaching and ongoing individual supervision with me and mandatory attendance at our ongoing training programme and attendance at our non-medical prescribing forum.

Thus, for an experienced band 7 community to think, yes, this psychotic patient who is believing that "they are out to get me" and is 'phoning police a dozen times a day and daren't leave the house really could use some additional medication (that a Consultant has written in a Clinical Management Plan with the nurse) to de-escalate their distress and help them cope, they have a rigorous training and ongoing development programme.

For a less experienced band 5 ward nurse to think, yes, this psychotic patient is agitated and I'll settle them down with some additional medication (that a Consultant has written on a drug card with a nurse at the MDT), they have no scrutiny or guidance or support or supervision or review of their practice.

This seems odd.

Is it just in my corner that life's like this?

Thursday 3 April 2008

Vascular Dementia

I've seen a young lady with vascular dementia. I thought it was F01.0 Vascular dementia in acute onset but on sleuthing it out over the last few weeks it seems it's in fact F01.1 Multi-infract dementia. I was interested 'cause I like to know (but not in such a psychopathic Gregory House sort of way) but also if it is acute then clever physicians could try and sort out why.

But this difference largely is irrelevant.

She has vascular dementia.

It's pretty classical. She has very well preserved "islands of ability" meaning some things are completely perfect. She can recognise faces and people, she can sequence tasks, she's good concentration, she's got mildly impaired memory, she's got only mild disorientation. She's no dyspraxia. She can manage buttons on her blouse, she managed her espresso coffee machine that looked as complex as the dashboard of the space shuttle, she managed to use fiddly buttons on her mobile 'phone to text a friend.

She has profound nominal aphasia. She knows what she wants/means, she just can't connect with what the word for that is. She was able to tell me she wanted "that thing" to stir a coffee but simply couldn't generate the word "teaspoon" at all.

This has had a significant impact on her, socially. She's stopped meeting friends, no longer enjoys her walks around the village to the bookshop and back, she's stopped having lunch in the local cafe every Tuesday "with the girls" as she used to, she's stopped going to antique/second hand shops and browsing for a certain type of pottery she likes to collect. Why? She's too self conscious that she can't speak fluidly any more.

She's bright, animated, intelligent, active and oh so very aware. But she's locked in. She's a massively constrained social repetoire as a consequence of her impaired expressive aphasia.

Tuesday 1 April 2008


Shamelessly nicking more themes from more inventive folks blogs, I happily found Hospital Wallpaper's medical student blog after she commented below. She wrote about communication skills and wondered :
"Can communications skills be learnt or are they inherent in a person's character?"

I don't think it's that black or white a nature/nurture thing. If someone's inherently good at it, that's great. But I know medics with a brain the size of Saturn who really are great at diagnosis and therapy but were bad communicators who have improved lots. Experience in medicine, maturity, training can help.

What helps me improve more than anything is what Hospital Wallpaper did. She sat in and saw a clinician communicate. You learn what they do well, and nick that, and what they could do better, so learn to do it differently.

Every week I go on joint visits with nursing colleagues, every week I'm aware of little things they do better than I do, that I nick in my approach to consultations.