Dr Crippen got me thinking.
"One of the most dangerous places to get a serious physical illness is in a mental hospital."
No no no, surely not. Our hospital has had no MRSA and no significant hospital aquired infection for years and years. Patients are cared for better than the New York USA model, i.e. staff review and intervene. We've had no assaults on my (old age psychiatry) wards causing physical harm to patients that I can recollect, ever.
Okay, I trained as a GP then did physiciany whatnots and am appointed as a Consultant psychogeriatrician but am also appointed and employed as a Consultant doing physiciany work too. And I work in old age psychiatry, where physical comorbidity is routine and addressing physical health problems is a daily part of my work. So I concede I'm more medical than most psychiatric colleagues.
But even so, aren't all patients having biopsychosocial elements of their presentation addressed? Aren't all elements of physical comorbidity being considered, not simply as good medical care but also as a necessary intervention to address neuropsychiatric sequelae to the physical presentations?
On reflection, Dr Crippen is quite correct.
I actively look for physical illnesses. I speak with patients and their GP and seek informant history. I find illness. I investigate. I formulate and diagnose. Often, I treat. But, not infrequently, I find something I can't or shouldn't manage myself.
One patient recently had hyperthyroidism. In GP training I worked on an endocrine firm but that was rather some time ago, the world's moved on, I'm not the best placed person to orchestrate optimal care of thyroid dysfunction. Although clinically and biochemically hyperthyroid, our local endocrinologist did not attend the ward, did not see the patient and did not review care. Hmmm.
A lot of drugs I use can affect the heart. It's common to find heart murmurs (i.e. it's not silent between the heart sounds), but most are innocent flow murmurs of no clinical significance. Many years ago I worked on a coronary care unit, fiddled with clever chronotropes and inotropes, but there's no way I'm competent let alone expert at the management of complex cardiac disease nowadays. On finding a murmur and pulse that I thought was significant, then getting appropriate investigations, then referring on to a cardiologist, the patient on my ward wasn't seen. Two weeks through her admission on my ward she went in to high output cardiac failure, my junior doctor 'phoned the Consultant cardiologist, a diuretic was suggested and still my patient wasn't seen. Hmmm.
Dr Crippen has a point.
Even with the best will in the world, with mental health teams having awareness and interest in physical illness, looking for it and treating it, hospital in-patients on mental health wards still get suboptimal care.