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.