Thursday 24 September 2009

Doctors' work

I find myself increasingly reliant on good nursing colleagues, with investment in our service over the last 5 years involving reducing medical staff numbers whilst increasing nursing staff, OT and social work staff numbers substantially. Still fretting that I don't have enough pharmacy time, but that's a battle for another day.

My junior doctor does very little work. It's not a criticism. He's there in a training post, to learn. Gone are the days when junior doctors worked every hour and were the cheapest resource; I was paid less than porters, student nurses and domestics for my work out of hours and on bank holidays. Come to think of it, I still am. But my junior doctor's hours are scrutinised and all have to be purposeful in progressing his training needs.

Also, all junior doctors in psychiatry now have to do Old Age Psychiatry in their first year. This mean my junior doctor has done his medical training at university, then his Foundation training as a doctor, then started in psychiatry with me last month. He had an induction so he's being doing psychiatry for all of, oooh, about 4 weeks. Clearly he's not in a position to give meaningful input, on his own, in out-patient clinics or the like.

The Royal College of Psychiatrists recognise this and define what it's reasonable/desirable for junior doctors to do at different stages of their training. In their first year, as mine is, they're to learn core skills. It's even called Core Training, so if after a year he thinks psychiatry's a terrible mistake and he want instead to be, say, a gynaecologist, off he can go and his year in psychiatry is useful and translates into a year of gynae training through teaching him consultation skills, approach to examinations, documentation, governance frameworks, evidencing rational prescribing practice, undertaking clinical audit and other such skills a medic is expected to develop.

As such, he can't do clinics on his own. Or skip off and see new referrals in the community. Or do liaison psychiatry, seeing folk on medical/surgical wards.

It's genuinely a training role which has the advantage that the service ticks along quite nicely whether he's here or not, it gives him time to read and study and shadow loads of folk to get a good understanding of practice, and it's hardly a stressful post. It also means patients get medical psychiatric input from a Consultant Psychiatrist, not a junior doctor.

As well as junior medical staff having a training (rather than a service commitment) role, as a Consultant Psychiatrist I input into other peoples' work. Mornings and afternoons our teams meet up and discuss the work to do/work done and consider what needs to be changed. As such, every patient has both this informal discussion when a Consultant can think if specific investigations need to be done, or psychiatric/other medication reviewed, or physical health symptoms unpicked or whatever. Every patient has formulation and care planning discussed with a Consultant Psychiatrist. Equally, all mine are discussed with nurses, OT, support work, pharmacy and social workers so they can chirp up with their thoughts on input into care.

The consequence of this is that all medical decisions within our service are through a Consultant Psychiatrist, and through both formal and informal forums there're mechanisms for medical input into every patient's care, every day.

At least when someone's stuck and refers in to our service, the diagnosis is made by a Consultant Psychiatrist (for good or bad, in my corner, nobody else does diagnosis) and medical dimensions are considered by the Consultant. I think this is of value, enabling non-medics to work at the top of their game doing what they do best, with medics contributing their bit, and the whole working synergistically.

I have seen a gentleman with mild cognitive deficits. He's in his 40s. He's unfortunately got dementia. He had a jerky tremor and poor balance/coordination. He said his mouth wouldn't work; he often chomped down and chewed his cheek, sometimes he couldn't swallow solid things easily. I thought he had something other than Alzheimer's disease or another neurodegenerative dementia unfolding, it looked like he'd neurological deficits. Huntington's disease sprang to mind, or p'raps normal pressure hydrocephalus. More sleuthing by clever physicians was in order.

I wrote back to his GP giving the results of his assessment, mental state examination, cognitive testing and brain imaging, suggesting that an assessment and neurology opinion would be helpful.

A few weeks later, I got a copy of my own letter back, as part of a referral to me, with a covering letter asking if I could give an opinion on this gentleman who had been invited into the GP's surgery and seen and discussed referral, so could I please see and advise. A mistake had been made. It should have gone to a neurologist, not back to me. It happens. The mistake had been made by a First Contact Practitioner. It rang bells because this is not the first time she's made a mistake.

I shouldn't, but I do feel somewhat piqued if I spend 2 hours assessing and investigating a patient, identify organic disease that merits more sophisticated assessment than I can do (it's many years since I worked in GP land, now), but the history and examination and formulation and care planning is undertaken by someone who consistently doesn't seem to be doing a brilliant job. Maybe it's bias and prejudice, maybe it is factual, maybe it's idealistic but unfounded, but I do reckon it all worked better (for our patients) when GPs did this work.

I'm all for clinical teams doing work that they do best, but inadequate assessment/management of neurological deficit, trying to gain tighter glycaemic control of a diabetic patient and making things worse, review of a patient's use of triptans with a poor outcome, and stopping someone's lithium (that had kept them stable for decades) are all recent undertakings of a First Contact Practitioner that perturbed me.

Most GPs in my area are really, really good. I'm fearful that in the future most Primary Care won't be. Much badness.

Monday 14 September 2009


I've differing views on the use of lorazepam and other benzodiazepines (here and here).

The Jobbing Doctor has quite rightly highlighted how mental health can be overly zealous in dishing out lorazepam. Got me thinking.

Bit of a delay in getting an answer to this one since it got me hassling a pharmacist to suss things out for me.

The outcomes were rather heartening.

Most patients prescribed lorazepam within my corner receive it as part of an adjunct to their dementia care. By "most patients" I in fact mean all of them. I have two patients who are prescribed a benzodiazepine for anxiety states. Every other patient on a benzodiazepine is taking it as a part of their package of dementia care.

One lady has anxiety which necessitated hospital in-patient care over many months, she relocated to my corner a few years ago to be near to family and now is on oxazepam 5mg as required. The tablets are 10mg, so it's half a tablet a time. The dose range in older adults is 10mg to 20mg, 3 or 4 times a day. 30mg to 80mg a day, then (which is what she was taking when we first met). She now takes 5mg a couple times a week. At such a tiny dose there's no risk of pharmacological dependence, no problems of side effects. Okay okay, it's homeopathy in all but name, yet for her it's invaluable. She finds that when she's anxious she can take half a tablet, she's in control, it's a key tool for her in her toolbox as part of her anxiety management. Developing an internal locus of control, patient choice, an empowered patient, person centred care, frame it how you will. For her, being able to have a bottle of tablets with just one tablet used up each week is incredibly effective in enabling her to manage her mood state and functional level.

Another lady's had a major adjustment disorder and is currently taking diazepam 2mg half to one tablet once a day. Again, a dose that doesn't cause pharmacological dependence (or side effects for her) but a dose which gives her feelings of relief that she finds necessary to help her cope. And cope she does, now managing activities of daily living that six months ago eluded her. Sure, her CBT and SNRI and twice weekly CPN input are far more meaningful than a sniff of diazepam, but for her the choice of taking a dose (or not) when she wishes is a choice that she feels she needs, a choice that puts her back in control, a choice that enables her to feel she's better equipped to cope.

Other than these two patients, every other prescription for a benzodiazepine since April has been purely as an aid in the management of dementia care. It's not used a lot, at all. We've specialist teams to support care in my corner so if there're problems then the team looks at causes and understanding and interventions, I look at physical comorbidity and concurrent medication, our commonest intervention is stopping drugs not starting them.

I still find it amazing how much medication is used for the right reasons at the right time, but then when dementia progresses the medication's side effect profile and tolerability generate treatment emergent adverse events (e.g. wailing, sobbing, battering carers) which a GP and I can improve upon through review and rationalising a drug regimen.

But if you've dementia, and this advances to cause the inevitable cognitive decline but also non-cognitive changes (i.e. behavioural and psychological symptoms of dementia, BPSD), and these are intense (e.g. battering your wife), and these are pervasive (happening in most situations or most of the time or in a repeatable fashion such as each time personal care's delivered), and there's distress to the patient and carer through this, and practical changes haven't improved things, and behavioural changes haven't helped, then I'll consider medication too. I'm not keen on antipsychotics in the first instance since they ramp up risk of serious things (like strokes and death) significantly and invariably the patient's not psychotic (so an antipsychotic's use is contentious). The evidence base increasingly shows that an acetylcholinesterase inhibitor is more effective with less side effects in the management of BPSD than an antipsychotic. If you've Alzheimer's disease. What if you've vascular dementia, or you've Alzheimer's and the drug doesn't work?

Increasingly the evidence suggests that in this patient population (of dementia and BPSD) that a benzodiazepine is a safer and more effective agent than an antipsychotic. Makes sense, too. It's an anxiolytic, it reduces anxiety, it's a "minor tranquilliser" and if someone's distraught through poor memory, or frustration, or through misperception of situations, or misinterpretation of activities/events, or losses, or fears, it helps reduce the anxiety and distress.

On using a benzodiazepine, it's then reviewed by a nurse or myself to see if it works. If it does, huzzah! If not, can it be increased to have a therapeutic trial at a decent dose for a decent duration? Still no benefit? Then it's stopped. We have to do this otherwise I end up writing FP10s forever (which I've not the inclination to do) and my nursing colleagues are locked in to reviewing outcomes forever, which they've neither the capacity nor the need to do. Hence a desire to robustly evaluate effectiveness then determine whether to continue or stop the drug.

A less distraught patient's a good thing, since they feel better and have a lower symptom burden. Too, they're then more likely to accept the reassaurance, reality orientation, personal care or other interventions from carers more successfully, more of the time.

Overall, I'm with the Jobbing Doctor that the NHS can be keen to dish out benzodiazepines too readily, some of the time. But, babies an' bath water, I'd not want to unhelpfully simplify the discussion into use of benzodiazepines is bad, since that's not true. Inappropriate use of benzodiazepines is bad. Rational prescribing practice is not bad. On that basis, within such a framework, I'm far more enthusiastic about a bit of lorazepam than haloperidol/more noxious agents.

Sunday 6 September 2009


I work full time. If patients problems through the working week, I am keen to sort them out with them. Sometimes, problems can be around the use of medication. Maybe it isn't working. Last week I had a patient 'phone because they'd been prescribed something else and wanted to know if she could take both tablets together. Maybe it's side effects (a patient last week had his rivastigmine patches stopped and a yellow card filled out after they caused ghastly rashes beneath each patch). Often it's because something destabilised the otherwise manageable situation (such as a patient last week with a chest infection who's otherwise manageable confusion/dementia became unmanageable and another lady who's daughter was going on holiday so couldn't give mum her tablets for that week).

My secretary receives messages from patients and carers that need attending to. Partly because it's important to them, partly because I don't like delays, partly because I've to do the work anyway so may as well do it straight away and largely because I get stressed if there's work to do that I leave for another time, I sort out such queries straight away. Well, my secretary gets their file out and attaches the message to the front, but such queries are invariably dealt the same morning or afternoon.

Some GPs write to me for advice about medication, which I very much welcome. Whether it's about a specific patient or whether it's about a concern they have/have read I usually get a touch too enthusiastic in replying. Because I know GPs need the information to be clinically relevant and because in Primary Care those who work with the GPs and need to understand and give the same message/work in the same sort of way, my letters back to Primary Care are not too abstract/theoretical and instead focus on the broad clinical headlines. Sure, I'll mention authors' names if relevant, so the GP can look it up if they have an interest, and so it's clear what the sources of my opinions are (and it's not just me making stuff up!) but by and large shared information is me waffling a bit about a topic. This is in my thoughts because the last letter was on why I wanted an ECG done before I planned to see a patient with dementia (who'd been seen by my nursing colleagues) in her care home. The typed letter was a touch over 2 A4 pages long. This is typical. What can I say, as is evident here, and as nurses chide me, I all too readily can waffle.

Getting medication right and sharing information about it matters. Patients, rightly, are keen to remind us of this.

Clinicians changing medication that another clinician initiated can cause difficulties. A GP changed a gentleman's lorazepam to haloperidol last week. The gentleman was under my care and had been for a couple months, with progression of his severe dementia, with nursing colleages and me seeing him at least once every week.

The gentleman was in respite care, where I'd seen him and nurses spoke with staff about his management.

He was wandersome, the home called his GP saying he was restless and distressed and hard to manage, the GP stopped lorazepam and started haloperidol.

The gentleman's Lewy Body dementia did not respond well to haloperidol, oh no. Poor bloke was rigid the next day. And drooling, come to that. By rigid, I mean he was so rigid he couldn't stand up, couldn't walk and couldn't eat. He was on 5mg of haloperidol twice a day which in older adults is a very significant/high dose, typically x10 what could be started.

The marketing authorisation for haloperidol says, "Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . ." and when the dose goes up an ECG is desirable, "During therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed . . ."

No ECG was done for this gentleman before starting haloperidol or during it's use.

Drugs in dementia cause risk as well as benefit. My GP colleagues can't be reasonably expected to keep up to date with this since it's a specialist area of prescribing and consideration to risk/benefits, often with incapacitated adults. Can a GP reasonably be expected to have read about the DART trial published this year and the effects of an antipsychotic doubling your risk of death in dementia (with 3 year survival of 30% on placebo vs 59% on an antipsychotic)? The trial was published in the Lancet Neurology. If a GP reads that, they can't read about, say, dermatology. GPs have so much to keep up to date with I can't expect GPs to know that this Summer a trial showed that dementia drugs increase your risk of syncope (collapse from an abnormal heart rhythm) by 12.9 per 1000 patient years) because reading such trials within the Archives of Internal Medicine and digesting and considering clinical implications. These are meaningful to Consultants who prescribe a lot (e.g. 1 in 77 patients every year will have a syncopal event, which is serious, since I've far more than 77 patients on these drugs) but less meaningful to individual patients (e.g. a patient would need to be on the drug for 77 years to be likely to have one episode of syncope).

Because of this, I have offered to take all decisions on prescribing of all antipsyhotics off my GPs. I offer to visit all GP surgeries a couple times a year for an hour on a lunchtime to talk through what heads up they may need about new stuff, what they want our service to do well/differently. Most GPs bit my hand off in their enthusiasm to do pass it over prescribing decisions to me. I visit every single care home in my patch, they all know to call our service if they've problems (since we've a specialist team to support them who're in the care homes every week).

The GP who stopped the lorazepam and started haloperidol was a locum GP covering for a GP who was on holiday. There were reams of letters from me/my team about the gentleman but still the systems didn't work optimally.


Time for more thought on how to solve that one.