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.


Milk and Two Sugars said...

Fear of the future for medicine is something I worried about for a time. I was reminded that most doctors are people who work hard and hold themselves to high standards of practice. Best not to let a few badnesses influence your ourlook unduely. :)

You're a person who deals with such problems in a proactive way, usually with improved outcome. I don't see you letting these examples of poor practice go un-addressed...

Milk and Two Sugars said...

*Outlook, oops!

Milo said...

It is really sad seeing this happen and to see actual people suffer as a consequence. It is also hard to see how it frustrate people who do give a damn (like yourself). Of course i can only relate to it as a patient with temporal lobe epilepsy being misdiagnosed as a paranoid schizophrenic for 12 years.
God bless you for caring.
please take care and with kindest regards,Milo