Friday 30 July 2010

Writing Style

Dr Shock invites us to consider our writing style. Copy and paste some of your text here and see.

Going through my last few posts, I get results either of David Foster Wallace or of Dan Brown. Curious!

Tuesday 27 July 2010

Mental health work

The Girl asked two questions here, sensibly querying the stigma against psychiatry and how to manage without burnout.

General Practice is different from specialist care because it's harder. It's a specialist area in it's own right, but is mostly unidisciplincary in approach (you see a doctor, or a practice nurse, or a midwife, but you don't usually see several clinicians who've all discussed your care as a team) making it a harder area as a clinician (to my mind). And you never get to discharge anyone. And you get all problems/symptoms and have to divine what's of medical significance and what isn't. Which is often difficult, because if the patient has a symptom (e.g. of being knackered all the time) but it's investigated and not caused by any clinically significant illness or process, so medicine has little to offer, the patient's still usually keen for resolution of their target symptom. An explanation that it's not serious, not due to major disease or anything significant, placates so far but doesn't solve the patient's symptom burden. Before even managing patient agenda, governance frameworks, central DoH/NICE mandates, local PCT/APC/LMC direction, just thriving in a world of clinical uncertainty is trouble enough. Especially when you just have 10 minutes or so with each patient. Having trained and worked in Primary Care I know it's a challenging speciality and not one I've the stamina for.

With that caveat aside, that Primary Care is a separate complex speciality, what are my thoughts on Secondary Care specialities and mental health in particular?

Clinical practice within psychiatry is a very mixed field indeed. Most areas of Secondary Care medicine have diversity in approach but, by and large, the majority of doctors have similar approaches to care. Management of MI, childhood atopy, pre-eclampsia, lateral epicondylitis, angina, COPD or whatever is variable. But not that variable. Maybe one clinician would favour a NSAID over a moderate opiate, but by and large the care pathway is similar. Maybe one medic would do X first then Y, another would do Y then X, but over time most of their patients end up with mostly the same treatment.

Not so in psychiatry.

You may have a very biomedical psychiatrist who's interested in genes and biology and neurochemistry. Process is very medical, with complex imaging and serum rhubarb tests. Management is very pharmacological, or neurological (magnetic stimulation, ECT, whatever) to effect chemical change within what's seen to be a chemically imbalanced brain. When things don't work, you need more drugs. Or heroic doses. Or complicated drug augmentation strategies. Or specialist referral to centres who do psychosurgery or treatment with rare drugs. Got to fix the chemistry.

You may have a very psychosocial psychiatrist who's interested in a patient's current experience and life events and past experiential learning and ongoing maintaining factors. Process is very psychological, or practical (such as diary keeping) to gain understanding of why things are as they are. Management is very pragmatic or behavioural. Psychological therapy to aid acceptance. Behavioural therapy to effect meaningful change in the here and now. Got to either accept how things are, or make changes.

You may have a very community oriented psychiatrist. Problems arise in the patient's real world. The patient's going to return and live and thrive there. Why bring them in to what's been shown to be a "toxic environment" of a ward, where activities have little that's real for the patient's world, the situation's dislocating the patient from their problems and, when it comes down to their clinical needs, what can happen in a psychiatric hospital that can't happen in the community? Okay, often ECT is started/done in hospital (but even this can be done in the community), psychosurgery is certainly an in-patient procedure. But what else? Really, why have lots of hospital beds at all? Nobody gets admitted.

You may have a very hospital oriented psychiatrist. Problems arise in the community, if the patient could fix them they would have. Who'd choose to be miserable and not coping? They need time out, some solace and sanctuary and space to reflect or make sense of things. Or somewhere for rich assessment and investigation and and fiddling with drugs day to day. Really, if they've become unwell in the community and can't cope, how can they realistically be expected to recover and be cured there, in a timely manner? Everybody gets admitted.

You may have a liberal psychiatrist who accepts and supports everything. You may not. Someone with schizophrenia assaults a member of the public in a supermarket. One psychiatrist says they were hearing voices but just as if they heard you say to punch someone they could say no, they had control and chose not to exercise it, they made an elective choice to punch the victim. Charge them and go down the criminal justice system route. Another psychiatrist says they were hearing voices so not in control of their actions, there's no criminal intent and the person's unwell, needing disposal through health with hospital admission and in-patient care. Same patient, same action, sometimes it goes to police, sometimes it goes to health services.

Other disciplines look at psychiatry and shake their heads. It's all a bit of a mess, isn't it? It's not sensible. It's not seen to be about patients or clinical needs. It looks random and chaotic. It can be seen to be ineffective. Why would any doctor want to work in that world, as a career, when other options of proper medicine exist?

Worse, a lot of mental health services are poor. In particular, working age adults can get pretty shoddy care. Services often are under valued, under commissioned, under resourced and not fit for purpose. So sometimes there's bad care. So sometimes medical colleagues look at psychiatry and think, it's all a bit rubbish, really, isn't it.

But when it's done well, it's just brilliant. Everything works. It's fantastic for patients, getting help and improvement and appropriate care and feeling better for our input. It's fantastic for staff, feeling they're part of an effective, ace service. It's fantastic for families and carers, getting support and help and time to assist in how they can cope. It's fantastic for colleagues, GPs in particular, who know everyone is seen promptly (within days if routine, hours if urgent), everyone has nurses and social workers and pharmacist and psychiatrist inputting into every single patient (true multidisciplinary care) with all medication clearly sorted out, all care clearly documented and typed/faxed/posted to the GP/referrer, with patient/carer feedback and service evaluation and audit and monthly PCT reporting evidencing outcomes and quality of care, continuously.

When it's done well, nobody else knows. The patient and family are happy, they don't go back to their GP or other Consultant and wax lyrical about psychiatry because, appropriately, subsequent clinical contacts focus on their clincal needs. The system works, GPs get a 3 to 4 page letter when the patient's discharged but won't read all that; the detail isn't needed most of the time by most GPs.

The variability in practice often evens out, particularly if there's clinical supervision. There're plenty of ways to skin a cat. It'd be grim if we got to a day when every patient got the same treatment, in the same place, for the same duration, in the same way, with no personal care, no consideration of variables, no choice. That psychiatry still has latitude to be flexible in models of care is, to my mind, a great strength. Sure, we need to evidence it's effective and not just careless/maveric care, so I'm more than willing to evidence process and outcomes. Helps us improve the services too.

How to reduce emotional burnout is simple. Work in a way that's not stressful. To me, that means a range of things need to be in place.
1) I need to have clinical freedom, so can do what I feel is right for my patients. This is something we still enjoy in psychiatry, with no care pathways or algorithms or edicts directing what we must do. Our Trust has no hospital formulary, I can prescribe what so ever I wish.
2) I need to have colleagues I trust and can work with and share care with. I do. I'm blessed with brilliant teams. It can be hard (had several internal and external applicants for a post and couldn't appoint and none met the standard for the team), so 5 internal candidates were disappointed and we had a team with a vacant post. But it matters too much to me, we need the right people in the team and patients deserve the right people.
3) I need to have a good working relationship with managers. I meet our service manager at least once every fortnight. I meet a member of the Trust Board at least once every couple months. I meet with the Medical Director every month. I meet the Chief Exec too and write on average twice a month. Me talking with managers about how it is, and writing, and emailing, and making time to meet them matters.
4) I need a good relationship with partners. I meet GP colleagues in their surgeries, I meet Consultant colleagues on their ward rounds/meetings/teaching, I meet PCT commissioners every month so can help them with commissioning process/decisions whilst also having confidence in security of core bits of our service. Knowledge and security of the cash flow reduces stress and burnout.
5) I need to be able to blow off. Half the week I'm too busy for a lunch break but usually once a week a colleague and I'll skip off 30/40 minutes for lunch and blow off about what's going well, what's a real bitch, what needs changing, what we just need to grit our teeth over and accept. Being listened to and understood by someone who works in that world whilst you sound off and whitter on and on is awfully cathartic.

Well that's my initial thoughts on reasons for bias 'gainst psychiatry, reasons why that's not always valid, and thoughts on how I manage to remain up beat and optimistic without burnout. But you can always email me if you've specific stuff you want to chew over!

Saturday 17 July 2010

Holistic healthcare

Not all medical specialities look holistically at all elements of a patient's presentation :

Wednesday 14 July 2010

NHS Reform

I have read through the NHS white paper, "Quality and excellence : liberating the NHS" that was published 2 days ago.

It perturbs me.

This is unusual. Usually I can look at things with a "glass half full" kind of take on it, looking for positive opportunity and what it can enable us to do better. Most papers and policies and DoH edicts have not immediately been embraced as wondrously helpful, but on unpicking things I've usually found something that we can use to push commissioning buttons or support change we're making or that strengthens a case to resist dismantling of/meddling in services.

This paper's "vision" is all very positive.

The implementation superficially is neutral but on thinking it through I see it as concerning, with significant opportunity for negative effects. The detail scares me. It's noteworthy that there has been much comment with GPs being less than enthusiastic or critical or pessimistic about the changes to PCTs and commissioning.

What perturbs me is not the ill ease of grappling with uncertainty, which is normal/continuous life in the NHS. Change and uncertainty and wrestling with unknowns is a normal state of affairs. No, what worries me is the implications and explicit intentions of the white paper. I'm worried since it erodes the NHS.

As reported, the intention is for GPs to commission health care. More than an intention, it's forced upon them (since no sane GP would volunteer for this role). It's a poisoned chalice that's offered, and no mistake. GPs are then seen to be responsible for all deficiencies, since they've failed to commission the right services. Rubbish access for paediatric ADHD clinics, no easy access to tattoo removal, no service for aymptomatic varicose vein removal, it's all laid at the GPs door (a door that can't be closed). Rather than government cuts and suboptimal resourcing, it's then poor GP management that results in inadequate healthcare provision. Mmmm.

Worse, how are GPs going to spend the hours and hours necessary to commission care? It takes ages to go through each service. Just to commission older adults' mental health services (with community services, liaison services, early onset dementia care, forensic care, in-patient services, day hospital services, memory clinics, memory therapy day care, Mental Health Act arrangements, psychology services, Cognitive Stimulation Therapy etc) is a lot of detail to think over. Then do it with adults of working age and crisis services. Then with child and adolescent services. Then with forensic services. Then learning difficulty services. Then drug and alcohol services. Then IAPT and community mental health services. The with partners like MIND and Alzheimer's Society and Age Concern and others. Then do that for every other bit of health. There's no way GPs can absorb this activity. Hence the intention that as reported that the money will go, ". . . to private corporations which will buy hospital and community health services on behalf of GPs."

GPs are private businesses already. This paper strengthens and extends this, generating a situation where large companies can pick off small GP practices (then sack the expensive staff, like GPs, and go for First Contact Practitioners) and through block contracts/large consortia can then purchase Secondary Care from hospitals to get what they want. Except what they want, as a business, is a good balance sheet for their share holders.

A company buys/owns/represents all the GPs in my locality. The GPs advise the company on what they want then the company negotiates contracts and commissions services. The private health company, maybe it's BUPA, maybe it's another, then thinks where it wants to spend it's share of the £80 billion pounds. Does it give it to an NHS hospital? Or does it give it to a sister company or to itself, commissioning services from a BUPA hospital?

I'm perturbed since I see this paper as a mechanism for dumbing down healthcare (through eroding quality to save costs), devolving blame (but not power) to GPs and effecting the privatisation of healthcare, to the marked detriment of NHS care.

Much badness.

Saturday 10 July 2010


I was rummaging around the BBC News, this afternoon. Initially it was to see Acting Chief Constable Sue Simm, since she's great to see on telly. Not only has she eschewed the whole "I'm going to be glam and gorgeous" thing, she's opted straight for the Ashes to Ashes look, appearing as though she should be sitting next to Gene Hunt. It was female friends in the police who first drew my attention to her "special" hair style and how she seems locked in that error, erm, I mean era.

But hats off to the lass. Or hats on, my friends in blue suggest she sticks a PSU riot helmet on her head, whatever one of those may be. But really, it is great that the woman sits infront of the nation's media, without a care that her appearance isn't sculpted and classically elegant. Very laudable. It's her substance, her actions, that matter.

Whilst on the BBCs site and looking through the video news, the top editor's choice was an article on Donald McGill and his saucy postcards.

He even drew pictures of nurses. I fear that Unison would not approve. But truly I don't care what they think. I'm invariably interested in what a proper RMN or RGN who works with patients has to say. Those who used to be clinicians are like those who used to do PE at school . . . everyone did it, it's not impressive, it doesn't qualify you to talk about it or claim to be an expert in it still. An ex-nurse (or ex-doctor) lacks credibility.

Therefore I'm happy to ignore the view of pompous folk telling me nurses should wear sacks and look beige, so we see their actions and not their looks. Many RMNs are of the Jo Brand school, or male, with an average age in my corner that's within a decade of retirement. The demographics mean that NHS nurses in older adult's mental health really have very little in common with the Benny Hill/Donald McGill images of nurses.

I'm not sure how nurses should be portrayed by main stream media.

Still, on seeing Donald McGill postcards, I could stand to see my nurses in more traditional atire :

Sexy nurse


Doctors are known to self medicate with alcohol, at least as enthusiastically as the general population. The sterotype is that problematic use of alcohol's an occupational hazard. Personally I drink less than 21 units a week (in fact, it's invariably less than half that).

Although it's not that I partake frequently and regularly, I guess it's fair to say that nursing and medical colleagues can indeed sink a fair bit of drink on nights out. Social workers are a bit more sensible and never seem to drink to excess. Although we're all totally outclassed by secretaries; my they can drink.

After a fraught afternoon yesterday I got home and had a real Withnail moment, "I demand to have some booze!" My wife helpfully obliged. But then, having to read stories and do bathtime and put the kids to bed kind of tempers ones options for sinking into oblivion with drink and rubbish telly. I had to make do with one drink then later crashing out with Ms McCall and her Big Brother.

Gets you thinking.

How do we cope with stress, how do we manage to de-stress? As usual, it wasn't clinical work or patients causing stress, but was management activity (and inactivity) that added woe to my week.

I shall try not to mix my drinks :

Thursday 8 July 2010


I do not like them in a box.
I do not like them with a fox.
I do not like them in a house.
I do mot like them with a mouse.
I do not like them here or there.
I do not like them anywhere.

- Dr Seuss

It's always good to get a second opinion on contentious and contested issues. As well as frequent consults with Dr Google, it's sometimes good to reflect 'pon the wise counsel of Dr Seuss, too.

My current raison d'etre seems to be to manage policy. It's impossible for front line clinicians to manage policy day to day, so we have team meetings where we agree what policies we're not able to do, reason why we can't, which I then minute and send to managers. Maybe we'll be the next Mid Staffs with managers being informed by clinicians and Consultants what the problems are, but doing modest amounts to effect change. Who knows. We shall see. The important bit of it is that clinical teams are 'fessing up to what we can and can't deliver on, documenting that our practice is at variance with Trust guidance, reasoning why we're not doing it and informing the managament structure of this different clinical care.

It's not ideal, to meet up once a month to have to reflect on how we work, especially since 2 hours is a fair bit of time for a whole team to take out, but it's saved us a lot of time, in the long run. Not doing form filling, when the information's already captured and documented in 3 places already, has saved masses of time. And moved to a more paperless practice. And made everything more legible. And made it easier to print/email information. Clinical and secretarial staff have a lot of clever ways of working smartly.

But the main reason for this is the massive industry of policy generation that's become unhelpful. Excluding corporate/finance policies, our Trust has over 200 policies that apply to clinical staff, seeing patients. In a moment of ennui, I popped onto the web site and looked.

My oh my.

How can that work? A new junior doc or seconded nurse or bank nurse or trainee AMHP social worker or psychologist is in our service. They go to a clinic or DV or ward to see a patient. They have all their clinical process and knowledge and skills in their heads, structuring what they do and how they do it. They have the GMC/NMC/regulatory body directives in their heads, structuring what they do and how they do it. They have national guidance influencing their thinking. Maybe. They have legislative direction (particularly that MCA 2005 and MHA 1983) structuring how they work. There's usually us Consultants with our foibles, meaning certain types of assessment or interventions are "how we like things to be" which influences clinical care. On top of all this professional material, can anyone credibly believe these staff will also read, understand, implement and use over 200 policies in their practice, as well?

My angst is that oft times too much policy is generated by folk who aren't clinicians. Worse, it's done without any consultation with practising coal face clinicians. Even worse, the decision to make something happen is usually to make a policy, then consult on the policy. It's as if any alternative to a policy is never ever even entertained as a possibility. Yet how many clinical teams working in creative, iterative models of care, have working their practice defined clearly within a policy? Even the operational policies of the teams seem to be works of fiction that bear little resemblance to the function and activities of the teams.

How many times has a clinical team said, "Oooh yes, our clinical care in this area is so much better than it was last year, because we've embedded this Trust policy into our working practice and now everything's brilliant!"
Never happened, in my corner. Curious, then, that policy documentation is generated at such a staggering rate when the outcome/utility from it is evidenced as so poor. Hmmm.

People working far away from a specific clinical team will generate a policy that applies to that clinical team. They're working in the dark and generate material that's usually pretty sensible on reading through it, but is oft times unnecessary, overly tortuous and very very rarely impacts on direct clinical care.

I'll leave the final words, once again, to my colleague Dr Seuss :

Say! In the dark?
Here in the dark!
Would you, could you, in the dark?
I would not, could not, in the dark.

Monday 5 July 2010


A colourful lady in her 80's now, with paranoid schizophrenia that's well controlled, but leaves her with delightfully eccentric foibles.

"No, I don't suffer with madness . . . I enjoy every day of it!"

Saturday 3 July 2010


I was told by a couple of different managers last week that I was obviously "passionate" about my work.

It's a word I struggle with. You can be passionate about a woman. Catholic friends have talked long into the night, over far too much drink, about, "the passion of Christ." It's a word that is often over used.

Some words that had a strong meaning are hijacked and over used, to somehow increase the weak meaning of a point. Politicians, they're often doing it. Politicians are presented with a statement of how they cocked up. How do they respond?
"Erm, yeah, bit of a mess I made, wasn't it?" Nope, never.
"Hey, it wasn't my fault!" Sometimes, but then politicians in power have responsibility so it's their fault or their bosses, so it's not a response we see so often now.
"I deny that!" This used to be a common response. Whatever some half arsed journo dreamt up as a claim, it's just dismissed and brushed aside. Doesn't sound convincing or drawing a line under it, though.
"I refute that!"
It's refuted.
A refutation, what is that? It's much stronger than a denial. It sounds clever and impressive and definitive, how can the conversation possibly continue once the debater has refuted the argument you've contended? Your argument, by definition, has been proven false.

Of course, they say they refute the charge, but they don't offer the evidence that then goes beyond explaining and suggesting and incontestably provides the necessary proof that they're right.

But still, politicians continue to say they "refute" a claim instead of saying they "deny" or "don't like" a claim, despite this being more accurate. Refute is carelessly used by politicians and is becoming a weaker word through such use, soon to lose it's definitive meaning of proof and simply be a posh way of saying deny.

I like a range of words, with subtly different meanings.

So is it right to claim to be passionate about work? I love David Mitchell's rant about passion because it's exactly how I think. Passion is a word that's vastly over used.

But then I saw a video about an astrophyscist who's the Director of the Hayden Planetarium in New York. The clip is here, the site is here, click When I Look Up. Okay, maybe some people are passionate about their job, their speciality, their field, their work . . .