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!


BenefitScroungingScum said...

I know that was meant to be a post about choosing psychiatry as a speciality but thanks so much for an excellent insight into how psychiatrists work from a lay perspective!

Dr Andrew Brown said...

A superb summary, Shrink. Thank you.

The Girl said...

That was brilliant.

Hearing about psychiatry from psychiatrists makes it sound so exciting and positive. The more I learn and see, the more sure I get about following that path.

Thank-you for answering my question.

Anonymous said...

Where do you work? I am moving house to use the mental health services provided in your trust. It sounds amazing.

The Shrink said...

Crazy Nurse, I've had one elderly family move to my catchment area in the last year, the main reason being to access mental health care. Four families this year access care from my corner, despite have 3 teams all delivering care closer to them.

But that's rare. Most people prefer care from their local services.

The neighbouring Trusts have harsh constraints on care options, prescribing and CMHT input that thankfully we're not burdened by.

As with GPs, some patients are really really keen to join with a team who they reckon they'll get good care from, but usually folk go for the local option. And each year some families move to our corner, purely to access care/drugs that neighbouring Trusts can't/don't provide.

Postcode lottery, I'm afraid.