Generosity

I'm interested in how we think, in what internal and external processes impact 'pon how we see ourselves, how we value ourselves, how we perceive ourselves to be. A positive sense of self is important. TED talks are often engaging, this one on generosity (and social change, challenging poverty, altruism, philanthropy and business) is worth shamelessly snaffling and displaying here :

Sasha Dichter: The Generosity Experiment from TED Blog on Vimeo.

Shambling

I was reading through a lot of guidance today that's been published by the National Institute of Health and Clinical Excellence (NICE) since I've been drawn into doing some work on quality standards and care pathways and stuff. It's not an organisation directly controlled by the government, but it's funded by it. Sort of independent, but sort of State organised.

I've issues with guidance, since it's easily given too much authority and seen as the best and only "evidence" and direction. When mis-used in this manner it's worse than having no guidance at all and actively undermines both appropriate commissioning/resourcing of services and undermines patient centred care.

When used well, as something to consider and actively follow or consciously discount for valid patient factors/reasons, NICE guidance is a very useful resource.

Taking it simply for what it is, of informed opinion, so one credible point of view, it's got a very useful place.

It's quite a formal organisation. Proper. Seemly.

In the USA they have formal health bodies, like the Centre for Disease Control (CDC). In their guidance for emergency preparation and readiness they've issued govenrment guidance on what to do in a Zombie Apocalypse.

Geeeenius!

Complementary Medicine

I can't recall who linked this YouTube video, it wasn't found by me. I chanced upon it on a blog which, to my shame, I can't recall. My wife thinks I read too many blogs. Meh.

Anyway, watch this :



"I'm like a rabbit suddenly trapped in the blinding headlights of vacuous crap."

Brilliant.

Art. Allegedly.

My wife persuaded me to see some art she was interested in. An effort for the poor lass, since my interest in culture seldom exceeds the remits of what's grown within a petri dish.

I'm no culture vulture and find my mind's attention when glancing at most modern art is roughly equivalent to my mind's attention when glancing at rows of bin bags in the supermaket. Which to choose? The work of but a moment, then time to move on. Unless it's Hunt, Millais or Rossetti. She effortlessly talked me to seeing Liverpool's pre-Raphaelite originals then impishly whooshed me along to the Tate Modern which regrettably lived up to my every expectation.

A few weekends ago we romped through London's museums and galleries, where I was pleasantly surprised, but she also fancied a trip to Yorkshire Sculpture Park to see some Henry Moore whatnots set out in the countryside. It looks interesting but what really got me was they'd the most weird Jaume Plensa creations.

Apologies for the images, they looked a lot sharper on my mobile 'phone!





Eerie, unnerving and unsettling, the glowing statues set in darkened rooms really were very powerful. Placing words like "Amnesia" and the like all over, to externalise what's usually internal, was lost on me and just seemed a bit naff, but the size, shape, structure, luminosity of it all was striking, with real impact.

Blame

A banker, a Daily Mail reader and a Benefit Claimant are sat round a table, and there are 12 biscuits.

The banker immediately takes 11 and whispers to the Daily Mail reader, "Be careful, that Benefit Claimant is after your biscuit."

Quote

I took my children to see Megamind recently. Great fun it was, too. One line from it made me laugh out loud at the time then resonated again with me when I saw someone today.

After making a mistake, but both wanting to save face and keep a positive sense of self, Megamind 'apologised' by saying, "You were right. I was . . . less right."

Brilliant :P

Blimey!

I'm surprised!

The readers of Mental Nurse have voted for favourite mental health blogs and have voted for this as their favourite Psychiatrist's blog.

Given the number of popular psychiatrist blogs, more established ones, more frequently updated ones, newer ones, more evidence based ones and almost all of them look nicer/are better presented, and more popular blogs (with me tumbling through 2010 from number 2 to number 15 now) I'm very surpised (and of course pleased) that folk rated my musings.

So, a big thank you for being so kind!

Now, get on to Mental Nurse and rummage around some really good top quality blogs!

Weather

Walking through the hospital grounds this morning, beneath bright sunshine, the grounds are a riot of colour. Trees shifting through golds, browns, yellows and vibrant reds.

I love Autumn.

t'interweb

I use the internet a lot.

I don't think I use it excessively. At work I rummage around blogs and web sites when I can. On evenings I browse through medical/mental health sites that interest me. A few times a week I'll pop on to Facebook but I don't use it a lot. I'll email* at work several times a day, mostly to managers.

I've a 'puter at home we use for online gaming on evenings, but rarely use it through holidays or weekends.

My mobile 'phone can do email and Facebook and stuff but I've not configured it to do so. I'm quite happy using it to call or text or occasionally take photos.

If I want to communicate then I still like face to face contact. At work I walk to offices to meet folk, I hardly ever use my 'phone. At home I drive to friends and family and hardly chatter by 'phone or texts or Skype or emails. One friend texts* loads, which works fine, since we meet up throughout the week too. To have a real relationship, where you can relate to people, supported by texts/emails works for me.

I'm aware that I'm practically prehistoric in how I interact with the big wide world, though. My wife, who loves gadgets, thinks that although my mobile 'phone can do loads and I use it for just texts/calls/photos, the only reason I have a modern 'phone is because they don't do rotary telephones any more so I was forced to move on.

I recently was reading through work by Kruger (2005) on computer mediated communication. Apparently we're all not very good at it.

Published work shows authors believe they're understood much better than they really are. Folks communicating face to face accurately assessed how often their meanings would be understood. Folks communicating electronically incorrectly thought meaning would be understood about 80% of the time, when it was just a little over half the time. 44% of the time the important meaning (such as sarcasm) simply wasn't got.

Contextual meanings such as sombre or sadness or humour were poorly conveyed. What of smilies and emoticons? They were used and didn't help improve the outcomes. Even with such cues, anything (other than facts) such as sarcasm or emotion or attitude or irony or humour aren't meaningfully conveyed almost half the time.

This comforts me, knowing electronic communication is but a small part of my world. But, gentle reader, just in case you read anything I generate within this blog or comments on other blogs and take issue, can I play the "it's through using t'interweb" card and claim it was meant sarcastically, ironically or humorously? :-)


* email, electronic mail, is it just a noun or is it fair to use is as a verb? Texts, text messages, is it just a noun or is it fair to use is as a verb too?

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!

Holistic healthcare

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

Nurses

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 :

Booze

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 :

Passion

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!"
My.
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 . . .

Offence

'It's now very common to hear people say, "I'm rather offended by that", as if that gives them certain rights. It's no more than a whine. It has no meaning, it has no purpose, it has no reason to be respected as a phrase. "I'm offended by that." Well, so fucking what?'
- Stephen Fry

Genius.

Lifestyle

Blood

I learnt something new today.

I do most days, mostly from nurses, but on this occasion it was after our monthly team CPD (continuing professional development) meeting. We'd rattled through a discussion of recent papers and how they should affect our practice, we noted the bias of one review and chewed over how we were doing with NICE guidance. We discussed depot olanzapine's evidence of what the pharmaceutical company report as a "post injection syndrome" and how everyone else calls it "a coma" and how this seemed bad.

It was noted that I brought a number of abstracts from British and US journals but nursing colleagues didn't. Yet they're very interested in the 10 minute discussion of each paper, grabbing the headline messages and learning points, with their "care pathways" having changed for the better over time through considering new research and reviewing what we do. A number of articles and papers have been published by us over the last year. If nurses embrace new research (in a balanced and critical way) then adopt the good bits, why aren't they sharing lots of papers at our monthly meeting?

It's all down to what's valued. Consultant Psychiatrists have time set aside each week for CPD. Nurses do not. Nurses are told what to adopt and articulate how they're not given time to provide even basic nursing care. I wonder how many nurses have time for CPD in their week? Do any have time to browse web sites, muse over abstracts, download papers and read through NICE, DoH and other advice, guidance and direction? I know of no nurses who do.

So for a hour a month we do it ourselves, rattling through a couple papers (no more than 10 minutes on each, just to distill what the issue was, what the paper shows us, the weaknesses of the paper and how we then could use it in our work) and any new guidance and obstacles to good practice.

At least this means we've a fighting chance of spotting quackery that's increasingly peddled in more mainstream literature. Like this, which I learnt of today. Live Blood Analysis (LBA). You take a spot of patients blood, both you and the patient just look at it on a big screen for 2 hours, you see stuff move and decide what this means. Such as, "Look at those moving, they must be alive, you have parasites in your blood, take this herbal medication that's expensive but look at your blood, it's so worth it."

A Dr Rubin looked at this and found no papers on LBA in the scientific literature. None. Yet there were 2.5 million hits on Google. Interesting. Someone's advertising and making a lot of money from this LBA thingy. So, does LBA work? Is the scientific community elitist and simply ignoring a helpful diagnostic intervention? Actually, no. It's pseudoscience and doesn't work.

That's a helpful paper. I've learnt today of a new entity, Live Blood Analysis, and learnt of rigorous review of LBA which found it to be so much stuff and nonsense. Which is worth knowing.

Should I charitably tag this post as "Complimentary Therapy" or should I generate a new tag of "Fraud" I wonder . . .

Homeopathy

A number of people, indeed most, will look at options of self management, which is a good thing. Some will be desparate and try things which have little benefit. But hey, what's to lose. Some will be even more desparate and try things that have little benefit but cost money. Hmmm.

Complementary Therapy has had bad press, because much of it that is useful is understated (since it's obvious and now mainstream rather than "complementary" to maintstream practice) so it's the more extreme claims that are pushed. Which invariably aren't valid.

The bottom line is that sensible people try stuff and find it doesn't work very well.

"Herbal medicine has been around for thousands of years, indeed it has, and then we tested it all and then the stuff that worked became 'medicine' and the rest of it is just a nice bowl of soup and some pot pouri."

"Well, science knows it doesn't know everything, otherwise it'd stop."

"I'm sorry if you're into homeopathy; it's water! How often does it need to be said, it's just water!" and, "The great thing about homeopathy is you can't overdose on it. Well you could fucking drown!"

Not very politially correct at all, but pretty darn amusing :

IAPT

The Improving Access to Psychological Therapies (IAPT) programme is seen in different ways.

Okay, I chide myself to remember as Billy Shakespeare penned in The Life Everlasting, "There is nothing good or bad, but thinking makes it so," yet I still think of IAPT and think, "Yes, but . . ."

It's a big "but" too. A really big arse of it all. Because IAPT piques me.

I had the fortune to work with pioneers (they really were called pioneers) who pilotted IAPT and wrote up how ace it all was. Of course, it wasn't, but who could present their work as a failure when their career/credibility and national policy and being seen to do something positive was necessary?

Subsequent external criticism and internal comment from IAPT workers 'fessing up that it's a service which is self-selecting the "worried well" generates concern. Why? Because IAPT uses a "step tiered" model and, arguably, uses it in an unhelpful manner.

If you're having mild problems, in theory there's "watchful waiting" but in practice these individuals who have contact with IAPT and then over time get better are evaluated by outcomes which suggests that IAPT have facilitated the recovery of someone who, through waiting, got better anyway. Okay IAPT may have a role in surveillance, but to argue that IAPT have improved this person's wellbeing in a meaningful and cost effective and active manner is rather overstating the case.

With mild and self limiting problems being seen within IAPT and then getting better, in spite of (rather than because of) anything that is done, simply through time passing and people recovering, IAPT claims success. Again I think it's disingenuous to suggest IAPT have major impact here because, of course, mental health services aren't amazingly brilliant at curing folk. Shock, horror, but usually we're good at facilitating improvement, hurrying along restoration of wellbeing as nature takes it's course, giving support to make things more understood whilst processes are unfolding, but by and large interventions aren't as miraculous as people would wish to believe.

People had depression before there were antidepressants. People got better. Effectiveness of antidepressants were reviewed in the Journal of the American Medical Association this year and found to work as well as placebo in mild, moderate and severe depression, with drugs only starting to work better than placebo in very severe depression.

We know that drugs, psychological therapy and ECT can help with depression for some people, some of the time. Some people get stunningly good results. Would paying for a good holiday help people with mild depression feel better? Probably. Would talking with IAPT mean that, 2 months on, things were better for someone with mild problems? Probably. Would not talking with IAPT but talking with friends/having a moan/challenging your boss/getting more sleep, mean 2 months on, things were better for someone with mild problems? Probably.

IAPT is attractive to politicians, it's seen as delivery of psychological therapy to large numbers of people. The presence of such a programme then satisfies the desire to do something, to have something.

But what of the process, what of the content?

The people usually have telephone advice. My patients have not felt listened to and heard and understood. IAPT screens for suicidality every contact. My patients weren't suicidal so felt that asking questions that weren't relevant meant they clearly weren't being listened to, with their agenda/needs not being addressed. This switched them off IAPT so much they disengaged. I asked IAPT what had happened in their care, after their GPs referred them to us. In 3 cases IAPT replied that the patient had worked with IAPT and, having made progress, then no longer needed contact. The patient sees their contact with IAPT as an unresponsive self-serving protocol driven process that's not helping them, with failure, resulting in GP contact and referral to mental health services. IAPT report it as a success with a positive patient outcome. In all 3 cases the patient was going through a normal bereavement and didn't need specialist psychological work or medication, yet IAPT couldn't support peoples' mental wellbeing through a normal but unpleasant time.

IAPT should, in tier 3, deal with "high intensity" need such as severe depression and PTSD delivered by CBT trained therapists but they don't. They say they're complex patients who need specialist services so turf them to us.

Mild, self limiting problems are seen within IAPT and reported to do well. Patients who drop out with bad outcomes are seen by IAPT and reported to do well. High intensity severe problems are part of IAPT's role which they fail to deliver on but since it's their role and they've no failures (referring them all) they report they do well.

IAPT therefore paint themselves as stunningly successful, seeking expansion and resourcing. There's only finite cash. Colleagues have described how psychological therapy that was historically accessed in Primary Care or Secondary Care no longer exists because IAPT has consumed those resources and is seen to meet the need, so alternatives aren't commissioned/delivered.

A cheap and cheerful high volume largely telephone advice protocol driven service, to meet most of the psychological needs of most of the patient population needing help . . . I can't help but think it's all gone spectacularly wrong. But we've an election, so I'm sure since the NHS and spending and return to work and family life are such big issues, parties will be offering us choices, no?

Erm, no.

So it goes.

Perfection

Do you like speaking to an answering machine, to leave a message? It seems that most people don't. And yet talking down the 'phone to leave dialogue on a machine that reproduces what you say, perfectly, should be seen as a good and reliable way to communicate. Better than the alternative of leaving a message through just a few words of text, surely? But no, most of us choose to text a few words (despite how fiddly it might be) rather than leave a voice message, just talking, which should be a more natural and effortless and familiar way to be.

Machines, even those which are perfect at what they do, don't always deliver sweeping changes and aren't always warmly embraced.

How desirable is perfection?

Common sense says it's got to be a good thing, right?

Clinically, in mental health we often strive for "good enough" or "as good as can be" rather than perfection.

Our machines have loftier aspirations.

It seems that every ECG machine now wants a perfect reading. Anything less than perfect is flagged as abnormal. Indeed, it's printed out, "Abnormal ECG," along with conjecture as to why. Almost always it is normal. Or normal enough. Not something that a doctor would document as "abnormal" anyway. But unless it's perfect, the ECG machine chews out paper documenting "abnormality" which causes no end of stress and nuisance.

I really do want to do something quite gratuitous to it's rusty innards.

Sometimes I don't want perfection, I want normal.