I was out at a local Chinese restaurant with Mrs Shrink, after a fatality within the oven in our kitchen wrote off a nutitious evening meal, 'less your idea of nutritious involves burnt unidentifiable charcoal clumps.
Out we went. We ordered lots of nibbly things. Very nice they were, too.
The owner kept looking at me. I couldn't think why. He came over to thank me for treating his daughter, in the 1990's sometime, when I was working out in GP land. Apparently I'd diagnosed her skin condition correctly as eczema, I'd given her the right creams and oils and she'd been cured.
He remembered that. He remembered me and what I'd done for his child. Patients do that, with GPs. The current NHS changes invite discourse on what GPs do that's important, what GPs do that's delegable, what GPs do that can be displaced to other services. This contact stirred thoughts that, frankly, that's all missing the point. The gentleman approached me 2 decades on to offer his gratitude because that consultation and care within General Practice had rich meaning to him. It mattered. And that's the bottom line . . . what GPs do makes a difference to peoples' lives, is valued and deeply meaningful.
Showing posts with label GP. Show all posts
Showing posts with label GP. Show all posts
Monday, 27 June 2011
Monday, 4 October 2010
The past
When I trained as a GP there was consistent recognition of the book "The Doctor, his Patient and the Illness" by Michael Balint. Given that Balint's work involved GPs and psychiatrists meeting up and chewing over discussions of patients the GPs had been seeing, the themes and processes were right up my street. Although I enjoyed working in GP land, having swapped to psychiatry I still find the work equally appealing.
Work within my training in Primary Care was about medicine, obviously. Delivering it as a GP needed additional, specialist training that took 3 years. Much of this training was on clinical content, I knew I was weak at rashes so spent a year sitting in a dermatology clinic for a day a week which was great training, both on dermatology and on consultation style/case load management/clinical decision making that you attend to when training as a GP. I learnt more about rashes through that time, but also learnt a lot more about broader patient care.
A good proportion of time training as a GP was rightly devoted to considering the patient's agenda. Firstly it's the right thing to do, because it purposefully addresses what the patient presents with and wants addressing, attending to what the patient's concerned about. Sure, clinicians may note that the cause of the patient's issues/concerns are something else, or see a chance for opportunistic health promotion, but it evidently makes sense to help the patient with what the patient brings. Secondly it's the right thing to do, because patients usually know what's normal/right for themselves so presenting with an issue that may initially seem to be of dubious medical relevance oft times does become of import. Maybe it's an uncommon symptom manifesting. Maybe it's an explanation used to show me something they can't otherwise describe, which we all commonly do (such as describing ourselves as "off colour" or "out of sorts" or "feeling blue" or "not myself today" which medically means nothing but practically is important) so describibg "being tense" but having normal muscle tone and no headaches isn't as spurious as initially I might have thought.
As a medical student I used to think of things in categories, we were trained to do so. There's a medical problem or there isn't. It's mental or physical. It needs surgery or it doesn't. Medication is indicated or it isn't. Someone is coping or they aren't. I look on my past training and am very glad I've had these training experiences. Even in the training posts for both General Practice and Psychiatry, when I was doing them I really enjoyed them, it isn't just a rose tinted view that time's given me. The training, over so many years, taught me the clinical content to start working as an autonomous, unsupervised medic (a Consultant, in the NHS) but also developed my approach and understanding of consultation style that's much richer now than it was, as a medical student. As a medical student I thought I needed to know all the medicine, and it was true. But as a practitioner, I need to know the medicine and need to know how to work with patients. Sitting in with GPs and Consultants in surgeries and clinics was of enormous value in helping glean an understanding of what works well, what can be done better, what I shouldn't be doing and what I can adopt in my own practice.
On talking through a portfoloio and training with my junior doctor, it dawned on me how diverse and interesting and valuable my own training has been. The brevity of current training concerns me. Even if the tick box clinical content can be delivered in such a short time, will future practitioners step in to post with the balance and maturity that my colleagues developed through longer and more flexible training? No, no they will not. I try with my junior doctor we focus on clinical topics and on broader consultation style and operational/management matters but he's not at a point in his training when he's receptive to this. He needs to know the medicine, he can't pass his exams without it. Anything else is interesting but not as important to him. But, in a bit over 3 years, he'll probably be a Consultant.
"The past is a foreign country; they do things differently there."
- L P Hartley
Work within my training in Primary Care was about medicine, obviously. Delivering it as a GP needed additional, specialist training that took 3 years. Much of this training was on clinical content, I knew I was weak at rashes so spent a year sitting in a dermatology clinic for a day a week which was great training, both on dermatology and on consultation style/case load management/clinical decision making that you attend to when training as a GP. I learnt more about rashes through that time, but also learnt a lot more about broader patient care.
A good proportion of time training as a GP was rightly devoted to considering the patient's agenda. Firstly it's the right thing to do, because it purposefully addresses what the patient presents with and wants addressing, attending to what the patient's concerned about. Sure, clinicians may note that the cause of the patient's issues/concerns are something else, or see a chance for opportunistic health promotion, but it evidently makes sense to help the patient with what the patient brings. Secondly it's the right thing to do, because patients usually know what's normal/right for themselves so presenting with an issue that may initially seem to be of dubious medical relevance oft times does become of import. Maybe it's an uncommon symptom manifesting. Maybe it's an explanation used to show me something they can't otherwise describe, which we all commonly do (such as describing ourselves as "off colour" or "out of sorts" or "feeling blue" or "not myself today" which medically means nothing but practically is important) so describibg "being tense" but having normal muscle tone and no headaches isn't as spurious as initially I might have thought.
As a medical student I used to think of things in categories, we were trained to do so. There's a medical problem or there isn't. It's mental or physical. It needs surgery or it doesn't. Medication is indicated or it isn't. Someone is coping or they aren't. I look on my past training and am very glad I've had these training experiences. Even in the training posts for both General Practice and Psychiatry, when I was doing them I really enjoyed them, it isn't just a rose tinted view that time's given me. The training, over so many years, taught me the clinical content to start working as an autonomous, unsupervised medic (a Consultant, in the NHS) but also developed my approach and understanding of consultation style that's much richer now than it was, as a medical student. As a medical student I thought I needed to know all the medicine, and it was true. But as a practitioner, I need to know the medicine and need to know how to work with patients. Sitting in with GPs and Consultants in surgeries and clinics was of enormous value in helping glean an understanding of what works well, what can be done better, what I shouldn't be doing and what I can adopt in my own practice.
On talking through a portfoloio and training with my junior doctor, it dawned on me how diverse and interesting and valuable my own training has been. The brevity of current training concerns me. Even if the tick box clinical content can be delivered in such a short time, will future practitioners step in to post with the balance and maturity that my colleagues developed through longer and more flexible training? No, no they will not. I try with my junior doctor we focus on clinical topics and on broader consultation style and operational/management matters but he's not at a point in his training when he's receptive to this. He needs to know the medicine, he can't pass his exams without it. Anything else is interesting but not as important to him. But, in a bit over 3 years, he'll probably be a Consultant.
"The past is a foreign country; they do things differently there."
- L P Hartley
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.
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.
Tuesday, 26 May 2009
Fiddling
I trained as a GP, after going to med school. I sought the continuity of care, of looking after folk over the long haul, rather than fiddling for a day then passing them on. I sought the clinical freedom to work as I felt best within my own practice, rather than as I was told to do by hospital managers. I sought work that was biomedical and psychosocial, that was complex and meaningful.
Through this, I found myself spending rather a lot of time in care homes. Most lunch times, in fact. I liked it. Meant I rarely got lunch (a habit that persists to this day) but meant that I could while away time with elderly folk, talking through what was meaningful to them (notionally the "patient agenda") and what was meaningful to me (reviewing their chronic health problems and drug regimens) whilst passing the time of day with what was invariably engaging conversation with interesting folk.
I knew I wanted to work with older adults early on.
Oh, the child health surveillance clinics were good enough. I enjoyed my paediatric SHO job, and obsterics as an SHO and in Primary Care. But rather than kids or young adults, it's always been the older adults I've gravitated towards. So often they ask for nothing, you want to give them everything.
I knew I wanted to be a psychiatrist before I'd even finished my VTS. Somehow I managed to get through all my psychiatry training with just 12 weeks of pure General Adult psychiatry (of which hospital induction, annual leave and study leave wiped out over half of it). I've nothing against General Adult psych, it's just not for me, I knew it never would be, so I didn't want to do it as an SHO. I didn't do any, after being an SHO. I knew I sought to work with Older Adults, so for me it was old age psychiatry all the way. Oh, I did my CAMHS and forensic and rehab and a few specialist posts as an SHO, but thought I may as well focus on what was useful to me rather than fiddle with working age adult psychiatry when I knew my enthusiasm lay elsewhere.
Overall I'm very grateful for all the training posts I've had. Life in A&E and in Primary Care teaches you a lot about triage, consultations, decision making and safety netting. Every post I've had has given me useful training that's shaped me into the clinician I now am. Even though I'm not a physician, there're translatable skills gleaned from that post.
I'm in the habit of visiting all GPs in my patch. Some don't want to meet and over years the only contact we've had is through letters. Some want to but are too busy to. Mostly, though, meeting GPs is a good thing that's welcomed. Firstly so we can wrangle over how we can collectively iron out any wrangles. Secondly so we can share news on patient care (what the guidance released in March 2009 says about schizophrenia, how we should manage vascular dementia vs what stroke outreach do, how acetylcholinesterase inhibitors and memantine's used locally). Thirdy so we can form better relationships, with fewer barriers and more common sense.
One problem GPs have is what's happening in care homes. Out of hours, when struggling, especially if poorly staffed, care homes call the out of hours doctors. The doctors are presented with skewed information by the care home, of an unmanageable patient in profound distress who's generating risk to themselves and to others so needs something doing right away. Dementia typically progresses over months and doesn't typically get worse over minutes/hours - if they were settled at 4.00pm why are they now unsettled at 7.00pm? Their dementia's not warranting hospital in-patient care, suddenly, so what can the on-call doctors do? The deterioration could be delirium, so could be managed medically in Primary or Secondary Care. Usually the care home's just after some medication "to calm them down." The on-call GP has few options. The on-call GP invariably isn't in a position to effect changes in care plans generating person centred dementia care that addresses the causes and consequences of the person's presentation with nonpharmacological strategies. You need to know the staff, the care home, the environment, the patient, the resources and the context before you have a hope of that. The on-call GP is left with the stark choice of effectively do nothing or prescribe a tranquilliser, most often the antipsychotic, haloperidol. The care home reports a need for this to continue so it's added to a repeat prescription at low dose.
A local "audit" by the PCT has shown that invariably it isn't reviewed. The sampling wasn't perfect so I went through all care homes in my patch and reviewed every MARS and it was true - most psychotropics were initiated in Primary Care and most weren't reviewed. Was it audit? What was the gold standard being espoused, what was the GP and Consultant Psychiatrist's variance from this? No, it wasn't formal clinical audit. More a PCT survey, really. But the PCT pharmacist has at least got the discussion going. Scared the willies out of me, for a start.
Lots of elderly incapacitated folk, on psychotropic meds, without review.
Over the last year or two the amount of psychotropic medication used in care homes has plummeted. Care homes know that I'll pop in promptly, as will our CPNs, so there's little excuse for hassling a GP out of hours for mental health problems. Although I regularly go through every care home, it's a time consuming business. Most folk in care homes aren't known to our Trust. To suss out what's going on, why they're on medication, what the effect of the medication is, isn't straightforward. A lot of unpicking to be done. Usually the care home manager sits with a CPN and me as we review all their residents, sometimes it's the RMN if it's a nursing home, but someone has to be there to explain the consequences of medication and presentation of their residents. It's a good learning opportunity for all parties, too. Thus, as well as popping in to sort specific patient problems, we also review the drug regimen and mental health of all residents in care homes, which takes roughly 6 months to do. With current resourcing, that means we review everyone in a care home in my patch twice each year. Could be better, could be worse, I guess.
Usually we stop the medication and review this. Mostly they're better off the drugs.
Milo has suggested that, "I don't think that there are many psychiatrists out there (i haven't been able to find any!) who would not be judgmental towards someone who has paranoid schizophrenia and chooses not to take anti-psychotic medication!"
Dementia, schizophrenia, depression, anxiety . . . if you're taking medication there should be rational prescribing practice. I'm not judgmental towards someone not taking medication. I think GPs and Consultants simply need to evidence sound, rational prescribing.
Increasingly I'm of the view that Voltaire had the truth of it in saying, "The art of medicine consists in amusing the patient while nature cures the disease." Medication has a place. A very important place. Mental illness can be ghastly and can cause permanent structural damage. Medication therefore matters. Whether palliation, whether prophylaxis, whether effecting a cure, medication can be key in reducing/removing symptom burden and ensuring restoration of decent mental health. But it's often just part of the answer, a way to improve things so that "the proper treatment" can then work. And when the non drug treatment's working, often the medication's withdrawl is then useful.
I guess all this is a long way of saying I'd challenge Milo's view. I think mental health is better at reviewing patient's medication, offering choices and considering rational prescribing practice. I do think we fiddle less.
Through this, I found myself spending rather a lot of time in care homes. Most lunch times, in fact. I liked it. Meant I rarely got lunch (a habit that persists to this day) but meant that I could while away time with elderly folk, talking through what was meaningful to them (notionally the "patient agenda") and what was meaningful to me (reviewing their chronic health problems and drug regimens) whilst passing the time of day with what was invariably engaging conversation with interesting folk.
I knew I wanted to work with older adults early on.
Oh, the child health surveillance clinics were good enough. I enjoyed my paediatric SHO job, and obsterics as an SHO and in Primary Care. But rather than kids or young adults, it's always been the older adults I've gravitated towards. So often they ask for nothing, you want to give them everything.
I knew I wanted to be a psychiatrist before I'd even finished my VTS. Somehow I managed to get through all my psychiatry training with just 12 weeks of pure General Adult psychiatry (of which hospital induction, annual leave and study leave wiped out over half of it). I've nothing against General Adult psych, it's just not for me, I knew it never would be, so I didn't want to do it as an SHO. I didn't do any, after being an SHO. I knew I sought to work with Older Adults, so for me it was old age psychiatry all the way. Oh, I did my CAMHS and forensic and rehab and a few specialist posts as an SHO, but thought I may as well focus on what was useful to me rather than fiddle with working age adult psychiatry when I knew my enthusiasm lay elsewhere.
Overall I'm very grateful for all the training posts I've had. Life in A&E and in Primary Care teaches you a lot about triage, consultations, decision making and safety netting. Every post I've had has given me useful training that's shaped me into the clinician I now am. Even though I'm not a physician, there're translatable skills gleaned from that post.
I'm in the habit of visiting all GPs in my patch. Some don't want to meet and over years the only contact we've had is through letters. Some want to but are too busy to. Mostly, though, meeting GPs is a good thing that's welcomed. Firstly so we can wrangle over how we can collectively iron out any wrangles. Secondly so we can share news on patient care (what the guidance released in March 2009 says about schizophrenia, how we should manage vascular dementia vs what stroke outreach do, how acetylcholinesterase inhibitors and memantine's used locally). Thirdy so we can form better relationships, with fewer barriers and more common sense.
One problem GPs have is what's happening in care homes. Out of hours, when struggling, especially if poorly staffed, care homes call the out of hours doctors. The doctors are presented with skewed information by the care home, of an unmanageable patient in profound distress who's generating risk to themselves and to others so needs something doing right away. Dementia typically progresses over months and doesn't typically get worse over minutes/hours - if they were settled at 4.00pm why are they now unsettled at 7.00pm? Their dementia's not warranting hospital in-patient care, suddenly, so what can the on-call doctors do? The deterioration could be delirium, so could be managed medically in Primary or Secondary Care. Usually the care home's just after some medication "to calm them down." The on-call GP has few options. The on-call GP invariably isn't in a position to effect changes in care plans generating person centred dementia care that addresses the causes and consequences of the person's presentation with nonpharmacological strategies. You need to know the staff, the care home, the environment, the patient, the resources and the context before you have a hope of that. The on-call GP is left with the stark choice of effectively do nothing or prescribe a tranquilliser, most often the antipsychotic, haloperidol. The care home reports a need for this to continue so it's added to a repeat prescription at low dose.
A local "audit" by the PCT has shown that invariably it isn't reviewed. The sampling wasn't perfect so I went through all care homes in my patch and reviewed every MARS and it was true - most psychotropics were initiated in Primary Care and most weren't reviewed. Was it audit? What was the gold standard being espoused, what was the GP and Consultant Psychiatrist's variance from this? No, it wasn't formal clinical audit. More a PCT survey, really. But the PCT pharmacist has at least got the discussion going. Scared the willies out of me, for a start.
Lots of elderly incapacitated folk, on psychotropic meds, without review.
Over the last year or two the amount of psychotropic medication used in care homes has plummeted. Care homes know that I'll pop in promptly, as will our CPNs, so there's little excuse for hassling a GP out of hours for mental health problems. Although I regularly go through every care home, it's a time consuming business. Most folk in care homes aren't known to our Trust. To suss out what's going on, why they're on medication, what the effect of the medication is, isn't straightforward. A lot of unpicking to be done. Usually the care home manager sits with a CPN and me as we review all their residents, sometimes it's the RMN if it's a nursing home, but someone has to be there to explain the consequences of medication and presentation of their residents. It's a good learning opportunity for all parties, too. Thus, as well as popping in to sort specific patient problems, we also review the drug regimen and mental health of all residents in care homes, which takes roughly 6 months to do. With current resourcing, that means we review everyone in a care home in my patch twice each year. Could be better, could be worse, I guess.
Usually we stop the medication and review this. Mostly they're better off the drugs.
Milo has suggested that, "I don't think that there are many psychiatrists out there (i haven't been able to find any!) who would not be judgmental towards someone who has paranoid schizophrenia and chooses not to take anti-psychotic medication!"
Dementia, schizophrenia, depression, anxiety . . . if you're taking medication there should be rational prescribing practice. I'm not judgmental towards someone not taking medication. I think GPs and Consultants simply need to evidence sound, rational prescribing.
Increasingly I'm of the view that Voltaire had the truth of it in saying, "The art of medicine consists in amusing the patient while nature cures the disease." Medication has a place. A very important place. Mental illness can be ghastly and can cause permanent structural damage. Medication therefore matters. Whether palliation, whether prophylaxis, whether effecting a cure, medication can be key in reducing/removing symptom burden and ensuring restoration of decent mental health. But it's often just part of the answer, a way to improve things so that "the proper treatment" can then work. And when the non drug treatment's working, often the medication's withdrawl is then useful.
I guess all this is a long way of saying I'd challenge Milo's view. I think mental health is better at reviewing patient's medication, offering choices and considering rational prescribing practice. I do think we fiddle less.
Thursday, 19 February 2009
Chaos
Chaos is common. Not chaos theory. Or even the rather splendid radio Kaos. Just the haphazard vagaries life throws at us, one and all, that adds change and uncertainty into the best formed plans.
I've been looking after a lady, Christine, for a number of years. Actually, that's an unjust statement, I've not been looking after her, she's a delightfully feisty soul who's more than capable of looking after herself, thank you very kindly. But she's been referred to me on several occasions "for an opinion" by medical colleagues.
She's a lady who can be anxious. Now how to put this charitably; in the past she's had contact with mental health services, in eras when provision of psychiatric care was different from how services are delivered now.
Christine remembers the war. She remembers school children dying young, from infections. She remembers rationing. She remembers the miners strikes and the pit closures affecting her community. She remembers her husband's pneumconiosis and terminal illness, dying breathless and afraid. She remembers the unity and cohesion of her street and the community, resilient and united against "them," whether it was consellors or politicians or whoever. She remembers being a strong, strong woman having to fight time and time again for her and her husband and her childrens' needs to be met.
I find her thoroughly delightful company and have to consciously manage time when I see her, so consultations are clinically purposeful and I don't just while away an afternoon hearing her biographical narrative that's rich and engaging and utterly compelling.
I've had the opportunity (and needed) to read the exhaustive notes that have accrued, from many sources. It took a full afternoon. In the past, when she was challenging authority, she was seen to be paranoid. Neither her medical notes, nor her GP's Lloyd George files, nor her notes from a District General Hospital nor her obstetric records either suggested or documented paranoia. Yet, in the past, her psychiatric records document "challenging behaviour" through her being "confrontational." Her mood was assertive and she'd present time and time again to authorities to "get things done" which, in the 1970's, attracted a diagnosis of hypomania. And of personality disorder. And of anxiety disorder. And of schizophrenia.
Interesting.
Records and professionals support that she's never presented with hallucinations or delusions or thought passivity or formal thought disorder. She's never used drugs or misused alcohol. She's always been cognitively intact, and although not highly educated she's an exceptionally savvy, bright and insightful lady.
Christine's felt breathless, a lot, and has COPD so worries she's going the same way as her husband. Thus, she 'phones her GP and ambulances. A lot. she's comfortable pushing for what she sees as geeting her needs properly heard and attended to. She's 'phoned 17 times in one weekend. Her GP and our local A&E know her well. They invited my input explicitly to see if she's got Munchausens or if she's psychotic, but really through desparation because they're tearing their hair out over her.
She's well. Over the years, whenever I've seen her, she's been well. She feels anxious at times, she's terrible at using a metred dose inhaler so gets little real benefit from her inhalers and latterly has had several courses of antibiotics and steroids. She wants home oxygen but smokes. Her heavy smoking, with her COPD, is something her chest physician has talked through many times but she's adamant she's not going to change. But other than over valued ideas (and commensurate episodic anxiety) around her chest disease (which is understandable, given her husband's course, and that of many friends), she's mentally well. No obsessions. No compulsions. No delusions. No nihilism, no hopelessness, no catastrophic thinking, no depressive cognitions/significant cognitive distortions.
When I was a GP I really struggled with how to manage someone presenting frequently (e.g. several times a day) with a problem that concerned them, but wasn't clinically concerning. I've therefore every sympathy for her GP who's a real saint and far, far more tolerant than I could ever be.
Contriving to say it's a psychiatric problem isn't helpful. Clearly she doesn't have schizophrenia and never has. Her persistant diagnosis of personality disorder really doesn't seem justified, at all. Folk didn't like her behaviour, so labelled it as an illness.
I'm putting this down now, because things have been stable for almost a year, now. I was seeing her at home daily at one point. My psychologist was involved but achieved nothing, so they mutually and affably agreed to part ways. Christine doesn't have faith in what nurses say so my CPN, despite being excellent (and far better than me at the support) wasn't able to be helpful. So I saw her, a lot. Then 3 times a week. Then once a week. Then once a month. Then 4 times a year. Maybe I'll get to every 6 months this year. She 'phones once a week and leaves messages with my secretary that I can attend to (which is part of the plan we've agreed) so any non-urgent symptoms or changes that play on her mind can be shared with me. But all her 'phoning GPs and A&E attendances have stopped, the last contact being June last year.
It's an odd position to be in. I've invested a lot of time, initially, into meeting with her and her Consultant Physician and at her GP surgery with the partners, then seeing her an awful lot, and still seeing her episodically, when she's no psychiatric problem evident what so ever. But I deceive myself that rather than doing this to contain her behaviour and help her GP, I delude myself that I'm supporting her and alleviating distress, so doing something to maintain her mental wellbeing.
The fact that she's a feisty soul who's charmingly good company's irrelevant, surely!
I've been looking after a lady, Christine, for a number of years. Actually, that's an unjust statement, I've not been looking after her, she's a delightfully feisty soul who's more than capable of looking after herself, thank you very kindly. But she's been referred to me on several occasions "for an opinion" by medical colleagues.
She's a lady who can be anxious. Now how to put this charitably; in the past she's had contact with mental health services, in eras when provision of psychiatric care was different from how services are delivered now.
Christine remembers the war. She remembers school children dying young, from infections. She remembers rationing. She remembers the miners strikes and the pit closures affecting her community. She remembers her husband's pneumconiosis and terminal illness, dying breathless and afraid. She remembers the unity and cohesion of her street and the community, resilient and united against "them," whether it was consellors or politicians or whoever. She remembers being a strong, strong woman having to fight time and time again for her and her husband and her childrens' needs to be met.
I find her thoroughly delightful company and have to consciously manage time when I see her, so consultations are clinically purposeful and I don't just while away an afternoon hearing her biographical narrative that's rich and engaging and utterly compelling.
I've had the opportunity (and needed) to read the exhaustive notes that have accrued, from many sources. It took a full afternoon. In the past, when she was challenging authority, she was seen to be paranoid. Neither her medical notes, nor her GP's Lloyd George files, nor her notes from a District General Hospital nor her obstetric records either suggested or documented paranoia. Yet, in the past, her psychiatric records document "challenging behaviour" through her being "confrontational." Her mood was assertive and she'd present time and time again to authorities to "get things done" which, in the 1970's, attracted a diagnosis of hypomania. And of personality disorder. And of anxiety disorder. And of schizophrenia.
Interesting.
Records and professionals support that she's never presented with hallucinations or delusions or thought passivity or formal thought disorder. She's never used drugs or misused alcohol. She's always been cognitively intact, and although not highly educated she's an exceptionally savvy, bright and insightful lady.
Christine's felt breathless, a lot, and has COPD so worries she's going the same way as her husband. Thus, she 'phones her GP and ambulances. A lot. she's comfortable pushing for what she sees as geeting her needs properly heard and attended to. She's 'phoned 17 times in one weekend. Her GP and our local A&E know her well. They invited my input explicitly to see if she's got Munchausens or if she's psychotic, but really through desparation because they're tearing their hair out over her.
She's well. Over the years, whenever I've seen her, she's been well. She feels anxious at times, she's terrible at using a metred dose inhaler so gets little real benefit from her inhalers and latterly has had several courses of antibiotics and steroids. She wants home oxygen but smokes. Her heavy smoking, with her COPD, is something her chest physician has talked through many times but she's adamant she's not going to change. But other than over valued ideas (and commensurate episodic anxiety) around her chest disease (which is understandable, given her husband's course, and that of many friends), she's mentally well. No obsessions. No compulsions. No delusions. No nihilism, no hopelessness, no catastrophic thinking, no depressive cognitions/significant cognitive distortions.
When I was a GP I really struggled with how to manage someone presenting frequently (e.g. several times a day) with a problem that concerned them, but wasn't clinically concerning. I've therefore every sympathy for her GP who's a real saint and far, far more tolerant than I could ever be.
Contriving to say it's a psychiatric problem isn't helpful. Clearly she doesn't have schizophrenia and never has. Her persistant diagnosis of personality disorder really doesn't seem justified, at all. Folk didn't like her behaviour, so labelled it as an illness.
I'm putting this down now, because things have been stable for almost a year, now. I was seeing her at home daily at one point. My psychologist was involved but achieved nothing, so they mutually and affably agreed to part ways. Christine doesn't have faith in what nurses say so my CPN, despite being excellent (and far better than me at the support) wasn't able to be helpful. So I saw her, a lot. Then 3 times a week. Then once a week. Then once a month. Then 4 times a year. Maybe I'll get to every 6 months this year. She 'phones once a week and leaves messages with my secretary that I can attend to (which is part of the plan we've agreed) so any non-urgent symptoms or changes that play on her mind can be shared with me. But all her 'phoning GPs and A&E attendances have stopped, the last contact being June last year.
It's an odd position to be in. I've invested a lot of time, initially, into meeting with her and her Consultant Physician and at her GP surgery with the partners, then seeing her an awful lot, and still seeing her episodically, when she's no psychiatric problem evident what so ever. But I deceive myself that rather than doing this to contain her behaviour and help her GP, I delude myself that I'm supporting her and alleviating distress, so doing something to maintain her mental wellbeing.
The fact that she's a feisty soul who's charmingly good company's irrelevant, surely!
Wednesday, 23 July 2008
Cured
I received an urgent referral from a GP for a gentleman in his 90's. His GP was worried that he had depression and was seriously ill. I saw him at home with a CPN and his family to unpick why he'd gone to his GP and what the issues currently were.
He said he'd been, "in a dark place," which is why he went on Friday (and not Thursday, or Saturday). It was then, that day, that things, "got too much," and his family whooshed him off to his GP. He didn't want to go, but humoured them and 'fessed up that he wasn't coping.
His wife has always looked after him. She's got dementia, he's now looking after her, all the time. He's declined support (in fact, support's been arranged for him and his wife in the past but after a couple visits he's turned them away from his door, feeling he should be able to do it all himself).
His GP thought the gentleman wasn't coping because he was physically unwell with chronic illness, he was fretting over his wife's physical illnesses, he was caring for his wife all the time (meaning both day and night) so wasn't getting enough uninterrupted sleep/was tired all the time and had unrealistic expectations of how he should be caring for her. He wants, "to be independent," and not rely on others. His GP initiated a SSRI antidepressant at a therapeutic dose.
When I saw him he was cured. This was on day 4 of his antidepressant. He was fine, thank you very much, sorry for troubling you and making you come out. All's well. He thinks his GP is ace and has cured him.
One hour on and it's clear that he had a period where he wasn't coping at the end of the week, but is coping now. All that's changed is that his wife's getting physically better and he's had a better sleep since then. He feels his pills have cured him, "Even though the doctor said they will take 10 days to work."
He declined further support. I found some financial benefits he's not availed himself of that he should, but there wasn't anything I could improve upon. From suicidal and not coping one day to cured and symptom free 4 days on. If that truly is the case, it's miraculous and needs writing up. I rather fear he's not cured. I fear he'll not cope too well in the near future when his wife has her next exacerbation of COPD.
I'm seeing him again and offering ideas. But maybe he's right. Maybe he is cured.
He said he'd been, "in a dark place," which is why he went on Friday (and not Thursday, or Saturday). It was then, that day, that things, "got too much," and his family whooshed him off to his GP. He didn't want to go, but humoured them and 'fessed up that he wasn't coping.
His wife has always looked after him. She's got dementia, he's now looking after her, all the time. He's declined support (in fact, support's been arranged for him and his wife in the past but after a couple visits he's turned them away from his door, feeling he should be able to do it all himself).
His GP thought the gentleman wasn't coping because he was physically unwell with chronic illness, he was fretting over his wife's physical illnesses, he was caring for his wife all the time (meaning both day and night) so wasn't getting enough uninterrupted sleep/was tired all the time and had unrealistic expectations of how he should be caring for her. He wants, "to be independent," and not rely on others. His GP initiated a SSRI antidepressant at a therapeutic dose.
When I saw him he was cured. This was on day 4 of his antidepressant. He was fine, thank you very much, sorry for troubling you and making you come out. All's well. He thinks his GP is ace and has cured him.
One hour on and it's clear that he had a period where he wasn't coping at the end of the week, but is coping now. All that's changed is that his wife's getting physically better and he's had a better sleep since then. He feels his pills have cured him, "Even though the doctor said they will take 10 days to work."
He declined further support. I found some financial benefits he's not availed himself of that he should, but there wasn't anything I could improve upon. From suicidal and not coping one day to cured and symptom free 4 days on. If that truly is the case, it's miraculous and needs writing up. I rather fear he's not cured. I fear he'll not cope too well in the near future when his wife has her next exacerbation of COPD.
I'm seeing him again and offering ideas. But maybe he's right. Maybe he is cured.
Friday, 27 June 2008
GP Prescribing
5 years ago I had a disagreement with a local GP. Usually I'm pretty easy going and can tolerate the numerous foibles and idiosyncrasies that Consultant and GP colleagues may possess. 5 years ago a GP didn't want to prescribe galantamine for a patient with dementia. The patient had been on it for ages, was gaining benefit, was stable with no side effects and had moderate dementia . . . our shared care protocol (largely written by the APC) directs that the GP should then, ". . . reply to the request for shared care as soon as practicable," and add the drug to the patient's list of repeat prescriptions. This GP didn't want any truck with this shared care malarky, and as independant practitioners it's quite within their gift for them to do what so ever they wish. But with that latitude comes some responsibility. I wrote back to the GP conveying my disappointment that she sought to act outwith the district-wide agreed protocol but, if she had good clinical grounds to do so, she was perfectly at liberty to allow the galantamine to be stopped and explain to her patient why she was doing so. I'm normally hugely reasonable and go to inordinate lengths to support GPs but when I'm messed about I'm very Consultoid. Fortunate it only happens once every 5 years or so, then.
Sadly, it's happened again.
The problem is that a GP isn't wanting to prescribe any medication for any of her patients with dementia. This puts us all in a difficult position. The general public now perceive antipsychotics as dangerous and bad and speak of the, "urgent message" to GPs, "warning them of the danger." Tim Kendall (who really, really should know better) has said that GPs need reporting to the General Medical Council for such prescribing and saying clearly, "I think the doctors should be disciplined."
The Americans have said antipsychotics shouldn't be used in dementia care.
Our MHRA have said 2 antipsychotics should not be used in dementia care.
The GP is uneasy about prescribing. I'm happy to accept responsibility in the decision, initiation, titration and review of such prescribing. But at some point I need to discharge patients or I'll end up with squillions of patients and won't be able to be effective in addressing clinical need promptly. Other GPs are happy that if I get the patient sorted and stable and ask them to then prescribe, that's fine. Common sense gets a look in, hurrah.
After doing the work and getting things sorted then asking the GP to pick up the ongoing care, I guess I could just discharge the patient back to the GP to do with as they so wish, if having consulted a Consultant for an opinion they don't want to accept or action such an opinion.
What makes this a slightly thornier issue is that I was at a meeting with Anna Walker this week who's the Chief Executive of the Healthcare Commission. They're the body who regulate health, so are a pretty scary crowd. Her agenda for the near future now includes review and improving and rationalising prescribing in Primary Care.
Tempestuous times ahead, eh?
Sadly, it's happened again.
The problem is that a GP isn't wanting to prescribe any medication for any of her patients with dementia. This puts us all in a difficult position. The general public now perceive antipsychotics as dangerous and bad and speak of the, "urgent message" to GPs, "warning them of the danger." Tim Kendall (who really, really should know better) has said that GPs need reporting to the General Medical Council for such prescribing and saying clearly, "I think the doctors should be disciplined."
The Americans have said antipsychotics shouldn't be used in dementia care.
Our MHRA have said 2 antipsychotics should not be used in dementia care.
The GP is uneasy about prescribing. I'm happy to accept responsibility in the decision, initiation, titration and review of such prescribing. But at some point I need to discharge patients or I'll end up with squillions of patients and won't be able to be effective in addressing clinical need promptly. Other GPs are happy that if I get the patient sorted and stable and ask them to then prescribe, that's fine. Common sense gets a look in, hurrah.
After doing the work and getting things sorted then asking the GP to pick up the ongoing care, I guess I could just discharge the patient back to the GP to do with as they so wish, if having consulted a Consultant for an opinion they don't want to accept or action such an opinion.
What makes this a slightly thornier issue is that I was at a meeting with Anna Walker this week who's the Chief Executive of the Healthcare Commission. They're the body who regulate health, so are a pretty scary crowd. Her agenda for the near future now includes review and improving and rationalising prescribing in Primary Care.
Tempestuous times ahead, eh?
Wednesday, 11 June 2008
Me
Oliver Smith asked here for comment on the view, "Why would you want to go into psychiatry? It is a dying bread. They've lost a lot of credibility"
I quite like the typo. There's something very pastoral about bread, what with priests and vicars gifting it as the Host, restaurants benevolently tossing it out for free whilst you await your starters, families sharing it around a table.
But anyway, why would anyone opt for psychiatry?
A post in two parts. To answer the question, it's easiest for me to be shamelessly self indulgent and share some of why I am a psychiatrist. This at least gives a context and one account of why one person chose psychiatry. Thoughts on why others have opted for psychiatry are the musings of another post since it's more contentious.
Since the question's about psychiatry, I'll not wax lyrical about medicine, as a profession. Motives for being a medic usually are laudable and enduring. Friends who didn't do medicine earn more than I do, starting to do so whilst I was still a student; money's better gained elsewhere. You're part of a huge system with the Department of Health, numerous Institutes and Colleges and "expert bodies" having influence over how you can work. Specifically, commissioners and the hospital management structure can influence details of how you work, who you work with, when you work and what you do at work. You don't go in to medicine to be your own boss.
Suffice to say, most medics I know are in it to do good, which is why they stay on evenings and work extra hours and do work that's outside their contract, because they're keen to do what's best for their patients.
So from this viewpoint, why opt in to psychiatry?
Every individual will have their own motivations and ideas and desires, but I think a few themes emerge.
For me, I knew it was something I was interested in. I finished medical school and was fortunate, passing all exams throughout university clearly, never needing a viva or resits or anything stressful. I believe this was because I was simply lucky, I saw peers who studied as hard and were cleverer failing bits. But the process of endless exams that had to be passed left me weary, so on starting out as a doctor I didn't want more arduous exams right now, thank you kindly. This left me General Practice, a career choice that (at that time) didn't need Membership examination. So I trained as a GP. I loved the medicine. The scope of what came through, the continuity of care as you see someone over time, the exploring of issues together (that shift from issues to symptoms to resolution or to problems or to diagnosis) was great - little was straightforward, it was all challenging and engaging and immersive work. People generated symptom lists, medical knowledge was applied to sift through the significance of these, cluster relevant information together, consider pathological processes and illness that can generate such symptoms, formulate diagnosis, generate and effect management, supporting physical and occupational and relationship and social and practical dimensions of peoples' lives.
And it really was broad, with stuff to do on whether folk could have a shotgun, or drive, or had capacity to get married, or was fit to stand trial, or could fly on one last holiday to Australia, or had disability and couldn't work. Not just physical medicine, General Practice was a vibrant and stimulating and diverse environment that lived and breathed biopsychosocial medicine (rather than pure medical models of health/illness).
Through this I knew GP land was great medicine, but wasn't for me. I loved the work. I found the time constraints unacceptable. So, being pragmatic, this constraint was unacceptable so I chose not to accept it and left GP land.
I got in at 8.00am, started surgey at 8.30am, over ran 'til 11.30am. I then spent half and hour sorting all referrals and paper work and letters to the hospital or whoever and all Item of Service fee stuff and went through all the letters I'd get from the hospital. From there we're up to midday, when I'd do my home visits. Usually 3 or 4, with 10 minutes to drive there, 15 minutes with the patient and family to do the history/examination/diagnosis/treatment/safety netting, document it and on to the next. Often I'd go to nursing homes too since I loved reviewing elderly folks in care (so much is found that can be improved upon when it's looked for). So we're up to about 1.30pm and I'm back in the surgery to do my Child Health Surveillance clinic or minor ops clinic or Diabetes clinic or Asthma clinic or whatever. Two and a half hours on, 4.00pm to 6.30pm and it's evening surgey. Say someone comes in with something easy that I'm really, really shit hot at and well trained in like chest pain; I take a history to see if the pain's likely to arise from stomach, oesophagus, bone/costochondritis, lung/pleura, nerves, heart, mediastinum or is referred from elsewhere then I'd examine then I'd discuss formulation/diagnosis then we'd plan investigations and treatment (and detail risks and benefits and side effects) then safety net in case there were serious cardiac events then plan follow up then document all this, all in 10 minutes. I just couldn't do it. If someone came in with something complex there are times you could just weep. Usually over ran, usually had paper work, investigation requests, referalls and Item of Service stuff to do for half an hour after the last person was seen. 7.00pm now.
Hmmm, I've been working from 8.00am to 7.00pm and, heck, I've not had any lunch yet, have I? Oh, or had any 'phone calls from a District Nurse to sort, or Health Visitor, or Midwife, or Community Psychiatric Nurse, or any of the patient problems that crop up that others bring to a GPs attention. Eeek, I've not yet fitted in any urgent calls or visits either. Thus, days often over ran beyond 7.00pm and were very very stressful.
This left me with a problem. I loved the medicine, I loved the work, I loved the patient consultations, I just couldn't do consultations in 10 minutes and have no latitude in the day to do what needed to be done in a way that was "good enough" so General Practice wasn't for me. Liked the job, couldn't live with the system. But being fair on entering GP training I knew I wasn't wholly wrapped up in it and just wanted to do something that didn't need lots of hard exams at the time. Yes, at that time junior doctors were that frazzled.
I've nothing but respect for GPs, they do an incredibly diverse and difficult job and, as evidenced, they're better men and women than me, being able to stick it out and work in such a system.
So I swapped over in to hospital medicine and trained in psychiatry, which I knew when doing GP training that it was where I'd want to be. Patients I saw were not just similar to patients I'd see as a GP. They were identical.
"I'm tired all the time, doctor."
"I feel run down."
"I think I may have something serious, I ache a lot more and can't do as much."
"I've headaches all the time which won't go away."
Instead of 10 minute consultations, I had an hour. Time to explore the issues in detail and then work through things as I'd wish. I was home. I got to do a lot of medical stuff and in training worked with physicians. I had to revisit exams, but was lucky, getting through membership exams at the first attempt. This let me continue in to higher specialist training, specialising in old age psychiatry but also continuing to work in a subspeciality as a physician. I passed all my exams and training and was appointed as a Consultant Psychiatrist and as a Consultant in a medical subspeciality seeing folk of all ages. This leaves me being more medical than many psychiatrists.
It's noteworthy that this career path, with the valuable experience I gained through each and every post I did, is no longer an option for todays junior doctors. They have to decide promptly on one career path, have to start on it straight away and have to choose a career that has vacancies (so may have no choice at all, ending up being a pathologist or GP when they wanted to be a cardiologist or orthopaedic hand surgeon).
In old age psychiatry I get to work with older adults, which I prefer. They're often a disadvantaged group with few folk improving their lot. There's an affable and courteous nature to consultations that's very agreeable. There's a stoicism that arises from having coped with everything life's thrown at you for 60, 70, 80 years or whatever, so dealing with the problems of the here and now can be childs play compared to some of the past adversity that folk have had to manage. Almost always, there's a lot that can be done to improve things. There's usually physical comorbidity to improve upon. There's usually a drug regimen that can be rationalised and improved. Sometimes mental health problems can be improved upon, invariably even if we can't change/fix the condition we can help folk cope with them better. Usually their world (the environment, their relationships, their wealth, the richness of their social contact) can be improved significantly. I work in well resourced teams (a rare privilege in old age psychiatry) with sensible managers who've always given me what I've asked for (a very rare privilege in old age psychiatry) so have a service that I think is great. Community services have enough staff to see everyone as often as needed (daily, sometimes), in-patient wards are new and bright and spacious and everyone's got their own room. It's the service I'd want for my parents or my wife or myself.
For me, I get to work in an area of medicine that I thrive within, working with older adults over the long haul improving their mental wellbeing through addressing their psychiatric conditions as well as looking at medical and psychosocial interventions. The service has been shaped so that delivery's exactly how I'd wish it to be. I work with great teams. I'm working long hours but thoroughly enjoying it, I'm not frazzled any more, I choose to do so rather than need to do so.
At the end of the day, for my patients and the lives I touch, and follow through on, I see the difference that I make.
Much goodness.
I quite like the typo. There's something very pastoral about bread, what with priests and vicars gifting it as the Host, restaurants benevolently tossing it out for free whilst you await your starters, families sharing it around a table.
But anyway, why would anyone opt for psychiatry?
A post in two parts. To answer the question, it's easiest for me to be shamelessly self indulgent and share some of why I am a psychiatrist. This at least gives a context and one account of why one person chose psychiatry. Thoughts on why others have opted for psychiatry are the musings of another post since it's more contentious.
Since the question's about psychiatry, I'll not wax lyrical about medicine, as a profession. Motives for being a medic usually are laudable and enduring. Friends who didn't do medicine earn more than I do, starting to do so whilst I was still a student; money's better gained elsewhere. You're part of a huge system with the Department of Health, numerous Institutes and Colleges and "expert bodies" having influence over how you can work. Specifically, commissioners and the hospital management structure can influence details of how you work, who you work with, when you work and what you do at work. You don't go in to medicine to be your own boss.
Suffice to say, most medics I know are in it to do good, which is why they stay on evenings and work extra hours and do work that's outside their contract, because they're keen to do what's best for their patients.
So from this viewpoint, why opt in to psychiatry?
Every individual will have their own motivations and ideas and desires, but I think a few themes emerge.
For me, I knew it was something I was interested in. I finished medical school and was fortunate, passing all exams throughout university clearly, never needing a viva or resits or anything stressful. I believe this was because I was simply lucky, I saw peers who studied as hard and were cleverer failing bits. But the process of endless exams that had to be passed left me weary, so on starting out as a doctor I didn't want more arduous exams right now, thank you kindly. This left me General Practice, a career choice that (at that time) didn't need Membership examination. So I trained as a GP. I loved the medicine. The scope of what came through, the continuity of care as you see someone over time, the exploring of issues together (that shift from issues to symptoms to resolution or to problems or to diagnosis) was great - little was straightforward, it was all challenging and engaging and immersive work. People generated symptom lists, medical knowledge was applied to sift through the significance of these, cluster relevant information together, consider pathological processes and illness that can generate such symptoms, formulate diagnosis, generate and effect management, supporting physical and occupational and relationship and social and practical dimensions of peoples' lives.
And it really was broad, with stuff to do on whether folk could have a shotgun, or drive, or had capacity to get married, or was fit to stand trial, or could fly on one last holiday to Australia, or had disability and couldn't work. Not just physical medicine, General Practice was a vibrant and stimulating and diverse environment that lived and breathed biopsychosocial medicine (rather than pure medical models of health/illness).
Through this I knew GP land was great medicine, but wasn't for me. I loved the work. I found the time constraints unacceptable. So, being pragmatic, this constraint was unacceptable so I chose not to accept it and left GP land.
I got in at 8.00am, started surgey at 8.30am, over ran 'til 11.30am. I then spent half and hour sorting all referrals and paper work and letters to the hospital or whoever and all Item of Service fee stuff and went through all the letters I'd get from the hospital. From there we're up to midday, when I'd do my home visits. Usually 3 or 4, with 10 minutes to drive there, 15 minutes with the patient and family to do the history/examination/diagnosis/treatment/safety netting, document it and on to the next. Often I'd go to nursing homes too since I loved reviewing elderly folks in care (so much is found that can be improved upon when it's looked for). So we're up to about 1.30pm and I'm back in the surgery to do my Child Health Surveillance clinic or minor ops clinic or Diabetes clinic or Asthma clinic or whatever. Two and a half hours on, 4.00pm to 6.30pm and it's evening surgey. Say someone comes in with something easy that I'm really, really shit hot at and well trained in like chest pain; I take a history to see if the pain's likely to arise from stomach, oesophagus, bone/costochondritis, lung/pleura, nerves, heart, mediastinum or is referred from elsewhere then I'd examine then I'd discuss formulation/diagnosis then we'd plan investigations and treatment (and detail risks and benefits and side effects) then safety net in case there were serious cardiac events then plan follow up then document all this, all in 10 minutes. I just couldn't do it. If someone came in with something complex there are times you could just weep. Usually over ran, usually had paper work, investigation requests, referalls and Item of Service stuff to do for half an hour after the last person was seen. 7.00pm now.
Hmmm, I've been working from 8.00am to 7.00pm and, heck, I've not had any lunch yet, have I? Oh, or had any 'phone calls from a District Nurse to sort, or Health Visitor, or Midwife, or Community Psychiatric Nurse, or any of the patient problems that crop up that others bring to a GPs attention. Eeek, I've not yet fitted in any urgent calls or visits either. Thus, days often over ran beyond 7.00pm and were very very stressful.
This left me with a problem. I loved the medicine, I loved the work, I loved the patient consultations, I just couldn't do consultations in 10 minutes and have no latitude in the day to do what needed to be done in a way that was "good enough" so General Practice wasn't for me. Liked the job, couldn't live with the system. But being fair on entering GP training I knew I wasn't wholly wrapped up in it and just wanted to do something that didn't need lots of hard exams at the time. Yes, at that time junior doctors were that frazzled.
I've nothing but respect for GPs, they do an incredibly diverse and difficult job and, as evidenced, they're better men and women than me, being able to stick it out and work in such a system.
So I swapped over in to hospital medicine and trained in psychiatry, which I knew when doing GP training that it was where I'd want to be. Patients I saw were not just similar to patients I'd see as a GP. They were identical.
"I'm tired all the time, doctor."
"I feel run down."
"I think I may have something serious, I ache a lot more and can't do as much."
"I've headaches all the time which won't go away."
Instead of 10 minute consultations, I had an hour. Time to explore the issues in detail and then work through things as I'd wish. I was home. I got to do a lot of medical stuff and in training worked with physicians. I had to revisit exams, but was lucky, getting through membership exams at the first attempt. This let me continue in to higher specialist training, specialising in old age psychiatry but also continuing to work in a subspeciality as a physician. I passed all my exams and training and was appointed as a Consultant Psychiatrist and as a Consultant in a medical subspeciality seeing folk of all ages. This leaves me being more medical than many psychiatrists.
It's noteworthy that this career path, with the valuable experience I gained through each and every post I did, is no longer an option for todays junior doctors. They have to decide promptly on one career path, have to start on it straight away and have to choose a career that has vacancies (so may have no choice at all, ending up being a pathologist or GP when they wanted to be a cardiologist or orthopaedic hand surgeon).
In old age psychiatry I get to work with older adults, which I prefer. They're often a disadvantaged group with few folk improving their lot. There's an affable and courteous nature to consultations that's very agreeable. There's a stoicism that arises from having coped with everything life's thrown at you for 60, 70, 80 years or whatever, so dealing with the problems of the here and now can be childs play compared to some of the past adversity that folk have had to manage. Almost always, there's a lot that can be done to improve things. There's usually physical comorbidity to improve upon. There's usually a drug regimen that can be rationalised and improved. Sometimes mental health problems can be improved upon, invariably even if we can't change/fix the condition we can help folk cope with them better. Usually their world (the environment, their relationships, their wealth, the richness of their social contact) can be improved significantly. I work in well resourced teams (a rare privilege in old age psychiatry) with sensible managers who've always given me what I've asked for (a very rare privilege in old age psychiatry) so have a service that I think is great. Community services have enough staff to see everyone as often as needed (daily, sometimes), in-patient wards are new and bright and spacious and everyone's got their own room. It's the service I'd want for my parents or my wife or myself.
For me, I get to work in an area of medicine that I thrive within, working with older adults over the long haul improving their mental wellbeing through addressing their psychiatric conditions as well as looking at medical and psychosocial interventions. The service has been shaped so that delivery's exactly how I'd wish it to be. I work with great teams. I'm working long hours but thoroughly enjoying it, I'm not frazzled any more, I choose to do so rather than need to do so.
At the end of the day, for my patients and the lives I touch, and follow through on, I see the difference that I make.
Much goodness.
Wednesday, 21 May 2008
GPs
One of my patients with memory problems (F00.02 dementia in Alzheimer's disease, early onset, severe) has finally ground his wife down so much that he's been placed in emergency respite care.
She's been managing him, essentially single handedly, for an age.
He's got a lot of Parkinsonian motor symptoms and a changeable presentation and misperceptions suggesting visual hallucinations so I think he may well have Lewy Body dementia but he'd not tolerate DAT Scanning and is too advanced for detailed neuropsych evaluation.
He has behavioural and psychological symptoms of dementia (BPSD). He wanders, a lot. In our day centre, throughout the day he'd spend 6 hours walking and only half an hour sat down. He bangs walls when he's frustrated. Left alone, he never troubles other people.
In the care home, he's wandering at night. Staff didn't like that so tried to force him in to bed. He didn't like that. He's now labelled as "aggressive" and staff want more medication. Through the day he wanted to walk outside. He didn't want to wait 'til the afternoon when the late shift would open the doors and let him walk in the enclosed garden, so he walked around inside. He's now labelled as "restless."
It's an EMI Nursing Home so has qualified mental health nurses and experienced care staff, but to support them my nursing colleagues or I have been visiting 3 days a week.
He's on galantamine (to manage BPSD rather than improve cognition, now) and lorazepam to de-escalate arousal and distress. The care home sought haloperidol 3 times this week from his GP. His GP said no.
His GP 'phoned me up. We talked through what was going on. Because this was urgent respite placement, the nursing home is outside my patch, thus the GP looking after the home isn't someone I know or have ever had contact with before. But I could have kissed her. She's seen my patient, she thought maybe he had Lewy Body dementia and haloperidol would be A Bad Thing. She saw that the wife had managed the man alone, so why did a specialist care home with oodles of staff need medication when she did not? She saw that lorazepam had worked so a touch more may well help him settle in a disorienting environment. She saw him as active but no risk to others, not warranting sedating. She'd spotted relevant physical comorbidity that I'd spent half an hour sorting out last time, she generated sensible drug strategies to manage this over the next week.
The patient's in the right sort of care home, having rich input from specialist dementia care nurses and myself, is on appropriate medication and has a GP coordinating mental health and physical health care, and advocating for care home staff to use behavioural rather than pharmacological strategies to manage BPSD.
Some days, everything's just peachy! :-)
She's been managing him, essentially single handedly, for an age.
He's got a lot of Parkinsonian motor symptoms and a changeable presentation and misperceptions suggesting visual hallucinations so I think he may well have Lewy Body dementia but he'd not tolerate DAT Scanning and is too advanced for detailed neuropsych evaluation.
He has behavioural and psychological symptoms of dementia (BPSD). He wanders, a lot. In our day centre, throughout the day he'd spend 6 hours walking and only half an hour sat down. He bangs walls when he's frustrated. Left alone, he never troubles other people.
In the care home, he's wandering at night. Staff didn't like that so tried to force him in to bed. He didn't like that. He's now labelled as "aggressive" and staff want more medication. Through the day he wanted to walk outside. He didn't want to wait 'til the afternoon when the late shift would open the doors and let him walk in the enclosed garden, so he walked around inside. He's now labelled as "restless."
It's an EMI Nursing Home so has qualified mental health nurses and experienced care staff, but to support them my nursing colleagues or I have been visiting 3 days a week.
He's on galantamine (to manage BPSD rather than improve cognition, now) and lorazepam to de-escalate arousal and distress. The care home sought haloperidol 3 times this week from his GP. His GP said no.
His GP 'phoned me up. We talked through what was going on. Because this was urgent respite placement, the nursing home is outside my patch, thus the GP looking after the home isn't someone I know or have ever had contact with before. But I could have kissed her. She's seen my patient, she thought maybe he had Lewy Body dementia and haloperidol would be A Bad Thing. She saw that the wife had managed the man alone, so why did a specialist care home with oodles of staff need medication when she did not? She saw that lorazepam had worked so a touch more may well help him settle in a disorienting environment. She saw him as active but no risk to others, not warranting sedating. She'd spotted relevant physical comorbidity that I'd spent half an hour sorting out last time, she generated sensible drug strategies to manage this over the next week.
The patient's in the right sort of care home, having rich input from specialist dementia care nurses and myself, is on appropriate medication and has a GP coordinating mental health and physical health care, and advocating for care home staff to use behavioural rather than pharmacological strategies to manage BPSD.
Some days, everything's just peachy! :-)
Monday, 10 March 2008
GPs
I met with a GP rather early (because most GPs in my neighbourhood start work at some ungodly hour) to look at the care of a gentleman with dementia. If you're one for diagnostic labels, he's got F00.12 Dementia in Alzheimer's disease, late onset, severe.
On first appearences, he's muddled but manageable. He's not leaving the house, not posing risks to others outside, not wandering in front of traffic, he's fed and watered and cared for by his wife. Speaking with him he says all's fine and can't understand why my nurses and I visit him, or why we dragged his GP there on this occasion.
The truth of it is that the cost of keeping him at home is high. Arguably too high. His wife is going under, big time. He's disoriented so seeks reassaurance. All the time. Really, all the time, such that he follows her everywhere, even to the toilet. She's scared since at night he comes to shout at her, distraught, so she's had to buy a lock for her bedroom door. Her reassaurance doesn't work now, he just gets frustrated and angry and can't understand why things aren't as he recalls/believes they should be.
She's in floods of tears most of the day. She's not clinically depressed, she's just in an untenable situation where she's no longer valued or respected but, despite endless devotion, is shouted at and abused. She gets almost no sleep.
We know this because we visit her and I've been seeing her and her husband for some 4 years now. Their GP knows because I keep in touch with her and she visits them, mostly to support the wife. We're supporting his wife in letting go and choosing a care home for him.
When the government finishes shafting GPs and we've polyclinics in Tescos instead, will the medic or nurse practitioner see this couple at home over time, too? Will they do home visits at all? If they do visit him at home, not having met him or known him before, would they just take at face value what is seen or would they spend an hour unpicking it all then work with me and visit over time to see the system as a whole (physical health, mental health, disturbed behaviour, care for him, cost to the wife) or would they focus just on their patient? Focussing just on their patient, the wife would go under, he'd be placed in emergency respite care (so would be in a care home neither he nor his wife chose) and she'd feel tremendous guilt at having failed.
I've feelings of disquiet . . .
On first appearences, he's muddled but manageable. He's not leaving the house, not posing risks to others outside, not wandering in front of traffic, he's fed and watered and cared for by his wife. Speaking with him he says all's fine and can't understand why my nurses and I visit him, or why we dragged his GP there on this occasion.
The truth of it is that the cost of keeping him at home is high. Arguably too high. His wife is going under, big time. He's disoriented so seeks reassaurance. All the time. Really, all the time, such that he follows her everywhere, even to the toilet. She's scared since at night he comes to shout at her, distraught, so she's had to buy a lock for her bedroom door. Her reassaurance doesn't work now, he just gets frustrated and angry and can't understand why things aren't as he recalls/believes they should be.
She's in floods of tears most of the day. She's not clinically depressed, she's just in an untenable situation where she's no longer valued or respected but, despite endless devotion, is shouted at and abused. She gets almost no sleep.
We know this because we visit her and I've been seeing her and her husband for some 4 years now. Their GP knows because I keep in touch with her and she visits them, mostly to support the wife. We're supporting his wife in letting go and choosing a care home for him.
When the government finishes shafting GPs and we've polyclinics in Tescos instead, will the medic or nurse practitioner see this couple at home over time, too? Will they do home visits at all? If they do visit him at home, not having met him or known him before, would they just take at face value what is seen or would they spend an hour unpicking it all then work with me and visit over time to see the system as a whole (physical health, mental health, disturbed behaviour, care for him, cost to the wife) or would they focus just on their patient? Focussing just on their patient, the wife would go under, he'd be placed in emergency respite care (so would be in a care home neither he nor his wife chose) and she'd feel tremendous guilt at having failed.
I've feelings of disquiet . . .
Friday, 12 October 2007
Stopping Medication
Just to tease my favouritist blogging GP, commenting on Secondary Care stopping medication that with hindsight is inappropriate . . .
. . . I was referred a lady with Behavioural and Psychological Symptoms of Dementia. She bit, kicked and punched care staff in her nursing home. She pushed other residents out of the way, causing a fracture in one old lady.
After initiating galantamine and promazine, she improved. A week later on review there was no hostility (not even verbal hostility) and all was well. A month passed. The home was happy. Her husband was happy.
She had a review by her GP who halved her promazine from 4 times a day down to 2 times a day (just morning and night). I know this because the GP 'phoned me to ask for a prompt review this week since she's now screaming like a banshee and flailing at folk with her walking stick through the afternoon and evening when she's no longer receiving her promazine.
Sometimes, just sometimes, us mental health folk do get it right and it's best not to rock the boat :-)
. . . I was referred a lady with Behavioural and Psychological Symptoms of Dementia. She bit, kicked and punched care staff in her nursing home. She pushed other residents out of the way, causing a fracture in one old lady.
After initiating galantamine and promazine, she improved. A week later on review there was no hostility (not even verbal hostility) and all was well. A month passed. The home was happy. Her husband was happy.
She had a review by her GP who halved her promazine from 4 times a day down to 2 times a day (just morning and night). I know this because the GP 'phoned me to ask for a prompt review this week since she's now screaming like a banshee and flailing at folk with her walking stick through the afternoon and evening when she's no longer receiving her promazine.
Sometimes, just sometimes, us mental health folk do get it right and it's best not to rock the boat :-)
Wednesday, 19 September 2007
Context
I've said earlier this week that a key trait in mental health work is an interest in the patient's experience. It's from this that we can sleuth out both meaning and management plans.
Often it's assumed we're in the business of making people "normal" or curing "pathology" which are goals largley abandoned long ago in favour of helping people understand and cope with their experiences.
What's important then shifts so the emphasis is not to be reaching stratospheric doses of multiple psychotropics simply to abolish one specific symptom.
Imagine we've a patient who was in their kitchen hears footsteps walking upstairs when nobody's there. They also smell aftershave when no man's been in their house for ages. At night they feel someone lying next to them.
Auditory, olfactory and haptic hallucinations, mostly in clear consciousness (I'll concede feeling a body in bed with you could be a hypnagogic or hypnopompic experience as they drift in or out of sleep). Not illusions, not misperceptions whilst in a dreamy oneiroid state, these is crisp fully formed hallucinations.
Solid evidence of psychosis?
Not necessarily. I remember reading a paper from 1971 by a GP in Wales who looked back at 293 bereaved patients seen near the end of a life long career in General Practice and found that hallucinations were common. 46.7% experienced the presence of their departed spouse at some point, 13.3% had auditory hallucinations and 2.7% had tactile hallucinations such as feeling a loved one still in bed next to them, for example. In 1985 another paper found 61% of the 52 widowers they interviewed experienced hallucinations.
Hallucinations are typically seen as the hallmark of major mental illness. These papers and a wealth of evidence suggests that hallucinations can arise in folk who are not mentally ill. It's not simply the presence or absence of psychopathology that's key (even important psychopathology like hallucinations). Even in specialist mental health work what's key is the patient's narrative, their experience and the context.
Citations :
1) Dewi Rees W: British Medical Journal, 1971 Oct 2; 4 (5778): 37-41
2) Olson PR, Suddeth JA, Peterson PJ, Egelhoff C: J Am Geriatr Soc. 1985 Aug;33(8):543-7
PS : Isn't it great that good quality enduring research, informing and educating psychiatrists decades later, was done by a rural GP in Wales?
Often it's assumed we're in the business of making people "normal" or curing "pathology" which are goals largley abandoned long ago in favour of helping people understand and cope with their experiences.
What's important then shifts so the emphasis is not to be reaching stratospheric doses of multiple psychotropics simply to abolish one specific symptom.
Imagine we've a patient who was in their kitchen hears footsteps walking upstairs when nobody's there. They also smell aftershave when no man's been in their house for ages. At night they feel someone lying next to them.
Auditory, olfactory and haptic hallucinations, mostly in clear consciousness (I'll concede feeling a body in bed with you could be a hypnagogic or hypnopompic experience as they drift in or out of sleep). Not illusions, not misperceptions whilst in a dreamy oneiroid state, these is crisp fully formed hallucinations.
Solid evidence of psychosis?
Not necessarily. I remember reading a paper from 1971 by a GP in Wales who looked back at 293 bereaved patients seen near the end of a life long career in General Practice and found that hallucinations were common. 46.7% experienced the presence of their departed spouse at some point, 13.3% had auditory hallucinations and 2.7% had tactile hallucinations such as feeling a loved one still in bed next to them, for example. In 1985 another paper found 61% of the 52 widowers they interviewed experienced hallucinations.
Hallucinations are typically seen as the hallmark of major mental illness. These papers and a wealth of evidence suggests that hallucinations can arise in folk who are not mentally ill. It's not simply the presence or absence of psychopathology that's key (even important psychopathology like hallucinations). Even in specialist mental health work what's key is the patient's narrative, their experience and the context.
Citations :
1) Dewi Rees W: British Medical Journal, 1971 Oct 2; 4 (5778): 37-41
2) Olson PR, Suddeth JA, Peterson PJ, Egelhoff C: J Am Geriatr Soc. 1985 Aug;33(8):543-7
PS : Isn't it great that good quality enduring research, informing and educating psychiatrists decades later, was done by a rural GP in Wales?
Monday, 10 September 2007
Primary Care
Most poor mental health isn't anything to do with illness and disease and being sick.
Most mental health is to do with feeling rubbish, transiently, as life's given you a good kicking.
The severe problems (psychotic breakdowns) are few compared to the large number of folk with difficulty coping for a while (but not quite having an anxiety disorder or depressive disorder or whatever).
Thus, as we all know, most mental health work happens in the community and mostly in Primary Care.
It's of interest to me, then, that today it's reported that the Government is keen to whip GPs back in to working nights and weekends.
Will this generate better patient care?
Most mental health is to do with feeling rubbish, transiently, as life's given you a good kicking.
The severe problems (psychotic breakdowns) are few compared to the large number of folk with difficulty coping for a while (but not quite having an anxiety disorder or depressive disorder or whatever).
Thus, as we all know, most mental health work happens in the community and mostly in Primary Care.
It's of interest to me, then, that today it's reported that the Government is keen to whip GPs back in to working nights and weekends.
Will this generate better patient care?
Wednesday, 5 September 2007
Diagnosis
Psychiatrists diagnose mental health problems.
We have been trained to sift through symptoms and signs in order to ellucidate relevant psychopathology and ascribe significance to this, then weigh the constellation of relevant symptoms and signs and intensity and duration to generate a robust diagnosis.
One comment from my ST1 doctor (Specialist Trainee year 1 doctor, what used to be an SHO) stirred my thoughts. He's just finished his Foundation training which included a stint in GP land.
He was surprised at the diagnostic rigour in psychiatry.
A lot of diagnosis in Primary Care is based on clinical impression formed from history, examination and occasionally relevant investigations to confirm or refute a diagnosis. Many diagnoses are formulations made with the best evidence available before the GP, which can be a bit thin. Diagnosis of, say, Irritable Bowel Syndrome or a Chronic Fatigue Syndrome can be difficult to make in a robust fashion. Even before diagnosis, symptoms can be hard to quantify (such as dysmenorrhoea that means different things to different people).
My junior doctor was surprised that in Primary Care most GPs diagnosed problems intuitively through each consultation, seemingly at whim. Psychiatric diagnoses are determined within the World Health Organisation's International Classification of Diseases, 10th Edition, ICD-10.
In psychiatry we need to tick many boxes before we can say, "This patient has a diagnosis of F33.11 Recurrent depressive disorder, current episode moderate, with somatic syndrome."
It was interesting to see a young doctor realise that determining diagnosis of mental health problems is oft times more considered and robust than diagnosis of physical health problems.
We're not just musing and making stuff up!
We have been trained to sift through symptoms and signs in order to ellucidate relevant psychopathology and ascribe significance to this, then weigh the constellation of relevant symptoms and signs and intensity and duration to generate a robust diagnosis.
One comment from my ST1 doctor (Specialist Trainee year 1 doctor, what used to be an SHO) stirred my thoughts. He's just finished his Foundation training which included a stint in GP land.
He was surprised at the diagnostic rigour in psychiatry.
A lot of diagnosis in Primary Care is based on clinical impression formed from history, examination and occasionally relevant investigations to confirm or refute a diagnosis. Many diagnoses are formulations made with the best evidence available before the GP, which can be a bit thin. Diagnosis of, say, Irritable Bowel Syndrome or a Chronic Fatigue Syndrome can be difficult to make in a robust fashion. Even before diagnosis, symptoms can be hard to quantify (such as dysmenorrhoea that means different things to different people).
My junior doctor was surprised that in Primary Care most GPs diagnosed problems intuitively through each consultation, seemingly at whim. Psychiatric diagnoses are determined within the World Health Organisation's International Classification of Diseases, 10th Edition, ICD-10.
In psychiatry we need to tick many boxes before we can say, "This patient has a diagnosis of F33.11 Recurrent depressive disorder, current episode moderate, with somatic syndrome."
It was interesting to see a young doctor realise that determining diagnosis of mental health problems is oft times more considered and robust than diagnosis of physical health problems.
We're not just musing and making stuff up!
Thursday, 2 August 2007
Dementia
I concede that dementia subtyping is my role, not the role of medical colleagues. To sleuth out whether someone's got Alzheimer's disease and merits drug treatment, or has vascular dementia, Lewy Body dementia, or something obscure, sits firmly in Old Age Psychiatry. This I am happy with.
A local neurologist who I respect enormously (and has a brain the size of Saturn) also diagnoses dementia subtypes in her patch and does so incredibly well. Referrals from her are a joy. This too makes me happy.
Most of the GPs in my corner are very good indeed. They are committed, receptive to ideas, often doing what's best for their patients even if that does fall a touch outside protocols, guidelines and edits of What Thou Shalt Do. GPs with common sense, this makes me happy.
Although a diagnosis of dementia can be made by a GP or Consultant colleague, then referred on to me for dementia subtyping and appropriate treatment, some GPs aren't sure and refer patients who may or may not have dementia and don't make the diagnosis themselves. I'm fine with this, too. At best we're picking up dementia early, at worst I'm reassuring the GP and his patient that all is well. I don't have to be always treating and intervening. Supporting GPs in areas they're not sure about is, to my mind, a valid use of Consultant time.
It's good that local GPs can query concerns with me and express themselves frankly.
Still, there are some basics I would hope all clinicians have an appreciation of.
What surprised me in chatter with a local GP about our services was his honest question, "What's dementia?"
A local neurologist who I respect enormously (and has a brain the size of Saturn) also diagnoses dementia subtypes in her patch and does so incredibly well. Referrals from her are a joy. This too makes me happy.
Most of the GPs in my corner are very good indeed. They are committed, receptive to ideas, often doing what's best for their patients even if that does fall a touch outside protocols, guidelines and edits of What Thou Shalt Do. GPs with common sense, this makes me happy.
Although a diagnosis of dementia can be made by a GP or Consultant colleague, then referred on to me for dementia subtyping and appropriate treatment, some GPs aren't sure and refer patients who may or may not have dementia and don't make the diagnosis themselves. I'm fine with this, too. At best we're picking up dementia early, at worst I'm reassuring the GP and his patient that all is well. I don't have to be always treating and intervening. Supporting GPs in areas they're not sure about is, to my mind, a valid use of Consultant time.
It's good that local GPs can query concerns with me and express themselves frankly.
Still, there are some basics I would hope all clinicians have an appreciation of.
What surprised me in chatter with a local GP about our services was his honest question, "What's dementia?"
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