Case Based Discussion

We tell patients the truth. How much is valid consent, how much is coercion?

This is a theme that case based discussion threw up with my colleagues and me. I was pleased, I'd not expected case based discussion to be at all useful. On exploring, with a peer group, how a Consultant managed random in-patient episodes, reviewing the notes and talking it through, a significant difference in approach emerged.

One school of thought was that patients deserve the truth, patients need an honest account of what professional advice a Consultant is offering. More, patients also need to know the consequences of their choice, if it's to be making a considered and valid decision, so patients need to be aware of outcomes from choices. Consultants in this camp will tell patients something along the lines, "We're both agreeing that you're not as well as we'd both wish, we're seeing you're behaving in a way that's unhelpful to you and those you care about, we know being in hospital is helpful for you and over a few weeks has worked every time before, I strongly believe you need to be in hospital, now."
The patient declines the offer of support within an in-patient unit and then is told, "If you're not wishing to come in informally, I'll need to look at a Mental Health Act assessment and admission under section 2."
It was strongly argued that not to tell the patient this was unfair, since valid consent and joint guidance from the BMA and Law Society in 2004 requires that the patient needed to know the consequences of not accepting the proposed treatment.

The other school of thought was that patients deserve the truth and an honest account but this related to the immediate issue. Whether their choices could then perhaps lead to discharge or perhaps to compulsory admission or maybe to consideration of a depot or whatever is a future consideration and shouldn't excessively influence the decision in the here and now.
It was suggested you'd have the same identical conversation but if after you recommended hospital admission your patient declines, you'd walk away and discuss it with the MDT and an AMHP rather than suggest compulsory denention.
It was strongly argued that as well as essentially making a threat, however tactfully delivered, it was inappropriate to offer informal admission then in the same breath say that if you don't come informally, formal admission will be sought, because there's then undue pressure. The same joint guidance from the BMA and Law Society in 2004 reequire that valid consent is made with "free choice" to curtailing choice to "do this, or I'll make it happen" is a less than free choice.

Mostly the argumements and points of view expressed by the Consultants weren't medicolegal or clinical, but essentially were ethical.

Is it better to be totally honest and let patients know the consequences of their decisions? Is it better to offer the choice and then if patients choose to decline, to then approach the MDT/AMHP to discount informal admission and revisit options?

I was firmly in the second camp, I've never to my recollection said to a patient that I'm offering informal admission and if it's declined I'm coming back with pink papers, an AMHP, a GP and an ambulance (with or without police, to convey) since that to my mind could be perceived as somewhat coercive. The argument was that I'd then be admitting people under a section of the MHA 1983 more often than they otherwise needed to be. I typically have just a couple of section 2 admissions a year, I've only made recommendations and managed my patients under section 3 twice in my career to date, so my use of both section 2 and section 3 is lower than colleagues within my peer group.

Different points of view, with different Consultants giving different answers. Usually you ask half a dozen Consultant Psychiatrists a question and you get half a dozen different answers. Unusually we had agreement with just 2 camps and recognition that the opposing camp had valid views but maintaining strong views that their camp was the best way to practice.

I was surprised by how useful the case based discussion was. I'd expected a tedious hour. The open exploration of implications of different approaches to practice, reflection on how we worked and discussion of alternate view points was stimulating and genuinely useful.

A pleasant surprise.

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

Junior Doctors

I've met with my junior doctor, dutifully undertaking an hour's supervision each week, assiduously documenting what we discuss.

What he wants out of supervision is, most meaningfully to him, being equipped to pass his exams. Without that, his career is thwarted and he can't progress his training to become a Consultant Psychiatrist.

What the Royal College wants out of supervision is unrealistic, with a full lever arch file failing to contain all that's meant to be covered, but in essence there's an expectation that all elements of the GMC's Good Medical Practice and all core generic medical competencies and old age psychiatry will be delivered. Most meaningfully to the RCPsych is progress of the curriculum (evidenced in doctor's portfolio and online workplace based assessments).

What the Trust wants is a safe practitioner doing appropriate work so, most meaningful to the Trust, is a supervised practitioner who's learnt and is fully aware and using in their practice the hundreds of Trust policies we have.

What the patients want of him isn't really factored in.

What I want is different and diverse and aspirational. In 3 or 4 years, my junior doctor is likely to be a Consultant Psychiatrist. What should such a junior doctor be mentored, informed or developed in, through ongoing weekly supervision?

Teaching Hospitals

Where's the best place to get care? Where's the best place to work? Both are related questions; if you have a happy, motivated, enthusiastic, valued workforce then you're much more likely to have a better quality service and receive good care as a patient.

I've worked in many hospitals, through medical school training, then 2 more as a House Officer, then more whilst I trained as a GP, then more as I trained as a psychiatrist. Many different hospitals in different counties.

It's something that usually you come almost come across by mistake rather than by conscious design . . . do you favour working in a local district general hospital, or a big teaching hospital? At least as a professional I've the choice. For patients, especially if needing involved and ongoing care, we all invariably have to go with what the local service is. You might be referred to foreign parts for your specialist heart surgery or spinal cord stimulator or infectious diseases opinion, but if you're after a community mental health nurse, support worker, social worker, psychiatrist, pharmacist and psychologists' input a few times a week with ongoing contact over months/years, you're invariably not in a position to get that from far away. Private medicine doesn't do it well, either. You get to see a Consultant Psychiatrist (if not fobbed off) but how do you get input from the other disciplines? When a team contributes to care, so half a dozen folk add to it each week, it's a fearsome bill to generate each week in Private Practice. Having a menu from private companies and picking off just one bit (like a Consultant Psychiatrist or a CBT therapist) will work for some people some of the time, but isn't a sensible or coherent way to generate a service.

I don't do any private work so for me it's not an issue, but the point remains . . . for mental health care, usually it's only practical to have an NHS team involved and for this team to be local to you.

Is a teaching hospital a better place to be, then?

This issue is in my mind because, curiously, a family moved last month from their current city (and teaching hospital) 30 minutes up the road to my corner, specifically to have mental health care from our Trust. One relative needed appropriate dementia care (which they didn't think they were getting in the teaching hospital), one younger adult needed ongoing care in the management of a mood disorder. It's not uncommon that patients have strong views about their GP and seek to remain with good ones they trust (much as the Government seems to believe otherwise).

As well as a patient relocating to be under my care, I also had a supranumerary flexible trainee wish to work here. That surprised me anyway - how many bright young things are zealous to work in old age psychiatry?! But her rationale was seemingly sound. As an older graduate who was more reflective of her training scheme than most, she found that a teaching hospital usually wasn't.

She found that a teaching hospital, in striving to be a centre of excellence, had lots of people trying to gain experience so she was often displaced. More importantly, she'd found that a teaching hospital was driven by research, not by teaching. Teaching added nothing to the researchers' day, and indeed detracted from their research time. Jobbing clinicians were the poorer brothers to the Senior Lecturers and Professorial teams so had disproportionately larger workloads and couldn't find hours a week to teach. It's a valid point. Teaching hospitals usually are research hospitals and are not necessarily at all good at teaching.

Got me pondering.

Is a teaching hospital automatically a desirable place to train (when teaching can be scare), work (where publishing research competes with investing time in teaching/clinical care) or receive care?

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.

Having a stab at it

When I was training, procedural skills were taught at the bedside by someone a touch more experienced (an SHO or Reg or SR) who would talk you through something like cannulation or siting a chest drain or lumbar puncture or whatever. You just had to crack on and do these things, they're practical tasks, you can't just read up on them. A skill you aquire through doing it, we got better at intubation at cardiac arrests and suprapubic aspiration of urine in kids and siting central lines through doing more and more of them.

As one SR quipped, placing a needle at the ready, "You just need to have a stab at it!"
Ha.

The benefits of this system were that you got really immersed in the clinical work, your competence (and confidence) got better from aquisition of skills, it was you who were working intimately with patients so developed consultation/therapeutic skills and there was someone who knew what they were doing standing right next to you so if care wasn't right then they would do it (so there was no practising and playing, patients got the right care).

Nowadays, practical tasks can't be learnt "on the fly" like this.

No no no.

Our Deanery organises regular teaching on training, the current vogue for practical skills is of explanation, then showing someone the task talking it through for them, then you doing it silently, then showing them the task with them talking it through to you, then them doing it. Surely life's too short for this.

Worse, once a trainee has done something, it needs documenting. Not just documenting in clinical records what's been done, no, it needs documenting in the trainees logbook or portfolio that they've done whatever.

Worse still, it can't simply be a comment that the procedure was successfully undertaken and any positive/negative feedback noted, it has to also be documented online as a DoPS. DoPS, you don't know? It's unclear to you what a DoPS is?

Fear not, you're in good company.

The DoPS is undertaken on the Royal College of Psychiatrists own web site, entered online (since, of course, electronic information systems, especially online ones, are the safest and most robust methods of storing sensitive information on trainees successes and failures). The Royal College site describes DoPS as "DoPS Direct Observation of Procedural Procedures" one one page but then as "DOPS Directly Observed Procedural Skills" on another.

So, after a trainee successfully administered a depot antipsychotic injection under the auspices of a band 7 nurse, which was the work of moments, we then have to spend an age documenting it all for the trainee.

Is this better than when a nurse could toss the syringe over and say, "Have a stab at it!"

MDT Teaching

Like many better other folk, I am enthusiastic about teaching.

I teach medical students often, both on wards and in clinics and within the community as well as formal classroom teaching. I'm often asked to do some teaching outside our organisation, this month it's been within a GP surgery, two care homes and our hospice. But I also teach members of our teams.

Teaching small groups of nurses and social workers, student nurses, occupational therapists and support workers does give people the opportunity to ask about small things they would like to know about or clarify. It also means we can share new information. It's healthy for teams, I feel, since we can all get together and bat out our views on a topic and there's a sense of collective "buying in" or cohesion at the end of it.

This week I have been struck by just how much people learn within the working week :
- one nurse queried with me whether a patient we're seeing with atypical dementia (and still trying to formally diagnose what the problem is) could have Binswanger's disease.
And she's quite correct, it fits very well indeed, he may well do.
- one nurse student, on seeing a patient on an anticonvulsant who had recently been initiated on olanzapine, queried the dose. Starting at 5mg, she questioned whether the dose would be therapeutic because wouldn't the anticonvulsant mean that her cytochrome P450 would metabolise the olanzapine so there'd be less to work?
The answer was almost meaningless but it was the process, her thoughts on the medication and consequences of interactions, that was spot on . . . stunningly good thinking. We've titrated the dose up now but she was absolutely right that the patient was on an enzyme inducer.
- a social worker asked me if a younger patient who's been on donepezil for 4 years for Pick's disease should stay on it. It's working very well, but the patient's had a arthritis, has taken over the counter tablets since last year and now has heartburn and is being investigated for stomach ulcers.

An atypical diagnosis, impact of pharmacology on clinical care and knowing cautions of drugs we use. I'm really am blessed with such a good team.

Training

Burried deep within the comments of an interesting post on nurses' training experiences 'bout medication I found this gem.

FOFOY training.

Fuck Off and Find Out Yourself training.

I like being spoon fed. Undergraduate education seems to have swung too far away from this, though, with espoused "adult self directed learning" ideas.

FOFOY. It really is how far too much medical (doctors and nurses) training seems to be, nowadays.

Communication

Shamelessly nicking more themes from more inventive folks blogs, I happily found Hospital Wallpaper's medical student blog after she commented below. She wrote about communication skills and wondered :
"Can communications skills be learnt or are they inherent in a person's character?"

I don't think it's that black or white a nature/nurture thing. If someone's inherently good at it, that's great. But I know medics with a brain the size of Saturn who really are great at diagnosis and therapy but were bad communicators who have improved lots. Experience in medicine, maturity, training can help.

What helps me improve more than anything is what Hospital Wallpaper did. She sat in and saw a clinician communicate. You learn what they do well, and nick that, and what they could do better, so learn to do it differently.

Every week I go on joint visits with nursing colleagues, every week I'm aware of little things they do better than I do, that I nick in my approach to consultations.

Tick boxes

I've spent the morning here.

It evokes feelings of despondency in the brightest soul.

Much badness.

It's all about MEE

Well the new glossy Tooke Report is out, have a read of it here.

Their 2 new recommendations seem to be :

1) Recommendation 46, be aware of the European Working Time Directive and look for a more flexible way to manage this.

2) Recommendation 47. Lose the roles of the Postgraduate Medical Education and Training Board and have a new body (Medical Education England, MEE) that, "interface between policy development and implementation" and "coordinate coherent advice to Government" amongst others. See pages 64, 65 for the details.

I've spent time reading through this (and I'm slightly bitter that I've wasted time that is now gone and I'll never get back again, ever) but have yet to understand the implications or benefits to junior doctor training of having MEE. Can someone clever explain it to me?

The circus comes to town!

All Educational Supervisors (i.e. all Consultant Psychiatrists) in our wee corner of the world were summoned to learn about Workplace Based Assessments, last week. Although it kicked off in 2005 with PMETB (the Postgraduate Medical Education and Training Board) the behemoth of change rumbles over us, crushing past success and introducing change. Because, erm . . . change is good. I'm told. So it goes.

"Roll up, roll up, come see the greatest show on Earth!" We sat dutifully whilst clever folk told us about Why It Had To Be and flirted with selling the whole thing to us. No matter what magic and words were woven, this trick didn't work. To say the reception was "frosty" is rather like saying the void of deep space is "a tad chilly."

"See, see how friendly and enticing this is! Gasp at the splendor of it all! Why, it's even in colour, don't you know!" We then were directed (erm, I think they called it something more pleasing like instructed, though, or mentored, p'raps) in the use the plethora of Workplace Based Assessment forms that our otherwise sensible College is foisting 'pon us.

"Watch them perform! Come, come see the clowns!" Oodles of Consultants, who've all been training juinor doctors for many years, watched. All had just been indoctrinated (erm, mentored, facilitated, coached, did they say?) in Workplace Based Assessment then immediately we were given videos of trainee/trainer interviews to rate. Excellent, then, cutting to the chase. Let's just crack on and do that then, so we can get our trainees through the myriad of hoops they've now to jump through. "Jumping through hoops, high how can they go? Oooh, watch them skip and dance! What a performance, what a show!"

Our ringleader whipped us in to shape, working us in a score of small groups, scoring the performance of the trainees in the videos. We get through a few videos, a few different mini-ACE and Case-based Discussion. "Did they frolic, cavort and entertain? Did they leap to the hoops, only to fall? What scores, what ratings one and all?" We compared scores. A score of 4 is a pass, meeting the necessary standard. 5 or 6 is great (above standard and mastery). 1 to 3 is a fail, below standard. In one video we all watched the room scored the trainee from 1 to 5. Some failed the trainee as the worst ever, some passed her as above standard. This pattern unfolded itself again and again. We all watched the same video, had the same training and used the same scales at the same time (and discussed it in small groups so no one voice generated extremes). Yet there was huge variation in whether the candidate would pass (well) or fail (catastrophically). Not just a few voices in each camp, either, with most in the middle . . . there really was huge spread. So it goes.

"Ah, what mirth, what merry japes, 't is but practice, after all" And, in point of fact, it's the clinical practice of the whole next generation of doctors that's being flippantly fiddled with. Doctors who will be treating me. Treating my kith and kin. So it goes.

I've tried to register with the Healthcare Assessment and Training (HcAT) website who say they've sent me details to log on, but they lie. So since all forms are online I can't do any assessments with my trainee. None what so ever. So it goes.

Am I the only one who feels that form and theatre and checklists wholly eclipses merit and content? We live in interesting times. Junior doctor training has been modernised. So it goes.