Influences

I recently was talking to junior doctors about career options. They've been sharply curtailed and the freedom to explore specialities as active doctors in one speciality (rather than as a more passive student) has largely been lost. Speaking with one doctor it dawned on me how much even early clinical contact can have formative influences that resonate with how I work now.

My first clinical attachment as a 2nd year medical student was General Surgery. I loved being on the wards and seeing patients and finally getting "stuck in" to proper medicine.

The quirks (having to illicit Boas sign on a ward round), the theatre of it all (ward rounds with an entourage whirling around the deific Consultant at the epicentre), the needles (learning to take take blood and cannulating) . . .

. . . the patients were the thing, though. Finally doing history taking and examining folk, being proper medics, then clever folk sussing out what was going on, it was being a part of magic!

For me, over time I loved the patient work up on the wards, the sleuthing out why a patient had jaundice, then what could be done to sort it.

Sadly, the "sorting it" didn't interest me. Surgery as a speciality was great, 'cept I didn't enjoy the cutting which kind of wrote it off for me :-)

Still, that attachment was fantastic both for teaching a wealth of skills and for learning from surgical folk who were interested in their patients. At variance with the sterotype back then, good modern surgeons would delight that even way back then there were surgical teams that valued undergraduate medical education and were essentially patient centred (but never would have called it that). The patient focus stayed with me, drawing me to train as a GP before back to hospital medicine and mental health.

What was my conclusion with my trainee? It was that the sum of my training and experiences means that for me the heart of good medicine and the quiddity* of psychiatry is a genuine interest in the patient narrative.


* A great word I really must try and use more :-)

Edit : Milk & Two Sugars just blogged about surgical training this morning, too. Snap! Her more lucid medical student perspective is here.

Deliberate Self Harm

We know Deliberate Self Harm (DSH) is common. One study talking to over 350 interested parties found about 1 in 15 children doing it from age 12 upwards. Other studies quote up to 1 in 7 in certain subgroups. So it matters. We know DSH invariably is nothing to do with suicide. We know that in younger folk (12 to early 20's) it's usually concealed (e.g. cutting arms then hiding the cuts under clothes) and is not about overt attention seeking.

Some groups seem at higher risk than others.

The National Institute of Health and Clinical Excellence has guidelines about this.

One key issue is that the self harm is a way for the young person to cope. They've often no better way to cope, which is why they cut. Stopping the cutting is stopping them coping. Thus, guidance is (sensibly) directed at looking at the causes of the DSH and addressing these rather than simply abolishing the self harm behaviour.

All well and good.

But, the crunch . . . just how do you explain to a terrified parent that we're going to accept their 19 year old teenager is still cutting themselves?

We'll offer alternatives (many distraction techniques work brilliantly) and CBT (which has established benefits after just a couple sessions) and medication (lorazepam can give similar relief that cutting does and works quickly to de-escalate distress) to try and reduce cutting and we'll give advice on cutting safely, but it's the loneliness and college pressure he's put himself under that needs sorting out then (invariably) the DSH diminishes and stops.

A difficult management plan to sell . . .

Travel

I've spoken with a gentleman who's been to another planet, visited Heaven and divined the future. Through "revealed truth" this will be shared. He's seen that I shall write a book which will bring great rejoicing. On this other planet he visits he has great standing and has been promoted to the top of four tiers.

Travel to a far off planet where you have import, a future of happiness and rejoicings, it's not a bad way to journey.

If only his travels hadn't also led him down a rather more mundane route, crashing his car and abandoning it in oncoming traffic . . .

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?

Teamwork

There is no "me" in "team" unless you're dyslexic or a savant. Modernising Medical Careers and New Ways of Working threatens to undermine a lot of established good practice.

I work with several teams. There's one team, for example, consisting of two nurses, a social worker, a bit of an occupational therapist, a support worker, part of a secretary and me. We all spend a lot of time in the same office.

But what is teamwork? What's the difference between collaborative work, parallel working and genuinely working as a multi-disciplinary team?

Gloom

Our Directorate is fine, all our patients are seen within 2 weeks, patients and GPs love us, outcomes are consistantly above average and we've run without finincial overspend for over a decade. All is good.

And then . . .

. . . 10.00am, meeting with hospital managers and a number of Directors explain the "vision" for our Trust.

I have of late, but wherefore I know not, lost all my mirth and indeed it goes so heavily with my disposition that this goodly frame the earth seems to me a sterile promotory.

Being British

I often have doubts over a word's appearance and fret over the spelling or meaning of a word that seemed right but looks dodgy when typed out. Thankfully there are online dictionaries, huzzah.

Recently I was tempted to use the word "gaol" in one discussion, but typed out it looked odd and I wondered if I was being a tad too anachronistic and if the American "jail" or the term "prison" would be better. I learnt that "jail" and "gaol" are synonymous but that "prison" has a different meaning.

What tickled me was one online dictionary's definitions of "gaol" that simply has to be shared.

Rummage around here and read down to find what presumably an American has written 'bout British folk using the term "gaol" :

gaol
see jail, you tea-sodden football hooligan.

Online Etymology Dictionary, © 2001 Douglas Harper

Tea-sodden, well, quite possibly :-)

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!

A&E

This weekend I had to go to A&E, son had a broken bone.

Unlike Shiny Happy Person's recent forray into patient experiences, I was pleasantly surprised.

My local A&E is in a hospital that doesn't know me. I've never worked there (and work in a different county) so they didn't know I was a medic. I didn't tell anyone and avoided "doctor" and "consultant" and "clinical director" and such, pitching up just as someone helping their son.

We had a wait, half an hour. Other folk before us had similar waits.

We were seen and triaged and had another wait, half an hour. Folk around us said they'd waited a similar time.

We had an x-ray (undertaken promptly with no wait) then we were seen promptly by a medic who said it was a broken bone which I'd already surmised but it was good that it had been clarified one way or the other.

The limb was promptly treated and dressed and we went on our way.

Isn't it nice when a system just works?

Film

Extra chocolate rations for recognising this quote :

"Look at that, look at that. "Accident black spot." These aren't accidents. They're throwing themselves into the road, gladly. Throwing themselves into the road to escape all this hideousness. [To a pedestrian] Throw yourself into the road, darling, you haven't got a chance!"

Watched it, yet again, and love it more and more each time.

Some days, I'm easily pleased!