I've been talking with managers at work about psychiatrists. Rather a lot, of late. I work in the NHS, changes are afoot, changes are always afoot. I talk with endless folk, endlessly, because it allows me protect my corner and be left alone to do what we do best. All that seeing patients and making things better malarky.
Managers have a different agenda. They usually are not thinking about the personal and privileged relationship a doctor or nurse, in a room with a patient, have, and how management can make this work best for one and all. Many years ago, that's what I imagined managers did. Now I remain buoyant and optimistic but I'm not so naive.
As an aside, Professor Sir Bruce Keogh, Medical Director at the Department of Health, does seem to have his finger on the pulse. The Jobbing Doctor feels, as many medics do, that our Chief Medical Officer has much to be contrite over. I am heartened that Bruce Keogh was saying how everything managers do, all systems that are in place, should be to improve the quality of that privileged moment of a therapist and their patient, in a room together, getting help. Superb!
Most weeks I speak with managers in our organisation, in neighboring FTs and with the PCT. The LMC and APC like to shred Consultants in Secondary Care too. The role of psychiatry in undergraduate teaching is modest, discussions I have with the university policy makers as an old age psychiatrist are laughable. But I enter the lions' dens time and time again because if I didn't I'd get sold down the river and life for me, our teams and my patients what be a whole heap worse.
I've also undertaken formal investigation of rubbish psychiatry in a neighbouring area. As well as middle grade doctors who've needed performance management, it got worse than that. Always grim, to see practice by a Consultant that's beyond poor and in to utterly shameful.
With patients, commissioners and staff I find myself increasingly having to justify the role of a Consultant Psychiatrist. In my corner, oddly, Old Age services are well regarded by all parties, so the knives are out for colleagues. Therein lies another post.
Suffice to say, we live in interesting times.
Normally, when a crowd get together and pool decision making, decisions are better. Sources of bias and error are cancelled. Guess the weight of a jar of sweets. You'll guess wrong. So will most folk. But use the crowd's answers and pool the answers, take an average, and you'll likely get close. Still not right, maybe, but better than the guess you'd have made yourself.
It was of interest to me, then, to see that this "wisdom of crowds" effect got worse when you gathered 300 psychiatrists together. Read about it here.
My managers will love this . . .
Monday, 9 March 2009
Saturday, 7 March 2009
Friday, 6 March 2009
Speech
Okay, okay, time to 'fess up. I've been a tad naughty.
On commenting on my favourite Social Worker's blog, here, I used colourful vocabulary. I shouldn't have. Her "Comment Policy" even says :
"4. No swearing/bad language"
Although in fairness I never read it before today. Ooops.
Quite rightly, she's ammended my comment so it's clear what I said, but it's not obviously offensive. I feel suitably chided and won't sully her splendid blog with my base vulgarity again. Sorry, CB.
It did get me thinking, though.
I don't comment on people, often. It's not something I feel comfortable doing. The only people I comment on are folk I know very well. Whether it's to say they're a good person or a caring person or a loyal friend, or whether it's to say they're scatty or self centred or ruthlessly assertive, such comments can only be made on folk we know inside out.
I do comment on behaviour often. Someone may be a good or not so good person, which I can't know so can't comment on. But their behaviour, as Tolkein's Faramir would say, is a chance for a man to, "show his quality."
On this basis, I felt wholly justified and reflexively commented that, on considering a suitable description of Ed Ball I opted for, "I’d try for, “behaving as an utter cunt.”"
I have my quirks and foibles. One of them's language. I'm pretty easy going and am not seeking to change how other folk use language. I've no crusade. My use of language is often far from perfect. My schooling was in a local comp by a massive deprived housing estate; nuances of grammar were eclipsed by teachers' desire for us to simply write in something less troublesome than someone elses blood. So it's simply a personal position that I see careless, sloppy, wildly inaccurate use of language as "bad" language and see colourful/swearing as simply part of vocabulary to use when sought.
It's not often I swear, in truth. But I see such words as helpful interjections. Almost by definition, such interjections are exclamations and inherently have an exclamation mark. Thus they're useful if, like exclamation marks, they're scattered occasionally to succinctly reinforce a point.
My wife chides me over this. Brought up on a diet of Germaine Greer, Naomi Wolfe and the like, she doesn't like me using such words. And I'm not so bold as to frustrate the will of my wife. I curtail my use of colourful language in her good company. When it was in vogue in the '90s, she went to the theatre to see "The Vagina Monologues" with some female friends. She relayed how the audience had been challenged to see female words, like cunt, as positive. A bloke on the street shouts out, "You utter cunt!" The woman's response should be to beam radiantly and visibly cherish this, replying "Oooh, thank you!"
Reclaiming words. This appeals to me. A bit like mental health stigma, I like to believe we can reclaim unfashionable words to use them helpfully.
She's still mortified to hear the word cunt. I shall endeavour to behave better.
On commenting on my favourite Social Worker's blog, here, I used colourful vocabulary. I shouldn't have. Her "Comment Policy" even says :
"4. No swearing/bad language"
Although in fairness I never read it before today. Ooops.
Quite rightly, she's ammended my comment so it's clear what I said, but it's not obviously offensive. I feel suitably chided and won't sully her splendid blog with my base vulgarity again. Sorry, CB.
It did get me thinking, though.
I don't comment on people, often. It's not something I feel comfortable doing. The only people I comment on are folk I know very well. Whether it's to say they're a good person or a caring person or a loyal friend, or whether it's to say they're scatty or self centred or ruthlessly assertive, such comments can only be made on folk we know inside out.
I do comment on behaviour often. Someone may be a good or not so good person, which I can't know so can't comment on. But their behaviour, as Tolkein's Faramir would say, is a chance for a man to, "show his quality."
On this basis, I felt wholly justified and reflexively commented that, on considering a suitable description of Ed Ball I opted for, "I’d try for, “behaving as an utter cunt.”"
I have my quirks and foibles. One of them's language. I'm pretty easy going and am not seeking to change how other folk use language. I've no crusade. My use of language is often far from perfect. My schooling was in a local comp by a massive deprived housing estate; nuances of grammar were eclipsed by teachers' desire for us to simply write in something less troublesome than someone elses blood. So it's simply a personal position that I see careless, sloppy, wildly inaccurate use of language as "bad" language and see colourful/swearing as simply part of vocabulary to use when sought.
It's not often I swear, in truth. But I see such words as helpful interjections. Almost by definition, such interjections are exclamations and inherently have an exclamation mark. Thus they're useful if, like exclamation marks, they're scattered occasionally to succinctly reinforce a point.
My wife chides me over this. Brought up on a diet of Germaine Greer, Naomi Wolfe and the like, she doesn't like me using such words. And I'm not so bold as to frustrate the will of my wife. I curtail my use of colourful language in her good company. When it was in vogue in the '90s, she went to the theatre to see "The Vagina Monologues" with some female friends. She relayed how the audience had been challenged to see female words, like cunt, as positive. A bloke on the street shouts out, "You utter cunt!" The woman's response should be to beam radiantly and visibly cherish this, replying "Oooh, thank you!"
Reclaiming words. This appeals to me. A bit like mental health stigma, I like to believe we can reclaim unfashionable words to use them helpfully.
She's still mortified to hear the word cunt. I shall endeavour to behave better.
Rewards
Mr Edwards went to a cafe in a charming garden centre today, then walked around looking at the bedding plants, enjoying the riot of colour. I know this because a support worker relayed to me how cheery he was, ambling about seemingly aimlessly, chattering away to her with real zeal and passion. Mr Edwards has always been an enthusiastic gardener.
He has Parkinsons Disease (PD) which affects him in three particular ways.
Firstly, his speech sounds slurred. Although he's readily understood he's very self conscious of this because he reckons he doesn't sound like himself but worse, he reckons he sounds drunk. Happen he's right. I don't think his dysarthria sounds like drunken slurred speech, but I'm tuned in to medicalising stuff and in critiquing nuances of speech that means I sift through a number of reasons why he's slurring speech whilst folk in his neighbourhood would instead probably assume he's drunk. He lives in a hellishly deprived area. It's a statement of fact that lots of people are drunk lots of the time. He feels awfully self conscious that, if he speaks, folk will presume he's a drunken sot.
Secondly, his gait is poor. He staggers and sometimes falls. Steps are a nightmare for him. This compounds his belief that folk will see him as drunk. It also concerns him, whilst he's out and about, that he might freeze or fall in an awkward place. Tragically, he's not fearful that he'll come to harm through this, no, he's fearful that someone else will. He's terrified he could collapse in the road and cause someone to swerve and have an accident, all because of him.
Thirdly, as sadly everyone with PD will if they live long enough, he has developed dementia. It's expected and inevitable, PD is a progressive neurodegenerative disease so only goes one way, but for Mr Edwards his dementia's responding well to medication and he's just a little muddled with dates, a little forgetful of times (was it 2 days ago we last met up, or was it a week?) and a little impaired with recent declarative memory. Procedural memory, such as riding his bike to his allotment, is fine. So's managing finances. Orientation in his locale is fine (he's lived there all his life so knows his way around effortlessly). Judgement/decision making is still sound and has improved significantly on galantamine.
An Occupational Therapist sorted some practical changes for him, both in his home and his allotment and with tools. A Social Worker sorted out practical support, with a care package of home carers twice a day. A clever and devoted chap within our local Alzheimers Society branch has sorted out his benefits and finances. Nurses in our memory clinic have done exhaustive memory testing initially (to inform diagnosis) and periodically (to assess efficacy/effects of galantamine). A CPN gave advice to him and to his PD Nurse, several times, over a period of a month or so, with oodles of practical changes made consequent to this. She then did some CBT with him over four months. Yes yes, I know he's got dementia, but that doesn't preclude CBT. Indeed the behavioural stuff and experiential learning over a month or so, with a fortuitous ability to forget the bad things in the months before this, meant Mr Edwards regained significant confidence and competence through the CBT. Underpinning this, a Support Worker has been assisting him in maintaining function (e.g. going to his allotment, going to shops, using a bus for journies he can't cycle, going to his GP and hospital appointments for things that he'd been putting off, visiting friends he'd worked with for decades, getting to church).
I saw him at his home with a CPN (and the results of her initial assessment) and memory clinic assessment, the PD Nurse's referral details, the subsequent GP referral letter and blood results and the results of the CT imaging and ECG I'd requested. We'd considered a DAT scan but it wasn't necessary. I spoke to him at length, assessed his mental state, assessed areas of cognition that had been equivocal on memory clinic testing and reviewed all the results. The diagnosis was obvious. He had PD dementia.
We discuss options. It doesn't take long. My colleagues have already paved the way to this point, with ongoing discussion at each stage, by each person, so my words are simply the concluding confirmation, the distilled summary.
In my corner it's only Consultant Psychiatrists who start acetylcholinesterase inhibitor treatment, so having discussed medication out comes an FP10 and we start galantamine.
I've not seen him since. I hear about him several times a week, through working in the same office as the Support Worker and CPN. In his care I've been involved in over 20 conversations, from dicussions at the point of referral then assessment then intervention. I've consistently directed and influenced his care. But in terms of face to face contact, in truth, it's the support worker and CPN who've effected change and in his words, "Given me my life back."
Yet, this week, he gave the Support Worker a gift wrapped bottle of wine and card to give to me. The unqualified Support Worker has done the most work, yet she didn't get anything. The qualified nurse (a CPN) has done the next most amount of work, yet she didn't get anything.
I have a series of conversations with staff and see him once. I can't claim that's a lot of work.
Doesn't seem quite fair.
He has Parkinsons Disease (PD) which affects him in three particular ways.
Firstly, his speech sounds slurred. Although he's readily understood he's very self conscious of this because he reckons he doesn't sound like himself but worse, he reckons he sounds drunk. Happen he's right. I don't think his dysarthria sounds like drunken slurred speech, but I'm tuned in to medicalising stuff and in critiquing nuances of speech that means I sift through a number of reasons why he's slurring speech whilst folk in his neighbourhood would instead probably assume he's drunk. He lives in a hellishly deprived area. It's a statement of fact that lots of people are drunk lots of the time. He feels awfully self conscious that, if he speaks, folk will presume he's a drunken sot.
Secondly, his gait is poor. He staggers and sometimes falls. Steps are a nightmare for him. This compounds his belief that folk will see him as drunk. It also concerns him, whilst he's out and about, that he might freeze or fall in an awkward place. Tragically, he's not fearful that he'll come to harm through this, no, he's fearful that someone else will. He's terrified he could collapse in the road and cause someone to swerve and have an accident, all because of him.
Thirdly, as sadly everyone with PD will if they live long enough, he has developed dementia. It's expected and inevitable, PD is a progressive neurodegenerative disease so only goes one way, but for Mr Edwards his dementia's responding well to medication and he's just a little muddled with dates, a little forgetful of times (was it 2 days ago we last met up, or was it a week?) and a little impaired with recent declarative memory. Procedural memory, such as riding his bike to his allotment, is fine. So's managing finances. Orientation in his locale is fine (he's lived there all his life so knows his way around effortlessly). Judgement/decision making is still sound and has improved significantly on galantamine.
An Occupational Therapist sorted some practical changes for him, both in his home and his allotment and with tools. A Social Worker sorted out practical support, with a care package of home carers twice a day. A clever and devoted chap within our local Alzheimers Society branch has sorted out his benefits and finances. Nurses in our memory clinic have done exhaustive memory testing initially (to inform diagnosis) and periodically (to assess efficacy/effects of galantamine). A CPN gave advice to him and to his PD Nurse, several times, over a period of a month or so, with oodles of practical changes made consequent to this. She then did some CBT with him over four months. Yes yes, I know he's got dementia, but that doesn't preclude CBT. Indeed the behavioural stuff and experiential learning over a month or so, with a fortuitous ability to forget the bad things in the months before this, meant Mr Edwards regained significant confidence and competence through the CBT. Underpinning this, a Support Worker has been assisting him in maintaining function (e.g. going to his allotment, going to shops, using a bus for journies he can't cycle, going to his GP and hospital appointments for things that he'd been putting off, visiting friends he'd worked with for decades, getting to church).
I saw him at his home with a CPN (and the results of her initial assessment) and memory clinic assessment, the PD Nurse's referral details, the subsequent GP referral letter and blood results and the results of the CT imaging and ECG I'd requested. We'd considered a DAT scan but it wasn't necessary. I spoke to him at length, assessed his mental state, assessed areas of cognition that had been equivocal on memory clinic testing and reviewed all the results. The diagnosis was obvious. He had PD dementia.
We discuss options. It doesn't take long. My colleagues have already paved the way to this point, with ongoing discussion at each stage, by each person, so my words are simply the concluding confirmation, the distilled summary.
In my corner it's only Consultant Psychiatrists who start acetylcholinesterase inhibitor treatment, so having discussed medication out comes an FP10 and we start galantamine.
I've not seen him since. I hear about him several times a week, through working in the same office as the Support Worker and CPN. In his care I've been involved in over 20 conversations, from dicussions at the point of referral then assessment then intervention. I've consistently directed and influenced his care. But in terms of face to face contact, in truth, it's the support worker and CPN who've effected change and in his words, "Given me my life back."
Yet, this week, he gave the Support Worker a gift wrapped bottle of wine and card to give to me. The unqualified Support Worker has done the most work, yet she didn't get anything. The qualified nurse (a CPN) has done the next most amount of work, yet she didn't get anything.
I have a series of conversations with staff and see him once. I can't claim that's a lot of work.
Doesn't seem quite fair.
Friday, 27 February 2009
Nothing
I saw a lady in her 70's for a Mental Health Act 1983 assessment. She was on an acute hospital ward, having been admitted acutely confused. She'd decided to go home, had to look after her dog and kids. Her "kids" are grown up and live far away. Her Consultant Physician thought she shouldn't go home. Although all her investigations were normal she was, "confused and unsafe, please see urgently!"
So I did.
She was, indeed, confused. She believed nurses were poisoning her (because the opiate analgesia for her arthritis, which she was receiving now she was an in-patient but hadn't been taking at home, made her drowsy). They were torturing her, making her confused (because every night they moved the furniture and people around). At night she saw supernatural figures ghosting through the ward, disguised vaguely as people. She thought she was in a prison, but knew she'd done nothing wrong. She thought she was there because nurses had, "made something up" and, "it was in the papers, cruel lies about me."
She was in tears as I spoke to her. Over 40 minutes she spoke of how worthless she was, how nobody cared, which was proper, because she didn't deserve anything. She wanted to leave the prison, because she hadn't done anything wrong. "So why haven't you left yet?"
"Because I deserve to be here."
She felt empty and worthless and unloved. She saw herself as having no value. No wonder her children didn't visit her here, why would they? She didn't want to be there, she wanted to be home, but recognised she had to stay, "locked up" and was just, "waiting to go" now, to fade away and cease to be.
She was slowed down (psychomotor retardation), unexpressive (save for tears, a few times), unreactive, lethargic. She hardly looked up as she spoke, sadly, lamenting her miserable state of torment with stoic acceptance that this was all right and proper, and although unwelcome, was no less than she deserved. Marked dysprosody. She wasn't eating well. She didn't sleep well.
She was clearly depressed. She was unwell. Her medical team had noticed, had started an antidepressant and sought help. She can be helped.
Some patients make no demands, don't want to cause any trouble, don't want to be a nuisance and quietly fade away, putting nobody out. They're easy to ignore, especially when folk are busy. They're silent. Who advocates for them?
She's asked for nothing. I want to give her everything.
So I did.
She was, indeed, confused. She believed nurses were poisoning her (because the opiate analgesia for her arthritis, which she was receiving now she was an in-patient but hadn't been taking at home, made her drowsy). They were torturing her, making her confused (because every night they moved the furniture and people around). At night she saw supernatural figures ghosting through the ward, disguised vaguely as people. She thought she was in a prison, but knew she'd done nothing wrong. She thought she was there because nurses had, "made something up" and, "it was in the papers, cruel lies about me."
She was in tears as I spoke to her. Over 40 minutes she spoke of how worthless she was, how nobody cared, which was proper, because she didn't deserve anything. She wanted to leave the prison, because she hadn't done anything wrong. "So why haven't you left yet?"
"Because I deserve to be here."
She felt empty and worthless and unloved. She saw herself as having no value. No wonder her children didn't visit her here, why would they? She didn't want to be there, she wanted to be home, but recognised she had to stay, "locked up" and was just, "waiting to go" now, to fade away and cease to be.
She was slowed down (psychomotor retardation), unexpressive (save for tears, a few times), unreactive, lethargic. She hardly looked up as she spoke, sadly, lamenting her miserable state of torment with stoic acceptance that this was all right and proper, and although unwelcome, was no less than she deserved. Marked dysprosody. She wasn't eating well. She didn't sleep well.
She was clearly depressed. She was unwell. Her medical team had noticed, had started an antidepressant and sought help. She can be helped.
Some patients make no demands, don't want to cause any trouble, don't want to be a nuisance and quietly fade away, putting nobody out. They're easy to ignore, especially when folk are busy. They're silent. Who advocates for them?
She's asked for nothing. I want to give her everything.
Friday, 20 February 2009
Old Age Services
Our National Dementia Strategy is a document I've already commented upon this month, but this little gem raised my spirits so has to be shared.
It basically says, right on the last page of the whole strategy (just before the appendicies) that specialist mental health services for older adults should not be dismantled, absorbed into generic "depression" and "schizophrenia" and other "modular" general adult services, but should remain as they are and grow stronger. Hurrah!
You'll find it in chapter 6, page 74, of the full strategy document. In case you don't have it to hand, here it is in full :
"Implementation of this Strategy will need to be part of a broader focus on older people’s mental health services. Strong concerns were raised during the consultation exercise that some localities may be interpreting age equality in mental health services to mean a ‘one size fits all ages’ approach. This generally means using existing working-age adult services to look after older people with functional illness. With reflection, this is much more likely to increase age discrimination than it is to address it. This is because age here is a proxy for a different set of needs and therefore skills. Equivalent quality of care is likely to require enhancing current older people’s mental health teams to have higher levels of functionality in terms of the capacity for assertive outreach, for example. This would benefit those with dementia as well as those older people with functional disorder. The improvement of services for people with dementia must not be used as an excuse for diluting specialist services for older people with other mental health needs."
It basically says, right on the last page of the whole strategy (just before the appendicies) that specialist mental health services for older adults should not be dismantled, absorbed into generic "depression" and "schizophrenia" and other "modular" general adult services, but should remain as they are and grow stronger. Hurrah!
You'll find it in chapter 6, page 74, of the full strategy document. In case you don't have it to hand, here it is in full :
"Implementation of this Strategy will need to be part of a broader focus on older people’s mental health services. Strong concerns were raised during the consultation exercise that some localities may be interpreting age equality in mental health services to mean a ‘one size fits all ages’ approach. This generally means using existing working-age adult services to look after older people with functional illness. With reflection, this is much more likely to increase age discrimination than it is to address it. This is because age here is a proxy for a different set of needs and therefore skills. Equivalent quality of care is likely to require enhancing current older people’s mental health teams to have higher levels of functionality in terms of the capacity for assertive outreach, for example. This would benefit those with dementia as well as those older people with functional disorder. The improvement of services for people with dementia must not be used as an excuse for diluting specialist services for older people with other mental health needs."
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!
Saturday, 14 February 2009
Shock news!
You will not be startled to learn the results of the DART-AD trial.
The reason why we've Prescription Only Medicine (POM) is that it's thought to be, ". . . those preparations that are available only on a prescription issued by an appropriate practitioner."
It's the proper stuff. Stuff with risks and benefits. Stuff with real consequences (both good and bad). Rather than Over The Counter (OTC) medicine which anyone can get, over the counter, from a chemist, POM tends to be medication where risks, side effects, treatment emergent adverse events, monitoring, serious interactions or other elements of how the drug works needs careful thought and judgement made.
Hence the legal requirement for not just advice, not just safety netting and input from a manager or a scientist, these proper drugs require, "an appropriate practitioner."
A good turn of phrase, that. "An" suggests one, which pleases me. One GP (not polyclinics and walk in centres). One psychiatrist (not fractured models of a Community one, an Early Intervention one, a Crisis Resolution one, an Inpatient one, a Rehabilitation one etc etc). Optimistic, I know, but having one GP and one Consultant is a model I'm thoroughly wedded to.
"Appropriate" is a handy word, meaning that it's not just a practitioner, it's got to be an appropriate one. The pharmacist in my team's clear on what this means. It means someone who can make valid, rational prescribing decisions. Although, as a pharamcist, there's expertise in the drug's use and interactions, pharmacists don't do out-patient clinics so don't get to see all the consequences of medication used, so don't feel they're experts at prescribing. Sensibly, my pharmacist sees herself as a resource to inform on decisions (and explain medication issues to patients, and manage the governance systems around medicines management), she doesn't see herself as an "appropriate" prescriber.
The word "practitioner" is salient, too. It implies a need for someone in practice, someone practising clinical care. So not just someone who knows a lot about drugs, then. If asked, "Of the last 50 patients you gave advice on medication to, how many had no side effects (and you've documented that), and how many had side effects (which you've documented)?" a "practitioner" should be in a position to answer that, someone just giving advice couldn't. And if that someone's giving prescribing advice but not seeing the consequences of their clinical practice, then I'd suggest they're not "an appropriate practitioner" so should not be issuing prescriptions for Prescription Only Medicine.
Rant over.
POM are medicines that we shouldn't be cavalier with. They're drugs which have real effects, so often need judicious consideration on initiating, continuing, monitoring and withdrawing them.
Which brings me to this study. It's a good study. It's funded by the UK Alzheimer's Research Trust, not a drug company. It's a study that was conducted over an appropriate length of time. Each treatment arm was of a decent size. It's a very relevant research topic.
They looked at folk with Alzheimer's disease, for up to 3 years. They found that patients without antipsychotic medication lived longer than patients with antipsychotic medication. Shock news!
I'm ambivalent about this study, really. On the one hand, it's a well executed bit of credible research that's about a contentious and relevant theme. On the other hand, is it necessary?
In patients with crashing heart failure, with fluid pouring into their lungs, the dread and feeling of drowning, the weakness, then death, life isn't great. Diamorphine can be used to reduce the ghastly symptoms. Diamorphine causes respiratory depression. Stops you breathing. In a patient who's lungs are filling with fluid, reducing their breathing isn't a strategy conducive to a long life. But it's done, rightly, even though life may be shortened, because the clinical condition warrants this palliative care. Is a study necessary to show us that, in heart failure, patients dying without diamorphine live fractionally longer than patients on diamorphine? Probably not. We know diamorphine is a proper drug, a medicine with benefits and side effects that need to be weighed by "an appropriate practitioner."
The DART-AD trial shows us that antipsychotics generate risk in Alzheimer's Disease patients. Although my gut reaction is, "And?!" I do s'pose it's useful to have a well executed study evidencing that what we knew to be the case is actually the case.
So is there anything from this which will change my clinical practice? No. But it's good to know that what I thought (that the drugs were dangerous) is true, and decisions around their use should be very carefully throught through by senior clinicians with expertise in this area.
The reason why we've Prescription Only Medicine (POM) is that it's thought to be, ". . . those preparations that are available only on a prescription issued by an appropriate practitioner."
It's the proper stuff. Stuff with risks and benefits. Stuff with real consequences (both good and bad). Rather than Over The Counter (OTC) medicine which anyone can get, over the counter, from a chemist, POM tends to be medication where risks, side effects, treatment emergent adverse events, monitoring, serious interactions or other elements of how the drug works needs careful thought and judgement made.
Hence the legal requirement for not just advice, not just safety netting and input from a manager or a scientist, these proper drugs require, "an appropriate practitioner."
A good turn of phrase, that. "An" suggests one, which pleases me. One GP (not polyclinics and walk in centres). One psychiatrist (not fractured models of a Community one, an Early Intervention one, a Crisis Resolution one, an Inpatient one, a Rehabilitation one etc etc). Optimistic, I know, but having one GP and one Consultant is a model I'm thoroughly wedded to.
"Appropriate" is a handy word, meaning that it's not just a practitioner, it's got to be an appropriate one. The pharmacist in my team's clear on what this means. It means someone who can make valid, rational prescribing decisions. Although, as a pharamcist, there's expertise in the drug's use and interactions, pharmacists don't do out-patient clinics so don't get to see all the consequences of medication used, so don't feel they're experts at prescribing. Sensibly, my pharmacist sees herself as a resource to inform on decisions (and explain medication issues to patients, and manage the governance systems around medicines management), she doesn't see herself as an "appropriate" prescriber.
The word "practitioner" is salient, too. It implies a need for someone in practice, someone practising clinical care. So not just someone who knows a lot about drugs, then. If asked, "Of the last 50 patients you gave advice on medication to, how many had no side effects (and you've documented that), and how many had side effects (which you've documented)?" a "practitioner" should be in a position to answer that, someone just giving advice couldn't. And if that someone's giving prescribing advice but not seeing the consequences of their clinical practice, then I'd suggest they're not "an appropriate practitioner" so should not be issuing prescriptions for Prescription Only Medicine.
Rant over.
POM are medicines that we shouldn't be cavalier with. They're drugs which have real effects, so often need judicious consideration on initiating, continuing, monitoring and withdrawing them.
Which brings me to this study. It's a good study. It's funded by the UK Alzheimer's Research Trust, not a drug company. It's a study that was conducted over an appropriate length of time. Each treatment arm was of a decent size. It's a very relevant research topic.
They looked at folk with Alzheimer's disease, for up to 3 years. They found that patients without antipsychotic medication lived longer than patients with antipsychotic medication. Shock news!
I'm ambivalent about this study, really. On the one hand, it's a well executed bit of credible research that's about a contentious and relevant theme. On the other hand, is it necessary?
In patients with crashing heart failure, with fluid pouring into their lungs, the dread and feeling of drowning, the weakness, then death, life isn't great. Diamorphine can be used to reduce the ghastly symptoms. Diamorphine causes respiratory depression. Stops you breathing. In a patient who's lungs are filling with fluid, reducing their breathing isn't a strategy conducive to a long life. But it's done, rightly, even though life may be shortened, because the clinical condition warrants this palliative care. Is a study necessary to show us that, in heart failure, patients dying without diamorphine live fractionally longer than patients on diamorphine? Probably not. We know diamorphine is a proper drug, a medicine with benefits and side effects that need to be weighed by "an appropriate practitioner."
The DART-AD trial shows us that antipsychotics generate risk in Alzheimer's Disease patients. Although my gut reaction is, "And?!" I do s'pose it's useful to have a well executed study evidencing that what we knew to be the case is actually the case.
So is there anything from this which will change my clinical practice? No. But it's good to know that what I thought (that the drugs were dangerous) is true, and decisions around their use should be very carefully throught through by senior clinicians with expertise in this area.
Tuesday, 10 February 2009
Consultants
I know what a medical Consultant does. I've been trained to do the job over many years, I've ongoing appraisal and CPD and Job Planning and meetings that define my role iteratively.
Some roles are clearly medical and Consultant roles. In my corner, elliciting psychopathology and ascribing significance to this, to generate formal diagnosis, is seen as a Consultant Psychiatrist's job. Nurses (especially non-medical prescribers) have to be able to generate a sufficiently robust formulation, but formal diagnosis remains medical. DVLA work and fitness to drive is medical. Assessment of capacity is everyone's business but assessment of testamentary capacity or ability to undertake Lasting Powers of Attorney or fitness to stand trial is seen as medical work (because it's only accepted when done by a medic). Mental Health Act 1983 work is done by doctors (and even within the ammended Act, it's only doctors who can make Assessments and recommend compulsory admission).
We do more. Complex management plans. Case Conferences and Journal Clubs and Clinical Effectiveness. Taking a lead in safeguarding cases, saying How It Is. Expertise in medication, ECT and interventions. Being the one to speak up in court. Teaching of every discipline. Management meetings. We see a lot of patients out of hours (last weekend a Consultant Psychiatrist was called 16 times and drove out and undertook 12 assessments, and had worked 2 other nights in the month, for which she receives the princely sum of £183.50/month for being on-call, i.e. pay of £36.70/night for each night she had to be on-call). I like to know about and input in to every management plan (and at least everyone gets a Consultant Psychiatrist's input then, after a CPN sees them and discusses care with me when they're back in the office and we meet up each afternoon). Audit.
On top of that, we spend a lot of time seeing patients.
Senior clinicians, seeing patients, using their clinical expertise whilst also doing enough management stuff to develop their service as they'd wish. Life as a Consultant Psychiatrist is fairly clear.
In fact, mine is very clear. I share my Job Plan and Appraisal with anyone who's interested. Lots of folk have been curious. Nurses, OT, secretaries, managers. Why not? I'm busy, I do loads, I critique what other people do, it's only fair that we're transparent and folk can see what I do. My folder's a lever arch file full of stats so they can see how many patients I see, what my out-patient activity is, how many home visits I do, how many in-patients I look after, what their length of stay is, what comments (some) and complaints (none, yay!) there've been, what my sickness is (still at 0 days over the last year), everything.
I don't expect everyone to wish to be as open. But I'm surprised at how opaque non-medical Consultants can be.
So, without any rancor, could I pose the question more widely. Rather than existing senior posts, of the non-medical Consultant posts that are high profile (eg the SHA need to agree), what do these posts involve that the non-Consultant posts don't? What is the raison d'etre behind a Nurse Consultant, Physiotherapist Consultant, Occupational Therapist Consultant or Social Work Consultant?
Some roles are clearly medical and Consultant roles. In my corner, elliciting psychopathology and ascribing significance to this, to generate formal diagnosis, is seen as a Consultant Psychiatrist's job. Nurses (especially non-medical prescribers) have to be able to generate a sufficiently robust formulation, but formal diagnosis remains medical. DVLA work and fitness to drive is medical. Assessment of capacity is everyone's business but assessment of testamentary capacity or ability to undertake Lasting Powers of Attorney or fitness to stand trial is seen as medical work (because it's only accepted when done by a medic). Mental Health Act 1983 work is done by doctors (and even within the ammended Act, it's only doctors who can make Assessments and recommend compulsory admission).
We do more. Complex management plans. Case Conferences and Journal Clubs and Clinical Effectiveness. Taking a lead in safeguarding cases, saying How It Is. Expertise in medication, ECT and interventions. Being the one to speak up in court. Teaching of every discipline. Management meetings. We see a lot of patients out of hours (last weekend a Consultant Psychiatrist was called 16 times and drove out and undertook 12 assessments, and had worked 2 other nights in the month, for which she receives the princely sum of £183.50/month for being on-call, i.e. pay of £36.70/night for each night she had to be on-call). I like to know about and input in to every management plan (and at least everyone gets a Consultant Psychiatrist's input then, after a CPN sees them and discusses care with me when they're back in the office and we meet up each afternoon). Audit.
On top of that, we spend a lot of time seeing patients.
Senior clinicians, seeing patients, using their clinical expertise whilst also doing enough management stuff to develop their service as they'd wish. Life as a Consultant Psychiatrist is fairly clear.
In fact, mine is very clear. I share my Job Plan and Appraisal with anyone who's interested. Lots of folk have been curious. Nurses, OT, secretaries, managers. Why not? I'm busy, I do loads, I critique what other people do, it's only fair that we're transparent and folk can see what I do. My folder's a lever arch file full of stats so they can see how many patients I see, what my out-patient activity is, how many home visits I do, how many in-patients I look after, what their length of stay is, what comments (some) and complaints (none, yay!) there've been, what my sickness is (still at 0 days over the last year), everything.
I don't expect everyone to wish to be as open. But I'm surprised at how opaque non-medical Consultants can be.
So, without any rancor, could I pose the question more widely. Rather than existing senior posts, of the non-medical Consultant posts that are high profile (eg the SHA need to agree), what do these posts involve that the non-Consultant posts don't? What is the raison d'etre behind a Nurse Consultant, Physiotherapist Consultant, Occupational Therapist Consultant or Social Work Consultant?
Monday, 9 February 2009
Healing Hands
One lady in a care home, with advanced dementia, has a rather feisty disposition. Her daughter's more vehement in her assertions, saying, "She's a vile creature, she's always been evil, really evil!"
As her dementia has progressed, so her frontal lobe function's deteriorated and she's become more disinhibited, her natural demeanour has come to the fore, with any veneer of civility or decorum being long lost, now.
The care home staff describe her as being an active soul. She fills her time to her amusement and satisfaction, "Tormenting other residents with wicked words and abuse," through throwing food she doesn't like from her plate onto the floor, or at carers, grinning as she does so, snatching food from other folks plates if she wants it, saying hurtful things just to get a response, "That's your daughter going, is she? Must be bored with you, what with you saying the same things to her all the time, I expect she's glad to be away."
My nursing colleagues saw her a number of times. I saw her once to establish diagnosis, capacity and exclude a treatable mood disorder.
I use risperidone as a depot medication for a number of folk but I can't think, in the last couple years, of anyone I've prescribed oral risperidone for. My nursing colleague discussed this lady's presentation with me and sought to start a low dose of oral risperidone. She persuaded me it was a reasonable plan to try then review, so we did. She also gave the home advice on how to handle this lady's interesting presentation.
Just 2 weeks on when she was reviewed, the care home staff say she's cured! All the malicious talk's stopped. She's still swearing like a trooper and nipping and scratching when staff try and help her bathe, but she's no longer biting. At meals and in the lounge she watches everything and grins to herself but can now bite her tongue and remain, if not prosocial, at least asocial rather than being antisocial.
A good result.
As her dementia has progressed, so her frontal lobe function's deteriorated and she's become more disinhibited, her natural demeanour has come to the fore, with any veneer of civility or decorum being long lost, now.
The care home staff describe her as being an active soul. She fills her time to her amusement and satisfaction, "Tormenting other residents with wicked words and abuse," through throwing food she doesn't like from her plate onto the floor, or at carers, grinning as she does so, snatching food from other folks plates if she wants it, saying hurtful things just to get a response, "That's your daughter going, is she? Must be bored with you, what with you saying the same things to her all the time, I expect she's glad to be away."
My nursing colleagues saw her a number of times. I saw her once to establish diagnosis, capacity and exclude a treatable mood disorder.
I use risperidone as a depot medication for a number of folk but I can't think, in the last couple years, of anyone I've prescribed oral risperidone for. My nursing colleague discussed this lady's presentation with me and sought to start a low dose of oral risperidone. She persuaded me it was a reasonable plan to try then review, so we did. She also gave the home advice on how to handle this lady's interesting presentation.
Just 2 weeks on when she was reviewed, the care home staff say she's cured! All the malicious talk's stopped. She's still swearing like a trooper and nipping and scratching when staff try and help her bathe, but she's no longer biting. At meals and in the lounge she watches everything and grins to herself but can now bite her tongue and remain, if not prosocial, at least asocial rather than being antisocial.
A good result.
Subscribe to:
Posts (Atom)