Friday, March 23, 2018
Pre-Anorexia Nervosa & Pre-Raphaelites: A Profound Secret!
In life one should value chance encounters.Earlier in June we spent some time with our friends in Dorchester
In a chance encounter with Andrew Lloyd Webber, Josceline Dimbleby asked him bluntly if she could go and see the portrait he had of her great-aunt, Amy Gaskell.
“Ah, that wonderful dark picture,” Andrew said. “Yes, please come……Well, I think she looks rather like you......”
“Did you know that she died young?” Josceline asked Andrew.
“Of a broken heart.”
She told Andrew that she would try to find out more. This led her to start researching into the life of Amy, her mother May and the famous Pre-Raphaelite painter Edward Burne-Jones and the result was the book A Profound Secret.
I looked at the book cover and thought the portrait reminded me of the Picasso I used for my Anorexia Blog.
Leighton House Museum 2004/Andrew Lloyd Webber
Girl in a Chemise Picasso Tate
It is said that as a young man Picasso admired the pre-Raphaelites and Edward Burne-Jones so much that in 1900 he would have gone to London rather than Paris
“There was a hint in the book that she might well have died of Anorexia!” My hostess said.
It was a fascinating book, like good family biographies are, as long as you accept that it is not going to be as organised as fiction. A good writer helps and Josceline Dimbleby is a well established food and travel writer.
For a psychiatrist, it is especially interesting as he is allowed glimpses into the various personalities, their psychiatric problems and the resulting family dynamics, without the interference of the usual psychiatric labelling or coding. Unfortunately self medicating with alcohol, opium and other fancy substances was rife in that era and the result could often be tragic.
Indeed Josceline thought at one point in the book that Amy might have suffered from Anorexia although it was not a known condition at the time. She left it till the end of the book to let us into the final secret. You will have to find out for yourself.
Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.
Psychiatry may need to look again at what we have been doing, as we do not seem to have found another Burne-Jones.
Reference: "There had been a considerable vogue in Barcelona
........"Picasso assured me, when he was staying in London in 1950, that for him his [1900] trip to Paris was merely a halt on a journey that would take him further north to London England
Other References:
Related Posts:
The Book: The Cockroach CatcherRead more:
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
A Brief History of Time: Anorexia Nervosa
In life one should value chance encounters.
Earlier in June we spent some time with our friends in Dorchester
In a chance encounter with Andrew Lloyd Webber, Josceline Dimbleby asked him bluntly if she could go and see the portrait he had of her great-aunt, Amy Gaskell.
“Ah, that wonderful dark picture,” Andrew said. “Yes, please come……Well, I think she looks rather like you......”
“Did you know that she died young?” Josceline asked Andrew.
“Of a broken heart.”
She told Andrew that she would try to find out more. This led her to start researching into the life of Amy, her mother May and the famous Pre-Raphaelite painter Edward Burne-Jones and the result was the book A Profound Secret.
I looked at the book cover and thought the portrait reminded me of the Picasso I used for my Anorexia Blog.
Amy Gaskell by Edward Burne-Jones
Leighton House Museum 2004/Andrew Lloyd Webber
Girl in a Chemise Picasso
Tate
It is said that as a young man Picasso admired the pre-Raphaelites and Edward Burne-Jones so much that in 1900 he would have gone to London rather than Paris
“There was a hint in the book that she might well have died of Anorexia!” My hostess said.
It was a fascinating book, like good family biographies are, as long as you accept that it is not going to be as organised as fiction. A good writer helps and Josceline Dimbleby is a well established food and travel writer.
For a psychiatrist, it is especially interesting as he is allowed glimpses into the various personalities, their psychiatric problems and the resulting family dynamics, without the interference of the usual psychiatric labelling or coding. Unfortunately self medicating with alcohol, opium and other fancy substances was rife in that era and the result could often be tragic.
Indeed Josceline thought at one point in the book that Amy might have suffered from Anorexia although it was not a known condition at the time. She left it till the end of the book to let us into the final secret. You will have to find out for yourself.
Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.
Psychiatry may need to look again at what we have been doing, as we do not seem to have found another Burne-Jones.
Reference: "There had been a considerable vogue in Barcelona
........"Picasso assured me, when he was staying in London in 1950, that for him his [1900] trip to Paris was merely a halt on a journey that would take him further north to London England
Other References:
Related Posts:
The Book: The Cockroach Catcher
Read more:
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
A Brief History of Time: Anorexia Nervosa
: Yo Yo Ma
You may also want to read about Amanda.
Anorexia Nervosa Posts
May 22, 2012
She had been hospitalised for Anorexia Nervosa. She was cured. She got married. Then she had Chris. If she did not tell me, I never would have guessed she had Anorexia Nervosa. At first I did not even know how I knew
Mar 01, 2008
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
Monday, March 19, 2018
Child Psychiatrist: Just doing his job!
It is Spring, despite the snow, the Oak Tree is trying:
All photos ©2014 Am Ang Zhang
Spring reminded me of my adolescent patient, it was her spring too.
Rachel
Rachel could not get to school. She was having such bad back pain. Her family doctor wrote an urgent referral. As she would not see the psychologist at school, school was considering taking mother to court.
There was a change in managing school refusal. Education Authorities suddenly turned trigger happy and all over the country parents were taken to court. I did wonder if this was due to a shortage of Educational Psychologists who were now too busy dealing with Formal Assessments as a result of the new Education Act, or whether it was due to years of public criticism of the inadequacy of the softly softly approach to the problem. There is some truth that there is a hard core of children whom no teacher really wants to see at school and the authorities are quite happy they are absent. These are children who are entitled to free meals and the hidden saving of them not attending school adds up to a pretty substantial sum. To assess them would take up precious Psychologist time and also may generate expenses in terms of ferrying these children by taxi to special tutorial units or schools.
But Rachel came from a professional family. Mother was a lawyer and father an insurance executive commuting to London
Clinical judgment is indeed a kind of “profiling”. We judge our patients from a variety of information and we “profile” them. It may not be correct but we do.
I had my suspicion that the Educational Psychologist never got to see her record to realise that she was not really the type anyone should ever dream of prosecuting.
The family doctor thought that I should be given a shot before anyone should have a go. Mother was told in no uncertain term that she needed to get Rachel to see me.
“But she was in such pain!” mother said. She did protest but in the end succumbed. With the help of a neighbour, they managed to get her to the clinic and she was lying down in our waiting area.
I had one look at Rachel, perhaps 6 ft tall, lying flat in the waiting area and asked my secretary to call an ambulance whilst I talked to the Radiology Consultant. An X-ray examination was ordered and if necessary an MRI scan.
How could I come to such a decision without even spending half a minute with mother or the patient? Was I being over dramatic? Or was it what we have been trained for? Was it why psychiatrists are trained as doctors first?
I could of course have been entirely wrong and the girl might really have been school phobic. Would I have subjected her to an unnecessary X-ray examination? Would my reputation suffer as a result?
The ambulance came. The paramedics were excellent. They treated it as potential spinal injury and transported her that way. I accompanied her onto the ambulance. You had to see her face to know you were right. She was grateful someone believed her. For me it was worth all the drama. My only wish was we were not too late that she might not be able to walk.
Mother too shook my hand as the ambulance got ready to go. I always told my juniors. “Trust them, most of the time.”
I left a message for the radiologist to call me.
The call came back from the radiologist. She had two collapsed vertebrae, a common condition among very tall children who have just had a growth spurt. The Orthopaedic Surgeon was preparing for an emergency operation.
“Good work.” The radiologist said.
I knew. He meant: “Good work for a psychiatrist, and a child psychiatrist at that.”
Some time later mother arranged to see me to tell me in detail what was done.
“She wants to thank you for believing her.”
I was just doing my job.
The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US
From another doctor:
Absolutely riveting! Brings me back to working (in NHS psychiatry) when work was really interesting! The tone is quite conversational; it is like hearing you telling stories. I ordered more copies for my family and friends.
I knew it would be very special and it sure is. To us your trainees it is like going back on the rotation to have the joy of working with you again. The difference is that l can now learn at leisure from this book. Congratulations.
The book is very well written and makes very easy and interesting reading even for the laymen. You learn a lot about the Health System, a lot about child psychiatry and a lot about the growing up and development of the author.
Fascinating account of child psychiatry cases, including some creative yet effective treatments. Anyone who is a parent or around children or really anyone at all actually will find the book surprising, entertaining, thought-provoking, funny and moving.
The book makes me realize the difficult decisions with which a doctor is so often faced, the need for him to have faith in himself and, coupled with that, the need for continued idealism and enthusiasm. These don't, of course, apply only to doctors but are particularly important for them.
Great book. I have bought one to give to my son on his birthday.
Tuesday, March 13, 2018
Photography: The Old Days!
It was a rather somber day when I gave away all the chemicals that I have accumulated over the years of dark room work. As it happened the couple that got them were both medical doctors. Hopefully they can make good use of them.
There is indeed much that modern day software can do to duplicate the work of the traditional dark room. Yet there is something magical seeing your print wet and perfect in the dark room.
I have often been asked about some of my photos:
Here are some of the technical details.
Both are taken with Nikon FM2 180/2.8 ED lens. The lens was probably the best of the hand held pre-digital lens Nikon ever produced and I still use it with my Digital Body.
Mademoiselle
Film: Kodak Tmax100 Kodak developer.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.
Sharp-eyed photographers would notice Pan Am sign thus dating the picture.
Film: Ilford 400 developed by pushed Rodinal developer to get the sharp and huge grains.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.
It is vital to get the sharp focusing of the grains.
Photoshop can in the quadtone mode assign different tones to different levels at will and the level adjustment will enhance what is often a gamble on Lith. Modern printers cannot quite produce the exhibition quality of good Fibre Base Paper of old.
Saturday, March 10, 2018
Bright Young Doctors & Rainbow: Answer to Prayers!
In Medicine, it is amazing what the Bright Young Doctors can offer. In my day and now!
Thirty years ago, a patient of mine was unconscious for 23 days and it was mother's belief that it was through prayer that her daughter was saved. I did not argue with her then.
The Bright Young Doctor in my days:
" A good doctor is one who is not afraid to ask for help but he must also know where to ask.
“Get me Great Ormond Street
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
Who needs consultants when juniors have that kind of network? This girl will do well.
“Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
But perhaps God works through his people in his own way. Discoveries in Medicine should therefore enhance our faith rather than the other way round.
It took nearly 30 years for the real answer to her prayers to really emerge.
©2012 Am Ang Zhang
The Bright Young Doctor now:
I was staying at our resort in Boquete and was having dinner with three friends all of them with medical connections. One was in hospital administration and one a nurse. The husband of the nurse was a pharmacist. Somehow the conversation drifted into medical topics and knowing that I am a Child Psychiatrist the pharmacist started talking about his nephew who was nearly sent to a mental institution as he suffers from catatonia and doctors eventually diagnosed schizophrenia and put him on antipsychotics. Luckily the catatonic symptom probably saved him as some bright young thing just read the book Brain On Fire and gave him the Clock Test. That led to the NMDAR antibody testing that proved positive. He responded well to the treatment regime that has been developed and is off all antipsychotic medication.
My Teratoma patient was lucky as she belong to that group that improved without further treatment once the Teratoma was removed. She eventually had a baby.
The Power of Prayers & Teratoma: Brain & NMDA!
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Anti-NMDA Receptor Encephalitis
NEW ORLEANS — A mysterious, difficult-to-diagnose, and potentially deadly disease that was only recently discovered can be controlled most effectively if treatment is started within the first month that symptoms occur, according to a new report by researchers from the Perelman School of Medicine at the University of Pennsylvania. The researchers analyzed 565 cases of this recently discovered paraneoplastic condition, called Anti-NMDA Receptor Encephalitis, and determined that if initial treatments fail, second-line therapy significantly improves outcomes compared with repeating treatments or no additional treatments (76 percent versus 55 percent). The research is being presented at the American Academy of Neurology's 64th Annual Meeting in New Orleans
565 cases! Not so rare!
The condition occurs most frequently in women (81 percent of cases), and predominately in younger people (36 percent of cases occurring in people under 18 years of age, the average age is 19). Symptoms range from psychiatric symptoms, memory issues, speech disorders, seizures, involuntary movements, to decreased levels of consciousness and breathing. Within the first month, movement disorders were more frequent in children, while memory problems and decreased breathing predominated in adults.
My patient was under 18 and presented with catatonia symptoms. She later lose consciousness and was ventilated.
"Our study establishes the first treatment guidelines for NMDA-receptor encephalitis, based on data from a large group of patients, experience using different types of treatment, and extensive long-term follow-up," said lead author Maarten Titulaer , MD , PhD, clinical research fellow in Neuro-oncology and Immunology in the Perelman School of Medicine at the University of Pennsylvania
The disease was first characterized by Penn's Josep Dalmau, MD, PhD, adjunct professor of Neurology, and David R. Lynch, MD, PhD, associate professor of Neurology and Pediatrics, in Annals of Neurology in 2007. One year later, the same investigators in collaboration with Rita Balice-Gordon, PhD, professor of Neuroscience, characterized the main syndrome and provided preliminary evidence that the antibodies have a pathogenic effect on the NR1 subunit of the NMDA receptor in the Lancet Neurology in December 2008. The disease can be diagnosed using a test developed at the University of Pennsylvania
Teratoma: finally!
In earlier reports, 59 percent of patients had tumors, most commonly ovarian teratoma, but in the latest update, 54 percent of women over 12 years had tumors, and only six percent of girls under 12 years old had ovarian teratomas. In addition, relapses were noted in 13 percent of patients, 78 percent of the relapses occurred in patients without teratomas.
As Anti-NMDA Receptor Encephalitis, the most common and best characterized antibody-mediated encephalitis, becomes better understood, quicker diagnosis and early treatment can improve outcomes for this severe disease.
The study was presented in a plenary session on Wednesday, April 25, 2012 ET at 9:35 AM at the American Academy of Neurology's annual meeting.
[PL01.001] Clinical Features, Treatment, and Outcome of 500 Patients with Anti-NMDA Receptor Encephalitis
Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies
Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.
Related paper:
Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment
I remember my early days of psychiatry in a mental hospital in
Chapter 29 The Power of Prayers
The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers.
According to old Chinese advice, it is wise never to discuss politics or religion even amongst best friends.
Religious belief can often blur judgement in the wisest of people. In psychiatry it is sometimes not easy. This is particularly true in cases of florid psychosis, which often presents with symptoms of hallucination, delusion and even vision.
I remember my early days of psychiatry in a mental hospital in Hong Kong . Yes, it was the days of 2000-bed hospitals. Yes, it was the days of Medical Superintendents who had supreme power and all doctors of whatever rank and experience were Mental Health Officers with special authority to sign papers for compulsory admissions. The forensic unit was contained within the same complex. Those were the days when we encountered psychosis in the raw so to speak. All the colony’s really mad people were admitted to this one place set in the furthest corner of the colony. In our year seven of us decided without much discussion that we all wanted to go into psychiatry. That was over 10% and all had quite idealistic reasons. It was perhaps a bit of a disappointment to our parents that we did not pursue a more conventional specialty that might provide us with more status and financial reward. Then there was the fear of contamination that somehow one might become mad too. Recent day medical students are said to shy away from psychiatry for these same reasons. Education seems to have little effect on superstition.
......................................….read the full Chapter: HERE
Thursday, March 1, 2018
Dawning on Anyone: CCG Paying For Do Not Refer!
It is beginning to hit us that CCGs are no longer keeping it a secret: bring me a Cobra and we will reward you. The modern Cobra is: not referring a patient to the bad money grabbing Hospitals. Tell the patients, Community Care much better.
Next year, cut down more or no payment.
Then suddenly, there will be so many more desperately ill patients: part ot the Cobra effect.
It is already happening with NHS111. You have no way of authenticating the calls!
Dawn, anyone?
©Am Ang Zhang 2013
Enemy Of The People: NHS, Internal Market & Safety Net
DR. STOCKMANN: Should I let myself be beaten off the field by public opinion, and the compact majority, and such deviltry? No, thanks. Besides, what I want is so simple, so clear and straightforward. I only want to drive into the heads of these curs that the Liberals are the worst foes of free men; that party-programmes wring the necks of all young living truths; that considerations of expediency turn morality and righteousness upside down, until life is simply hideous.... I don't see any man free and brave enough to dare the Truth.... The strongest man is he who stands most alone. Ibsen
Be very afraid: see >>>>NHS Privatisation Divide and Conquer
I quoted Prof. Waxman in an earlier post that will be reprinted.
April 30, 2010 Jonathan Waxman
When I started in medicine, the hospital was run by about three people. Things were so much more simple when doctors and nurses treated patients, doing their best without the guidance of guidelines and targets, doing their best ... yes ... to make the patients better. How did we manage without forms to fill and waiting times compliance? Quite well actually. The medical director ran the medical side of things while matron and the accountant handled the rest. It wasn’t much of a business then: it didn’t have to be, because there was no internal market to manage.
The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford , when it is not Oldham or Oxford
And there are big problems with the billing process. For example, if a patient is seen in an outpatient clinic then there is a charge made by the hospital for his or her first attendance — but follow-up appointments are not charged. And if many treatments are given in a hospital to a patient, only the most expensive of the treatment episodes is charged.
There are savings to be made. It is alleged that there are just 75,000 administrators at work in the NHS but this figure is laughably mythological.
One report by the Centre for Policy Studies published in 2003 indicated that there were 250,000 administrative staff employed in the NHS: at least one administrator for every nurse.
There is a general feeling in the NHS of disempowerment of the professionals. People can’t face up to the incredible struggle, the disapproval that faces any of them if they have the temerity to suggest that things should be run differently.
The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it. The reality is gravediggers working with a cost improvement shovel made of rust.
Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.
So what should we do? Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid. At this election time please let us hear from all political parties that they will ditch this absurd love-affair with the internal market. Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.Remember Fund Holding?
The general practitioner (GP) fundholding scheme was introduced as part of the Conservative governments 1991 National Health Service reforms and abolished by the Labour government in 1998. This paper contends that the scheme was introduced and abolished without policy-makers having any valid evidence of its effects. In particular, it focuses on the salient features of the decision to abolish. These were:
(a) that it was not based on evidence;
(b) that it came relatively soon after the introduction of the scheme; and
(c) the GP fundholding scheme was voluntary and increasing numbers of GPs were being recruited. The overtly political nature of the introduction of GP fundholding is already well documented and is important in understanding the lack of evidence involved in the development of the fundholding scheme.
Yes, I remember! Not just Labour!
It was an interesting time during the brief few years of Fund Holding (FH). The idea that money should play no part in who gets seen was thrown out of the window. My hospital consultant colleagues all knew that preference will be given to referrals from Fund Holding practices. It was about survival. Less urgent cases would be seen if they come from FH practices.
Our Trust was small and we had to deal with two main FH practices and five non-FH ones. Child Psychiatry used to take self referrals but overnight that was stopped by our managers. Worryingly referrals from one FH practice dropped very dramatically. So the government’s clever idea may have some merit.
Then something strange happened. The other FH practice’s referrals shot up dramatically and this was across all disciplines.
Our managers thought: wow, more income for the Trust.
Not so the Cockroach Catcher and despite my protestation, I had to give their referrals preferential treatment.
“I thought it was based on clinical merit.”
Then, the bombshell: we were owed in excess of £2 million at the end of the second year and special administrator was sent in by the Authorities. We never got the extra money!
I quoted Prof. Waxman in an earlier post :
April 30, 2010 Jonathan Waxman
When I started in medicine, the hospital was run by about three people. Things were so much more simple when doctors and nurses treated patients, doing their best without the guidance of guidelines and targets, doing their best ... yes ... to make the patients better. How did we manage without forms to fill and waiting times compliance? Quite well actually. The medical director ran the medical side of things while matron and the accountant handled the rest. It wasn’t much of a business then: it didn’t have to be, because there was no internal market to manage.
The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.
And there are big problems with the billing process. For example, if a patient is seen in an outpatient clinic then there is a charge made by the hospital for his or her first attendance — but follow-up appointments are not charged. And if many treatments are given in a hospital to a patient, only the most expensive of the treatment episodes is charged.
250,000 administrative staff
There are savings to be made. It is alleged that there are just 75,000 administrators at work in the NHS but this figure is laughably mythological.
One report by the Centre for Policy Studies published in 2003 indicated that there were 250,000 administrative staff employed in the NHS: at least one administrator for every nurse.
Disempowerment
There is a general feeling in the NHS of disempowerment of the professionals. People can’t face up to the incredible struggle, the disapproval that faces any of them if they have the temerity to suggest that things should be run differently.
The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it. The reality is gravediggers working with a cost improvement shovel made of rust.
The Nation as a whole
Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.
So what should we do? Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid. At this election time please let us hear from all political parties that they will ditch this absurd love-affair with the internal market. Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.
Why should anyone worry who provides healthcare? Because the weight of evidence is that private markets in health bring exorbitant administrative costs, lead to cherrypicking of more profitable patients, increase inequity and the postcode lottery gap, generate conflicts of interest, are unaccountable, and increase pressure for top-up payments and "care package" limits.
Keith Palmer on competition and choice
“…….competition and choice in contestable services may inadvertently cause deterioration in the quality of essential services provided by financially challenged trusts, and therefore widen the quality gap between the best and worst performers. Market forces alone will rarely drive trusts into voluntary agreement to reconfigure in ways that will improve quality and reduce costs. In most cases, the most likely outcome is that financially challenged trusts will suffer a downward spiral of continuing financial deficits, deterioration in the quality of care and a further widening of the quality gap. The NHS will have no alternative but to continue to fund these deficits or allow the trusts to fail.” RECONFIGURING HOSPITAL SERVICES: Lessons from South East London
Cobra Effect:
A famous anecdote describes a scheme the British Colonial Government implemented in India in an attempt to control the population of venomous cobras that were plaguing the citizens of Delhi that offered a bounty to be paid for every dead cobra brought to the administration officials. The policy initially appeared successful, intrepid snake catchers claiming their bounties and fewer cobras being seen in the city. Yet, instead of tapering off over time, there was a steady increase in the number of dead cobras being presented for bounty payment each month. Nobody knew why.
A CCG is offering practices incentives to cut all referrals – including cancer referrals – Pulse has learnt.
Pulse’s ‘Cash for cuts’ investigation has found that NHS Rotherham CCG’s ‘quality contract’ scheme incentivises practices to cut referrals by 1% or come down to the CCG average.
However, unlike other schemes uncovered by Pulse, the scheme includes cancer referrals.
Under the quality contract, practices are expected to ‘reflect on current referral behaviour’, including peer review – especially of locums – in a scheme worth £3.36 per patient.
Monday, February 26, 2018
Finland: Lithium!
In medicine, population wide survey has its place not forgetting that when many modern psychiatric drugs went through the so called "robust" double blind control trial, it is never really all that double blind as many of the drugs tested have side effects that could easily biased both patient and researcher. The patient realising that he/she is taking the "real" drug might want to report improvement or the opposite. The observing researcher will realise very quickly and may unfortunately be biased even if unintentional.
I remember questioning the presenters of Olanzapine on this especially as patient reported great craving for food and put on weight, the presenter refused to answer my question.
Then there is the question of Bipolar or Unipolar. Well, my view is this and Psychiatrist might not like to admit it: we might get it wrong. If risk of suicide is high why use something that might provoke suicide. The same Finnish team that did the research came up with the answer on using Lithium in Unipolar Depression!
© 2012 Am Ang Zhang
Finland & Unipolar Depression: a nationwide cohort study.
Prof Jari Tiihonen, et al/ Here are the essential points and full summary here.
Background
MethodsFinland who had been admitted to hospital at least once for unipolar depression (without a diagnosis of schizophrenia or bipolar disorder) in Finland
Findings
Interpretation
The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”
“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”
Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.
“Get him admitted and I shall talk to the doctor there.”
He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.
He had one of the worst encephalitis they had seen in recent times and they were surprised he survived.
Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.
Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.
I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.
Sunday, February 18, 2018
The Cockroach Catcher & Adolescent Days: Prickly! Prickly! Prickly!
©2016 Am Ang Zhang
The Cockroach Catcher remembers his Adolescent days fondly, I mean my Adolescent In-patient days fondly. There was much politics to deal with and this time he used Ping Pong!The Cockroach Catcher: Chapter 24 Ping Pong
I |
t is the nature of life that now and again you have to do people favours. Sometimes you do it in case you need favours back. More often than not it is about doing the right thing.
One of my outpatient colleagues was female and ethnic. When she realised that I became in charge of the adolescent unit, she said to me, good, now I can get some of my patients admitted.
It was very difficult to decide if there was racism or sexism. It was true that many of her referrals did not get to be admitted and most of the time the nurses had justifiable reasons. One nurse in particular warned me from day one that I should not touch any of her cases.
Nurses are very powerful in an adolescent unit. They have front-end dealings with patients from pre-admission to admission to discharge. For someone new like me it would have been foolish not to take notice of such a clear cut warning. But anyone who knows me well enough would not expect me to be easily intimidated. I would not have an all out fight but I have my ways.
However, this consultant did not help herself in matters. Before my arrival she had been writing to the Health Authorities about her difficulties in getting patients admitted. Luckily for the nurses all the blame was laid on the previous consultant who was eventually suspended and dismissed.
By then, the nurses felt that they were in some position of authority and my emergence was not exactly met with fanfare, although there was for some a sense of relief as my success at the Children’s Unit in the last ten months was beyond anybody’s expectation except mine. The nurses working in the Children’s Unit, including the wife of the charge nurse at the adolescent unit, warned me that adolescents were different.
It was also difficult to turn up at a place that had been running on auto-pilot for some time. The staff began to feel that doctors might not indeed be necessary except for this silly rule that they alone could prescribe.
The consultant in question was known to have an “over-understanding” approach to cases and she felt sorry for a number of patients where there was a strong social element to the problem. Due to shortage of beds, we did try to limit admission to genuine psychiatric cases.
However when I was asked by the Health Authorities handling her complaints to look at one of her cases again what choice did the nurses think I had? Quite simply, admit or else.
But the decision was always mine!
One of the boy’s problems was that he lived with mum and had not been to school for nearly a year. As the consultant requested an assessment at a psychiatric unit, Education Department refused even to look at him until that had happened.
A stalemate.
In the meantime, Education Department had saved the better part of thirty thousand pounds and they had a legitimate reason. He was first kicked out of school because he used threatening language with a female teacher when asked to read his story.
Mother also reported how threatening he was to her at times.
From this bit of history he was definitely no good for our unit. The last time the unit had to be closed in the middle of the night was precisely because of violence to female staff.
We too had a legitimate reason not to admit him.
I took the charge nurse Martin on one side and asked him to tell me what he would think if we were dealing with a brand new referral.
I discovered months later that he found me genuine and really wanted to give me a chance to make a go of it. As such he had to tell me the problem.
©2016 Am Ang Zhang
The problem of anarchy.
There was amongst some staff a strong anti-authority feeling. There was no doubt they were let down by the previous consultant and some of the nurses could have been hurt. Following the incident, an outside consultant was employed to provide a report at great expense to the NHS Trust. I could have told them the problem free of charge.
Such is management nowadays that the dirty work has to be done by an outsider. We were still in the investigation period and no doubt everything I did would be under scrutiny. The survival of the unit would depend on the outside consultant’s report. I had lunch with him on many occasions and luckily his NHS views were in fact very close to mine. Six weeks he had to be with the unit and six weeks was a long time.
So I was lucky in that there had to be a truce. We could not let personal prejudices override clinical decisions.
In the end and some thousands of pounds later we managed to keep our unit running and in some little way I changed my view about outside consultants. The good ones are good and this one was a practising inpatient child psychiatrist so there was no need really to say too much about politics and anarchism. He understood because he experienced it himself, and he found a way to deal with it.
So running an adolescent unit is like running a mini-country. In our democratic age, the wisest thing to do is to bring about the changes you want when you are riding high, and then leave. Do not wait to be kicked out.
As psychiatrists, we do have certain power conferred by the Mental Health Act and that is often a sore reminder of the difference between us and the other staff – more so as we still had two Sectioned patients in the unit at the time: one anorectic on tube feeding and one psychotic.
Martin the charge nurse said he would visit the boy Leroy at home to assess him and if I could agree to a time-limited admission we might have a “goer”. He thought that Leroy was probably “all barks” only. His father was from the West Indies and the one time Martin met Leroy he was just loud and boastful and not as threatening as mother always made him out to be.
In the two years I lived on a Caribbean island, I discovered that many of the children there were in fact very gentle and timid, and they were never rude to their parents. I know not all the islands are the same and generalisation can be very dangerous.
“But you may have to speak with Kevin. He visited the last time.”
Kevin was the one who warned me not to even think about it. There were many ways to deal with violence in our kind of unit. More often than not if the adolescent patients sensed that there was no leadership they ran wild.
I decided on a direct approach.
“I am going to be frank with you, Kevin. I want you to go out with Martin and see this boy again and I want him in a.s.a.p. unless you can convince me that there is a good reason why he should not have the benefit of a six week assessment. I know you think I am doing a favour and I can tell you now, I am. Sometimes in life you have to because not doing it is going to hurt a lot more people, including ourselves.”
“Six weeks then.”
©2016 Am Ang Zhang
My new junior, who was a very timid girl, decided to go out on the visit too when she realised that there would be protection. Leroy had just turned thirteen and she told me that she thought he might well have the King’s disease.
“You mean what they claim King George VI had?” I thought it was very clever of the drug firms wanting to push the new drug for Social Phobia to involve the King. “Don’t forget King George VI had lung cancer and metastasis could do strange things.”
No problem. Leroy agreed to come in when he learned that we had two ping pong tables and that Martin played County Championship League. My junior said she was glad she went and she really did not understand what the fuss before was about. I told her that even in adult psychiatry, reports on patients could often paint an unreal picture and the mildest people could be made to appear like big monsters.
It was suggested that the only time there might be trouble would be when the boy came to be admitted, and therefore he should not come in his mother’s car but in a hospital bus instead, accompanied by some of the big male nurses. I might have given in to the idea but my junior came to my rescue. She would go with the charge nurse and bring him in her car. Mum could drive down on her own.
“It is a hospital lease car anyway.”
“The last time a male nurse offered to take a female patient home he was accused of touching her and he was suspended.”
“Was he guilty?”
“No, but he died of a heart attack. We shall send our bus but you can be the medical escort.”
I remember once escorting a Manic Depressive (Bipolar 1) from Hong Kong to London
Why should all the fun be left to the nurses, I thought to myself but I was never going to let her drive, Crown Car or otherwise.
Leroy looked as if he was going to camp, with his new white trainers and sports outfit that father presented over the weekend together with the latest sunglasses.
Martin told me sometime later that father called him wanting to know if I was “Cool, man. You know what I mean, man.”
“I told him you were actually Chinese. He said he did not want no white doctor putting no funny thing into his boy. I also told him the consultant would be happy to see him any time he liked.”
Martin reckoned he was doped up heavy with something from the way he was slurring his speech. He was all right as long as I was not white.
“Good, no more racism. Not from us.”
Father also gave Leroy a new sports-bag to carry all his stuff. It was really too big for him and my junior reported to me the verbal duel between mother and son.
“You are blocking the way with that stupid bag.”
“Dad gave it to me.”
“He is stupid.”
“He is not.”
“Why didn’t you go live with him?”
“You took his house.”
“He shouldn’t hit me and you are copying him. Stupid bag, you are not going to Jamaica
“Tag Heuer, they are the best.”
“Move your stupid bag. Stupid Nike bag.”
She turned to my junior, “He does not really want to go in, and that is why he is so slow.”
With that he moved.
“Have you read Jay Haley[2]?” Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's.
“I have read Bateson.” Gregory Bateson was the well known social scientist who wrote Steps to an Ecology of Mind, and Mind & Nature.
I am beginning to like her. She is going to be a good psychiatrist.
So Leroy arrived and was at a bit of a loss standing outside the Nurses’ Office.
It was time for mother to leave. We tended not to let mothers stay too long for admission for obvious reasons.
“Aren’t you going to give me a kiss then? Why aren’t you crying? I thought you did not want to come in.”
Did she not realise that maybe the boy was not that stupid? After a year shut up in the house with a mother like that, he would take up any chance to be away for six weeks!
He did kiss her and started to cry.
©2016 Am Ang Zhang
My junior cried too. I thought she did because she felt sorry for the boy.
“Leroy is a lamb, isn’t he?” Martin said to me later.
“So we shall be fine then.”
He smiled.
For the first weekend inpatients were normally not granted home leave to allow for settling in and from then on the weekend leaves would be dependent on their performance at community meetings and on how they were assessed by their fellow patients. They had to ask for a grade and if the grade was not good enough they were not allowed home. This system had been running for years and I really did not want to rock the boat at such an early stage.
It was all stage-managed by the teaching staff, who unfortunately found this the only way whereby they could have any control over the children’s behaviour.
The first weekend Leroy was fine except when mother visited. There was some silly argument and he took himself to the toilet and did not come out until he was assured mum was gone.
Then he said he missed his dad, who did not have a car and mum refused to drive him down as the last time she drove him somewhere he hit her after some argument.
“He wanted a new game from dad and dad promised he would get him one if he could get home leave,” Kevin told me the real reason he wanted to be home.
That is very much the modern way a parent relates to a child. They do not know any other way.
“Psychology, you see,” he told Kevin over the phone. “I want to help the China Man.”
“I need everybody’s help!”
“Do you agree that Leroy has Social Phobia[3]? Everything fitted in with the criteria in DSM IV.” My junior plucked up courage to ask me during supervision.
It was good to keep oneself on one’s toes with juniors who had just arrived from London
“What’s wrong with shyness?” I joked, “Do you want me to put him on SSRI (Selective serotonin reuptake inhibitors)?”
“It is supposed to work.”
“If he starts taking SSRI at thirteen, what is he going to do for the rest of his life?!”
“The newer short acting ones are supposed to be better.”
“Take one advice from me; think the opposite, the opposite to what the big Pharmas tell you. In pharmacology, shorter acting drugs are more addictive. That was what I learned in Medical School
By Community Meeting time nobody had a hard word to say about Leroy, but they all noticed he did not socialise much. He had to ask for his grade as per time-honoured ritual. He could not. Everybody tried to urge him. My junior sat next to him and tried to hold his hand. He rushed off to the toilet and locked himself in again.
“To lock yourself in a toilet is a down-gradable offence and to do it twice in a week is just not on. And, Doctor, we have to be very strict with these rules. Otherwise we shall start having problems again,” said a teacher.
So, I was warned. My junior got rather emotional and said that was just too much for her. It was her first case and why couldn’t they be more understanding?
Martin interjected and said that of course if there were psychological reasons the consultant could grant a special home visit like half a day so that everybody could save face.
I liked that. Saving face. But then how popular would I be with the teachers?
What about Leroy’s face?
I knew whose face I wanted to save.
So I arranged to see Leroy straight away. No, I did not ask him why he could not speak up for himself. I knew already.
“I hear you are a very good ping pong player.”
“Table Tennis, you mean.” He was speaking to me.
“O.K. Table Tennis. You know he is good.” I said, pointing to Martin.
“Yeah, that is why I am not playing him. I played with Gerry.” Gerry was his nurse.
“The fat one.”
He smiled a little, thinking I was rude.
“He was a bit slow.”
“You must have given him a good run.”
Smile again.
“I hear you did not play with the kids though.”
“How did you know? They are no good.”
“Well, how about this? Have you ever played a Chinese?”
“No.”
“We hold the bat differently, you know.”
“Weird.”
“We’ll play three games and if you win you can go home for half a day and if you don’t, you stay.”
The look on my junior’s face was something to be seen. Martin put on a look to pretend that he knew I would come up with something, although he admitted later that what I suggested was the last thing on his mind.
The scene was set for a three game match between the consultant and his patient to decide if his patient could go for a short week-end leave.
Even the headmaster came out to watch, shaking his head in disbelief.
It was spring, still cold but sunny. The sun was streaming in. I lost the first game. I had not played for fifteen years. I took off my jacket. I barely managed the second. That brought some cheers.
From certain quarters.
He beat me bad on the last one. I did not get past 9 and that was bad for ping pong – sorry, Table Tennis.
I thought everybody forgave me. I did not give the game to him. He beat me fair and square. The situation was too surreal for anyone to remember to get cross.
The girls clapped as they all loved him and wanted to mother him, especially the older ones, even when many of them did not have a chance of home leave as their weight was not good.
I became their hero. Nobody reported me to the General Medical Council. Not that time, anyway.
Mother was horrified but thought that if he had been good and had not attacked any female he would be fine. She would just take him to his father, who would buy him his game.
On Saturday I was there for a new admission. My junior rushed in saying there was a disaster. Leroy would not go with mum because she did not want to buy him a Diet Coke from the Petrol Station next door. She said there was a pack from Tesco sitting at home and the Coke from the Petrol Station was too expensive.
“After all that!” I exclaimed to myself.
He just sat near the door. I went out, waved my arm in a table tennis move and asked him to follow me to the car.
“Cool wheels,” he said, “but it’s for old people though.”
I ignored him, opened the car boot and gave him a can of drink – still cool from the overnight frost.
I knew where his problem was.
May 30, 2016 ... In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer. |
Jun 14, 2016 ... ... of childhood psychological problems. Indeed it was a sad day when the unit closed. From The Cockroach Catcher: Chapter 48 The Last Cook ... |
Apr 25, 2014 ... ... then the Tate also rejected Picasso………” The Tate now of course has several Mondrian works. Now you can read the whole chapter here: ... |
Jun 29, 2011 ... In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”: Jane got on well with me. |
Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ... |
Jul 20, 2016 ... The following is an extract from The Cockroach Catcher: “Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he ... |
The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US
[1] BOAC – British Overseas Airways Corporation, now British Airways
[2] Jay Haley - A brilliant strategist and devastating critic, Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's.
[3] Social Phobia (now renamed Social Anxiety Disorder): Everyone feels nervous from time to time. Going on a first date or giving a speech often causes that butterflies-in-your-stomach feeling, for example. Or maybe you feel shy at a party among a group of strangers, but then slowly warm up to them and have a great time.
Wednesday, February 7, 2018
Scarlet Fever & Mahler: Sadness and Creativity!
After decades of decreasing scarlet fever incidence, a dramatic increase was seen in England
The strangest finding is that there is no evidence of any genetic mutation of the bacteria concerned nor resistance to antibiotic treatment. Perhaps we need to look closely at Ed Yong’s masterful new book, I Contain Multitudes, which tells the stories of the microbes that swarm within and around us.
Are we too clean? Do we use too much "Antibacterial" laced cleaning things? Or is the new near religious fervour in not using antibiotics to blame? We simply do not know.
But Scarlet Fever reminds me of Mahler.
©2013 Am Ang Zhang
Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever.
Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.
Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.
Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth.
Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.
Mahler died on May 18th 1911 in Vienna.
"I think it is probably the most personal composition I have created thus far." Gustav Mahler
The first performance of Das Lied von der Erde was conducted by Bruno Walter after Mahler's death.
Bruno Walter described it as: "the most personal utterance among Mahler's creations, and perhaps in all music."
My first encounter was in the early 70s with the recording by Janet Baker and Waldemar Kmentt (with Kubelik conducting the Bavarian Radio Symphony Orchestra). I still think it is one of the very best performances of Das Lied von der Erde.
Tuesday, January 30, 2018
M + M: Morbidity and Mortality Conference
© Am Ang Zhang 2018
I had a most enjoyable time on a Viking Ocean
In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.
........Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”
What would lawyers say about M + M:
- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’
I read Gawande when in Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures.
Peggy's Cove: Charm & Complications!
What a charming place: Peggy's Cove of Halifax.
The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.
The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.
We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.
A great book for doctors in particular and when on holiday in a charming place.
(Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver
Quotes
- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’
- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’
- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’
Quotes
- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’
- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’
- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’
Sunday, January 14, 2018
Antidepressants or Lithium! Side Effects but you will live to experience it!
In recent write ups about antidepressants, there is no mention of Lithium. The Cockroach Catcher first worked with one Australian Psychiatrist that worked with Cade and I was, so to speak, very biased towards Lithium. Yes, Lithium has side effects that might be serious. But hang on, you get to live to experience it. Think about it.
Thank goodness: someone is talking about it.
Atacama where Lithium is extracted © Am Ang Zhang 2015
Lithium: The Gift That Keeps on Giving in Psychiatry
At the recent American Psychiatric Association annual meeting in San Diego Harvard Medical School
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.
These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).
Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless.
Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
APA Nassir Ghaemi, MD MPH
- In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
- We haven’t developed a drug that’s more effective than any other drug since the 1970’s
- All we have developed is safer drugs (less side effects), but not more effective
- Dose lithium only once a day, at night
- For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium (Originally by Dr. Frederick K. Goodwin)
Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.
In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $
I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here. It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.
The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”
“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”
Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.
“Get him admitted and I shall talk to the doctor there.”
He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.
He had one of the worst encephalitis they had seen in recent times and they were surprised he survived.
Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.
Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.
I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.
Latest: British Journal of Psychiatry
Related Posts:
Chile: Salar de Atacama & Bipolar Disorder.
Lithium in Tap Water and Suicide Mortality in Japan.
Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan Aomori
"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."
One might ask why there has been such a shift from Lithium.
Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.
Some felt it has to do with how little money is to be made from Lithium.
One might ask why there has been such a shift from Lithium.
Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.
Some felt it has to do with how little money is to be made from Lithium.
Related Posts:
Lithium Bipolar and Nanking
Bipolar Disorder in Children
Bipolar and ADHD: Boys and Breasts
Statins-Harvard-Roosevelt
Bipolar Disorder: Biederman Einstein God.
Antipsychotics: Really?
Bipolar and ADHD: Boys and Breasts
Grand Round: Medicine and War
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?
Lithium Bipolar and Nanking
Bipolar Disorder in Children
Bipolar and ADHD: Boys and Breasts
Statins-Harvard-Roosevelt
Bipolar Disorder: Biederman Einstein God.
Antipsychotics: Really?
Bipolar and ADHD: Boys and Breasts
Grand Round: Medicine and War
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?
Monday, January 8, 2018
Dark Side: Mother threw own baby in fire!
Another Baby Murdered:
“A mother stole a baby from a wealthy family. She proceeded to throw her own baby into a fire and bring up the baby from the wealthy family as her own.”
That was not another major Social Services blunder.
That was at the Metropolitan Opera on Sept. 25th 2015.
Verdi’s Il Trovatore is probably well known to most for its Anvil Chorus. For me it is about The Dark Side, the dark side of human nature.
The Dark Side:
“My hunch is that despite media coverage many of us still fail to grasp the dark side – the dark side of human nature. Until we do, we shall continue to read about child abuse, abductions and murders of the worst kind.”From The Cockroach Catcher.
Much has been written about training others to do the doctor’s work in an attempt to save health cost. What is not covered is the fact that there is training and there is a broader aspect of education. The ability to transmit culture external to genetic coding is what distinguishes Homo sapiens from other animal species on Planet Earth. Many bloggers are well educated in this cultural respect either by design, by choice or by accident. There is now an uncomfortable feeling of de-education in the Brave New World. Will the next generation of doctors, nurses and bloggers be as cultured? I do wonder!
That was not another major Social Services blunder.
That was at the Metropolitan Opera on Sept. 25th 2015.
Verdi’s Il Trovatore is probably well known to most for its Anvil Chorus. For me it is about The Dark Side, the dark side of human nature.
The Dark Side:
“My hunch is that despite media coverage many of us still fail to grasp the dark side – the dark side of human nature. Until we do, we shall continue to read about child abuse, abductions and murders of the worst kind.”From The Cockroach Catcher.
Much has been written about training others to do the doctor’s work in an attempt to save health cost. What is not covered is the fact that there is training and there is a broader aspect of education. The ability to transmit culture external to genetic coding is what distinguishes Homo sapiens from other animal species on Planet Earth. Many bloggers are well educated in this cultural respect either by design, by choice or by accident. There is now an uncomfortable feeling of de-education in the Brave New World. Will the next generation of doctors, nurses and bloggers be as cultured? I do wonder!
In the mean time unnecessary deaths continued since Dennis O’Neill & Maria Colwell with millions spent on QCs holding public enquiries. A Chronology of selected inquiries
Darker side:
Doctor suspended for blowing the whistle:
Doctor suspended for blowing the whistle:
Dr Kim Holt was suspended from Great Ormond Street Hospital
SOMEONE took a decision at the famous Great Ormond Street Hospital (GOSH), in Bloomsbury , to suspend a senior pediatrician, Dr Kim Holt, from her post.
We know why the good doctor was suspended on full pay.
These are the facts: Dr Holt, a specialist of 25 years experience, started working in Haringey in a children’s department run by GOSH
in 2004.
in 2004.
Two years later she started writing to her superiors complaining about the loss of staff, and the risk of a possible “disaster” at the child protection service in Haringey if more doctors were not attached to the department. This was a matter of “public interest” and should be “investigated”, argued Dr Holt.
As readers will know, such a “disaster” occurred when a locum pediatrician was called in to see Baby P and made a mess of her examination. Two days after the examination Baby P died.
Was Dr Kim Holt patted on the back for her whistle-blowing?
No, someone, or a committee at GOSH, felt offended by Dr Holt’s interference – and suspended her.
In Il Trovatore, Azucena is the mother who killed her own baby and Manrico was brought up by her. Manrico is the brother of Count Di Luna that burnt Azucena’s mother for being a witch. Azucena had to avenge her mother’s death. How much hate can you hold. She had to throw her own child in the fire, bring up Manrico so that he would one day be killed by his own brother! Unbelievable! The full synopsis here.
Most people were looking forward to seeing the Russian superstars take the stage for very different reasons. One hand there was Anna Netrebko, singing her first Leonora at the Met, a character that she has dominated in Europe . And on the other side of the bracket was the return of baritone Dmitri Hvorostovsky to the stage after months of battling a brain tumor. Safe to say that both stars were at very high levels, delivering nuanced and deeply poignant performances.
Opera posts:Doctor Atomic
Illness and Morality
Lunar Eclipse
Illness and Morality
Lunar Eclipse
Monday, January 1, 2018
NHS Hospitals: New Year sale?
Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
But in ourselves."
Julius Caesar (I, ii, 140-141)
© 2013 Am Ang Zhang
Looks as though the following might be surplus to requirements by the new NHS, as it was decreed that clients or service users do not really need hospitals.
The Background:
Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment.
For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.
“The shape of the London hospital system has also been affected by developments in medical science and medical education. In many ways it has been the activities of doctors which have determined the pattern of the hospitals. The increasing ability to treat disease and improved standards of care shortened the time patients spent in hospital, raised the demand for services and led to an escalation of cost. The development of specialisation led first to the development of the special hospitals and later to special departments within the general hospitals. Advances in bacteriology, biochemistry, physiology and radiology created the need for laboratory accommodation and service departments, so that hospitals no longer consisted merely of an operating theatre and a series of wards. Sub-specialisation ultimately meant that services had to be organised on a regional basis and the very reputation of the capital’s doctors affected the number of patients to be seen. The hospitals of central London have long served a population much larger than their local residents.
It is against this complex background of population movement, poor social conditions, disease, wealth and poverty, professional expertise, critical comment and publicity that the London hospitals developed. A complex institutional pattern emerged. Voluntary hospitals grew up beside the ancient royal and endowed hospitals. A local government service providing institutional care for sick paupers developed alongside the hospitals. A network of fever hospitals, scientifically planned from the outset, was established. Physically near to each other, staffed by doctors who had trained in the same hospitals, and often serving the same people, the different objectives and status of the institutions led them to work in virtual isolation from each other. Each hospital had its own traditions and nobody standing in the middle of a ward could have doubted for a moment the type of hospital he was in. Countless details gave each an atmosphere of its own, and the different methods of administration and levels of staffing set them apart.” Geoffrey Rivett
Most of my Medical School Orthopaedic Surgeons were trained here.
The hospital treats almost 10,000 patients a year.
Although most patients would not consider travelling too far for a routine hip replacement, which can probably be done as well in their local district general hospital, the specialist clinics at the Royal National Orthopaedic may provide a reason to make the journey.
Specialist clinics deal with bone tumours, scoliosis (curvature of the spine), rheumatology, spinal injuries, specialist hand and shoulder conditions and sports injuries.
One word of warning – the RNOH's trust did not do well in the Healthcare Commission annual health check.
Strange that. So it may be the next to go.
The Cockroach Catcher was there.
So was the MP, as a patient.
If you have a head injury, stroke or condition affecting the brain, such as Alzheimer's, epilepsy or multiple sclerosis, this is the place to go. Along with the nearby Institute of Neurology National Hospital for Neurology and Neurosurgery has 200 beds at its central London
Healthcare Commission quality of services rating: Good
Perhaps not for sale so soon. Or saving it for the needy MPs?
Neurologists wear bow ties in my days.
The largest specialist heart and lung centre in the UK , the Royal Brompton and Harefield acquired its reputation through the work of Sir Magdi Yacoub, the internationally renowned surgeon who pioneered heart transplants in the UK
The trust attracts staff and patients from across the country and around the globe, and is a centre for research with between 500 and 600 papers published in scientific journals each year. Its 10 research programmes each received the highest rating in 2006.
Each year, surgeons perform 2,400 coronary angioplasties (where a balloon is threaded through an incision in the groin to the heart and expanded to widen a blocked artery), 1,200 coronary bypasses and 2,000 treatments for respiratory failure – so they do not lack for experience.
Other specialist heart units with strong reputations are Papworth Hospital , Huntingdon, where Britain 's first successful heart transplant was carried out in 1979; and the Cardiothoracic Centre, Liverpool , formed in 1991.
Healthcare Commission quality of services rating: Good
It could not be anything else.
The first dedicated cancer hospital in the world, founded in 1851, is still the best. With the Institute of Cancer Research , the Royal Marsden is the largest comprehensive cancer centre in Europe, seeing more than 40,000 patients from the UK
It has the highest income from private patients of any hospital in Britain
Very ready for Medical Tourism!!!
Healthcare Commission quality of services rating: Excellent
The country's largest ear, nose and throat hospital is also Europe's centre for audiological research, with an international reputation for its expertise and range of specialties, all on one site on London Inn Road
Its services range from minor procedures such as inserting grommets (tiny valves placed in the eardrum of a child to drain fluid from the middle ear) to major head and neck surgery. A quarter of its 60,000 patients were referred from other parts of the UK UK
A measure of the Royal National's success is the fact that one third of patients referred from other clinics or hospitals with voice problems has their diagnosis changed on investigation there. Although there are many other centres where throat, nose and ear problems can be treated, none are pre-eminent enough to be included in this guide.
Wow!
Healthcare Commission quality of services rating: Good
Britain's leading national and international referral centre for diseases of the bowel is the only hospital in the UK and one of only 14 worldwide to be recognised as a centre of excellence by the World Organisation of Digestive Endoscopy.
It is a chosen site for the NHS bowel-cancer screening programme being rolled out across the country, which seeks to detect and treat changes in the bowel before cancer develops. Bowel cancer is the second most common cause of cancer in the UK
Bowel cancer can be treated via colonoscopy, to find and remove polyps – growths on the wall of the bowel. The hospital's education programme attracts clinicians from across the UK
The hospital is part of the North West London Hospitals Trust.
The liver unit at King's is the largest in the world. It is one of 31 specialist liver units in the UK UK
The unit performs 200 liver transplants a year, and more than 200 patients with liver failure are admitted to its intensive care unit each year.
King's carried out the first successful transplantation of islet cells – part of the pancreas involved in producing insulin – in a Type 1 diabetic, greatly reducing his need for injected insulin. Last month, the Department of Health announced plans to establish six new islet transplantation centres round the country, based on the research at King's.
Healthcare Commission quality of services rating: Excellent
No bargain price, I am afraid.
The Maudsley Hospital
The Cockroach Catcher was there too.
One of Britain
Today it is a centre of excellence for the delivery mental-health care. Its addictions centre offers new treatments for drug abuse, alcoholism, eating disorders and smoking, it provides innovative care for disturbed children and adolescents and is the largest mental-health training institute in the country.
It has pioneered new approaches to the treatment of heroin addiction and its specialists have raised concerns over the link between cannabis and schizophrenia which have led the Government to review changes to the law.
Healthcare Commission quality of services rating: Good
Ignore the bad press, GMC can no longer investigate its CEO as she has de-registered herself.
If you have a child with a rare or complicated disorder, this is the place to come.
And they do and many are from the Middle East .
So the bad press would not matter, good for the Medical Tourist trade.
It is the largest centre for research into childhood illness outside the US , the largest centre for children's cancer in Europe and delivers the widest range of specialist care of any children's hospital in the UK
Great Ormond Street
I have done that: see Teratoma: An Extract
Paediatrics is one of the most rewarding areas of medicine for doctors because it has seen some of the most spectacular advances over the past 30 years, especially in cancer, where survival has improved dramatically.
Many of those cared for at GOSH still have life-threatening conditions but they are promised the best care both because of the expertise of its medical staff and because of the trust's extraordinary success in attracting charitable donations, which have made it among the best-funded medical institutions in the country.
Healthcare Commission quality of services rating: Excellent.
Baby P or no Baby P.
My eyes still well up when Moorfields is mentioned. Honest.
The largest specialist eye hospital in the country and one of the largest in the world, Moorfields was founded in 1805. It treats more patients than any other eye hospital or clinic in the UK and more than half the ophthalmologists practising in the UK
However, in recent years the hospital has relied too heavily on its reputation and grown complacent. Though standards of academic excellence are still high, it has neglected the services it offers to patients, which were rated weak on quality by the Healthcare Commission in its annual health check last year.
The hospital carried out 23,000 ophthalmic operations last year, providing surgeons with extensive experience on which to hone their skills. The reputation of the trust is such that it has started to run clinics in distant hospitals, capitalising on its brand. The hospital employs 1,300 staff who work on 13 sites.
Perhaps it is not so good to be following on commercial branding. Stick to medicine!!!
Despite its recent problems, Moorfields remains Britain
Healthcare Commission quality of services rating: Weak
For bargain hunters then.
Material drawn from The Independent.
Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
"The fault, dear Brutus, is not in our stars,
But in ourselves."
Julius Caesar (I, ii, 140-141)
If you think you have read this before: you have indeed. As NHS reform is just re-cycling of earlier political dogma, the Cockroach Catcher can re-cycle his blog posts!!!
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