Thursday, September 19, 2019
Kibbutz Hagoshrim: Talmud & Taxi Knowledge Combined!
On our recent tour of Israel, we were having dinner with a couple on our tour at the amazing Kibbutz Hagoshrim. The lady herself said she volunteered and worked at a Kibbutz and talked a fair bit about her experience. Somehow the conversation turned to the husband who said he is a London Black Cab driver and asked if I have heard of Knowledge. It did not take long for him to work out that I am a doctor and he told me he had to go for tests at the Institute of ........
"Queen Square" I jumped in as usual.
"Yeah".
It is interesting that looking back on the research by Eleanor Maguire it is clear that out of 79 participants, only 39 pass the Knowledge test and they are the ones that showed the Hippocampi changes.
So here we have it, a Jewish London Taxi driver who was one of MacGuire's Guinea Pig passing the Knowledge test.
Did he have an advantage from his Bar Mitzvah ? I am pretty sure!
What a nice anecdote to our Israel Tour.
Kitbutz Hagoshrim
In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel was giving his lecture. I was fortunate enough to be able to secure a seat.
"Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes." Eric Kandel.
In his book In Search Of Memory, he remembered his arrival in
“My grandfather and I liked each other a great deal, and he readily convinced me that he should tutor me in Hebrew during the summer of 1939 so that I might be eligible for a scholarship at the Yeshiva of Flatbush, an excellent Hebrew parochial school that offered both secular and religious studies at a very high level. With his tutelage I entered the Yeshiva in the fall of 1939. By the time I graduated in 1944 I spoke Hebrew almost as well as English, had read through the five books of Moses, the books of Kings, the Prophets and the Judges in Hebrew, and also learned a smattering of the Talmud.”
Eric Kandel/Amazon
“It gave me both pleasure and pride to learn later that Baruch S. Blumberg, who won the Nobel Prize in Physiology or Medicine in 1976, had also benefited from the extraordinary educational experience provided by the Yeshivah of Flatbush.”
In Hebrew and English!!! That did not seem to have done him and Blumberg much harm. Right now some governments seem hell bent in doing away with rote learning and that includes some medical schools.
Lord Brain:
When I was training in London Queen Square Atlantic . It was drilled into us then that sadly we were given a number of brain cells when we were born and it was all downhill from then on or something to that effect. It was well known that neurologists were great diagnosticians but for most neurological conditions, not much could be done. How depressing indeed. Even as recently as four weeks ago, I heard a young doctor told his father that there was nothing he could do with his brain cells. One is given so many at birth and no more can be expected. Lord Brain (1895-1966) would have been so proud.
Knowledge:
Yet it was also London London London
Music, poetry & anatomy:
Playing musical instruments requires both manual dexterity and memory work, and musicians are often good mathematicians, possibly because of the proximity of the areas in the brain for these functions, although it may not be that clear cut. Making children recite poems is not a bad idea either, nor indeed the study of Latin, or anatomy work for medical students, as these activities all help to exercise their brain.
Now lessons in music instruments are no longer offered in most state schools in the U.K.
By the way, if you have been trained to have a good memory, that ability will transfer easily to the remembering of the taste of wine! Think about it, the brain is very economical in its application, and is still the best computer around.
Mmmm….perhaps that is why two of my friends started learning the piano when they retired. And they joined wine clubs too. They too might know a thing or two.
If we want our children to have a future, bring back music, rote learning and poetry, and let medical students toil through anatomy.
For us, learn a new instrument & drink wine!
Wednesday, September 11, 2019
To talk or not to talk: Trauma & Human Resilience
In The Cockroach Catcher:
The speaker was a Senior Registrar from the Maudsley.
"......He was a Registrar at the time of the King’s Cross fire. He was just coming out of the station when the accident happened, and so was at the front line so to speak not just as a pedestrian but also as a psychiatrist. He became interested in PTSD (Post Traumatic Stress Disorder) and did a fair bit of research on King’s Cross and other disasters.
He quoted a number of cases, including the Herald of Free Enterprise disaster. There were those who despite help of all kinds would commit suicide. Many were heroes in that they saved many lives. Yet the feeling that they did not deserve to live eventually overtook them and they committed suicide.
What was most surprising was how the group that had counselling generally faired worse, much worse than those without any counselling. The group that did best were the ones that drank, and drank a fair amount.
It was not his intention to promote vodka but he thought we could not be kept from the truth……
His research showed that talking about the incident seemed to make things worse, much worse than anyone ever imagined……”
From To talk or not to talk: Trauma & Human Resilience Part I.
Part II:
Then came September 11. I remembered I was on holiday in Spain
Then one of them said, “One of the World Trade Center Towers
I was trying to see if I heard right.
“In New York
“New York
Then moments later, the Spanish waitress came out and said to us, the second tower was down too.
I rushed back to our villa and shouted to my wife to turn on CNN and tried to contact our children, one of whom worked in Manhattan
Lines were dead.
Luckily, an Email came through our other daughter who was in England 55th Street Brooklyn .
What a shock. Unlike my parents’ generation we have had a long period of peace and prosperity but now everything was shattered.
The following day my office put a call through and I talked to my Associate Specialist.
The clinic just had an urgent referral. A local girl was referred. Very disturbed by what happened as one of her father’s good friends was one of the pilots whose plane went down. The family spent many holidays with them in their Florida
“Whatever you do, by all means talk to the parents but not to the girl. No one should see her. They should not turn on the TV and avoid any reminder of what happened.”
I then nearly said, “Give her Vodka, Gin or similar,” but I did not.
I gave the next best thing.
“Put her on a short course of Benzodiazepine to let her sleep for a few days.”
It shocked my Associate Specialist. It was not a drug I normally used, if at all, and why now?
Well, whatever happened, all I could say was that the family was in total agreement and months later my Associate Specialist told me that it was brave of me but it seemed to have worked for this girl.
In July last year I met a young couple at the swimming pool of our holiday condo. I thought they were Chinese but it turned out they were Vietnamese Chinese.
We started chatting. He said he left Nam (Vietnam
Jokingly, I said, you mean you were on the Helicopter?
“Yeah, how did you know?”
“You looked too young to be working for the Embassy.”
“My mum worked there. But my story was nothing, you should hear hers.”
His wife, an elegant looking petite Chinese swam closer.
“So, tell me.”
Well, she came out later. Her mother put her and four sisters on a junk (a Chinese fishing boat), one of those that took refugees out of Nam Hong Kong but they swam ashore. She spent the next three years in one of the Hong Kong camps.
“Yes, I remember those.”
“I know - the stench. We got used to it.”
Those camps were run under the auspices of the United Nations but the UN never really paid Hong Kong a single dollar. However that is beside the point. Conditions were very poor and one could hardly decide if it was Hong Kong ’s or UN’s fault. Every time we drove past it was like passing a local authority rubbish tip. We had to wind up the windows. Yet there were politicians who felt they needed to keep it bad to deter people. They continued to flow in right up to the handover. As it was still under British rule, Britain tried its best to keep people from going to Britain U.S.
I said something that sounded like an apology, an apology for Hong Kong , and for mankind.
“No. It’s fine. I am not bitter. We waited and we got to the U.S.
She told me someone suggested that she should have some therapy. She never did.
“Some things you can never change. If it happened it happened.”
But she managed to get most of her family out of camps and settled in the US
What a story of human resilience and triumph over adversities.
And I can still remember that lunch time meeting and the learning from King’s Cross.
©2013 Am Ang Zhang
Part 1:
Now mountains are once again mountains,
and waters once again waters.
From another doctor friend:
The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.
My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice (including me giving up private practice and my wife giving up a promising administrative career ) paid off.
Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.
Objectively, a reader outside of the UK UK
Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.
From Australia
I have finished reading The Cockroach Catcher and thoroughly enjoyed it.
Zhang, I particularly liked the juxtaposition and paralleling of your travel stories and observations with your case studies, Of course, I could appreciate it even more, knowing the author and hearing your voice in the text. Because I’m dealing with anorexia, ADD and ADHD students I was very interested in your experiences with patients and parents and your treatment. Amazing how many parents are the underlying causes of their offspring’s angst. It was an eminently readable text for the medically uninitiated like me. Keep writing, Zhang
The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US
Saturday, August 31, 2019
Nazca Booby and Siblicide: Jenner and Cuckoo.
We were fortunate enough to be in Galapagos and to be precise on Genovesa Island where two of the three main Boobies are abundant.
What I did not realise was that this Nazca Booby practices Siblicide:
From Galapagos Wild Life
The Nazca booby, like its relatives, practices siblicide; however, it takes siblicide to a whole different level. While the female typically lays two eggs, the parents never raise two young. The first egg is normally laid four to nine days before the other. This asynchrony is directly proportional to the hatching asynchrony, which is among the longest of all birds. This delay is a death sentence for the second chick that hatches, as the first can easily push it out of the nest, and it does so in every case, without fail. Once outside of the nest, the parents do not acknowledge the unwanted chick and it quickly dies from either starvation, temperature change or predation.
Siblicide is not uncommon among boobies. However, blue-footed booby chicks practice what is known as facultative siblicide, in which they kill the weaker chick only if there is not enough food. On the contrary, Nazca booby siblicide is obligate and unconditional. Experts are still not certain as to the cause for this unreserved murder between siblings. It is possible that the fierce trait developed as a result of recurrent food scarcity, as by killing its weaker sibling the older chick would be entitled to all of the resources that the parents bring. On the other hand, it is possible that the siblicidal allele was developed due to some past selection pressure, such as food scarcity, and was never lost.
All Photos ©2019 Am Ang Zhang
It reminded me of Jenner and his observation of Homicide in Cuckoos:
When I visited his home in Glouscestershire, the curator of the small museum, who was extremely knowledgeable, took pride in telling us how Jenner’s great work on Cowpox vaccination upset the medical establishment on the one hand, and how his observation on the murderous ways of the Cuckoo newborns upset the gentlemanly world of the Ornithologists on the other. It was the Royal Society that awarded him a Fellowship for his keen observation.
His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.
Thursday, August 29, 2019
Underclass: The Old Beggar
Selenium Toning is for archiving prints and imparts a lovely tone depending on concentration.
Monday, August 19, 2019
Anorexia Nervosa & Mountains: Misguided Belief in Psychiatric Diagnosis!
Thursday, August 15, 2019
Autism: Wrong & Right & Temple Grandin
Can wrong sometimes be right? A question I had to face in my years of practice in Child Psychiatry.
The Consult:
Nowhere else in medicine is “innovation” more appropriate than in Child Psychiatry!
The Consult:
Dear Cockroach Catcher:
We are a bit stuck with this Autistic boy with unusual OCD symptoms.
The boy was born in the US of American mother and British father. Diagnosed Autistic Spectrum Disorder age 4 with OCD symptoms. Was sent to an institution at age 5 when parents separated and mother could not cope. Father managed to get him to England after 10 months. His obsessional symptoms got worse and amongst them the most difficult is that he can’t bear to wear any clothes which are not brand new. He checks the tag, feels the clothing and sniffs it to decide if he would wear it.
He is on Prozac 40mg, which has reduced the aggressive outbursts but not made any real inroads into the dressing problem……except that he has occasionally managed to wear used socks.
Nowhere else in medicine is “innovation” more appropriate than in Child Psychiatry!
My first thoughts were: Cheat!
Then perhaps: Collude!
Neither would be in NICE or any textbook.
Cheat: get father to keep all the clothes tags or write to companies to get a lot of them to tag on to his clothes so that they are like new.
That saves some money. Failing that steal the tags.
(I can't believe I said that)
Patients come first.
Collusion: because he could sniff and tell that the re-tagged clothes are not new we may have to get him to agree to the ritual of tagging clothes and folding them nicely. One of my autistic patients turned our session into a TV session. So collusion is a better way.
It is a pity that nowadays we cannot spend enough time with these patients to understand them. If I may venture further and suggest that the boy perhaps associated new clothing to the new life with his father and he wanted to keep it that way. Obsessional symptoms are essentially a defence in psychodynamic terms and until the child (autistic or otherwise) can be sure of his place at his new home he is going to keep his defences.
So spend more time with him and you may well be surprised!
So spend more time with him and you may well be surprised!
It is probably good he was not in an institution. That was what they nearly did to Temple Grandin. There is so much we can learn from her story. She too was nearly institutionalised. She famously created a cuddling machine for herself!
Innovation again.
Wrong may sometimes be right.
Let me know.
Temple Grandin:
Dr Temple Grandin has a unique ability to understand the animal mind - and she's convinced her skill is down to her autistic brain.
Temple believes she experiences life like an animal. Her emotions are much simpler than most people's and she feels constantly anxious. It's this struggle with overwhelming anxiety that led her to discover just how much she has in common with animals and, in particular, cows.
Using her ability to observe the world through an animal's eye, she has been able to make an enormous impact on animal welfare. Her greatest achievement has been in the area of slaughterhouses - she has fundamentally changed the way animals are held and slaughtered.
Today she's an associate professor of animal science, a best-selling author and the most famous autistic woman on the planet.
Temple Grandin Website:
Dr. Grandin didn't talk until she was three and a half years old, communicating her frustration instead by screaming, peeping, and humming. In 1950, she was diagnosed with autism and her parents were told she should be institutionalized. She tells her story of "groping her way from the far side of darkness" in her book Emergence: Labeled Autistic, a book which stunned the world because, until its publication, most professionals and parents assumed that an autism diagnosis was virtually a death sentence to achievement or productivity in life.
Autism posts:
Thursday, August 8, 2019
NHS Hospitals: Not for you. Only the Elite!!!
Do you really think that hospitals and what hospitals do are not necessary?
Do you really think that a good health care system is just about Primary Care doctors or in the new world order of things nurses doing what doctors do? (Noctors as our lovely Dr Crippen called them).
The Elite
©2012 Am Ang Zhang
The pretending is over now that it is clear about the current governments plan for dismantling he NHS.
The children of my friends and contemporaries are in good jobs like, lawyers, bankers and dare I say, management consultancies. They are all scrambling to make sure that their Health Insurance will cover IVFs, antenatal care and full obstetric care and for those engaged in sporting activities, knee work and perhaps hip work for later.
For this the Elite of our society, it is not just about GP care.
They are there to refer them to the best specialist in the best Private Hospital or sometimes at the private section of a top NHS hospital.
I have maintained for some time that:
Most people in well paid jobs (including those at the GMC) have health insurance. GPs have traditionally been gatekeepers and asked for specialist help when needed. If we are honest about private insurance it is not about Primary Care, that most of us have quick access to; it is about Specialist Care, from IVF to Caesarian Section ( and there are no Nurse Specialists doing that yet), from Appendectomy to Colonic Cancer treatment (and Bare Foot doctors in the Mao era cannot do the latter either), from keyhole knee work for Cricketers to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. China realised in 1986 you need well trained Specialists to do those. We do not seem to learn from the mistakes of others.
So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.
What about medical training? If these hospitals are sold, who pays?
And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day.
Do we still have those: yes we do! See here>>>>
In London alone these are specialist hospitals that are famous the world over:
The Maudsley Hospital
Then there is Papworth. Need I say more!!!
I know that when you visit them nowadays, these places seem to be full of: non locals. Or could it be that these are now the new locals, I doubt as you can sometimes see the lovely foreign plated cars parked outside them. If I am wrong, I do apologise.
The truth is that medical tourists come not for the GP services we provide, they come for the cutting edge medical procedures and in England, it is also about value for money.
So, opening up many of these rather precious hospitals for up to 49% private will mean a severe reduction in actual medical times available to NHS patients.
That is why: the pretending is over. No, at the end of the day it will not be the medical care you can get from your GP or Noctors, it will be well trained specialists with up to date complex procedures that you or one of your relatives may need!
The plot to get punters not to use hospitals via A&E is failing. So, they are going to just close them.
Zebra in fact belong to the same family as the horse (Genus Equus) but unlike the horse has never been domesticated. It is believed that the stripes in a herd is protective as many animals merge together and thus appeared larger.
Thursday, August 1, 2019
Thumb Sucking & Nightmares: Winnicott & Mondrian
Composition with Yellow, Blue and Red (currently on display at Tate Liverpool)
This is how the scene was described in the book:
“……..“Mondrian.”
“Very neat,” I said.
“It is rather, I think you should have it in your room.” Miss Frys replied.
“Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already?In any case the Mondrian would be fine on its own.
Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso………”
The Tate now of course has several Mondrian works.
Now you can read the whole chapter here:
“Very neat,” I said.
“It is rather, I think you should have it in your room.” Miss Frys replied.
“Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already?In any case the Mondrian would be fine on its own.
Chapter 10 First Encounter
In the winter of 1972, something happened that sealed my fate to stay in England
By then I already had one of my higher qualifications (D.P.M. – Diploma in Psychological Medicine) and was in the process of sitting the first ever examination of the Royal College London
On a cold October morning I made my way to one of these old mental hospitals which was running the first ever training course for the Royal College
As you drove into the main gate of this rather imposing Victorian beauty or monstrosity, you got the same feel as in most mental hospitals of the same era. There was the odd one working the kerbs and gardens. A small group might be shepherded by a nurse to cross a road on their way to their morning’s appointment. Many had the typical shuffling gaits from the antipsychotics they were on.
The last of the summer’s Hydrangea flowers still tried to hang on. They looked tired and ugly. I would never have hydrangea in my garden.
The Post-grad place was easy enough to find as you just followed the majority of the cars. Wow, with half an hour to go, the car park was already nearly full. I suppose we all wanted to have a nearby spot to park on such a chilly morning.
I liked to be nearer the front as chances of falling asleep would be much reduced. I spotted a gap, made my way in and before I could sit down, someone offered me a hand.
Gail: Thumb Sucking
“I am Gail. I am from the Tavistock.”
The Tavistock? Many others would think this was the place they had pop concerts, and doctors would know that the British Medical Association was at Tavistock Square , London
Where I came from no longer seemed so important.
Synchronicity[1], you see. Gail put her thumb in her mouth and started sucking it vigorously.
“Sorry, my mother’s fault and she has already paid for my analysis for the last three years. Between you and me, I preferred my thumb. Who is your analyst?”
“Haven’t got one.”
“Oh, yes. Dr Collinwood is the odd one out. Her registrar does not need to be in analysis. However, one good thing the thumb sucking did was to get me my job at the Tavi. I was already in analysis.”
Analysis for thumb sucking? I thought to myself. Never! Whatever next? And a sought after job in London
What did I do wrong, or right to get my job?
“Ah, you see you are Chinese. You don’t need analysis. Your predecessor was Greek. She had the collective culture of the Ancient Greeks.”
Perhaps her next registrar would be Egyptian.
Over the next six hours or so, I began to understand the scale of her problem. It was really like having sex in public and she could be so engrossed in it. It would be wrong to suggest that she tried to reach orgasm but sometimes from the sound she was producing it was not far off. Now and again she noticed that I was paying more attention to the thumb sucking than to the lectures. She stopped and apologised.
It would be odd to have gone through years of training at a place where the perceived wisdom was that all problems big and small could be traced back to our childhood and more particularly to our sexual development that I should write about my work without any reference to these aspects. It would also be peculiar if I, having been brought up in a Psychoanalytic Centre of world class reputation, could pretend that sex did not play a significant part in human psychopathology.
My first encounter with my future colleague certainly shocked me. What was I getting myself into? Was I going to see even crazier people?
The staff, not the patients.
My start at the Tavistock was straightforward enough. They had a good introductory pack. I was first briefed by Miss Frys the social work team leader. She was the nicest person one could meet and work with. Warm, kind and she listened carefully. She looked normal enough. I found out later that she was a Quaker and she came from a family where every female member lived to over a hundred. She looked like she was heading that way too.
She told me Dr Collinwood was very fond of her previous registrar who was a Greek girl. She was going back to Greece
“We are rather fond of Greeks here right now, as there are two others whom you will meet probably at lunch.”
One later on became a Health Minister in charge of Psychiatry and the other started the Athens
Mondrian
Miss Frys had some impressionist prints on the wall and they just seemed to match the colour of her hair. A peculiar picture with coloured squares was by the cupboard and was obviously not hers.
“Ah, an imposition here. You see, our local library is very good. They have all these prints they lend out to clinics and public offices. This one seemed to be the one left when everybody else have had their pick. I thought, well it is not my type of picture, but it is mathematical and perhaps a Chinese would appreciate it.”
There were not as many Chinese in the U.K.
Well, it is not in my nature to speak my mind, not at a first meeting with someone who seemed to ooze wisdom and kindness. I took another look and asked, “Who is the artist?”
“Mondrian.”
“Very neat,” I said.
“It is rather, I think you should have it in your room.” Miss Frys replied.
“Thanks.” Had I managed to resolve some irresolvable conflict or had I been categorised already? In any case the Mondrian would be fine on its own.
Years later I found out that even the Tate rejected Mondrian, but then the Tate also rejected Picasso.
Now I am going to be cultured as well.
“Do you like music? The library has a superb collection of records and they get every thing new as well. I live very close to the Festival Hall. I must take you to a concert there some time unless you have been already.”
I must confess that with all that studying and preparing for the arrival of our first baby, concerts seemed like a lot of trouble; but I would certainly try and get the records as I had a very good sound system. Radios and electronics had been my hobby from the age of nine, and over the years I had built at least eight systems of my own, starting with a simple crystal radio set, then graduating to a triple valved receiver system and ultimately to a high fidelity amplification system with EL84[2], which remains the gold standard of the industry.
It was not until some years after her retirement that I finally took up her offer and met up with her at the Royal Festival Hall. There is no better place to be in London
“So you are having a new baby in March. Dr Collinwood is very pleased because you will be able to observe your own baby’s development. It will save a lot of time. But I shall arrange for you to do your nursery observation about three streets away.
“Now here is Dr Collinwood, I can hear her coming down clanging two cups. She had this kidney stone problem years ago, and her doctor advised her to drink lots. So she takes two cups of coffee instead of one. Oh, I see the coffee lady is bringing down two more. I presume one is for you and one for me.
“We have this coffee lady who comes in at ten to make coffee. I do not think they pay her very much, but the clinic is thinking about instant coffee and tea-bags so that they can save some money. She has been here twenty two years, as long as I have been, and is part of the fixture. We are all writing letters.”
Winnicott
I greeted Dr Collinwood, my consultant. She put the coffees down and shook my hand. She looked less scary than the first time I met her. There were now more smiles. What was she making of this young Chinese doctor from across the globe, I wondered.
Her first concern was the baby. Well she was a real children’s doctor. I later found out that she had worked for years with Winnicott. Winnicott is someone I still have a lot of time for. He was really a paediatrician but his psychological understanding of children and mothers was nearer to my heart than many of the Viennese psychoanalysts such as Sigmund Freud, Anna Freud, and Melanie Klein etc. Dr Collinwood continued to show great interest in both our children and after she retired the whole family had spent quite a number of summer holidays at her retreat in Suffolk
I knew straight away that I would be fine at the Tavistock.
“There is this case I need to talk to you about. We missed the last two case presentations (maternity leave and all that) and I promised that we would try and do one six to eight weeks after your arrival.
“I do not normally give my new junior any old case to take over but this is a nice boy and you might get on with him. I shall continue to see his mother.”
Meeting with the psychotherapist was another really nice experience. There was so much gesturing that I later discovered was a Jewish thing. But Miss Horowitz you cannot fault. Her father was a famous child psychiatrist and she was really an Anna Freudian[3]. Not so much of the penis envy or bad breast good breast stuff that Gail kept talking about.
We had twelve cupboards all with individual keys. Each therapy patient got assigned one and they could put their first name on it. There were packs of toys that the other psychotherapist sorted out and it included drawing material. Drawing paper was multicoloured and we tried not to let the children take their drawings home as a rule, as they were important material for analysis.
Nightmare
All that medical training and exams and so on had not prepared me for what I had to do. I had to start from scratch. I was not even going to take a history. The first session with Michael would be a play oh, sorry psychotherapy session.
“You will be fine, although it would have been better to learn on a new case.”
All the Nation’s pride and glory was up to me now. I could only succeed.
Michael turned out to be a very nice boy as I was promised. He had two problems: nightmares and soiling.
The nightmares annoyed mum but she really could not stand the soiling.
“There must be something physical, Dr Collinwood. He has already seen the Greek doctor for six months and now you want him to see this China
“Oh, very nice to meet you,” she said, putting her unlit cigarette back in her big handbag. She had a very Jewish look with a very Cockney accent. If I knew what I know now, she looked exactly like one of those handing out drinks in one of the New York
“I brought his pants from school. He soiled it again. I thought the doctor might want to see it.”
I was beginning to “like” her. Such consideration!
“Sorry mummy.”
“There is no need to show Dr Zhang. I hope with a few more sessions we may get to the bottom of the problem.”
Dr Collinwood was confident. I was not sure if I was. But my tough medical training saved me – the important rule of using long words and never expressing doubt. I did not hesitate and said, “Sure we are going to.”
Mrs Green was evacuated during the war. Dr Collinwood and Miss Frys were trying to put a series together on the effect of evacuation on problems for mothers with the next generation. It was quite unique in its way as hopefully there was not going to be another war and perhaps evacuation would not be used if there was one.
Her husband was probably Jewish as well and was on Incapacity Benefit as a result of some illness or other.
Michael soiled only at school and almost always just before going home or coming to the clinic. He often woke up screaming in the middle of the night and insisted that mother should go and see him. She now put him in bed with her to save getting up, she told Dr Collinwood. Mother cleaned for the school so Michael stayed at home with father.
Mrs Green was so fed up that the previous week she took Michael up Archway Bridge
At least in those days we did not have tons of local authority social workers around you once something like that happened. Nowadays Michael would probably have been placed with another family at some point.
Michael got into a routine pretty quickly. First, we played football - a soft ball. I kept goal three times and he three times. Then we wrote the score on the little black board. He wrote his name on the card provided for the cupboard but insisted on putting three black lines round it. What would Miss Horowitz say? Then he played with the animals and then arranged the family dolls around the table. Mother, father and a little girl. A boy would probably be too close to home.
Though he was eight, he was more like six in size and was very timid. He asked permission for just about everything.
He would then finish with a game of draughts. I made the mistake of leaving the pieces as they were. He saw me three times a week, and he was my first and only patient then. He asked if I saw anyone else. I quickly learned to put some names on the other cupboards and tidied up the draughts. An obstetrician delivering his first baby must not let the mother know it was his first.
He soon started drawing. Mother, father, and a baby girl in the middle. We religiously put all these in his cupboard.
“I like that drawing,” he pointed to the Mondrian, “So neat.” He was right.
We saw mother and son separately at the same time for fifty minutes twice a week. Mum always said goodbye to Michael outside my door, with a kiss and darling this and that. One day after a few sessions, as she walked with Dr Collinwood to her consulting room, she said very loudly, “Is your new doctor any good? He seemed quiet and sensible, but Michael tells me he only plays football and draughts with him.”
It was much later that I realised that children are equipped with defences so varied that it sometimes takes one a while to understand what has happened. Michael was an intelligent boy. He had set up decoys. He had now established with mum that I only played football and draughts with him. No wonder we only ever played for a few minutes each time and no wonder it did not matter if the draughts game finished.
Now instead of putting the girl in the family group, it was a boy, and he no longer drew a girl on his pictures. He drew a boy.
He kept putting the father in the toilet in the doll’s house.
One day Michael drew me a picture that I could no longer hold back from Dr Collinwood until supervision time. I intruded into her fluid loading time.
Michael drew a naked mummy complete with big boobs and pubic hair. The boy in the middle was naked too and had a rather large tool on him. Father was in his pyjamas and Michael drew tears down his face.
We made the case presentation. It was well attended by nearly everybody including those from the other teams. Word must have got out that Dr Collinwood had a case that had sex features.
Father suffered from severe diabetes and had been impotent for years. Mother had very bad abuse history from the evacuation days and had become rather needy of sexual gratification. In a desperate attempt to shame her husband she slept stark naked and put Michael in the middle. She would get Michael to have an erection and then say to her husband, even your eight year old can do better than that. She would not contemplate leaving him, as the benefits were good and she got to drive his car. Dr Collinwood did not mince words on erotic stimulation etc. etc. All the way through, Gail never sucked her thumb. We passed around the drawings. Freudians made their bid with Oedipus and all that. Kleinians[4] insisted on bad breast. To me it was just an abused mum having a bad time and using the boy to get back at her husband. But it was only my first case.
Gail gave me a thumbs up (the other thumb) approvingly afterwards and said I passed the test. I told her that attending Dr Collinwood’s case meetings could save her lots of money. “It’s my mother’s anyway,” she said.
Michael continued to see me for the best part of the rest of my stay at the Tavistock. His nightmares disappeared and he stopped soiling. Nobody knew if his mother stopped fiddling with his penis but to me it was an eye-opener. At least being Jewish she had no qualms about bringing Michael to the clinic three times a week for his therapy sessions. Since then, I have collected quite a few other similar cases, but I shall always remember Michael and Mondrian.
[1] Synchronicity – In The Structure and Dynamics of the Psyche Jung describes how, during his research into the phenomenon of the collective unconscious, he began to observe coincidences that were connected in such a meaningful way that their occurrence seemed to defy the calculations of probability. Unfortunately it is often quoted as a scientific basis for astrology and other improbabilities.
[2] EL84 - a vacuum tube (a.k.a. valve) of the power pentode type. It has a 9 pin miniature base and is found mainly in the final output stages of amplification circuits, most commonly now in guitar amplifiers, but originally in radios and many other devices of the pre-transistor era. However, even now, hi-fi connoisseurs still prefer sounds produced by valve amplifiers to digital transistor sound.
[3] Anna Freud - Anna Freud moved away from the classical position of her father, who was concentrating on the unconscious Id (a perspective she found to be restrictive) and instead emphasized the importance of the ego, the constant struggle and conflict it is experiencing by the need to answer contradicting wishes, desires, values and demands of reality. By this, she established the importance of the ego functions and the concept of defense mechanisms. Focusing on research, observation and treatment of children, Freud established a group of prominent child developmental analysts (which included Erik Erikson, Edith Jacobson and Margaret Mahler) who noticed that children's symptoms were ultimately analogue to personality disorders among adults and thus often related to developmental stages. At that time, these ideas were revolutionary and Anna provided us with a comprehensive developmental theory and the concept of developmental lines.
As such, the formation of the fields of child psychoanalysis and child developmental psychology can be attributed to Anna Freud.
“……I think that a psychoanalyst should have...interests...beyond the limits of the medical field...in facts that belong to sociology, religion, literature, ,[and] history,...[otherwise]his outlook on...his patient will remain too narrow. This point contains...the necessary preparations beyond the requirements made on candidates of psychoanalysis in the institutes. You ought to be a great reader and become acquainted with the literature of many countries and cultures. In the great literary figures you will find people who know at least as much of human nature as the psychiatrists and psychologists try to do.” Anna Freud
[4] Melanie Klein - child psychoanalyst who worked in London (as the US required a MD degree to practise psychoanalysis) had a strong following and some severe critics too. Her theories – (as portrayed in Nicholas Wright’s 1988-Mrs Klein) include references to: "good breast" and "the bad breast"; "symbolic urine"; playing the violin as "a repressed masturbation fantasy"; automobiles being penises and mountains being breasts.
Tuesday, July 30, 2019
NHS : World Class Medicine without trying!
Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US Hong Kong or the rest of the commonwealth.
Why?
We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.
Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.
Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals.
Can we continue to practise World Class Medicine even if we wanted to?
Here is a reprint:
It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.
Patients or their relatives are used to trust the judgement of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.
David Cameron is no different and he has stated so on record.
I am not here to analyse his faith.
I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978
RHA days:
The year was 1977 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.
Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom
Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.
We used to practice real, good and economical medicine.
The unusual cases:
Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.
As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.
Supermarket:
Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.
But supermarkets can get things wrong too. In Spain
©Am Ang Zhang 2010
Back to the patient:
Would my patient be dealt with in the same way in 2011?
GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
Paediatrician to me: ? Psychosis or even Catatonia.
Seen same day and admitted to Paediatric Ward, DGH.
Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
Radiologist (Hospital & no India
Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
Patient unconscious and transferred to GOS on same day. Seen by various Professors.
Patient later transferred to Queen’s Square (National Hospital
Seen by more Professors.
Regained consciousness after 23 days.
Eventually transferred back to local Hospital.
None of the Doctor to Doctor decisions need to be referred to managers.
We did not have Admission Avoidance then.
How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.
The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.
Not to mention the operation etc. and the transfer to the Centres of excellence.
Here is an extract from my book The Cockroach Catcher: Chapter 29 The Power of Prayers
Just like Mayo Clinic:
“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”
But it is probably too late:
…………Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
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.”
“Yes, you do and thanks a lot.”
I told mother that we were transferring her daughter to the best children’s hospital in England
“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."
David Cameron, if it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.
Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.
King’s Fund: Million £ GP.
See also:
6 comments:
Anna :o]
... but I never liked the word 'underclass' ... or 'subhuman', two of the same vocabulary, because of the degradation to humanity that is associated with such expressions. Surely, humanity with all it's ills, is still less vicious than that, or am I underestimating our 'exclusive' arrogance?
Well done, as usual, CC, you've made me think, and stirred some emotions :-)
I am glad you liked the portrait. Photography portraiture is difficult as it was only a split second thing unlike painting which often takes many sittings (painting from photo is the modern way and that is why much of the BP stuff is not good in my humble opinion.
Saw One Man, Two Guvnors at the National: all the classes were bad----Public School class, butler class, mafia class, lawyer class, waiters class.
... one of the most amazing, and very disturbed, paintings done from a photo, is [Gorky's mother and child]. He was influenced by Cezanne and Picasso, but that painting has something, a life of it's own, despite it's artist death long ago ... I find it scary and very disturbing ... Gorky needed you CC, check him out :-)
It is the same with many Catholic countries and Portugal is one of them.
He was given some bread so from under his seat he pulled out some raw garlic cloves and ate the bread with it. He is going to live a long life.
My old man was doing good, much good.
COI: I did give him some money, after the photo of course.