As far as the terminally ill go... bring back the brompton cocktail: http://en.wikipedia.org/wiki/Brompton_cocktail If I'm terminally ill with cancer, I want to be high as a kite for the duration, thanks...
I'm glad you pulled me up on that. It occurred to me as well after logging off yesterday, and I've been thinking about it since. Child mental health is even trickier than adult mental health, for exactly the reason you point out. I think the biggest factor is that children are not considered competent decision makers (unless explicitly proven), so in this case "normality" is defined by the substitute decision maker - usually the parents, but often other members of society such as teachers, counsellors, or government agencies (eg child services). No easy answers. You're correct. Everyone has their own individual circumstances that need to be considered.
pete, im sorry but your WAY to textbook on this, thats fine if you want to know WHICH mental illness someone has so you can work out which drugs to give them but its not how someone is defined as mentally ill. Someone is defined as having a mental illness by distress. Saying the CIA is following you could mean a few things, 1) your a spy 2) your a terrorist 3) you write or tell stories of the thriller type 4) your delusional. If 1 or 2 your PROBABLY not going to be seeing anyone in the health care system but even if you did the first 3 wouldnt be showing distress (well the terriorist might bePlease Register or Log in to view the hidden image!). The delusional person though would be in distress. Someone who has lost there wife 20 years ago and now cant leave the house, cant funtion AS THEY WANT (not as sociaty wants) is going to be in distress. Ect ect the common factor is the pt is showing or expressing some form of distress
I am really learning from this thread. Big thanks to everyone contributing. I'll be qualified in a few years, so the things you say here have the potential to make a real difference to the attitude of at least one doctor. Catching up on some posts from the Captain... I appreciate where you're coming from. I should again stress that I'm a preclinical student, so most of my understanding comes from textbooks and the classroom. Most of our lectures and tutes do come from practicing health professionals, and I do spend time in hospital wards each week, but my perspective still includes a heaping helping of naive student idealism. (Edit - I see Asguard has just pointed this out!) I expect that the reality of practice I experience in the future will not live up to the ideals I'm describing in this thread... but I would like to keep them as a standard to aspire to nonetheless. But hang on... you described someone with long term thoughts of suicide and poor functioning well because of their ongoing misery. I think that's more than a bad mood? I don't know much about psychologist career paths, but for psychiatrists and family health doctors... There's a potential issue here in that psychiatry and primary health are generally perceived as a poor cousin to other specialties. This means that training program places tend to be high in supply and low in demand. So interns who try and fail to get on to more exciting or lucrative specialty training programs may be able to enter a psychiatry or general practice training pathway, and may settle for that as an 'easy' option. Caveat - while this training market might lower the average quality of practitioners, please don't apply it as a stereotype for individual psychiatrists or GPs. Most chose their path as a calling, are very good at what they do, and have wonderful human skills. Even the ones who "settle" for psychiatry are highly intelligent, and well trained both in medicine and in good human interaction. Unfortunately, it's boring to hear about people who do their job well, so the few psychs who do a poor job get all the press. Please Register or Log in to view the hidden image!
Yeah, I'm still preclinical - overloaded on theory, way short on practice. Agree. I was trying to include that aspect by mentioning the person's 'past and current preferences'. Distress would be a really important part of the picture. But... what if someone is not distressed, say they are having a manic episode? I was surprised to learn this week that 90% of people having their first manic episode are hospitalized, and it was recommended to us that we schedule them (or at least prepare the paperwork) even if they consent to being admitted. So, what do you think of this idea: In the case of a manic episode, we are aiming to prevent future distress. We are judging from the pre-manic person (their 'normal' state) that the post-manic person (again, their 'normal' state) will be distressed by the decisions and actions of the manic person (their 'abnormal' state). Another thought, for the case of hallucinations and delusions... how do you tell whether someone is hallucinating/delusional by their distress? If someone really does have worms crawling under their skin, wouldn't they be just as distressed as the person who suffers that delusion?
One thing I'd like to observe as a patient of people doing their residencies in the county, both psych and medical? I keep getting textbook answers from them. Strictly textbook. Very standard. If the textbook answers were working, I wouldn't be there bugging them, I'd be at home, sleeping in. Just wanting to point that out... Anyway... Yeah, but I was an a$$hole... seriously. I didn't like me, nobody liked me, I wasn't functional, and I was going to kill myself. I'm alive. This life thing has been unexpected and unplanned for-the fact that I failed to kill myself in high school, was hospitalized for six weeks and therefore graduated... I did fundamentally change who I was...I am currently at work on me 4.0, in fact. We'll see if I make it or end up finally offing myself this time.:shrug: I'm not having a good day today. Flashbacks are teh suck Please Register or Log in to view the hidden image!uke: I feel horrible. I don't know whether the struggle is worth it today. Maybe I'll feel differently tomorrow. Guess what, Bork? there isn't a whole lot that's not mutable...I suspect the not mutable part has to do with the physical body-like gender and sexual orientation. Mood is, to some degree, part of that, but it's more mutable. Especially with pills/supplements.
true, i guess then we fall back to looking at are they a danger to themselves, others and can they give informed concent. If the answer to each of those is no and they arnt seeking treatment then yes inspite of the fact that they will need treatment when they come back down its incorect (in my opinion) to use the mental health act to force treatment on them. Ive been involved in a few detainment cases road side and they are not easy choices for anyone. CptBork might suggest we use them to force our views onto pts but thats simply not the case, they are very much a reluctent last resort. I surpose there is one advantage the health system gets and that is that something has to trigger it. Sure sometimes the "creepy man" walking down the street talking to himself may get called in for attendence but for the most part we get called either by the pt themselves or by there spouse and its going to be for something out of the ordionary. The first question we ask after getting a basic history (if this is an ongoing thing either medical or mental) is "why have you called us today?". Ie we want to know what is the change which has concerned the pt or there partner (or children or other carer ect).
Answering this one from the Captain separately, because it leads to a broader issue. This is an awfully long post - sorry! Take it in bite size chunks, or just ignore. I learned a lot just by typing it up, so it's not wasted if no one reads it. Really good questions, to which I have no answer. Part of the problem is that we can't actually measure central levels or specific brain cell activity, so we can't objectively tell if someone has a real pathology or not. I find this really frustrating. To me, it feels like a lot of DSM criteria sets will often be inadequate to make sound management decisions... but it appears they are the best tools currently available. Now, the broader issue... It's particularly stark in psychiatry, but this is actually an instance of a pervasive problem in medicine - how to decide on tests, treatments, and management. Consider the (ideal) process of addressing a medical problem: Someone presents with symptoms, You ask questions to elicit other symptoms, general wellbeing, environmental features, past health and medical treatments, family history, sociocultural setting, and so on, looking for risk factors and clues relating to their presenting complaint, other complaints, and their holistic health. You'll also often get a feel for their values and attitudes, which are important later on. You conduct examinations and investigations to get some objective information about the person's physical body (and sometimes their mind). Using everything you've learned about the patient, you consider possible courses of action, and their potential outcomes You present the choices to the patient, who decides (with assistance if required) which course of action to take according to their values, priorities, and attitudes. Repeat as necessary Step 5 is the kicker. It may be surprising just how much uncertainty is involved. In the ideal case, predicting the possible outcomes is based on good evidence - for each course of action, you can point to good research that says "for every 1000 people who had the same physical, sociocultural, and environmental features as this patient and made this choice, (X1,X2,X3...) of them were in situation (Y1,Y2,Y3...) after time (Z1,Z2,Z3...)". Note that even in this ideal case, there is a lot of uncertainty. In many cases (most?), there is much more professional judgement and guesswork involved. (There is still a good deal of professional judgment involved in the ideal case, of course, in choosing what information to gather and what courses of action to consider.) But, lets assume you have the best evidence available. How do you present it to the patient, and how does the patient decide how to proceed? In a perfect world, we might like the process to go like this: Unwell -> Investigate -> Diagnosis! -> Treat -> Well again! Unfortunately the real process is much more branching, with probabilities every step of the way. For each potential course of action, the patient has to consider several uncertain outcomes, weigh them up against the cost of proceeding, and against the uncertain outcomes of doing nothing. Aside - This shared decision-making process is still under development. Part of my study is learning how it has improved and is continuing to improve, but unfortunately it's a small part of a big degree... the profession has a long way to go. I think we (patients and doctors both) are often blinded by the well-defined, discrete appearance of medical diagnosis, and the desire for unambiguous cause-and-effect patterns of disease. You either have cancer or you don't, and a doctor can tell for sure. If someone smokes, they'll die of COPD or lung cancer. Eating well and exercising means you won't have a heart attack in your 60s. Black and white truths.Your initial interview and examination suggests a number of possibilities (differential diagnoses), of varying probability. There are many information gathering tests to choose from to help refine the possibilities and probabilities, but: Each test comes at a cost (not just financial), Test results are often not definitive (they only alter the probabilities), Test results might not alter the chosen course of action anyway (doctors - don't order a test unless the result could change what you do!) So there are tricky choices to be made even in the investigation stage. Then there a number of treatment options. Broadly: Do nothing (an important option that should always be considered), Lifestyle changes (eg diet, social activity, work...) Medications Procedures (eg surgery) But again, each option has its own costs (not just financial), and each option can have a several possible outcomes with different probabilities...Aside II - This extended decision making process also applies for preventative health measures such as vaccinations and screening tests. Prostate cancer screening, for example, is of questionable value for most men. Screening does result in more cancers detected and treated, but it does not seem to save lives, and the resulting treatment side effects include erectile dysfunction and incontinence. It has even been suggested that Kimberly-Clark's prostate awareness campaign sponsorship is less about public health than it is about selling adult diapers.This uncertainty underlies pretty much every health management decision. You just don't know for certain whether a health management choice is going to harm or help a patient. The best you can do is gamble on the odds: Oxford Handbook of Clinical Medicine: ...Rather, medicine is for gamblers: gamblers who are happy to use subtle clues to change their outlook from pessimism to optimism and vice versa. Sometimes the gambling is scientific, rational, and methodical (odds-ratio analysis): sometimes it is not, as when the gambling is based on prior knowledge (vital but ill-defined) of one’s patient, or the faint apprehension of terror in this new patient’s eyes that shows you that there is something wrong, and that you don’t yet know what it is. Being lucky in both types of gambling is a requisite for being a successful doctor: after all we would all rather have a lucky doctor than a wise one. In this game, especially when it gets deadly serious, the chips are not just financial (the most cost-effective next step). They betoken time (for you are spending yourself as surely as you are spending money, as you walk the wards), your reputation, and the health or otherwise of your patient. So do not worry about the fact of gambling: gambling is your job. ... The foregoing explains why courage is the cardinal clinical virtue: without it we would not follow our hunches and take justified risks—and all our other clinical virtues and skills (holistic care, diagnostic acumen, and operative dexterity) would not be deployed to their full advantage, while we pass the buck. Please Register or Log in to view the hidden image! Her ESR is 21. Is it normal? Heads or tails? Play rouleaux–roulette to find out
I have a slightly different outlook because of my own training. I work in a clinical field which means we dont get to sit back and play house and do every complicated test in the book. We relie up to 90% on pt history and this gives me a slighly different outlook on mental health\illness too. Lets say you have 2 people, you do blood tests on them and pt 1 has x seritonin level and pt 2 has y X is concidered to be pathological and y is concidered to be normal However pt 1 is reporting no signs of distress, is having no problem funtioning as s\he desires where as pt 2 is reporting server distress and diminished ability to funtion. Who gets treatment? Oviously pt 2 is the one in need of treatment and thats where your comment about tests must change treatment comes in. Even if we had a way to measure the chemicals in the brain and some kind of normal range to judge it against it would be irrelivent. Its called CLINICAL depression for a reason, that reason is that its based on a CLINICAL assessment not a medical invesitigation and thats how it should be. The indicators for intervention is a pt in distress, not numbers on a chart.
Yeah, my exposition was a bit extended - I understand that it's much abbreviated when you actually do it. We were taught in our first week that a good history is the most important investigation, and that we should never let tests do our thinking for us.
i was trying to think of a medical exaple to give you and it finally came to me. There is a thing called an SpO2 probe (everyone has seen them, they are a little clip with a red light that goes on your finger). Now this is a measure of how much of the hemoglobin in the blood is saturated with O2. Now lets say you have 2 pts, one is sitting comfertably, no signs of respitory distress, no use of axallery mussles, pt doesnt report being short of breath, nice regular pulse and respitory rate. You put the probe on there finger and it says they are saturating at 89%. You have another pt reporting server SOB, ovious use of axallery mussles, rapid shallow breathing, tachicardic. Probe says they are saturating at 99% on air. Do you withhold O2 from the second pt simply because a red light says they are fine when your CLINCIAL findings clearly show you they are in respitory distress? HELL NO, you put them on AT LEAST 8L if not 14 with a non rebreather (that bag thing that grant in mythbusters has on everytime they test sea sickness, though they use it wrong because it should be inflated so the flow rate they use is WAY to low)
This is from an actual medical book???!!! The biggest problem that I, as a patient have with doctors is that they expect me to believe they are absolutely right, like God, in everything they say. To doctors, patients are simply living pieces of meat, and doctors expect patients to view themselves as nothing but that. As if we are things, not people.
I have this problem also. Which is especially annoying when they hand me another antibiotic that my sinus infection's resistant to and won't listen to me tell them it's resistant.Please Register or Log in to view the hidden image! I think because I'm a psych patient the medical people assume I'm some sort of blithering idiot about my medical problems. I also had a psych doctor impressed that I had a job at all!!! This when I told him I was working below my capacity and frustrated at not being able to take more classes. Jeebus!
there is 2 issues in that, the first is the doctor trying to distance themself from the pt and thats something i compleatly understand. Even taking into account that my experiance is vollenter work and placements some of the things i have seen... lets just say staying detached is the only defence there is to having every health care proffessional commit suicide by there 5th year. In some situations its easy to get more involved. For instance i do first aid work for a bike club and i am quite close to some of the people there because i do it almost every week and the sorts of injuries im dealing with are minor so there is no emotional issues with being there friend but what i have had to deal with on the ambulance is compleatly different. Alot of it is VERY traumatic emotionally, put it this way it was alot easier doing CPR on a 29 year old and canulating him for practice before we called him than it was to deal with his partner when we told her there was nothing else we could do for him. The fact there would have been if they had called us 2 hours before rather than him just going to bed made that case harder. the other issue is pt autonomy and that is a cultural issue. The pt centered model is relitivly new to health. My grandmother expects the doctor to tell her what to do, My generation expect to make the decisions in most situations, my parents are somewhere in between. However that requires time (most GP apointments are less than 5 min), a certain level of knowlage from the pt and assertivness. It also requires newish doctors who accept that there job is to explain the options to the pt and let them make the choices
Found this - I agree. The Western medical system is designed by and for extroverts. As an introvert, I find it absolutely appalling.
The modern system is not fair. Because in it, the patient takes the whole blame if a treatment fails ("You agreed to it") and if they opt against one ("It was your choice") - while at the same time, doctors are regarded as all-knowing and blameless. The modern system is designed to protect the doctors, not the patients.
that is the stupidist thing i have ever read and i have read some really dumb things. If there was a way to analylise blood chemistry and pair it with the right medication dont you think they would have already DONE that? Hell blood tests have been around for years and you can get quite a good break down of whats in the blood with standed test. Course that tells you nothing about whats in the nurons but hey why let science get in the way of stupidity?
HA, your wrong. I wish i could rember the name of that high court case (maybe pete knows it) but i will describe it from memory A women who was blind in one eye was recomended to have eye surgury on her blind eye. The doctor neglected to inform her of the small risk of her going blind in the other eye because of the sugury. She went blind in the other eye. The court found that the surgen acted with all the skill and care he could but found in HER favor because he didnt disclose the risk. INFORMED CONCENT, If the concent is not INFORMED, then the courts concider it not to have been given.
Actually, they probably could do an fMRI, or just a brain scan, as depression causes certain anatomic brain changes. This is a very preliminary study: http://www.ncbi.nlm.nih.gov/pubmed/17988366 But I thought it rather interesting that both bipolars in the study evinced manic symptoms. If you could find something that always caused temporary mania in bipolars, you could then produce a challenge test to differentiate between bipolar depression and agitated depression, which look quite alike but tend to respond differently to different meds. The last time I had sinus surgery, they did have to warn me that they might accidentally punch a hole in my braincase, especially as they were going to be working right up against it. Chronic fatigue for years inclines one to not worry about such things. Kill or cure, I signed the forms. And they did neither, in the end.
Yes, the Oxford Handbook of Clinical Medicine. Somewhere between a pocket reference and a text, it is widely used, well respected, very good, and very human. Here's another section: ...You come to realize that simply treating the patient’s anaemia may not be of much help—so go on asking “Why?”: “Why did you bother to go to the doctor if you aren’t interested in getting better?” It turns out he only went to see you to please his daughter. He is unlikely to take your drugs unless you really get to the bottom of what he cares about. His daughter is what matters and, unless you include her, all your initiatives may fail. Talk to her, offer help for the depression, teach her about iron-rich foods and, with luck, your patient’s breathlessness may gradually begin to disappear. Even if it does not start to disappear, you are learning to stand in your patient’s shoes and you may discover what will enable him to accept help. And this dialogue may help you to be a kinder doctor, particularly if you are worn out by endless lists of technical tasks, which you must somehow fit into impossibly overcrowded days and nights. - You never really know a man until you stand in his shoes and walk around in them. - Harper Lee; To Kill a Mockingbird Doctors are often thought of as being reductionist or mechanistic—but the above shows that asking “Why?” can enlarge the scope of our enquires into holistic realms. Another way to do this is to ask “What does this symptom mean?”—for this person, his family, and our world. A limp might mean a neuropathy, or falling behind with the mortgage, if you are a dancer; or it may represent a medically unexplained symptom which subtly alters family hierarchies both literally (on family walks) and metaphorically. Science is about clarity, objectivity, and theory in modelling reality. But there is another way of modelling the external world, which involves subjectivity, emotion, ambiguity, and arcane relationships between apparently unrelated phenomena. The medical humanities explore this — and have burgeoned recently — leading to the existence of two camps: humanities and science. If while reading this you are getting impatient to get to the real nuts and bolts of technological medicine, you are in the latter camp. We are not suggesting that you leave it, only that you learn to operate out of both. If you do not, your professional life will be full of failures, which you may deny or remain in ignorance of. If you do straddle both camps, there will also be failures, but you will realize what these failures mean, and you will know how to transform them. This transformation happens through dialogue and reflection. We would achieve more if we did less: every hospital should have a department of reflection and it should be visited as often as the radiology department. Find another doctor. They're not all wankers. And thanks - I'll remember this. One more gem (I love that book): So, every so often, be pleased with your difficult patients: those who question you, those who do not respond to your treatments, or who complain when these treatments do work. Often, it will seem that whatever you say is wrong, misunderstood, misquoted, and mangled by the mind you are confronting, perhaps because of fear, loneliness, or past experiences that you can only guess at. If this is happening, shut up—but don’t give up. Stick with your patient. Listen to what he or she is saying and not saying. And when you have understood your patient a bit more, negotiate, cajole, and even argue—but don’t bully or blackmail (“If you do not let your son have the operation he needs, I’ll tell him just what sort of a mother you are …” ). When you find yourself turning to walk away from your patient, turn back and say “This is not going very well, is it? Can we start again?” Don’t hesitate to call in your colleagues’ help: not to win by force of numbers, but to see if a different approach might bear fruit. By this process, and by addressing the psychosomatic factors perpetuating your patient’s illnesses, you and your patient may grow in stature. You may even end up with a truly satisfied patient. And a satisfied patient is worth a thousand protocols.
