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The Royal College of Psychiatrists Improving the lives of people with mental illness

1 psychiatrist per million

BSMMU medical staff
Time to report back after a somewhat busy first week. Work here begins at between eight and half past, and after a quick cycle- ride (I have bought a bicycle, much to the amusement of the local doctors, and have become quite adept at constant bell-ringing whilst cycling) and ascent of eleven flights of stairs (also amusing to the local doctors, but better than waiting twenty minutes for the BSMMU lift) I arrive at work.

 

The day generally starts with junior doctor reviews of the inpatients, followed by a split into ward round or outpatient reviews. After this follows the special clinics, such as psychotherapy or child and adolescent, then teaching for the junior doctors and more patient reviews. The junior then tend to spend the latter part of the afternoon pursuing research interests. The RCPsych volunteer scheme talks about the bilateral exchange of knowledge, skills and experience – I am certainly receiving my own share of all three. During the first clinic I saw more patients with conversion disorder than I have seen in total in my previous training. Clearly one of the most common conditions here, it is skilfully diagnosed and managed by doctors of all grades. The outpatients is extremely busy. Around 30 patients are seen by each doctor over a three to four hour clinic. Most are new patients, and severity and diagnosis varies greatly.

 



My new bicycle
My initial thought was that the doctors diagnose and treat with medications too soon… but that is from a western perspective. Given the vast pressure of patient numbers, and the likelihood of a lack of follow-up, or “watchful waiting” doctors have to treat here, and patients expect medication. Inpatients is much calmer than the clinics, and patients receive a comprehensive clerking (with a proforma that is better than any I have seen in the UK) and a strong academic focus to investigations and management. There is a broad range of patients in terms of diagnosis, and turnover is swift. To provide a flavour, I have seen a 16 year old girl with treatment resistant bipolar, conversion disorder ranging from seizures, to paralysis to head-aches and head tremor, liaison patients including acute lupus psychosis and yet again more conversion disorder. Relatives stay with the inpatients, providing much needed support (and staffing) on the ward. The confidentiality issue struck me initially, in that the next patient in the queue (and their family) at outpatients gather round whilst the doctor is seeing the preceding patient. Also, at ward round, the doctors are usually joined by an interested group of patients and relatives. This is in part due to space constraints at the BSMMU (psychiatry is due to move to a larger ward in the next few years) but is also, not dissimilar to the situation that occurs in Bangladesh anywhere – the bank, the train station, buying cha (tea), and although bizarre to myself, is not seen as strange here. A counter argument that has been explained to me by the doctors is that the support generated by such a crowd is actually beneficial in patient recovery – perhaps an interesting qualitative research project?
BSMMU Department of Psychiatry
I have found it difficult as an overseas doctor to understand the vast variance in services between different parts of the country. I spoke last time about the private and public split. I do not want to sound critical of any part of mental healthcare in Bangladesh, it is what it is, with huge financial and logistical constraints. The reality is that there are around 150 psychiatrists in Bangladesh, and with a population of around 150 million - 1 per million people. The BSMMU is producing psychiatrists every year, all of whom have been through a very rigorous education programme, and the total number of psychiatrists is growing slightly. However, this is countered by a “brain drain” of trained psychiatrists to other countries (I guess including the UK) Because of the financial and logistical restraints, huge parts of the country are without any psychiatric input at all. I have seen several people at outpatients who have travelled up to eight hours to get there, not ideal if you are being monitored for clozapine/lithium, etc!


That brings me to the question of what is my role in the link is. It is tempting to decamp into the rural areas where there is no psychiatry and see patients to prevent them having to travel so far. The reality is, however, that any similar attempts would only be temporary. There is already a WHO programme training community workers in mental health to improve capacity. The BSMMU is a fantastic place to start due to its key role in training the doctors of the future. Identified aims of the volunteer scheme link include 1) a collaborative research project to culturally validate rating scales 2) An update of the curriculum using my experience of training through the royal college version 3) Teaching sessions in transcultural psychiatry, early intervention and crisis intervention, 4) The establishment of a mock OSCE for the junior doctors (who have just started OSCES and quite nervous having never been through this type of examination)
Aside from work – over the last week I have been improving my cultural competence through attending a local wedding and going to the Bangladesh Premier League Cricket final – weddings and cricket being two of Bangladesh’s favourite pass-times.
Local wedding
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Comments

Re: 1 psychiatrist per million
Thank you for your posting. I am a Bangladeshi by birth, graduated from Rangpur Medical College. I did my post graduate training in US and I am a Diplomat/fellow of American Board of Psychiatry and Neurology. I am currently working at a Community Mental Health Center, in a very rural area in the State of West Virginia ("brain drain").
Left my country about 20 years ago. Unfortunately, I could not keep up with many aspects of medicine in Bangladesh, however, I do aspire to know, therefore the web searching. Your blog depicted some picture of psychiatry practice in Bangladesh. I see hope, as I see huge improvement from my time there (relatively speaking). However, I serve an "underserved community" here. Meaning the doctor to patient ratio is unexpectedly high. I also worked at a Veterans Affairs Hospital and have seen patient drive (US Highway) 3 hours to get to the Hospital. For some very remote and distant places telehealth is provided. What is the prospect of telehealth in Bangladesh?
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About this blog

Dr Adrian Phillipson

 

 

 

 

 

 

Dr Adrian Phillipson is an ST5 in general adult psychiatry, based in South Yorkshire.  He is currently part way through a year out from his training rotation, utilising the time to pursue research and travel interests.  Adrian is the first psychiatrist to take part in a new Royal College of Psychiatrists Volunteer Scheme Link with the Bangabandhu Sheikh Mujib Medical University in Dhaka, Bangladesh.  He hopes that this blog will provide good insight into the link, and will encourage others thinking of taking part in the volunteer scheme.

Adrian’s attraction to transcultural psychiatry stemmed from a chance encounter with a local practitioner in Malawi in 2003, where he witnessed a traditional healing ceremony for psychosis.  He has further developed his interest through completing a masters degree in Transcultural Mental Health Care at Queen Mary, University of London, as well as through further overseas exposure.   In 2010 Adrian made an initial scoping visit to Bangladesh to look at mental health services and help establish a sustainable link.  A report from this project can be found here.