Contents:
- Editorial
- Top tips: how to get
published
- Psychiatry Societies Dinner at King’s
College London
- ‘So you want to be a Psychiatrist?’
Medical student workshop at the Royal College of Psychiatrists’
Annual Meeting
- So, why a career in psychiatry?: a
personal perspective
- The anti-psychiatry movement: antecedents
and destinations
- Psychiatry: no healing, no
soul?
- Bringing new life into
psychiatry
- An ethical minefield: my journey through
Grenadian psychiatry
- Harvard Elective in
Consultation-Liaison Psychiatry
- Lessons from an experience of
delirium
- Size does not matter: focusing on a
train the trainer programme in Botswana
- Transcultural reflections: the
psychosexual history
- Interview: Dr Steve Peters − a
psychiatrist with GB Olympic Cycling
- A novel approach to training
doctors?
- Prizes for medical students
- Website contributions
- Editorial team
1)
Editorial
Vivek Datta, Final
year medical student, King's College London School of
Medicine; Visiting Research Fellow, Institute of Psychiatry,
King’s College London and Student Associate Member, Psychiatric
Trainees’ Committee (PTC)
One year
ago a student attended the medical students’ day at the Royal
College of Psychiatrists’ Annual Conference. Having been further
enthused to pursue a career in psychiatry, she got in touch with
the Psychiatric Trainees’ Committee who co-opted her as a student
representative in order to better establish links between the
College and medical students, and to further promote medical
student interest in psychiatry. At that time, there was only one
medical student Psychiatry Society in the UK, at King’s College
London, which I was President of. Today there are over 13
Psychiatry Societies at medical schools across the country. In this
issue, Georgina Fozard reports on the first meeting of
representatives from different Psychiatry Societies at King’s. One
year on and there has been another medical students’ day, which
Cheryl Bennett reports has once again been most insightful.
In November 2008, the College
revealed that only 6% of trainees sitting MRCPsych Part 1 were UK
graduates – but why is this the case? In this issue, Neel Burton
explains why he chose psychiatry, and speculates why others may be
deterred from following this career path. Psychiatry is more
heavily criticised than any other medical specialty and below I
consider what we can learn from the ‘antipsychiatry’ movement,
whilst Benjamin Sünkel-Laing argues that psychiatry must return to
its etymological roots and focus once again on the task of
‘healing’ the elusive soul.
It seems that psychiatry electives
might be one way of stimulating further interest in psychiatry.
Rebecca Slack describes how her psychiatry elective reminded her
not to forget her general clinical skills; Natalie Thomas’ elective
in Grenada threw up ethical dilemmas, whilst Katherine Townson is
considering a career in liaison psychiatry following her elective
at Massachusetts General Hospital. Delirium, a common referral in
liaison psychiatry, is considered from the experiential perspective
by Philippa Aveyard. There are of course places in the world where
there are no psychiatrists. South African psychiatrist Leverne
Mountany describes her mental health training programme in
Botswana, whilst Shameel Khan considers how cultural boundaries
make the psychosexual history an even more difficult endeavour in
Pakistan. Some psychiatrists travel all over the world and Stania
Kamara interviews Steve Peters, the psychiatrist working with GB
Olympic Cycling.
Psychiatry is in the position of
not only benefitting from advances in genetics and neuroscience on
the one hand, but also the social sciences and humanities on the
other. Gemma Ward argues that literary texts can be used to help us
understand somatisation and abnormal illness behaviour, and perhaps
become better doctors.
This is the first student associate
newsletter to be edited entirely by medical students, and its
existence is testimony to the tremendous strides the College has
made since Jude attended the conference a year ago, whilst its
contents dispels the myth that medical students aren’t interested
in psychiatry. We hope you enjoy reading!
Back to top
2) Top tips: how to get
published
Professor Robert Howard, Dean,
RCPsych
Getting published is easier than
you might think and since having a couple of references on your CV
and job application forms will distinguish you from the rest of the
herd – why not try one of the following:
1. Write a letter. Read the (to
you) most interesting paper in any medical journal. Did it raise
any questions in your mind? Did you disagree strongly with the
conclusions? Where do you think the field ought to go next? The
answers to any of these questions would make a good letter to the
Editor – just be sure that you are quick to submit after the
original paper has appeared.
2. Write a filler article. Journal
editors like to fill the empty spaces between papers with something
and are always desperate for good fillers. Look at your favourite
journal and see what kind of material they use. I’m always looking
for fillers for the British Journal of Psychiatry, which I hope you
read…
3. Short case reports are always
popular with some journals. Look for which like to use them and
write up a case that you’ve seen and that interested you. Brevity
is important – use every word.
4. Ask a consultant or more senior
trainee if they have anything that they have been meaning to
publish but haven’t time to finish and submit. In return for your
name on the paper you’ll do this for them.
5. Speak to a journal editor and
offer to write anything they need. They might want a book or a film
reviewed or even a personal view from a motivated medical student.
Be imaginative and say you’ll deliver within three days if
they commission you.
6. Above all – have some fun. I
still get a buzz out of seeing something I’ve written appear in
print. You’ll be amazed at the people who will read your work and
communicate with you to make comment. Good luck!
Back to top
3) Psychiatry Societies dinner at King’s College
London
Georgina Fozard, 4th Year
Medical Student, King’s College London School of Medicine, and
President, KCL Psychiatry Society
On the 7 May 2009 King’s College
London Psychiatry Society (KCL PsychSoc) hosted a meal for students
in charge of psychiatry society start-ups from universities around
the UK. KCL PsychSoc was the only one of its kind for a number of
years, but 2008 saw similar groups springing up all over the UK,
prompted by the Royal College of Psychiatrists’ plans to get more
graduates thinking about a career in psychiatry.
We began the evening with a talk
entitled ‘Drugs, Drink and Doctors: It could never happen to me…’
by Dr Jane Marshall and Dr Andrew Parker, which was a KCL Psychsoc
event. We had some drinks and students from UCL, Oxford University,
Leicester University and Southampton University met the current
committee of KCL Psychsoc, as well as the now Foundation Year 2
doctors who founded the society as medical students, and the
consultant psychiatrists (Drs Charlotte Wilson-Jones and Francis
Keaney) who give us at King’s advice, contacts and guidance. Later
on we went for a curry, which was generously funded by King’s
College London, and spent the evening exchanging ideas. It was an
opportunity for the students who are currently battling for
funding, interest and members for their fledgling societies to get
some tips from people who have been there before.
Unfortunately, representatives from
Nottingham, Peninsula, Barts and the London, Sheffield, Leeds,
Dundee and Edinburgh were unable to come due to exams. However,
they are part of our email discussion group and we welcome any
students from other universities who want to start a psychiatry
society to get in touch and join the rapidly expanding clan for
advice and tips! Email KCL PsychSoc’s Vice-President, Stania at
stania.kamara@kcl.ac.uk
if you would like to join the group.
Overall it was a brilliant night,
it was quite inspiring to meet so many people who share the same
interests, outlook on life and medicine and to be united in our
task to get more students interested in psychiatry.
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4) ‘So you want to be a Psychiatrist?’: Medical
student workshop at the Royal College of Psychiatrists’ Annual
Meeting
Cheryl Bennett, 4th Year
Medical Student, Keele University
On the sunny morning of Friday 5
June Gemma, my friend and fellow psychiatry-enthusiast, and I set
out on our way up the M6 on our way to Liverpool from
Stoke-on-Trent. After a two hour journey, following a Sat.
Nav.-directed detour off the M57 and a tour through the towns of St
Helens and Prescot, we arrived at the BT Convention Centre just in
time for some lunch at the Royal College of Psychiatrists’ Annual
Conference.
We filled our plates with colourful
couscous and bread rolls and went off to find somewhere to sit to
fuel ourselves for the afternoon ahead. After enduring the spiel of
sales reps who spoke so quickly we couldn’t interrupt to say we
were only students, Clare Oakley, Chair of the Psychiatric
Trainees’ Committee, guided us kindly to some spare chairs in the
trainees’ lounge.
Once there, Clare introduced us to
the Dean, who asked us about our experience in Psychiatry as
medical students, and enquired as to why we were interested in a
career in Psychiatry. My response, ‘because I’m quite nosey and
like to know a lot about people’ was met with great appreciation.
He then went on to explain how fascinating he still found
Psychiatry and that it was definitely suited for inquisitive minds
like mine.
The afternoon programme for the
student group involved talks from service users and practising
psychiatrists about their experiences in Psychiatry. Clare Oakley’s
talk on the training programme was very informative, and I can now
answer confidently when my appraiser and other students ask me
about it!
We were approached by many other
practising psychiatrists throughout the day, and their friendliness
and enthusiasm for the subject is unmatched by any other specialty
I’ve come across. This strengthens my gusto for psychiatry, and
eases my anxiety when I think about the long career I have ahead of
me. The next annual conference is to be held in Edinburgh and if
there is a similar student afternoon taking place there, I would
highly recommend attending.
Back to top
5) So, why a
career in psychiatry? A personal
perspective
Neel Burton, Academic Tutor
in Psychiatry, Green-Templeton College, University of Oxford and
Author of The Meaning of Madness
In 2008, just 6% of candidates
sitting Paper 1 of the MRCPsych exam were UK graduates, evidence if
any were needed that recruitment into psychiatry is facing an
unprecedented crisis.
In my experience, most medical
students enjoy learning about mental illness and talking to
mentally ill people, who often have a refreshing knack for saying
things exactly how they are. In a fit of inspiration, some medical
students tell me that psychiatry is the only specialty that enables
them to think about themselves, about other people, and about life
in general. They also like the lifestyle: an hour for each patient,
‘special interest’ days, protected time for teaching, light on
calls from home, and guaranteed career progression. In medicine
they might treat yet another anonymous case of asthma, chest pain,
or pulmonary oedema. In surgery they might do one knee replacement
after another, up until the day they retire or collapse. But in
psychiatry there can be no factory line, no standard procedure, and
no mindless protocol: each patient is unique, and each patient has
something unique to return to the psychiatrist. I often come across
those same students again, months or sometimes years later. After
the smiles and the niceties, it transpires that they are no longer
so interested in psychiatry. So what happened?
The students are never too sure,
but I think I have an idea. Whilst I was a medical student in
London, an American firm offered me a highly paid job as a strategy
consultant in their Paris office. So I gladly left medicine, and
the many inconveniences of working in (and increasingly ‘for’) the
NHS. I had a great time in Paris, but the job itself turned out to
be more about dealing with personality disorders than about having
good ideas. I quit after six months and freelanced as an English
tutor to high-flying executives, bankers, venture capitalists, and
such like. As my clients already spoke good English and merely
wanted to improve their fluency, all I had to do was to make
conversation with them. My lessons often turned into something akin
to psychotherapy, as I realised that I could make my clients open
their hearts and minds simply by listening to them speak. Although
they seemed to have everything in life, they were actually deeply
unhappy, and had rarely stopped to ask themselves why. I wanted to
find out why, so I decided to go back to the UK, do my house jobs,
and specialise in psychiatry. I had always been far too ‘ambitious’
to consider psychiatry, but by then it had become clear that I
didn’t want to pursue a career that didn’t allow me to think and
feel, and to relate to others and to the world in a genuine and
meaningful way. There are not many such jobs, but psychiatry –
along with general practice, teaching, academia, and the clergy –
is certainly one of them, and is even, arguably, their archetypal
form.
The following year whilst going
about my house jobs I put up with all sorts of abuse from my
colleagues in medicine and surgery. One of the other house
officers, by then a good buddy, took me aside one day and said with
an alcoholic mixture of concern and disdain: ‘Why do you want to go
into psychiatry? You’re a good doctor. Can’t you see you’re wasting
your talents?’ It became very clear, first, that the stigma that
people with a mental disorder are made to feel also extends to the
doctors who look after them, and, second, that this stigma emanates
most strongly from the medical profession itself, mired as it is in
middle class preoccupations and prejudices and, as a whole, far too
grounded in neurosis not to be terrified of psychosis.
Of course, it is simply not true
that psychiatry is ‘a waste of talent’. The term ‘psychiatry’ was
first used 200 years ago in 1808, in a 188-page paper by Johann
Christian Reil. He argued for the urgent creation of a medical
specialty to be called ‘psychiatry’, and contended that only the
very best physicians had the skills to join it. These physicians
needed not only to have an understanding of the body, but also a
much broader range of skills than standard physicians. Indeed, a
psychiatrist can change a person’s entire outlook with a single
sentence, so long as he can find the right words and the right
time. No protocols, no high-tech equipment or expensive drugs, no
pain or side-effects, and no complications or follow-up. Now that
is talent, and one so great that I can only ever aim at it. And
each time I fail, I always have medicine to fall back on.
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6) The
anti-psychiatry movement: antecedents and destinations
Vivek
Datta, Final year medical student, King's College London
School of Medicine; Visiting Research Fellow, Institute of
Psychiatry, King’s College London and Student Associate Member,
Psychiatric Trainees’ Committee (PTC)
In an
era of vehement opposition to the Vietnam War, the celebration of
individuality, an anti-establishment counterculture, and
suspiciousness of a profession which defined and managed abnormal
behaviour and experiences as mental disorder, the anti-psychiatry
movement was born. Although the term ‘anti-psychiatry’ implies a
unified critique of psychiatry and psychiatrists, it actually
applies to a number of disparate criticisms of the theoretical
basis and practice of psychiatry, which share only a deep disdain
for psychiatry and its practitioners, many of whom rejected the
‘anti-psychiatry’ label. Although our understanding and treatment
of the mentally distressed has advanced since the 1960s, and the
more extreme sentiments of these critics are untenable, now more
than ever we should reconsider critical perspectives of
psychiatry.
1. Michel
Foucault. Foucault believed that civilisation defined
normality, by defining abnormality. In this way the margins between
what would and would not be tolerated were delineated. Deviants
such as the deluded, demented, depressed, drug addicted,
dipsomaniacal and sexually dissolute were thus warehoused in
asylums under the gaze of the medical superintendent, and these
individuals later became seen to have a mental disorder. Foucault
further believed that the concept of abnormality was socially
constructed and that each era had a particular discourse for
conceptualising what was acceptable. What relevance do Foucault’s
ideas hold for us today? The asylums are now long closed, and the
mentally ill are largely treated in the community. The scope of
psychiatric practice has thus vastly expanded with disorders such
as depression and bipolar disorder over-diagnosed, and
antidepressants prescribed by GPs where their use is not warranted.
It could be argued that the government’s campaign to improve access
to psychological therapies is simply another way of regulating a
mentally healthy workforce and managing subjectivity. Today,
biological and cognitive models of madness hold sway, where
spiritual, social and psychoanalytic discourses once did. Perhaps
these are simply different ways of viewing mental illness, and no
better than previous conceptualisations.
2. R.D. Laing.
Glaswegian psychiatrist R.D. Laing did not believe that
schizophrenia existed, arguing the behaviour ‘that gets labelled
schizophrenic is a special strategy the person invents in order to
live an unliveable situation.’ In the context of the familial or
social space the person occupies, the seemingly bizarre behaviour
becomes intelligible. Laing has been (unfairly) maligned in recent
years, but what can we learn from him? Recent epidemiological and
genetic research suggests that schizophrenia is not in fact a
discrete disease, and psychologist Richard Bentall has called for
abandoning the term altogether. The content of delusions and
hallucinations, rather than form, are again becoming a central
clinical concern. It is increasingly clear that the boundaries
between mental health and mental illness are fluid, and the social
environment plays a significant role in the development of
psychosis. Perhaps we live in a mad world after all.
3. Thomas Szasz.
Hungarian-born psychoanalyst Szasz believed that, whereas medical
illnesses had been discovered, psychiatric disorders had been
invented. He did not believe that mental illnesses were diseases
because there were no anatomico-pathological lesions for mental
disorders. Furthermore, Szasz was critical of involuntary
hospitalisation, and did not believe it was a psychiatrist’s role
to prevent suicides. Some of these testaments seem particularly
outmoded, but do hold some relevance for us today. Community
Treatment Orders make involuntary treatment in the community a
reality for a minority, and it is clear there are effective
alternatives to coercive methods in psychiatry, such as joint
crisis plans. Further, Dangerous and Severe Personality Disorder is
a recent invention which is paradigmatic of how problems previously
seen as moral and spiritual have been reframed in a medical and
psychological discourse. The ‘bad’ have become ‘mad’; ‘sin’ has
become ‘sickness’.
Whilst many ‘anti-psychiatry’
critiques were a product of their time, they still hold some
relevance today. Most of the problems and antagonism that
psychiatry faces stems from a history of a profession and
professionals who have failed to articulate what psychiatrists can
and cannot do. If psychiatry is to withstand the slings and arrows
of its critics, and better serve those in need of its help, it is
time we looked closer at what it is that we can and cannot offer,
before we consider what we should and should not do.
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7) Psychiatry: no healing, no
soul?
Benjamin Sünkel-Laing,
Final Year Medical Student, Liverpool University
From the Greek, the term psychiatry
literally means ‘healing of the soul’. Therefore, the pathology of
the mad was believed to reside within the soul and, thus, the
spirit. Through the soul, many believed one could communicate with
God. Madness was regarded as a religious experience. Psychiatric
theory has moved on somewhat from this ideology and has had to
adapt extensively to a changing identity. Two fundamental
discoveries, or lack thereof, have prompted this rapid
transformation. Firstly, as thorough neuroanatomical exploration
advanced, the ‘seat of the soul’ eluded, and indeed still does
elude, all investigation. Thus, in all men of reason, the ‘soul’
ceased to exist: the soul was now a scientific nonentity. Secondly,
the discovery of neurological causes of previously labeled
psychiatric conditions, such as neurosyphilis and presenile
dementia were discovered, and it was believed pathological lesions
for other abnormal mental states would follow. Several brutal and
dehumanising somatic measures were developed and implemented to
‘treat’ the psychiatric patients in whom no clear somatic cause
could be found.
The ‘anti-psychiatry’ movement of
the 1960s was a response to this brutality and was partly fuelled
by a general social discontent. The enactment of both political and
military game theory and the focus on efficiency, materialism, and
financial gain, led to a counterculture. This edifying movement
affected psychiatry in a number of ways: firstly, the incongruity
between the etymological root of the term ‘psychiatry’ and the
clinical practice of the time was highlighted and debated
publically. Secondly, several psychiatrists refused to treat
patients with routine methods, placed more value on experiences and
founded alternative therapeutic centres. Although the social
experiments that were conducted during this time were not always
successful by conventional standards, several lessons have been
learnt from the anti-psychiatry movement. The misinterpretation of
meaningful human behaviour or praxis for mechanical processes is
now less prevalent in psychiatric practice. The continued effort to
elucidate the neural correlates of mental phenomena diagnosed as
psychiatric disorders must not obfuscate research into the
sociocultural context of madness. While the ‘soul’ seems not to
have a biological correlate, it does have an experiential one. By
avoiding both unnecessary reductionism and the homogenisation of
human experience, the practice of psychiatry will move closer to
enacting its etymological meaning.
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8) Bringing new life into psychiatry
Dr Rebecca Slack, Academic
Foundation Trainee, John
Radcliffe Hospital, Oxford
I spent my elective doing psychiatry in a world-renowned
hospital in the USA. I went hoping to confirm my interest in
psychiatry as a career, but also as a way of avoiding the practical
nature of most developing world placements. I am not a ‘hands-on’
person, much preferring talking therapies to actually doing
anything practical.
During my time on the inpatient
unit, a patient with bulimia nervosa was admitted with hypokalaemia
secondary to thrice-daily purging. This was not an unusual
scenario, but this lady happened to be 34 weeks pregnant. One
morning, having arrived on the ward at 6:40am to prepare for the
daily rounds, I was asked to review the patient as she was having
abdominal pain. From the end of the bed I could see that she was
sweaty, pale, and looked to be in severe discomfort. I was
concerned, and asked the nurse to contact an obstetrician urgently.
Moving closer, I saw that there was bloody fluid on the bedclothes,
and the patient starting yelling that she could ‘feel something
coming out’. I took the plunge and asked for permission to examine
her and, after the usual psychiatric ward struggle to find some
equipment, I performed a vaginal examination. I was alarmed to feel
a head pushing down on my hand, and immediately went into the
push…stop….push mode I had learnt during obstetrics. A few moments
later and I had delivered the baby, which thankfully started to
breathe by itself. I put the baby onto the mother’s chest, and then
started to panic as to what to do next. I was saved by the arrival
of a pediatrician, swiftly followed by someone with a pair of
umbilical cord scissors. Now all I had to do was to sort out the
fourth year resident - obstetrics was optional in her training, and
witnessing her first delivery left her feeling quite faint. Whilst
I hated obstetrics as a student, and complained about most
practical specialties, I am extremely glad the UK training system
remains for the most part general and all-inclusive. I’m still
heading for psychiatry, but perhaps will put a little more effort
into honing my practical skills.
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9) An ethical minefield: my journey through Grenadian
psychiatry
Natalie Thomas,
5th Year Medical Student, Peninsula College of Medicine and
Dentistry
An eight week elective in Mount Gay Psychiatric Hospital,
Grenada threw up numerous ethical dilemmas related to patient
care.
The 80 bed hospital houses an
excess of 140 in-patients, with some patients allocated to
mattresses on the floor. Patient excess contrasts staff shortage:
only three doctors, three nurses and three health care assistants
are employed in the hospital, limiting patient supervision. This
naturally generates tension and hinders patient progress, but staff
struggle to manage patients in any other way.
There are no paediatric psychiatric
services in Grenada, so children as young as 11 are hospitalised
with adult patients. This seemed immensely inappropriate,
particularly as many young patients had been sexually abused.
Currently, however, without availability of an adequate paediatric
facility, hospitalisation of vulnerable children remains safer than
risking assault in the community.
Grenada does not have a Mental
Health Act, so patients are not legally obliged to remain in
hospital or to receive treatment. However, patients can be
forcefully medicated in hospital and community settings if they do
not co-operate. Although this administration of medication was in
the best interests of the patient and the safety of others,
witnessing the use of physical restraint was distressing.
Furthermore, the notion that next of kin hold the right to refuse
hospital admission and may withdraw a relative at any time,
regardless of the patient’s age, capacity or wishes, was difficult
to acknowledge as it prevented doctors from acting in the best
interests of the patient.
I was initially stunned by the
hospital’s poor conditions and the ethical challenges that faced
me, but I learned to accept that patients were treated to the best
of the doctors’ abilities and health systems’ capabilities. Even
though I faced many challenges during my elective, my enthusiasm
for a career in psychiatry has not faltered. However, I feel that I
would struggle to work in a developing country where resources are
very limited and fewer patients recover to live independently in
the community.
Overall, my elective was a
wonderful experience and I learned a lot about myself and the
psychiatry speciality. Grenada is a great place to study psychiatry
in its ‘rawest form’ and I would highly recommend it to students
who are considering a future in psychiatry.
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10) Harvard Elective in Consultation-Liaison
Psychiatry
Katherine
Townson, 5th Year Medical Student, University of
Manchester
In April 2009, I spent one month at
Massachusetts General Hospital in Boston as part of the
consultation-liaison psychiatry team. The team’s input was
requested by medical and surgical colleagues for various reasons.
These included management of longstanding psychiatric conditions
for patients who were hospitalised for medical or surgical care,
management of substance abuse or withdrawal and recommendations to
hospital staff concerning the management of ‘difficult patients’,
for example those with borderline personality disorder.
I was encouraged to assess patients
with a wide range of psychiatric presentations, develop
differential diagnoses and formulate management plans, which were
then reviewed by the resident. The cohort of patients included
those with conditions that I had not been exposed to previously,
such as catatonia and conversion disorder. I was particularly
interested in two patients whose psychosis was suspected to be
related to their medical conditions, namely myasthenia gravis and
limbic encephalitis.
There were two areas where I
observed cultural differences between the UK and US. The first was
the attitude of patients towards mental illness and its treatment.
Patients seemed to be more open emotionally and there appeared to
be less stigma surrounding the need for psychiatric treatment. For
example, the team were called to encourage a patient to access a
detox programme. He looked dishevelled with facial bruising
sustained whilst intoxicated and I imagined that he would be
resistant to a psychiatric assessment. However, he was very open
and cooperative and told me that he had been working on his
addiction and thought that his latest relapse was due to his ‘self
sabotage issues’ that he was continuing to work on with his
therapist. I could hardly imagine a British man uttering those
words so unselfconsciously!
Payment for treatment, and the
moral conflicts it raises, was an interesting point that I
considered after watching a recording of a patient discussing
intimate details in a psychotherapy session. The psychotherapist
teaching us was able to show this recording as he had an agreement
with the patient whereby he would give her therapy at a reduced
rate if she consented to be filmed and for the recordings to be
used for teaching and research purposes.
I would wholeheartedly recommend an
elective in consultation-liaison psychiatry to others who enjoy
both psychiatry and clinical medicine. It was an amazing
opportunity to learn more about this fascinating sub-specialty and
I would definitely consider it as a future career.
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11) Lessons from an experience of
delirium
Philippa Aveyard,
SpR in General Adult Psychiatry, Edinburgh
Feeling ill... whatever that
means. Sick maybe? Something’s not right. Disorientated. Was I
drinking? No. Spiked? No. In hospital. Since when? I remember
arriving. But where am I now? Who is here? What time is it? What
day is it? So sleepy... Trying to explain...Something’s not... Oh,
back again. Trying to concentrate. To articulate. To explain? I
just can’t keep my eyes... drifting again...What are they saying?
‘You’re tired’. No. Not like that. It’s something else... Do they
even notice? Drifting again... Incoherent. Blurring. Slurring?
Then... nothing.
The experience of delirium is
terrifying. The degree of insight maintained may strike the
unfortunate balance between clarity of recognition that something
is very wrong, together with an inability to express these concerns
coherently. It may not be experienced as a peaceful, drowsy,
confusional state, but as a disturbing, frightening loss of
awareness and inability to take control.
Consistent, supportive nursing
care, a calm nursing environment, and cues for orientation are all
cited as factors important in the treatment plan. As often may be
the case with the non-clinical aspects of patient management, these
may be overlooked or considered of secondary importance by medical
teams, left to other disciplines to prioritise. This experience
reinforces my appreciation of the necessity of a comprehensive
approach to patient management. As doctors, it is easy to ‘relapse’
into treating illnesses, not people.
The impact of the memory of, or the
recovery from, an episode of delirium should not be underestimated.
We should be reminded that recovery, from an acute episode of any
mental or physical illness, should not simply be measured by the
successful treatment of clinical symptoms and signs, but also by
the patients’ individual perceptions of their abilities to resolve
and come to terms with what has happened to them.
I am reminded that non-clinical
aspects of care during and after an episode of illness may have a
greater impact upon an individual’s perception of their recovery
than we, as clinicians, may choose to attribute.
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12) Size does not
matter: focusing on a train the trainer
programme in Botswana
Leverne Mountany,
Psychiatrist in Private Practice, Fourways, South
Africa
My name is Dr Leverne Mountany, I
work as a psychiatrist in private practice in Fourways
(Johannesburg). It is not my story, however, that I want to tell.
This is a bigger story of passion, inspiration, challenges, rewards
and new friendships.
There are currently 490
psychiatrists registered in South Africa. This might sound like a
small number, but wait, it gets more challenging, there are just
five registered psychiatrists in neighbouring Botswana.
This is where our journey begins.
We have a plan: hundreds of psychiatrists will not appear overnight
to supply the critical needs in the area, but if we train existing
General Practitioners to help us diagnose and treat the mentally
ill we might win the battle. Hence a ‘Train the Trainer’ Programme
is born.
On a hot day in February 2008 we
travel the 500 km from Johannesburg to Gaborone (or Gabs if you are
local!) Our Land Rover (‘Fanny’- it is a long story…) has
negotiated packs of local donkeys and circumvented herds of goats
sleeping in the road! We arrive at the prearranged venue, excited
and fired up, ready to change the world, and then we wait….we wait
longer…. Eventually three of the potentially 30 delegates arrive
for the workshop. We are despondent, have we miscalculated the
needs? Is this a grandiose plan with no future? We reevaluate,
reorganize, and contemplate ….A LOT!
It is then that we discover the
spirit of people in Southern Africa. Dr. Diane Dickenson, a
Zimbabwean, invites us to her house for pancakes and high tea! (She
has since become a dear friend.) She tells us of the needs of the
country and convinces us that this was poor timing, just the wrong
day and the wrong venue. Eventually we decide that we will give it
another chance. (Thank you Diane for believing in the program.) The
following month we arrive: a motivated audience awaits us! People
are eager, enthusiastic and willing to learn, but also to share.
Our first workshop is officially underway! We start off with a
presentation skills module. My partner Hendrik Odendaal gets even
the most timid participant engaging in role play and individual
feedback. Then we use these newfound skills in order to introduce
the topic of the day: Depression. Group work and case study reviews
follow (the Zung Self-Rating Scale becomes a handy and practical
new tool). Suicide risk is addressed with the help of clips from
popular films. The day ends with insights gained, horizons
broadened and a lot of new friendships forged.
‘Sepela Gabotse’ – Walk Well
N.B. To date it is 15 workshops
later and the programme is still going strong and expanding to
other neighbouring countries.
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13)
Transcultural reflections: the psychosexual
history
Dr Shameel Khan,
ST4 Psychotherapy, Basildon and Thurrock University Hospital
Trust
Sexual instincts are so fundamental to all living
beings. However, their expression follows certain display rules set
by an individual society and culture. Talking about sex is a taboo
subject in Pakistan. Premarital sex is a punishable offence and
homosexuality is considered as a sexual perversion, which creates a
very difficult task for professionals, including psychiatrists,
dealing with psychosexual problems.
Last year, whilst on an elective
placement in Pakistan, I saw a man in his late twenties who was
accompanied by his mother in her late fifties. On getting a chance
to see him alone he was anxious about getting married. In a culture
where immense emphasis is laid on male virility and female
fertility, acknowledgement of such a problem is incredibly
difficult. But talking about sex was not only difficult for my
client but also for myself. As I started taking a psychosexual
history I felt thoroughly incompetent to enquire in Urdu. I
struggled to ask him about erection and ejaculation and his sexual
fantasies. There was a feeling in the room that we should get over
it as soon as possible and move on. It was much more difficult to
enquire about his sexual orientation. When I dared to ask him about
his sexual orientation I asked in a tangential manner. The
experience felt never-ending and my attempts to conduct a
psychosexual assessment in Urdu sank altogether. But I wonder if
the issue was not just of translation but of certain inhibitions
within me as well to ‘talk about sex’ as I am a product of the same
society. Following this experience I wondered if we sometimes
choose to remain blind to the patient within each of us. The second
important question was how practical is my training in England to
enable me to function as a psychiatrist in Pakistan and am I
playing the dangerous game of applying what is available in the
West to the frameworks of my own native society?
The experience helped me to decide
about my next post, which involved working with families from
various cultural backgrounds in first episode psychosis. It also
embarked me on my own personal therapy for experiential training.
There is a need to teach cross-cultural psychiatry in current
training programmes beyond culture-bound syndromes which trainees
hardly remember the names of. I feel that if cultural and social
contexts are taken into account then conversion from atypical to
typical human conflicts becomes easier to accomplish.
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14) Interview: Dr Steve Peters − a
psychiatrist with GB Olympic Cycling
Stania Kamara,
4th year Medical Student, King’s College London School of Medicine
and Vice-President, KCL Psychiatry Society
Firstly, thank you for
agreeing to be interviewed for the Student Associate newsletter,
could you please introduce yourself to our readers?
I’m Steve Peters, I’ve been a
psychiatrist for over 20 years and I currently work as a
psychiatrist with the GB Olympic team and have done so for about
eight years now. I am also Undergraduate Dean at Sheffield
University Medical School.
How did you get into psychiatry in the first
place?
My first degree was in mathematics.
I then decided working with people was more my thing and so I went
back to university and studied medicine. Initially I wanted to be a
surgeon but absolutely hated surgery as a junior. I changed to
Psychiatry and ended up in forensic psychiatry which I enjoyed. I
liked working with people with personality disorders; much of my
work was in changing personalities.
What about the Olympics,
how did you get into that and what do you do?
Well, most of my time is spent
motivating athletes and helping them to understand their own mind
and how their mind works. It is all about shifting personalities. I
have devised an entire system; I call it ‘the chimp model’, which
is all about managing anxiety. I work with many of the GB Olympic
teams and especially closely with GB cycling. I’ve also worked with
other sports teams such as England Rugby and Cricket. I also deal
with more ‘mainstream’ psychiatric cases such as depression,
bipolar disorder and so on.
What do you enjoy most about your job?
It’s an exciting career; no two
days are the same. It’s a 24-7 lifestyle, I get to travel and visit
many countries all over the world. I also like that in this post
there are very broad boundaries for clinical practice, day-to-day I
deal with a wide variety of problems. There is never a dull
moment.
Who are some of the famous people you have worked
with?
(Laughs) I’ve met quite a few
athletes who are supposed to be mega famous and I have no clue who
they are. We had a lot of medals at Beijing last year with the
Olympic cycling team, so you may have heard about some of them.
People like Chris Hoy, Bradley Wiggins and Victoria
Pendleton?
Yes, I’ve worked with those guys, they are very nice people.
What are the difficult things about your
job?
You are always on the move, and
although I enjoy the travelling, not sleeping for days at a time
can sometimes be a little tiresome.
Any advice to burgeoning sports
psychiatrists?
There is definitely a need for more
psychiatrists in elite sports, I’m the only one. Plus it’s an area
that’s growing, so if you enjoy sports, like to travel and fancy a
fast paced lifestyle: we’d love to have you!
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15) A novel approach to training
doctors?
Gemma Ward, 4th Year Medical Student, Keele
University
Reading fiction can help us all to
be better doctors. This is the conclusion I have drawn from a
project that I have been lucky enough to undertake as part of my
undergraduate course. I have had the opportunity to investigate the
portrayal of illness behaviour in fictional writing, looking
particularly at abnormal illness behaviour and the somatoform
disorders.
Abnormal illness behaviour is any
maladaptive manner of interpreting, attributing and responding to
symptoms, and is enthralling to study because it presents in a
myriad of forms, is influenced by many factors, and has a multitude
of effects. Somatisation, the presentation of medically unexplained
physical symptoms, often as a manifestation of psychological
distress, is inextricably linked to abnormal illness behaviour, and
is a remarkably common psychiatric presentation. Yet it is paid
little attention by psychiatrists, despite its association with
increased healthcare utilisation, strain upon the doctor-patient
relationship, unnecessary investigations and treatments, and a high
economic burden.
Abnormal illness behaviour and
somatisation are concepts clearly extremely worthy of
investigation. But why explore illness behaviour as it is
represented in fiction? Novels can provide something normally
denied even to the most proficient psychiatrist. Within a book we
are offered the minutiae of a character’s relationships, social
status, stresses, likes, dislikes, personality and intimate
thoughts, and all those other factors that we know in our hearts
have a profound impact upon the patient’s experience of illness,
but rarely have the time or inclination to ask about. Reading
fiction can allow a reintegration of the doctor with the world of
the patient, reducing that damaging tendency to detachment that
occurs in modern medicine as a result of our scientific approach.
Fictional literature can highlight those most vital influencing
factors and thought processes that lead to illness behaviour, in
order to help us better understand our patient’s reactions to
illness.
A Spot of Bother by Mark Haddon,
for example, emphasises the ways in which an unsuccessful
doctor-patient interaction can perpetuate a destructive cycle of
abnormal illness behaviour. Jane Austen’s Emma skilfully
demonstrates how secondary gain may lead a person to subconsciously
somatise, and from Austen’s Sense and Sensibility we learn how the
influences of upper class culture lead to an inability to verbally
communicate distressing emotions, resulting in an acceptability to
communicate them somatically instead. In short, fiction offers a
chance of being better able to understand our patients that should
be grasped by all psychiatrists as a means of improving patient
care.
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16) Prizes for
medical students
Many of the Faculties and Divisions
offer prizes and bursaries for medical students. More information
can be found on this
website.
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17) Website contributions
A few foundation trainees were keen
to work on a section on the website for foundation trainees. If you
would like to help with this work, please contact us at:
ptc@rcpsych.ac.uk
Back to top
18) Editorial
Team July 2009
- Vivek Datta, Final year medical student, Visiting Research
Fellow, Institute of Psychiatry, King’s College London
(Editor)
- Fizzah Ali, Final Year Medical Student, University of
Birmingham (Sub-editor, Electives and International Mental
Health)
- Samyami Sangeeta Chowdhury, Final Year Medical Student,
University of Warwick (Sub-editor, Events)
- JJ Thompson-McCormick, 5th Year Medical Student, University of
Southampton Medical School (Sub-editor, Education)
- Jonathan Nicol, 4th Year Medical Student, University of Leeds
Medical School (Sub-editor, Psychiatry and the Arts)
- Emma Hogan, Medical Student, Brighton and Sussex Medical School
(Sub-editor, Psychiatry Societies)
Articles for the next
edition of the newsletter are welcome. Jude Harrison will be
editing the next edition and can be contacted at: J.R.Harrison@dundee.ac.uk
Back to
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Page last updated on 22 July
2009 by E Baker-Glenn