Doctors and Nurses

From the patients point of view, therefore doctors, don’t take offence!

I’ve been reading Dr. Crippen’s blog, as I usually do. He’s a GP who is very critical of “nurse specialists” who he feels are part of the intrinsic “dumbing down” of the NHS, doing jobs that they’re not qualified to do. His blog is excellent, even if he does tag his posts with enlightened words like “slag” and “lard bucket”. It’s like reading the words of people who shout names at me in the street and confirms my opinion that GPs are by and large massively prejudiced. Still, it does make for interesting reading.

I accept his points, and I can see why it would bother him, from the point of a patient. I think people believe that if you’re in NHS mental health services that you would see a psychiatrist on every visit, as they are the only medical types who are qualified to diagnose mental illness and to prescribe medication for it. This isn’t the case, and the actual frequency is around every six months. (Which makes me wonder sometimes what some psychiatrists are actually paid for. The consultant in my CMHT works part-time yet earns roughly three times as much as the full-time mental health nurse. I guess a lot of them work in inpatient facilities). They’re sometimes called in during crisis points and when your nurse believes that a medication needs to be adjusted or changed. Aside from that, though, in my case at least the input of the psychiatrist has been minimal. I couldn’t even tell you his name.

The vast majority of patient work in my CMHT is undertaken by nurses. It’s a bit of a treadmill; sometimes a person will end in hospital, be stabilised by nurses, be diagnosed by a psychiatrist then will be punted back into the community under the care of even more nurses. This is how it worked with me.

The role of my CPN is to keep an eye out for serious mood shifts, to note down how I seem to be doing, to see how medication is affecting me and to be someone who I can talk to for an hour a week about how I feel. Shes currently trying to sort out some therapy (and hey, it’s only taken two years) so her role is more therapeutic than medical. She rarely crosses that line, so Dr. Crippen would probably like her. She’s never suggested medication or medical treatment. She leaves that to the psychiatrist.

I much prefer dealing with nurses than I do with psychiatrists. Part of this is due to one of my own prejudices- I am uncomfortable with wealth. I don’t like sitting opposite someone who is judging me and who will drive to his or her own nice home when I will shuffle back to my existence on benefits. I feel deeply ashamed sitting in my ill-fitting clothes as their designer watch glints in the morning light. It is a prejudice, I’m aware of it.

I have never met a psychiatrist who has even attempted to show a shred of humanity to me. Nurses do, because you establish a rapport with them. Occasionally, you’ll see a slice of their own life. In my CPN’s car, I saw her baby seat so then knew she had a young son who she sometimes mentioned afterwards. I know she used to smoke and is jealous when I roll my cigarettes at the end of our meetings. Psychiatrists, though, are all business, and it’s difficult to speak to someone like that, especially when you are already guarded and paranoid.

I did like the psychiatrist who I met in hospital. He had a whiff of eccentric geography teacher about him. He airily entered room with stitched patches on his tweedy elbows and introduced himself by first name and last name with a firm, toothy handshake. He explained my diagnosis to me (and I hadn’t realised that the previous conversation I had had with another consultant was an interview) and remarked that I was manic at the moment, which I vehemently denied. (I was, of course, and spent the bus journey home believing that we were being followed).

Over time, though, I liked him less because of his businesslike manner. Yes, he was quite charming, but his to-the-point-ness worked in a setting where I needed a firm plan, and less so in the period afterwards where I needed a thread of sympathy or understanding as I struggled to accept my diagnosis and suffered badly from ongoing mood episodes.

Another psychiatrist I met years and years before was someone that I hated instantly. In retrospect, I was pretty unwell at the time. I had an appointment booked because my school were worried about my behaviour. I was fairly paranoid, and I sat in the waiting room for an hour or so, increasingly convinced that this whole scenario was a set-up and that I was being filmed. When I finally did meet him, I trusted him so little that we barely spoke, and that was that. I just thought that he was fooling me and lying to me, and I wouldn’t go back.

I admire psychiatrists and would love to be one, if I had the education. Mental illness is fascinating, but I think you need a different touch when dealing with mentally ill patients. A wham-bam-thank-you-mam plan is excellent, of course, but sometimes your patients will be paranoid, terrified and not wholly accepting that they’re unwell at all. A clinical approach to a person like that isn’t going to be helpful. Mental illness is not as easily explainable as physical illness, they are feelings, sensations, ideas and beliefs rather than symptoms and sites of pain. “Psychotic” is not psychotic, it’s the way you’re perceiving the world and yourself. You can’t point to a part of the brain and say, “This is wrong”. The whole “wrong” thing is horrible in itself. Mental illness suggests that your mind is broken and faulty, when to the person suffering from it, its inexorably linked with who they are.

The psychiatrists who have treated me have been very straightforward when it comes to my treatment. Dr. Isaacs, for example:

“I hate my medication. I hate the side effects and how it makes me feel”.

“Well, if you don’t take it, you’ll end up in hospital again”.

“…”

“I keep getting fired from work because of my behaviour”.

“Well, if you stop working, you’ll have no money”.

“Fab, I hadn’t thought about that”.

With my CPN, though, it’s a bit different. Same conversation, but a little more exploration of why I hate my medication, and the trade-off of being insane and being numb. She understands that it’s my choice as to whether I take medication or not, and is not so stark as to bluntly tell me that I’ll become really ill again if I quit taking it, although she implies it often.

Nurses, then, I think are extremely important in mental health care. For the paranoid, they are not as consistently scrutinising as psychiatrists are, nor as clinical. They’re not there to diagnose you with anything, even if it’s fairly clear that you do in fact have a certain diagnosis. They are just that little bit more human and on your level.

And, as I said, I think GPs are a massively prejudiced group of people. They see a lot of preventable or near preventable illnesses caused by lifestyle choices so, in my experience, if you smoke or you’re fat, you’re not even worth treating because everything that’s wrong with you is your fault. Tarring a lot of people with the same brush here but if Dr. Crippen can do it, then so can I. In terms of mental illness, I’ve been told in the past to “cheer up”, “stop moping”, “lose weight” and “sleep more”. Easy, innit.

The doctor blogs I read are at once fascinating and disturbing. We are all human, I know, but I think that if you’re a doctor, you are in such a position of power that, like the police, you really must push your own prejudices to one side. The reason I read those blogs is because they are all want things to change. I would like to reform the NHS, too. Pay staff more, make therapy mandatory and easily available for seriously mentally ill patients, pour funding into mental health care, set guidelines so that all patients get the same high standard of care (and abolish private healthcare. Yes, people like choice but it inevitably means that people who can afford it get better care) and open crisis centres across the country as alternatives to hospital treatment.

I’m not bashing doctors and especially not doctors who call for reform and care about their patients. What I don’t like, though, is the contempt for some patients that run through blogs. They’re written by humans, but it scares me to think that doctors size up their patients as lardbuckets or drunks.

It also frightens me how mental health services vary from borough to borough. My borough, Islington, is so much better than my old borough, Haringey, to the point where Haringey has a reputation for being awful. They’re only two miles apart, and yet the treatment that you receive in each is vastly different. This is really one of my contention points and probably why I have such a dim view of mental health services in general. I haven’t dealt with the best psychiatrists, just overstretched, oversubscribed ones. Then it’s no wonder that nurses take the helm, and no wonder that I prefer being treated by them.