This field of medicine requires much more physiological and pathophysiological knowledge than most people give it credit for. Psychiatric illness DO have physical manifestations of symptoms; in fact those symptoms help form the main criteria for differential diagnoses. For example, key physical symptoms of depression, besides having a low mood for more than two weeks (yes, two weeks is all it takes to be classified as 'depressed'), include fatigue, change in appetite, unexplained aches/pains, changes in menstrual cycle if you're a female, altered bowel habits, abnormal sleep, etc. Aside from this, studies suggest that psychiatric illnesses put you at higher risk for physical conditions including heart disease, osteoarthritis, etc. (the list really does go on)
Although some mental health conditions, like cognitive impairments, still do not have very effective treatment options; most psychiatric medications work very well, and are necessary for treating the patient. The stigma surrounding them by the public causes a huge problem for doctors. Many patients are reluctant to comply with medications because they are not as widely accepted as the ones for non-mental health conditions. A psychiatrist holds a huge responsibility for patient education. It can be tough to teach your patients about their medication, when many of them refuse to belief there is anything wrong with them (this is also because of stigma).
Contrary to my previous beliefs, psychiatrists DO NOT sit around talking about feelings all day. The stereotypical image of someone lying down on a couch talking about their thoughts/feelings while the doctor holds up ink blots, is done more in 'cognitive behavioural therapy.' While this is a vital healthcare service, it's not really what a psychiatrist does. Taking a psychiatric history is just like taking a regular, structured medical history; except you have to ask further questions about their personal history (their relationships, professional life, significant life events, etc), forensic history, substance misuse history (if applicable), and childhood/developmental history. Taking a psychiatric history for a new patient usually takes at least an hour.
The interesting thing about about treating a psychiatric patient is that the best guidelines you have for making them healthy is their personality before the symptoms started (this is called 'pre-morbid personality'). This can be difficult to establish, and can often be an ambiguous goal for a doctor to reach. Of course, there is structure/protocol for each illness, but each patient will be unique. This is a challenge because personalities constantly evolve, healthy or not, and the human mind is perpetual.
On top of this, whether mental or physical, a serious illness usually significally impacts a person's personality.
Most psychiatric conditions, while being very treatable, will affect the patient will struggle with for their whole life. This leaves the psychiatrist with a large portion of the responsibility for the patient's quality of life and well-being; this can be vey rewarding and challenging. The state of a person's mind is a perpetual thing, choosing the right medication is not enough.
Before I had done this rotation, I was quite sure that this was a field I was not interested in. I still don't know if it is something I would pursue, but I'm definitely more open-minded to it now!
PS: It has also taught me some valuable life lessons; most of the patients I met were just ordinary people who were pushed a little too far by the unfortunate combination/sequence of circumstances in their life. Even the ones who have committed crimes or were capable of doing awful things.. It could happen to anyone, and just because I have been lucky enough to not experience the things those people have, does not mean I am a better person for not behaving the same way as them.
In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees.
Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this.
In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment.
In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room.
What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it?
Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important.
Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.
This month’s case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395) For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e, with 15% off using the discount code: MEDUCATION.
The case below is followed by a quiz question, allowing you a choice of diagnoses. Select the one letter section that best describes the patient’s condition.
A 28-year old woman has an unremarkable pregnancy through her first 28 weeks of gestation, with normal weight gain and no serious complications. She has no previous history of diabetes, hypertension of other systemic disease before or during her current pregnancy. During her 30-week checkup, her blood pressure measures 128/85, and she complains about feeling slightly more “bloated” than usual with swelling in her legs that seems to get more uncomfortable as the day goes on. Her obsterician recommends that she get more bed rest, stay off her feet as much as possible and return for evaluation in one week.
At the one-week follow-up, the patient presents with noticable”puffiness” in her face, and a blood pressure of 145/95. She complains she has been developing headaches, sporadic blurred vision, right-sided discomfort and some shortness of breath. She has gained more than 10 lb (4.5kg) in the past week. A urinalysis on the patient revelas no glucose but a 3+ reading for protein. Her obstetrician decides to admit her immediately to a local tertiary care hospital for further evaluation. Over the next 24 hours, the patient’s urine output is recorded as 500mL and contains 6.8 grams of protein.
Her plasma albumin level is 3.1 g/dl, hemacrit 48%, indirect bilirubin 1.5mg/dl and blood platelets=77000/uL, respectively. Her blood pressure is now 190/100.
It is decided to try to deliver the foetus. The expelled placenta is small and shows signs of widespread ischmic damage. Within a week of delivery, the mother’s blood pressure returns to normal, and her oedema subsides. One month later, the mother shows no ill effects of thos later-term syndrome.
What is the clinical diagnosis of this patient’s condition and its underlying pathophysiology?
A. Gestational Hypertension
C. Gestational Diabetes
D. Compression of the Inferior Vena Cava
The correct answer is "B. Preeclampsia".
The patient’s symptoms and laboratory findings are consistent with a diagnosis of Preeclampsia, which is a condition occurring in some pregnancies that causes life-threatening organ and whole body regulatory malfunctions. The patient’s negative urine glucose is inconsistent with gestational diabetes. Gestational hypertension or vena caval compression cannot explain all of the patient findings. The patient has three major abnormal findings- generalised oedema, hypertension and proteinuria which are all common in preeclampsia. Although sequalae of a normal pregnancy can include water and salt retention, bloating, modest hypertension and leg swelling (secondary to capillary fluid loss from increased lower limb capillary hydrostatic pressure due to compression of the inferior vena cava by the growing foetus/uterus), oedema in the head and upper extremities, a rapid 10 pound weight gain and shortness of breath suggests a generalized and serious oedematous state. The patient did not have hypertension before or within 20 weeks gestation (primary hypertension) and did not develop hypertension after the 20th week of pregnancy with no other abnormal findings (gestational hypertension). Hypertension with proteinuria occurring beyond the 20th week of pregnancy however is a hallmark of preeclampsia. In addition, the patient has hemolysis (elevated bilirubin and LDH levels), elevated liver enzyme levels and thrombocytopenia. This is called the HELLP syndrome (HELLP = Hemolysis, Elevated Liver enzymes and Low Platelets.), and is considered evidence of serious patient deterioration in preeclampsia.
A urine output of 500 ml in 24 hours is 1/2 to 1/4 of normal output in a hydrated female and indicates renal insufficiency. Protein should never be found in the urine and indicates loss of capillaries integrity in glomeruli which normally are not permeable to proteins. The patient has substantial 24 urine protein loss and hypoalbuminemia. However, generally plasma albumin levels must drop below 2.5 gm/dl to decrease plasma oncotic pressure enough to cause general oedema. The patient’s total urinary protein loss was insufficient in this regard. Capillary hyperpermeability occurs with preeclampsia and, along with hypertension, could facilitate capillary water efflux and generalized oedema. However myogenic constriction of pre-capillary arterioles could reduce the effect of high blood pressure on capillary water efflux. An early increase in hematocrit in this patient suggests hemoconcentration which could be caused by capillary fluid loss but the patient’s value of 48 is unremarkable and of little diagnostic value because increased hematocrit occurs in both preeclampsia and normal pregnancy.
PGI2, PGE2 and NO, produced during normal pregnancy, cause vasorelaxation and luminal expansion of uterine arteries, which supports placental blood flow and development. Current theory suggests that over production of endothelin, thromboxane and oxygen radicals in preeclampsia antagonize vasorelaxation while stimulating platelet aggregation, microthrombi formation and endothelial destruction. These could cause oedema, hypertension, renal/hepatic deterioration and placental ischemia with release of vasotoxic factors. The patient’s right-sided pain is consistent with liver pathology (secondary to hepatic DIC or oedematous distention).
Severe hypertension in preeclampsia can lead to maternal end organ damage, stroke, and death. Oedematous distension of the liver can cause hepatic rupture and internal hemorrhagic shock. Having this patient carry the baby to term markedly risks the life of the mother and is not considered current acceptable clinical practice. Delivery of the foetus and termination of the pregnancy is the only certain way to end preeclampsia.
This case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395)
For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e.
Save 15% (and get free P&P) on this, and a whole host of other LWW titles at (lww.co.uk)[http://lww.co.uk] when you use the code MEDUCATION when you check out!
About LWW/ Wolters Kluwer Health
Lippincott Williams and Wilkins (LWW) is a leading publisher of high-quality content for students and practitioners in medical and related fields. Their text and review products, eBooks, mobile apps and online solutions support students, educators, and instiutions throughout the professional’s career. LWW are proud to partner with Meducation.
The NHS is one of the largest employers in the world. It is one of the largest healthcare providers in the world and it is one of the most loved and needed institutions in this country.
The downsides to the NHS is that it is constantly ‘in crisis’ and it is expected to provide better care and newer treatments with less money and not enough staff. Recently, this has caused a significant drop in staff morale and the beginnings of an exodus of trained staff out of the NHS. This needs to be addressed.
If you read almost any management textbook, journal article or magazine, they will tell you that happy staff perform better. This ethos is easy to theorise but less easy to practice. Companies like Google and Apple have taken this to heart but so did some of the old Victorian companies like Cadbury’s and Roundtree. These companies aimed to make a profit but also to invest and look after their staff because of moral and economic principles… and it worked.
I believe the NHS needs to embrace this old fashioned paternalistic concept, if it wishes to continue to be a world leader in excellent, affordable healthcare and professional training. If the NHS invests in its staff now, it will increase staff morale, encourage people to stay working in the NHS and ensure top quality patient care.
Staff canteens open 24/7 (or near enough), that serve good quality, healthy and affordable food. If staff have to work unsociable shifts, it seems unfair not to provide them with the chance to eat a healthy meal at 2am rather than a Domino's. Staff canteens also allow the staff to unwind and socialise away from the wards and the public, they can be unofficial hubs of productivity where the 'real business' takes place away from the meetings.
Staff rooms with free tea and coffee - it doesn't cost much and every appreciates a 'cuppa'.
A** crèche** for the children of staff, on site or nearby. Reduces the stress of having to take children to carers and pick them up, allows greater flexibility for the staff.
Free staff car parking (if they car share). Staff have to get to work and cars are the most practical way for most people, so why punish them by charging car parking?
An onsite gym that is free/reduced price for staff and open 24/7 so that staff can pop in around their various shifts. The physio gym could just be expanded so patients and staff use the same facilities. Providing healthcare is stressful, takes long hours and is antisocial. All these factors make it easy to put on weight, especially with most hospitals only providing unhealthy meals, Costa and Gregs. So, an onsite gym would make it a lot more convenient for the staff to get the exercise they need to burn off all that stress and calories. Healthier, happier staff!
A hospital/ centre social society like a student ‘MedSoc’ to organise staff socials and sports teams etc. This organisation could even organise special events for the staff like a summer ball or sports day. Anything fun that would bring the staff together and let them blow off steam. It could easily incorporate, elected officials from the professional bodies and elected representatives of the different employees and act as an unofficial staff voice.
Regular staff forums that allow each group of employees to raise concerns or solutions to problems with the organisations management and senior staff.
Staff rota’s should not just be imposed by management but should be organised in a flexible manner that allows staff input.
The NHS management should encourage and provide extra learning opportunities for the staff. By investing in staff education they provide people with opportunities to develop them selves which will benefit the organisation and increase their sense of satisfaction with what they are doing.
Team based points systems for good performance and regular rewards for excellent care. These points systems can then be used to promote competition between teams which should raise the level of care. Have a monthly leader board and reward the best team with a day at a spa or something.
These changes may hark back to ideas that are out of favour now with the increased desires for measured ‘efficiency’, but I believe that these suggestions would hugely increase staff well being, which would hopefully improve their attitudes towards the organisation they work for and would hence make them happier and less stressed when they are caring for patients.
If you have any other suggestions for improving staff wellbeing please do leave comments.
The NHS is enormous and has a huge variety. It would be fascinating to survey as many parts of it as possible and see how many places have these services available for the staff already. Please feel free to contact me if you know of any study like this or if you are keen of setting up a study like this with me.