Psychiatry, so far

And I'm halfway through my stint in psychiatry already. Barely 2 months to go before I (hopefully) rejoin a proper medical ward. And it's not that psychiatry isn't enjoyable, seeing 4 patients a day and being able to go home on time (or early!) is most definitely a welcome change from running around the ER trying to persuade doctors from other specialties that my patients really are theirs, and trying to persuade my registrars that I'm not a total idiot. I usually succeed, on both counts.

There is a learning curve to psychiatry, no doubt about that. However, after 2 months of seeing patients on my own and only running to my consultant for help when I really need to, I've sort of settled in.

And I don't like it.

The only physical contact you'll ever have with a patient is the initial handshake before the consultation. Sometimes, there's a handshake after. Occasionally (last week), you have to stab a guy in the ass with a needle to administer some medication that he doesn't really want to stop him from clawing the eyes out of every patient and staff member on the ward. At least I'm not the one trying to pin him down and shouting 'Any time now doc!'.

And the there's all this talk about the 'mental state exam'. Important words are thrown about: appearance, behaviour, mood, affect, risks, harm, perceptions, thoughts, insight, cognition etc. I was told quite early on that someone else reading your notes should be able to go into the waiting room and pick out your patient from the crowd. Seriously? Don't take it seriously. As another doctor told me: 'Just cover your ass'.

I've taken numerous psychiatric histories. I've talked to patients about their childhood, hobbies, likes and dislikes, aspirations, feelings, partners, parents, children, finances, associated physical health issues, sleep patterns, dreams; well, almost everything in their lives up to the point when I see them. And somehow, I feel further away from the person who is the patient than I've ever been in my entire medical career (which hasn't been that long). Somehow, by knowing everything about the patient, there is no connection anymore. Sounds paradoxical, but most certainly feels real.

And then we come to weekly small group discussions, otherwise known as Balint groups. A group of doctors, mainly psychiatry trainees (which I'm not) come together and someone talks about a patient they've seen and the rest of the group with the aid of a facilitator is supposed explore the patient-doctor relationship and emotions involved. Somehow though, it's become more of a speculation exercise about how the patient got into into his current situation and not so much about how the doctor has (or has not been able to) connect with the patient. Maybe I'm just too insensitive to realise how this should be helping me 'connect', or as a colleague helpfully put it (still not sure if I understand it), 'it's like a controlled mind-fuck'.

Maybe it's because I have to keep telling patients things like 'It's going take a few weeks (sometimes 6 to 8) for the medication to kick in and maybe you'll start feeling better. 'Maybe'. I've come to loathe this word that I've most definitely overused. It's almost a lie a lot of the time. And then you say something like, 'If that doesn't work, we'll increase the dose. If it still doesn't work, we'll need to find something else that hopefully does. But it will be a few weeks before we can try something else. Why do they take so long to work? Well, for those who are interested, there's an excellent paper on the subject (http://bjp.rcpsych.org/cgi/content/abstract/195/2/102). Which is so not frustrating, regardless.

Am I actually helping anyone in this specialty? I don't know. Some patients thank me. Some thank me regardless of how the consultation went. Some even shake my hand again. Some break down and cry. Some get angry. Some don't tell me anything. Some tell me they want to kill themselves. And there was this one chap who wanted to kill someone else. That was slightly disturbing. Most were on medication, some on more than one. Does medication help, I don't know. I haven't been here long enough to find out on my own. I suppose with psychiatry being such a large specialty medication HAS to help, right? Please tell me it does, I've been prescribing all week.

I'll be so glad to get back into MEDICINE. Only 2 months to go. The Force is with me.

Kinder Scout, Peak District

First it was misty and cold.
At least it wasn't snowing.
The ridge of Kinder, mist included. Compulsory, if anything.

Rocks. And the prospect of a nasty fall.
And then the sun came out. We headed down this way, enjoying the sunshine.

And realised that we had to head back up, and it was now unbearably warm.

But it did give us the opportunity to have a look at the ridge again, with less mist and more sun. I'm told that there is supposed to be a waterfall where the sheep is.

The 'river' bed which supposedly leads to the afore-mentioned 'waterfall'.

The trek back, in the blissful sunshine.