NHS : World Class Medicine without trying!

Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth. 

Why?

We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.

Dr No said...

Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?

May 25, 2011 5:10 AM 

What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. 

Can we continue to practise World Class Medicine even if we wanted to?

Here is a reprint:

Tuesday, May 24, 2011

Teratoma: An Extract

It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.

Patients or their relatives are used to trust the judgement of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.

David Cameron is no different and he has stated so on record.

I am not here to analyse his faith.

I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978:

RHA days: 
The year was 1977 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.

Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom.  

Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.

The unusual cases:

Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.

As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.

Supermarket:

Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.

But supermarkets can get things wrong too. In Spain after the Christmas of 2009 there were 4 million unsold hams.

©Am Ang Zhang 2010

Back to the patient:

Would my patient be dealt with in the same way in 2011?

     GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.

     Paediatrician to me: ? Psychosis or even Catatonia. 

           Seen same day and admitted to Paediatric Ward, DGH.

     Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.

     Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.

     Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.

     Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.

     Patient unconscious and transferred to GOS on same day. Seen by various Professors.

     Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases), 

             Seen by more Professors.

     Regained consciousness after 23 days.

     Eventually transferred back to local Hospital.

None of the Doctor to Doctor decisions need to be referred to managers.

We did not have Admission Avoidance then. 

How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.

The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.

Not to mention the operation etc. and the transfer to the Centres of excellence.

Here is an extract from my book The Cockroach Catcher:  Chapter 29 The Power of Prayers

Just like Mayo Clinic:

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

But it is probably too late:

          …………Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.

          Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.

          A good doctor is one who is not afraid to ask for help but he must also know where to ask.

          “Get me Great Ormond Street.”

          “I already did.”

          She is going to be a good doctor.

          “Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”

          Who needs consultants when juniors have that kind of network?  This girl will do well.

          “Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”

          “Yes, you do and thanks a lot.”

          I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.

“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome. 

"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."

David Cameron, if it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.

Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.

King’s Fund: Million £ GP.

Sir Roger Boyle: 'It is horrific that the NHS's future is threatened'

NHS : Andrew Lansley, his Doctors and MPs.

See also:

The NHS wasted over £22 million on ISTC.

The Cockroach Catcher: One Patient One disease

Leadership Lessons from Mayo Clinic

NHS Reform: Dr House & Integrated Service.

Book: Brain On Fire

Anorexia Nervosa:Failure & Enmeshment!

Enmeshment:

This is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.       Minuchin

 ©2013Am Ang Zhang  

From The Cockroach Catcher
Chapter 34  Failure?

I

t is not easy to admit to failures and harder still for doctors to do so especially if they did everything right and according to protocol. 

         Doing the “right” thing is not an indication of success.  

         Hardly.

         Yes. I am coming back to Anorexia Nervosa again and I do not apologise for it. I am apologising for our failures though.

         The British Daily Mail reported in March 2007[1]:

         “It is thought there are between 60,000 and 90,000 adults being treated for eating disorders at any one time in the UK. The average age of diagnosis is between 16 and 18between 60,000 and 90,000 adults are estimated to be treated for eating disorders at any one time in the UK.

         Over a 13-month period from March 2005, 206 preteenage children across Britain and Ireland were newly diagnosed with serious disorders ranging from bulimia and anorexia to binge eating.

         Half were admitted to hospitals for in-patient treatment. Some were showing symptoms of starvation such as a low temperature and a slow heart rate, while 10 per cent had to be fed by tube.”

        

         In the same month, the British Independent[2] reported:

         “Anorexia Nervosa has the highest death rate of any psychiatric condition. In ten years 3% of these patients died, and although half were by suicide, the rest were related to the starvation process.

         Just this week in Rome a 27-year-old model identified only as Ilaria died of Anorexia after an illness lasting ten years. She weighed 35kg at her death. Luisel Ramos, 22-year-old Uruguayan model died at a fashion show in August, 2006 after suffering a fatal heart attack that was thought to be the result of Anorexia. Ana Carolina Reston Marcan, the Brazilian catwalk queen died only three months later in a Sao Paulo hospital.”

        

         When I took over the adolescent unit as its consultant in charge there were six Anorexia Nervosa patients in varying stages of emaciation or weight gain depending on from which side you want to look at it.  It is not always wise to have so many anorectic patients together as they do share tricks with each other and it is often more difficult to customise treatment.

         What needed my urgent attention was of course Sammy. Sammy had a very feminine name but preferred the nickname Sammy. Sammy’s Section was due to expire in less than 14 days and I had to compile a report for the Tribunal which would be sitting to decide on her fate.

         It was perhaps a sign of our failure as psychiatrists to effectively treat Anorexia Nervosa that eventually case law was established to regard food in Anorexia Nervosa as medicine.  Therefore food may be used forcibly to treat Anorexia Nervosa when the condition becomes life threatening. 

         The usual test of mental capacity no longer applies. Instead the law is used forcibly to feed a generally bright and intelligent person “over-doing” what most consider to be “good”.  They try to eat less and eat healthily by avoiding fat and the like and wham we have the law on them.

         I have to admit that I have not liked this aspect of Sectioning. Unfortunately it is used often, judging by the high numbers of tube fed patients.

         On the other hand not everybody is able to treat Anorexia Nervosa patients or, in reality, do battle with them. It requires experience, energy, time, wit, charisma and often impeccable timing. However, sometimes I do wonder if we are indeed doing a disservice when we take things out of parents’ hands by agreeing to take over.

         With hindsight and upon reflecting on a number of cases I have dealt with, I often wonder: if hospitalisation had not been an option at all, would improvement rate and, more importantly, mortality rate have been any different.

         We do not section people for smoking, drinking, or doing drugs, which all endanger life. Nor do we stop people running the Marathon or eating raw oysters when these activities regularly lead to mortalities.

         Society is coming round to do something about over-eating in children but it will take some time before they apply the Mental Health Acts. 

         To me, the moment a psychiatrist turns to the law he is admitting that he has failed. 

         At least that is my view and if I perpetuated the Compulsory Order with Sammy, I too would be part of that failure.

         There had been no weight gain in Sammy despite the tube feeding and the debate was: shall we increase the feed or shall we wait? Everybody just assumed that she would stay on as a compulsory patient.

         Despite bed rests and even more embarrassingly the use of bedpans, many Anorexia Nervosa patients managed not to gain weight whatever we pumped into them. The balanced feeds were in fact quite expensive. There was no secret that they were aware of the exercises they could perform even on bed rest and the determination not to put on weight had to be seen to be believed. If such determination was applied elsewhere I was sure these young girls could be very successful.

         I had to find an answer, an answer for Sammy and an answer for myself.

         Being forced to eat by the State remained the treatment of choice for everybody except for one stubborn consultant.

         “At least we did all we could,” my staff constantly reminded me.

         “And she is the most determined of all the Anorectics we have right now.”

         More reason to show the others that this new psychiatrist had some other means than brute force, I thought to myself. 

         Yes, I could be as determined as they were.

         The hours of family therapy only brought about accusations and counter accusations with hardly any resolution. Middle class families have certain ways of dealing with things where some branches of family therapy are not particularly good at all.

         The modern trend is certainly moving away from blaming families.  Or that is the rhetoric of most who write publicly about it.

         Whatever the official line, families cannot help feeling blamed.

         “If we are not to blame, why do we need family therapy?”

         “There are so many other families like ours.  Why do they not have the same problem?”

         We may reassure them that there are and that is the truth, but the truth is that there are also Anorexia-free families.

         Yes, it might help if they do find a gene like they did with obesity.  Yet that cannot explain why there are more extremely obese people in say the U.S. which collects gene pools from across the globe.

         So Sammy’s family had the full benefit of eight sessions of family therapy by two very experienced therapists. In the end, there was just a lot of recrimination between all parties including the therapists and all agreed it would not be the way forward. That was when tube-feeding started.

         Minuchin[3] dealt with over-involvement, over-protectiveness and conflict avoidance in these families with no special apology on whether he blamed the family or not. He used to start with a meal session with the family. His success, like many such methods, probably had more to do with his charisma than his method and is thus difficult to replicate.

         For Sammy and her family the message was simple and clear enough, no matter how hard we lied.

         The family had failed and the hospital had to take over.

         That was the blunt truth. 

         But the hospital had failed too and we had to resort to the Mental Health Act on one of society’s most sensible and decent and safest citizens. 

         I decided enough was enough. I could no longer perpetuate the no-blame approach. I could no longer continue to hide behind the power conferred onto me by the law. 

         In short, I had to reverse just about everything that had gone on before, and more.

         Just two weeks before the tribunal sat we had the big review meeting. To most at the unit, the review was fairly routine as there was hardly any choice – a full Section for Hospital Treatment primarily intended for difficult to treat Schizophrenics and difficult to control Bipolars in the acute manic phase. Sammy would be “detained at Her Majesty’s pleasure”, and classed with the likes of the few psychotics who had committed the most heinous murders. To save Sammy’s life, it would be natural to continue with the Mental Health Act.

         Yes there would be weeks of tube feeding and bed rest, but the State had to take over the complete care of this bright young thing for her own sake.

         I could not see any other way either.

         Unless …….I could reverse everything that had gone on before.  

         If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative.  Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.

         I had a plan.

         These meetings were attended by just about everybody who had anything to do with the patient.  They were held at school times so that most of the teaching staff could be present as well. These meetings also had a tendency to drag on as everybody seemed to have a lot to say about very little, a trait not just limited to psychiatrists but also seen in social workers, therapists, nurses, junior grade doctors, teachers and visiting professionals. People always seemed to have a lot to say on cases where there was the least progress. 

         My personal view is that this was a sure sign of anarchy which had unfortunately drifted into our Health Service, encouraged in part by the numerous re-organisations that had gradually eroded the authority of the doctor. 

         Saul Wurman[4], an architect by training but also an author of business and tour books, famously wrote that meetings really do not always need to be an hour long. Why can it not be ten or twenty minutes?

         Could I achieve that?

         After briefly explaining to all the purpose of the meeting, I turned to Sammy, who still had the nasal feeding tube “Micropore’d[5]” securely and said, “What do you think?”

         “It is so unfair.  Now I shall not be able to go to Harvard.”

         It is generally perceived as a given that a U.K. citizen who has been Sectioned will not be able to use the Visa Waiver to visit the U.S. If that person then has to apply for a Visa, having been detained under the Mental Health Act must be a major hindrance, although I have never seen this applied in practice. One of my patients did have to cancel a horse trial trip to Kentucky because she was sectioned at the height of a manic episode.

         I did not know she had aspirations to get to Harvard but I was not surprised given what I already knew about mother.

         “Before I say anything else, can I ask you a few things?”

         “What? Sure!”

         “Do you smoke, drink, take Ecstasy or go out clubbing?”

         “No.  Why?”

         “Do you have piercings and tattoos on you?”

         “Tattoos—yuk!  Yes, I having my ears pierced. That is all.”

         “Do you like Pop music?”

         “No way. I play the violin and I like Bach and Bartok!”

         Everybody was attentive now.

         “Do you shoot heroin or smoke Cannabis?”

         “No way!”

         She was getting annoyed.

         “What about boys and sex?” I felt bad even to ask especially in front of her mother, who I thought would faint if we knew something she did not.

         “How can you even ask and in front of my parents? You know I don’t do things like that!”

         I can remember my own adolescence. I did not do any of those things either and I did not even have pierced ears.

         I then turned to the parents.  Mother was a history teacher at a famous private school in one of England’s most middle class town. She also spent a year at Harvard, hence Sammy’s ambition to follow her. Father was a prominent city lawyer.

         “You have always provided well for her, a good education, European and U.S. holidays, a comfortable home and expensive music lessons.”

         “We are fortunate enough to be able to do that. She is our only child.” Mother replied in a tone implying, “what’s wrong with that?”

         “And she has always been a bright child, strong willed and single minded. She passed her Grade 8 violin with distinction at 14 and could have become a musician. But she wanted to do International Studies.” Mother added.

         “So she always had her way.”

         “She has always got on with everything, studying and practising the violin. And she keeps a tidy bedroom!”

         A tidy bedroom! My goodness, everything was falling into place.

         “Sammy……”

         “Yes……”

         “You know what? You are the first adolescent I know that keeps a tidy bedroom, do not do drugs, do not drink, do not smoke and you do not do a load of other things I asked you about. You are by modern standards a FAILED adolescent!”

         Then I turned to the parents.

         “And you, FAILED parents!”

         “And we FAILED you. We failed you because we had to hide behind the law and force feed you.”

         Sammy said, “I can’t do all those things even if you make me.”

         Ah, the turning point.

         “No, don’t get me wrong. I don’t want you to either.”

         I then told her that I would like to take the tube off her despite lack of progress, or because of it.

         It simply had not worked.

         I wanted her to take over, do what she needed to do and I would decide in about ten days if I had to extend the Treatment Order.

         Forty five minutes. The meeting took forty five minutes as people had to present summaries of different reports, the details of which were irrelevant here.

         The battle was over. Sammy looked relaxed. Nobody was fighting her now. She was back in control.

         I took her off the Section as she started to put on weight and before long she was discharged. 

         We forget how easy it is to entrench. To entrench is a sure way to perpetuate a problem.

A Brief History of Time: Anorexia Nervosa

A Chapter on Anorexia Nervosa,  

Anorexia Nervosa: Private Health vs NHS ...

Anorexia Nervosa Posts

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

---

[1] Daily Mail report on 26^th March 2007 – Children as young as six suffering from aneroxia.

http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=444646&in_page_id=1774

[2] Independent report on 29^th March 2007:  The Versace family: Allegra and the curse of anorexia

http://www.independent.co.uk/news/europe/the-versace-family-allegra-and-the-curse-of-anorexia-442347.html

[3] Salvador Minuchin:  (born 1921 in Argentina), in 1965 became the director of the Philadelphia Child Guidance Clinic, which eventually became the world's leading center for family therapy and training. He is author of a number of books including Families and Family Therapy and Family Kaleidoscope and coauthor of Psychosomatic Families: Anorexia Nervosa in Context and Mastering Family Therapy.

[4] Richard Saul Wurman: (born 1936) an architect by training, published over 81 books including his best-selling book Information Anxiety and his award winning ACCESS Travel Guides. His latest books are UNDERSTANDING Children and UNDERSTANDING Healthcare (January 2004). http://www.wurman.com/rsw/

[5] Micropore™:  Micropore consists of a conformable, non-extensible non-woven fabric manufactured by 3M from 100% viscose, coated with a layer of an acrylic adhesive.

NHS & ADHD: Ban the diagnosis & Save!

©2016 Am Ang Zhang

As I drove into work this morning the radio was playing Green Green Grass of Home. Must have
been years since I heard it. Tom Jones!

As soon as I stepped into the clinic, my trusted secretary asked: Have you heard, the new Health Secretary is banning ADHD and its benefits!

“Wow! Genius?”

“That’s it. He is banning the diagnosis made by private clinics. Diagnosis can only be made by NHS Child Psychiatrists and those on medication would not get benefits. Only those not on medication might be considered for some benefits. And only for school holiday time!”

“So the Daily Mail can no longer rant and rave about it!”

“Parents are up in arms because of the benefit thing. But you have always said that a third of our patients are fakes!”

“Don’t quote me or I will get the sack”

Then I heard Tom Jones again! Strange! We do not have a radio at the clinic!

“Then I awake and look around me, at four grey wall surround me

and I realize that I was only dreaming.”

Yes, I have retired! 

And it is TEA, not GRASS. BOH Tea in Malaysia.

Then I read in The Guardian

“According to data obtained exclusively by Education Guardian under Freedom of Information legislation, there has been a 65% increase in spending on drugs to treat ADHD over the last four years. Such treatments now cost the taxpayer over £31m a year.”                          More>>>>

Neurologist Richard Saul 

“ADHD Does Not Exist: The Truth About Attention Deficit and Hyperactivity Disorder” (HarperWave)

After a long career treating patients complaining of such problems as short attention spans and an inability to focus, Saul is convinced that ADHD is a collection of symptoms, not a disease, and shouldn’t be listed in the American Psychiatric Association’s Diagnostic and Statistical Manual.

Ritalin: no long term benefits

Related:

Please don't poison our children with stimulants
Bipolar and ADHD: Boys and Breasts

ADHD: Back To Nature?

ADHD: Why?

The File Snatching Sign

ADHD, Heart Risks, Kinko and Jetblue

ADHD: Posts.

©2012 Am Ang Zhang 

Adult A.D.H.D. & Faking: Real Psychosis ...

Feb 19, 2013

Adult A.D.H.D. is open to faking and more so by medical students. In children, it was my experience that often parents would report symptoms in order to secure disability benefits.

ADHD: Bipolar Disorder & others!

Aug 14, 2012

Over the last ten years or so, I kept meeting friends in the U.S. whose children seemed to progress from one psychiatric diagnosis to another with frightening regularity, the most common being from ADHD to Bipolar.

Bare Foot Doctors & ADHD: Golf, Piano & Swimming!

Aug 03, 2012

It has long been held that there is no alternative treatment to ADHD! Stimulant in its various forms is the answer. In life nothing is easy or indeed straightforward.

ADHD: To treat or not to treat?

Sep 18, 2011

“According to data obtained exclusively by Education Guardian under Freedom of Information legislation, there has been a 65% increase in spending on drugs to treat ADHD over the last four years.

Bipolar and ADHD: Fashion & Breasts

Sep 23, 2011

First came ADHD. The use of stimulants benefits mainly teachers during school hours. Parents and doctors soon find a quick fix in antipsychotics, and for good measure the newer ones, believing that they have fewer side ...

Spring City Golf: ADHD & Music

Sep 20, 2011

Is the piano China's answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants?

ADHD: Back To Nature?

Oct 21, 2008

Results: Children with ADHD concentrated better after the walk in the park than after the downtown walk or the neighborhood walk. Effect sizes were substantial and comparable to those reported for recent formulations of ...

ADHD, Heart Risks, Kinko and Jetblue

May 15, 2008

On April 21, 2008 A News Release came through: “Children with ADHD should get heart tests before treatment with stimulant drugs”

ADHD: Why?

Jul 28, 2008

I have in my travels met other psychiatrists who often ask why there is such a discrepancy in the diagnosis of ADHD in the US and the rest of the world. WHY! Perhaps it is something they have in the diet.

Medicine: Real or Rare Conditions

Sep 26, 2011

Has everything got to be ADHD, Bipolar or psychosis. Especially ADHD for a 39 year old?! In this week's ... But why should the patient not have pheochromocytoma and ADHD and paranoid psychosis and a touch of bipolar.

Lithium: FDA & Bipolar in Children

Aug 31, 2012

Over the last ten years or so, I kept meeting friends in the U.S. whose children seemed to progress from one psychiatric diagnosis to another with frightening regularity, the most common being from ADHD to Bipolar.

The File Snatching Sign

Jul 24, 2008

So Sharon brought this boy to see him. It happened to be his first ADHD assessment. He came out to see me after an hour. He did not think the boy suffered from ADHD but every answer Sharon gave on Conners would point ...