Wednesday, April 29, 2020

Chatter: Parenting & Dependency!

It might be of interest to present a record of one of my chatters (group supervision) with juniors! Names were obviously changed to protect them or me or even patients. 

The Cockroach Catcher learned a good deal from these chatters!

©2015 Am Ang Zhang

Minnie: Mrs B. just called from Canada. Your secretary said that this is one mother you will talk with anytime anywhere.
C.C.: Right, let me take the call and I’ll come back.


Minnie: so what is so special about Mrs B..

Jessie: Dr. Zhang has a few of these Patients that are basically untouchables and after the number of years of working with him I am just about making out that he has indeed a number of good points about it.

Trish: I know that many consultants do not talk to parents on the phone.

Jessie: I think Dr. Zhang does not either for good reasons as many parents get confused over the phone and it is best to explain things face to face in person.

C.C.: You learn over the years that there are inherent dangers in telephone conversations with parents especially if you do not know them well enough.  This is particularly true of cases involving access or abuse.  People either misconstrue or worse deliberately twist things in their favour.

Jessie: You have been known to refuse to see the other parent if there is any major dispute. Remember the one who finally broke into the wife’s house?

C.C.: Luckily he is now serving time.

Joss: What happened there.

C.C.: It really was a sad case of Domestic Violence. One day the wife pluck up courage and got an injunction. He moved to his parents in Brighton. Mother came to see me because of nightmares the daughter has been having. He demanded to have details of the notes and threatened to sue. I refused on grounds newly conferred on us( that it may be harmful to one other person). He wanted to talk to me and I refused. He complained and the investigating manager ask if I would see him at least once to see what it is all about. I said I would only do it in her presence. I explained my position and the right conferred to consultants. He became very threatening and we quickly terminated the meeting before it got uglier. Within a week of our meeting he broke into her house whilst she and her daughter was away, took her car and crashed it. From then on, I stuck to my guns and nobody bothers me anymore including the manager.

Minnie: But there are parents you would talk to.

C.C.: Over time you develop certain relationship with certain Patients and their parents that you are in some ways better off talking to them than not. First there often is an obvious need for them to talk to you. Then it saves time if you take the call and money too if they are calling from abroad. You also become their personal therapist and they really need to consult you even if it is about making decisions on buying a condo.

Paula: You advice people on buying a condo?

Jessie: And a few other things. Marriage, having babies!

C.C.: It is a long story.

Mrs B. was one of the first parents I went to see on a domiciliary visit when I became a consultant over 24 years ago.

Trish: You kept a patient going for 24 years?

C.C.: It is true that patients do not grow old, they just become familiar.

I think that the B.s are some of the nicest parents you can ever meet and over time they become your friend without becoming your social friend.

Tom: you mean you do not meet them socially.

C.C.: Not at all.

Joss: These are the people that gave the clinic the filing cabinets.

C.C.: That is very good. Exact same ones. I once had to take a call from one of the managers turning down my order for more filing cabinets. I was in the middle of seeing the B.s parents. I told them what happened and how and the next day two filing cabinets were delivered to the office.  You do get frustrated in the NHS when such basic items were not provided for. I obviously never thought that they would done it as I probably have other ideas such as toys for children if they were going to donate money. I was more grateful for the thought than for the actual cabinets.

What is important is that over the years I have learned a lot from this family.

Jessie: They shaped your view on adoption.

C.C.: This is the problem with a lot of psychodynamic understanding of people and if the truth be told, even the likes of Freud and Jung and Piaget based their theory on a very small number of Patients. I already have my own views on adoption and over time some cases encapsulate features that appear in a number of other cases. With these kinds of cases it is difficult to do research in terms of statistical significance and all that. I suppose people turn them into books and over time you hope to gain some insight into the complexity of human behaviour that way.  Some people argue that you cannot form an opinion say on adoption based on a few cases or not such a few number of cases.

Trish: At the adolescent unit over the years there are such similarities with types of cases that it becomes quite scary.

C.C.: I think that adopted children are ten times more likely to be disturbed than non adopted population and that is saying something. One can argue that human resilience is quite amazing and if it is not due to that we may see more disturbed individuals because of the kind of abuse and traumatic life experience they have.

Tom: Prof. Rutter had a good paper on these girls that we would have written off now if we see them in A & E after an overdose.
C.C.: I was actually at his paper presentation at a Royal College Conference.  You never would have thought that Rutter would move away from Autism to these wayward girls.  I think if I remember correctly they all by chance or fate met some nice men and married and settled down. I do not think boys are as lucky somehow. One might argue that somehow oestrogen, the great protective hormone might be at play and genetically, one needs to preserve the great species of Homo Sapiens.

Joss: Do you think that perhaps adoption does not work so well because the necessary hormones are not at play.
C.C.: Winnicott and Maternal Pre-occupation. You should all try and get to read his collected essays as human observation from a paediatrician seemed that much nearer whatever is going on than adult observers.  I think Child Psychiatry is such a great discipline for understanding human behaviour and to me it is the greatest discipline of all psychiatry if not all Medicine.

Minnie: Despite all the fakes.

C.C.: Don’t get me wrong, the fakes are in fact part of the fun. What I tried to bring out is we need to be able to distinguish between real mad and real bad.

Paula: You do not think it is non-pc to call someone mad.

C.C.: I know it is non-pc but sometimes one can shy away from these terms and Child psychiatric discipline moved from being called Child Guidance to Family Consultation where the role of the medical professional has been eroded.

Minnie: And patients cannot be called patients!

Tom: Service Users or Clients!

Jessie: It was Dr. Zhang who renamed our clinic the Department of Child & Adolescent Psychiatry.

C.C.: To Americans I call myself Pediatric Psychiatrist with the American spelling.

Jessie: not Family Guidance Service Provider!

C.C Proud to be a doctor, still.

Tom: With more discoveries of neurotransmitters the medical role is more important than ever.

C.C.: Yet a lot of the time we are dealing with what I called anthropological situations and all that is going on is rather external than microscopic.

Joss: Like with adoption.

C.C.: Adoption is a great cop out for many.

Minnie: Do you mean if it works it is the adoptive parents’ good work and if it didn’t it is not their genetic fault?

C.C.: This fault problem has been bugging me for a long time and most parents would tried their hardest to get some proof that it is not their fault and that is why diagnosis such as ADHD, ME, Aspergers,  Dyslexia are so popular with parents that at one stroke you remove the guilt from them.  Most parents nowadays seem to accept the most horrendous incurable diagnosis than having to face themselves or their own dark family history.   Obviously it is good in some ways for the parents and not so good for the child who one day will have to face the fact that they are labelled something they are blatantly not.  It was quite a revelation to me with the American medical students last week after I talked about my views on ADHD that two of them stayed behind to tell me that they have been on Ritalin since as long as they can remember and there is this great fear that if they stop now they may not get their grades.  I think they can see the sense of my arguments and were rather perturbed by it. One girl asked to see me on her own and it was blatantly clear that she never had ADHD but somehow was hooked on Ritalin to help with her work and was unsure now how to get out of it.

Paula: What did you do.

C.C.: It is obvious that you will shake her whole confidence now before exams and so on so I suggested that since I am not her treating doctor I can only suggest that she should look at it after her exams are over and move on into her medical career. She was most grateful and relieved.

Jessie: So they were psychologically dependent.

C.C.: Obviously. I think sometimes we need to look at the bigger picture.  There is no real research to back this up. But obviously cocaine is the closest of abuse drugs to Ritalin. We all know which country has the biggest Cocaine problem and we also know which country leads the world in Ritalin and stimulant prescription. One day, surprise, surprise some smart guy will find a link and maybe banished from that country and the medical world.

Joss: There is obviously the fear of missing out and I think your idea of getting her to sort things out after her graduation is a really kind one.

C.C.: it is often difficult when you give seminars as nowadays we touch on rather personal problems, eating disorder, parental divorce, abuse and adoption.

Minnie: Yet none of us wants you to tone down because of one of us as we need to know the full story.
C.C.: I suppose those of us brought up with a cadaver on the first day of medical school are programmed to face the stark facts of life.

Paula: Except some medical schools no longer do that which I suppose is sad in a way.

Jessie: What about Mrs. B.? Are you going to tell us more?

C.C.: Well maybe next time!

Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                      The Way We Were

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Wednesday, April 8, 2020

SARS-CoV-2 & SARS: Unbelievable! Unbelievable! Unbelievable!

Looks like Canada’s top doctor never learned from 2003 SARS:

Canada's chief public health officer Dr. Theresa Tam said on April 6 that transmission has been happening more often than previously thought right before development of symptoms, as well as evidence of asymptomatic transmission. As a result, she said the special advisory committee for COVID-19 has determined wearing a non-medical mask can help people prevent transmission to others and protect others.Similarly, there is also emerging evidence that some people who have the virus but never develop symptoms are able to transmit the virus as well, Canada’s chief public health officer said.
“Wearing a non-medical mask, even if you have no symptoms, is an additional measure that you can take to protect others around you in situations where physical distancing is difficult to maintain, such as in public transit or maybe in the grocery store,” Tam said.
Yet on March 30, Tam said that "putting a mask on an asymptomatic person is not beneficial."
Has she forgotten her predecessor Dr. Low in 2003 made a similar mistake!
Unbelievable! Unbelievable! Unbelievable!
Strange also that I watched the 2007 film Pandemic when LA public were all wearing masks.  Also Hong Kong so far has below 1000 cases and 4 deaths but the population has 95% of higher of mask wearing.  Why tell people only the best medical ones are good. Like in Pandemic, they might go and grab or rob them.  
I am reprinting my Chapter about that in my book.

SARS, Freedom & Knowledge

Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
 Adapted from Ching-yuan (1067-1120)

In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.
         For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease.  The alarm was first raised by its first victim, Carlo Urbani.  He was an Italian physician employed by the World Health Organisation (WHO) and based in Hanoi, Vietnam and he gave the disease its current name. It was as if this newly mutated virus knew what it was on about. Get the doctors as they would be the first who could deal with you. Urbani died. So did some of the medical staff that attended the first few patients.
         Doctors often thought that they would be immune, a God given right I suppose.  Not so this time! The virus obviously knew what it was doing.
         Our knowledge base was in total chaos. What we knew was obviously not good enough. Nor were the most up to date antiviral drugs. Even then in some places they were sold out as rumours spread. There were rumours too of vinegar and certain dietary items giving protection to certain ethnic groups, notably Koreans. The lack of knowledge about this new infective agent led to the great proliferation of myths that were soon spreading like wild fire on the Internet. Anyone with cold symptoms was treated as if he was carrying the plague. It was the plague, the new plague.
         Without any sound knowledge authorities took draconian measures – any measure anyone could dream up.  Some worked well if only to raise public awareness. One actually caused more harm and unfortunately deaths. That was the restriction of movement in one of the tower blocks in Hong Kong – a true quarantine. In the absence of insight into how the infection was spread, more people were infected. Some broke the law and fled the buildings before the quarantine. Unfortunately 321 people were infected and 42 died. Eventually someone was sensible enough to move them to another quarantine site.  Otherwise there would have been more deaths.
         Canada's hasty decision to declare its virus free status when so little was known about the virus proved costly and further eroded the public's trust in governments and people in positions of influence. Clinicians’ view no longer seemed to hold any sway where commercial interest was more important.
         Except in Canada, one advice was almost universally adopted – the wearing of a mask.  During this time, I was in correspondence with many of my medical colleagues and relatives in Hong Kong and Canada. One thing was clear: even the most difficult child complied and wore a mask. To this day one still needs to wear the appropriate mask to visit someone in hospital in Hong Kong, on top of having a dollop of alcohol gel to sterilize one’s hands. Many clinics require patients and staff to do the same.
         Now this must be the clearest lesson to every parent in every land. Where life and death is concerned, there can be no compromise.
         So it started me thinking about my practice, specifically Anorexia Nervosa and other difficult cases that I have encountered.  Take Anorexia, it may have been unnecessarily classified as a mental illness, given that it is the result of the parents giving the individuals concerned too much right and freedom for self determination.  If a child can be made to wear an uncomfortable mask, why can parents not make a child eat?
         The answer may lie with our view of freedom. Many parents of Anorexia Nervosa sufferers are highly educated, and some hold high positions in big corporations and even in Health Authorities. Many are professionals. Many have a great respect for individual freedom and self-determination and unfortunately they get caught in a bind of not being able to be authoritarian as far as their own children are concerned. It is not difficult to see why many parents of Anorexia Nervosa sufferers are not prepared to give up being a modern parent, and until they do, we psychiatrists will have to soldier on with the difficult task of treating what need not necessarily be an illness, let alone a mental one. 
         My second thought is that when something as familiar as chest infection can turn out to be a deadly new plague called SARS, we need to examine again the relationship between our existing knowledge and medical practice. We have to keep an open mind. What we know from the past should be an aid, not a hindrance.

Otherwise we shall never see the mountains and waters for what they really are.       

                                                                                                           From The Cockroach Catcher

Thursday, April 2, 2020

Medical Heresy from Plague to SARS-CoV-2; : Airborne & Masks

It was the 2002-3 SARS epidemic that led to the massive adoption of face masks as personal anti-viral protection in China and elsewhere in East Asia: More than 90% of Hong Kong residents reportedly wore them during the SARS epidemic. 

Credit...Rungroj Yongrit/EPA, via Shutterstock

Anti-epidemic masks as we know them today were invented in China more than a century ago, during the Chinese state’s first effort to contain an epidemic by biomedical means. When the plague struck the northeastern provinces of the China in the autumn of 1910, the Chinese authorities broke with their longstanding opposition to Western medicine: They appointed Wu Lien-teh (also known as Wu Liande), a young and brilliant Cambridge-educated Chinese doctor from British Malaya, to oversee efforts to stem the outbreak. The plague that was killing at least 1 in 3 was about to meet its match.

Credit...Jonathan Klein/Agence France-Presse — Getty Images

Soon after arriving in the field, Wu asserted that this plague wasn’t being spread by rats, as had been assumed, but was airborne. The statement was heresy, and turned out to be correct. Wu proved his point by adapting existing surgeons’ masks — which were made of a cotton wad encased in gauze — into easy-to-wear protective devices and ordered Chinese doctors, nurses and sanitary staff to use them. He also made sure that the masks were worn by patients and their immediate contacts, and he distributed some among the general public.
Credit...Institut Pasteur/Archives Henri Mollaret
Wu’s Japanese and European colleagues on the ground were skeptical until the death of an eminent French doctor who wouldn’t cover up even while attending patients. Gauze masks were soon adopted, extensively. Some wearers would first stamp them with a seal from a temple — more than simply medical devices, the masks became talismans.

Covid-19 or SARS-CoV-2: Airborne so 2 metres distance meaningless!

SARS ACCOUNTS: Dr Yannie Soo, Tom Buckley.
Other Posts:

SARS, Freedom & Knowledge