Dr. Gerry Rafferty's guest blog

One of the nice things about a blog is that it can remain dormant for a while and then be suddenly reinvigorated by new material. 

So when Dr. Gerry Rafferty recently sent me on his excellent essay on the uncertainty within psychiatry, it was a clear opportunity to reawaken this blog. Gerry is a Trainee in Child and Adolescent Psychiatry in south Tipperary and, as you can see from his essay below, he is a deep and expansive thinker.

When I asked Gerry about artistic accompaniments to his essay, he replied 'Anything by Goya' and I've included a few images from that artist, works relating primarily to mental illness. 

So many thanks to Gerry for this stimulating piece and for introducing me to the (sometimes quite dark) world of Francisco Jose de Goya y Lucientes (1746-1828).

The Madhouse, by Goya (1812-1819)

'In psychiatry we must tolerate partial knowledge, ambiguity and uncertainty'

 

Dr. Gerry Rafferty

 

 

'Science has not yet taught us if Madness is or is not the sublimity of intelligence'

Edgar Allan Poe

There is an urban myth that circulates amongst undergraduates of every discipline , usually approaching their final exams, about the philosophy student sitting their finals in metaphysics. There is only one question on the paper which is “Why”. The hero of the myth answers “why not “ and leaves. He is awarded a distinction.

There are several attractions to this story: the precision of the answer, the wit or possibly the dream of minimal effort gaining maximum reward, which is particularly appealing when you are stressed before an exam.

However, underlying it there is an academic or at least scientific distaste for philosophy, its vague questions, seemingly pointless musings and the lack of useful product. Drill further and you find a deep distaste for something which promotes thought for thoughts sake and the existence of opposing views with no possibility of definite resolution, no winner, no definitive paper which resolves the debate at hand. For example, is it better to be good or right? 

The dialectic of scientific contempt for philosophy is the equally famous quip about the medical student who asks the Professor: “What qualities does it take to be an orthopaedic surgeon?”. “Strong as an Ox and half as intelligent”, replies the learned physician. Here is exposed a contempt for the doer, with no deep thought or complicated investigation, the lack of wrestling with a series of difficult results and then breaking the code of the thorny problem. 

I would argue that this dialectic has existed in medicine for centuries. This is hardly surprising given the diverse parentage of what is now called Medicine. Born of the first professors in universities, i.e. those of physic who bore the title doctor and the upwardly mobile Honourable Company of Barber surgeons, who had to carry the title Mr. just so people knew they were the newest members of the family. 

Times change and things evolve and Mr. is now worn as a badge of inverted snobbery by surgeons. With the passage of time the family of medicine grew strong and more influential, and with its status the profession increasingly portrayed that it was an authority that was certain of what it knew. Medical opinions carried weight in law. At work and in general these opinions were not argued with. The intellectual development of medicine was to consolidate to produce an Orthodoxy. Definite books of reference were written and read, research and development did not stop, new technologies and breakthroughs in other sciences were taken on board, but they had to proven as fact. Healthcare assumed there were facts beyond doubt and it was sure of them.

In to this noble family a cousin was adopted, Psychiatry, its parentage uncertain but definitely with some questionable heritage and its impure lineage was obvious, its behaviour wild and unpredictable. Patients were locked away for life, electrocuted or tortured with little sound reason. We spoke of lunacy as if a celestial body could affect the afflicted, as a consequence it was humoured and not taken entirely seriously. 

The consequence of this is understandable to psychiatrists now, like an invalidated teenage girl teased for her weight, psychiatry developed an adverse relationship with uncertainty, its behaviour changed, it restricted on uncertainty, purged on doubt and over exercised on classification. Such behaviour doesn’t do anorexics any good and it hasn’t done psychiatry much favours either. 

With this background in mind, not only should psychiatry tolerate partial knowledge and ambiguity and uncertainty, we should embrace them. For it is these concepts that will advance our science or craft. In the following I will seek to persuade the reader of this.

To begin with, let’s consider partial knowledge in the context of Schizophrenia. The difficulty in following the history of Schizophrenia is proof (1,2). The disease that we now call Schizophrenia as originally described by Bleuler (3) was not in fact a positive diagnosis. He just described what it wasn’t, i.e. it wasn’t dementia simply based on the grounds that people sometimes got better with Schizophrenia and didn’t with dementia, but he didn’t know why.

In the same way Newton didn’t discover gravity - it had always existed and he just described it, the same can be said of Bleuler - he didn’t discover what is now called Schizophrenia, he described it. Now that in itself is noteworthy because it was led by a process of intellectual development driven by partial understanding to an important set of paradigm shifts in the development of psychiatry. 

Many argue about the historical validity of schizophrenia as a discrete entity or whether it represents a culturally specific set of symptoms(4). However, what is not possible to deny is that by the turn of the 20^th century , the concept of insanity had been replaced by one of mental diseases (5). Following an Aristotelian desire to classify, important shifts were made. Psychoses began to be seen as an entity. 

Kraepelin in his classification separated manic depression out as a separate entity and ultimately as a consequence of this epilepsy was moved from Psychiatry to Neurology, which is a Copernican revolution because now the link between psychiatric symptoms and brain function is made (6).

Clearly the timeline as described his distorted Kraepelin described a systemic disturbance which was called multi system failure in early life and several people used various versions of the term dementia praecox in what retrospectively sound like schizophrenia, such as Sir Thomas Coulson (7). 

Whilst a full history of understanding (or lack of) Schizophrenia in the 20^th century would be a topic worthy of more detailed analysis than I can give it here, a brief overview further reinforces my argument that acceptance of partial knowledge drives us to look for better understanding, whereas assuming what we know is the unalterable truth leads to abuse and stigmatization. 

In the first instance Schneider tried to more specifically define symptoms that suggested Schizophrenia as a separate entity. His first rank symptoms are still of use today (8,9).

In contrast, eugenics grew in popularity worldwide, it was used as a justification for forced sterilization and murder because mental illness was considered to be inherited by Mendelian genetics and the world would be better off without it. This is only possible as an intellectual construct if you believe with certainty that you know this is a condition without cure, thus leading to the conviction it should be eradicated.

The advent of pharmacological interventions has led over recent decades to strive for a greater understanding of the brain chemistry behind Schizophrenia and the development of newer antipsychotics (10,11). Even if the motivation is financial in part the tolerance of incomplete knowledge leads us to strive for improvement. 

The questioning of the 'anti -psychiatry' movement in the 1960s and 1970s can be argued to have forced mainstream psychiatry to be more open to the biopsychosocial model of mental health (12).

The drive for greater understanding, because we accept we have partial knowledge, has led in recent years to continuing developments in new directions. CBT seems to have a role to play especially in relapse prevention (13). Early intervention programmes in psychosis are now well established in Europe and the US and seem to be beneficial in preventing prolonged periods of psychosis (14,15). I think this portion of my argument is best summed up by a poet 'Ah but a man’s reach should exceed his grasp, or what is heaven for' (Robert Browning). 

The Sleep of Reason Produces Monsters (1799)

I am not sure how I feel about ambiguity. In fact, my career to date in Psychiatry has made me more accepting of ambiguity. I think that this may be in part due to the Balint component of training, the component of self-reflection and awareness of transference and counter transference that has made me see the world differently. It has increased my empathy in a sincere way and led me to personal acceptance and the practice of mindfulness, most specifically the loss of judgement, which in turn leads to greater personal contentment, which I am of the opinion makes you a better psychiatrist and a nicer person.

It is from this personal perspective that I wish to argue that tolerating and embracing ambiguity is not only necessary for a psychiatrist but highly desirable.

Consider Borderline or Emotionally Unstable Personality Disorder - the model for ambiguity even in its own lexicon. It provokes severe negative countertransference in many mental health professionals (16). I find this curious. Whilst I accept that the behaviour of people suffering from personality disorders can be challenging and the splitting defence mechanisms can be anxiety inducing, they are a group who have in the majority had their condition inflicted upon them. Up to 70% are the victims of child sexual abuse, and in most of the rest the damage and invalidation is usually obvious from their history (17). Why do they provoke such ambiguous responses in psychiatrists and other mental health professional?  

There is considerable evidence that medical professionals find both risk assessment and ambiguous decisions difficult, particularly around end of life decisions (18). Surgeons report difficulty in a personal sense when deciding on operations with marginal gains and high risks (19). They often rank the patient’s own preference to make these decisions as poorly informed (20). 

Cynically, you could say that they don’t want their statistics distorted, with an increasingly blame centred culture. They are understandably uncomfortable around interventions which may have a negative outcome. A more compassionate view might be that all of us in our medical training are taught “first do no harm” it is ego syntonic to save or help and deeply ego dystonic to fail or for someone to die in our care. 

The consequence of this is we have very ambiguous attitudes to the only thing we can be certain of - death. Death is seen as being someone’s fault, it can be prevented. We do post mortems frequently (21). This is a false belief and at our core we know it but it’s painful and distressing from a personal point of view to think about it.

Nobody enjoys existential crises so we repress it. This leads to psychological stress which expresses itself in ambiguity in difficult decisions. Psychiatrists are not often confronted with such battlefield decisions but we are often confronted with giving advice or making decisions where none of the outcomes are particularly appealing, or dealing with resource allocation where there is clear ambiguity.

In the case of Borderline personality disorder, especially severe or refractory cases, we are presented with a number of options: long-term hospitalisation which we know may well be counterproductive and may be damaging to our patients, access to DBT which is resource intense and may be sabotaged by the patient, medication for which there is little evidence for efficacy or, if resources permit (and they rarely do), admission to a therapeutic community. The alternative is tolerating the ongoing risk of someone we have no effective treatment for. 

These options are all unattractive. In an ideal world there would be limitless DBT or psychotherapy, but we don’t live in an ideal world. Our imperfect world is full of ambiguous choices or moral positions.

Sometimes we are confronted with taking the least worse option and this challenges our desire to do the best we can for our patients. We find ourselves doing something less than perfect but it’s the best we can do. We need to be able to function in a world full of ambiguity and in order to do this we must learn to not only tolerate ambiguity but understand it and be comfortable so that we can treat and advocate for those we care for 

As Tolstoy says in The Devil “the doctor arrived towards dinnertime and said of course that although the recurring phenomena might well elicit apprehension nonetheless there was strictly speaking no positive indication, yet since neither was there any contraindication, it might, on the other hand, be supposed. And it was therefore necessary to stay in bed and  although I don’t like prescribing nevertheless take this and stay in bed”.

Yard with Lunatics (1794)

Finally, we turn to the cumulation of ambiguity and partial knowledge, which is uncertainty. Much of what has gone before could be presented again to advance the argument that we must tolerate uncertainty.

But I wish to expand my proposition, to a case were our certainty gives rise to harmful and negative consequences for us as psychiatrists regarding situations over which we have little control and yet are perceived to be responsible for.

The case in point is that of suicide. 'It is a very frightening world where one professional group is given the impossible task and then censured by society (and themselves) for failing to achieve it”(22).

The previous quote is a free text response from a psychiatrist who had been involved with a patient who had completed suicide. It illustrates two important points. 

Firstly, there is a societal expectation upon us that is unreasonable. The emotive topic can spark newspaper headlines and the perceived censure from the public and the profession. 

There is resentment that Cardiologists are not subject to such scrutiny after someone dies from a myocardial infarct having been recently seen. However, I would contend that most branches of medicine feel the pressure of unreasonable public expectation. 

The most startling part of the statement is that we the mental health professionals buy into the notion that we can prevent suicide, this in spite of a substantial body of evidence that most suicide victims have no contact with mental health services or that less that 2% of suicides are rated as intermediate risk by accepted risk assessment tools (23)(24). 

Yet there is considerable evidence that psychiatrists who are involved with a completed suicide feel responsible for it and this exacts a heavy toll (25)(26)(27). What is of considerable interest from surveys is that most psychiatrists had high expectations about their own capacity to prevent suicide (22). 

The dialectic is clearly formed here. We believe we can prevent suicide, society thinks we should be able do so but the evidence is clear that our ability is very limited.

There are no validated risk tools which perform well, no single set or sets of risk factors which allow us to accurately predict suicide or usefully guide decision making (28) 'Given this, the attribution of personal responsibility for suicide prevention is clearly challenging' (22). 

The question to be addressed now is, why? 

Why do we take personal responsibility for something that the evidence clearly shows we have little control of. Leave aside unreasonable public perception, the point of interest here is unreasonable expectations of a profession that craves the accolade of being evidence based, yet we are happy to disregard a fairly convincing body of evidence when we apply it to ourselves. 

This is clearly not a logical or analytical approach. This is clearly an emotional, ego driven and, dare I say it, irrational response.

Now previously I have outlined the desire of modern psychiatry to be taken seriously and shy away from anything that is not statistically analysable.

What is the root cause of this dialectic which causes so much distress, makes psychiatrists change career and prevents people from entering psychiatry? 

It is uncertainty. More precisely, it is the inability to tolerate uncertainty. 

We could clearly seek to educate the public to the facts, but we don’t do that. We don’t do that because our unwillingness to acknowledge our limitations and acknowledge the gaps in our knowledge has the power of a ruminant thought in OCD. We generate temporarily soothing rituals: more risk tools, obsessive data collection and note keeping and, although they provide temporary relief , all they really do is increase the power of the resisted thought.

It appalls and offends our collective egos to say “I can’t” or “I don’t know''.

We collectively suffer and undermine our patients' faith in us because we cannot accept uncertainty.

Uncertainty is all around us in every aspect of the world: the weather, the stock market, Brexit or whether we will wake up tomorrow. 

The dawning of the reality that even in a place where we have studied, trained and practiced for years is no surer than anywhere else provokes anxiety and distress and causes something of an identity crisis.

It is upon this analysis and conjecture that I base and assert my almost certain conclusion that psychiatrists must learn to tolerate uncertainty, and not only tolerate but understand and embrace it and accept it for the universal reality that it is. 

Uncertainty is the fear food to the chronically invalidated teenager with anorexia, constantly seeking to please the expectations of overbearing parents: exposure to it exposes are deepest insecurities. 

I think Douglas Adams outlined our conflict the best: 'We demand rigidly defined areas of doubt and uncertainty'.

Saturn Devouring his Son (1819-1823)

References

1. Yuhas, Daisy. ”Throughout history ,defining Schizophrenia has remained a challenge “ Scientific American Mind(March 2013)

2. Berrios G.E., Luque R.,Villagran J (2003) “ Schizophrenia :a conceptual history” International journal of Psychology and psychological therapy. 3 111-140

3. Bleuler, Eugen(19080”Die Prognose der Dementia Praecox- Schizophrenigruppe Allgemeine Zeitschrift Fur Psychiatrie 65:436-464

4. Cutting, John and Shepherd, Michael (1987)” The clinical Roots of Schizophrenia concept: Translations of Seminal European Contributions to Schizophrenia. Cambridge: Cambridge University press, pp59-74

5. Berrios GE, Hauser R (1987)”Historical Aspects of the Psychoses :19^th Century issues ”.British Medical Bulletin.43(3) 484-498

6. Berrios GE, Hauser R(1988)” The Early development of Kraepelin’s idea on Classification .A conceptual History” Psychological Medicine.18(4) :813-821

7. O’Connell P., Woodruff PW, Wright I, Jones P, Murray RM (February 1997) “Developmental insanity or dementia praecox:was the wrong concept adopted . Schizophr.Res 23(2) 97-106

8. Clinical Psychopathology. 5th ed.New York: Grune&Stratton:1959

9. Nordgaard J, Arnfred SM, Handest P, Parnas J. The diagnostic status of First Rank symptoms. Schizophrenia Bulletin. 2008; 34(1) :137-54

10. Meyer, J.S., & Quenzer,L.F (2005) Psychopharmacology: Drugs, the brain and behaviour. Sunderland, MA,US:Sinauer Associates

11. Goran C Sedvall MD.Ph.D & Per Karlsson MD “Pharmacological manipulation of D1-Dopamine receptor function Schizophrenia . Neuropsychopharmacology 21 S181-S188(1999)

12. Crossley, Nick (1 October 1998) “R.D.Laing and British anti-psychiatry movement :a socio- historical analysis” Social and Science and Medicine .47(7):877-889

13. G.Haddock,N.Tarrier,A.P. Morrisson, R.Hopkins ,R.Drake ,S.Lewis .”A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis” Social psychiatry and Psychiatric Epidemiology (May 1999 34(5) 254-258)

14. Birchwood M; Tood P; Jackson C.” early intervention in psychosis the critical period hypothesis” British journal of psychiatry Supplement 33(33):53-59

15. Killackey E,Yung AR,McCorry PD92007)”Early psychosis : where we’ve been , where we still have to go” Epidemiol Psychiatr Sci. 16(2) 102-8

16. Black DW, Pfohl B, Blum N, McCormack B, Allen J, North CS et al “Attitudes towards Borderline personality disorder : a survey of 706 mental health clinicians “CNS Spectr 2011;16:67-74

17. Lieb,K. Zanasrini, M.C,Schmahl,C.,Linehan,M.M,.& (2004).Borderline Personality Disorder. The Lancet,364,453-461

18. Beresford, EB. ” Uncertainty and the shaping of medical decisions,” Hastings Centre Rep. 1991;21:6-11

19. Allison,JJ.Kiefe,CL,Cook,EF, Gerrity,MS,Orav,EJ,Centor ,R.”The Association of physician attitudes about uncertainty and riak taking with resource use in the MedicareHMO. Med Decis Making 1998; 18:320-329

20. Entwhistle,VA,Watt,IS.”Treating patients as persons :a capabilities approach to support delivery of person centred care”, Am J Bioethics (2022) 26: 242-250

21. Morris, DB. Illness and culture in the post-mortem age. Berkley and Los Angeles.CA: University of California Press ; 1998

22. Nurse K.L Brand,F. Carbonnier, A.,Croft,A.,Lascelles, K., Wolfart, G.,Hawton,K.”Effects of patient suicide on psychiatrists : Survey of experiences and support required”(2019) BJPsych Bulletin 43 (5) ;236-241

23. Large, M ,Ryan,C, Carter ,G, Karpur,N.”Can we usefully stratify patients according to suicide risk? “Br Med J 2017; 359

24. Healthcare Quality Improvement Partnership.” National Confidential inquiry into homicide and Suicide 2018. HQIP 2018

25. Sequin, M., Bordeleau, V., Drouin, M., Castelli-Dransart,D., Glasson, F. ”Professionals’ reactions following a patient suicide :review and future investigations , Arch Suicide Res 2014;18:340-62

26. Alexander, D.,Klein,S.,Gray N.M , Dewar,I.,Eagles ,J. “Suicide by patients a questionnaire study of its effects on Consultant psychiatrists . BMJ 2000;320:1571-4

27. Dewar, I.,Eagles,J.,Klein,S.,Gray,N.,Alexander, D.,” Psychiatric trainees experience of and reactions to patient suicide. Psychiatr Bull.2000 24:20-3

28. Rahaman,R., Gupta,S., While,D.,Rodaway R.,Ibrahim,S.,Bicckley ,H. et al “Quality of risk assessment prior to suicide and homicide :A pilot study, June 2013. National confidential inquiry into suicide and Homicide by people with mental illness. University of Manchester,2013

Thank you!

Psychiatry - the training tips blog

Over the past 3 months, this blog has had almost 3,000 reads in at least 20 different countries and across all continents. 

The first 8 posts included two introductory articles, followed by articles on CV writing, clinical experience, research, teaching/medical education, management and postgraduate qualifications.

There then followed a series of guest blogs from Psychiatrist colleagues at different stages of the career ladder and a blog from a GP colleague. I am very thankful to these guest bloggers: Dr. Diarmuid Boyle, Dr. Noreen Moloney, Dr. Kevin Lally, Dr. Frank McKenna, Dr. Niall Byrne and Dr. Pat Harrold. 

I am also very thankful for the support, encouragement and positive feedback for this blog, provided by so many colleagues, friends and family members who have taken the time to read and share it.

The blog has now come to a natural pause but there may be occasional pieces added in future. 

I hope that the blog will serve as a useful guide for anyone interested in a career in Psychiatry or indeed anyone with a general interest in the area of mental illness and its treatment. 

Please feel free to share the blog links and to contact me directly on hpoconnell@yahoo.ie with any comments or suggestions for future blog postings.

But for now, thank you!

Guest blog: Dr. Pat Harrold reflects on his days in psychiatry

This week I am delighted and honoured to welcome Dr. Pat Harrold as guest blogger. For his 'day job', Pat is the adored and gifted GP of the people of Nenagh, a trainer of GPs and a teacher to countless cohorts of medical students over the years. Along with his day jobs, Pat is also one of Ireland's leading medical writers, with regular publications in medical and mainstream newspapers. And he is also a prolific and award winning writer of fiction. To add to his 'Renaissance Man' profile, Pat is also a talented musician and a lover of all things artistic. And despite all his skills, talents and passions, you could not meet a sounder, lovelier gentleman in a day's walk. 

Pat spent two years working in psychiatry back in the early 90s and his blog is a beautiful and reflective piece of writing on an era that has only recently passed into history. For artistic accompaniment, Pat suggested that I include some images from his artist friend Joe Boske. 

Thank you, Pat.

Self-portrait, 1990

Thirty years ago I handed back the keys, picked up the stethoscope and left the high walls behind me and I now try to remember why I swapped the deep waters of Psychiatry for the rapid shallows of General Practice. I still have no idea why I left, and probably did not then, in the days when I saw life as something that happened to me, and just hoped for the best. Probably somebody offered me a job somewhere, which was the cause of most of my misfortunes and a few happy results.

My first SHO job after the war zone of internship was in Psychiatry. I did the interview and found them friendly and more importantly they liked me so that was the next six months sorted. After the interview I took an optimistic look at the Doctor’s Res and was chased out by a screaming Senior Reg who thought I was a Drug Rep. I must have had a good suit.

Along the margins of the unknown tide, 1970

So I got the start, in a huge Victorian building in the process of what was then called “rationalisation” by the top brass, and “chucking the residents out“ by the staff. I remembered the Richard Gordon quote that Psychiatrists chose to hide behind the same high walls as their patients but it seemed those walls were coming down. I mean no disrespect to Psychiatrists of today but in those days the doctors were an odd bunch. The unfriendly Senior Reg, who I was alarmed to see was still there when I started, had the patients shaking their heads and tapping their foreheads as he passed, twitching and snarling like an elderly terrier. Of course he had no cop on, and saw Psychiatry as a Doctrine, which if he obeyed would make sense of a cruel and bewildering world. I encountered quite a few like that, and some wore their qualifications in Psychiatry like a Priest’s collar.

I was entranced and appalled at the size of the place .The surrounding Parkland was the remains of the old farm, where the patients, most of them from a rural background, had worked in the fields. It must have done them good if living in a locked ward was the alternative.

Night tide, 2003

I was loaned a bunch of keys that would open every door in every Psychiatric Hospital in the UK and was told to never put them down in an unguarded place. As I opened and locked each door on my way around the Hospital and I am sure I was not the first person who remembered the opening scenes of “Get Smart”.


There was a cloud of cigarette smoke everywhere, dreamily lit by the light from the too high to climb out windows. The new arrivals were put in dressing gowns and slippers, for all the world like the Darling children in Peter Pan. The unshaven ones stretched on their beds with a jug of orange juice by the side were detoxifying from alcohol. The long term patients wore shabby suits and dresses, like refugees after the war. Many of them clutched dolls and they all wore straw hats in the summer .A schizophrenic school teacher taught an imaginary class in the corridor. It was a pleasure to listen to him skilfully running through Latin Grammar and he obviously had been gentle and caring with his pupils.

Late one night I was called to a young man who was so psychotic and suicidal he was literally climbing the walls. He turned his tormented face, lit by moonlight in the darkened ward to me and told me he was possessed by the devil and in hell, and there was nothing a doctor could do for him. He died suddenly soon afterwards, probably as a side effect of neuroleptics that nobody knew about at that time.


Galway Arts Festival poster, 1991

There was a celebrity patient, a famous artist who painted with his non dominant hand. He had cut his wrists smashing through a window and destroyed the tendons in his good hand. Within weeks he was painting skilfully with his left. He was invariably cheerful but his paintings were bleak and hopeless.

In the mornings I would cycle from building to building. In those days the SHOs had to look after the medical needs of the patients; their psychiatric needs were no longer an issue. None of the SHOs knew what they were doing as they tried to treat the many conditions of elderly, sedentary chain smokers. I became fascinated by the old notes, the crinkly yellowing sheets of paper that summed up a life in a folder. One old man had been there for sixty eight years and I read his notes from cover to cover. It seemed that the only time he had seen a doctor in the early days was for an “annual review “ - a one liner in exquisite copperplate .The review was short of medical information but long on invective. “Moron, Imbecile, Cannot read or write”. That was all it took to keep him banged up for another year.


A woman in her late middle age had been put in by her strictly religious family for rebellious behaviour at 13. She had done nothing more than wearing make-up and cheeking a teacher. A Locum consultant wrote a stern report when she was 24 saying she had no evidence of mental illness and discharged her. When the usual psychiatrist returned from his holidays he sent the police to bring her back, which they did, and she had not left since. Sometime in her thirties she became pregnant and of course the baby was taken from her, never to be seen again. Nobody asked who had fathered the child in a locked female ward and her pregnancy was seen as further evidence of her wayward nature. When I saw her she was too institutionalised to live on her own, and suffered the side effects of years of sedating medication.

Every ward had its nurses. The male nurses had been hired when there was a height and weight requirement .They were strapping men in suits, and I quickly discovered that the bigger and scarier they looked the nicer the person they were. One fearsome looking giant, with crossed eyes and teeth like an ogre, was one of the kindest and saintliest men I have ever met. The women nurses wore uniforms .They all listened to the stories, doled out the fags and medication, and observed their charges like skilled naturalists.


On Tuesday mornings I administered ECT. “Shocking weather!” the anaesthetist would say. He said it at every session, and we smiled dutifully in that sad place, like soldiers in a firing squad before the prisoners arrived. Then the patient would be wheeled in on a trolley, given an IV shot and when they had passed out I would press something like an earphone to each temple. The patient would jerk in a modest seizure, which we would dispassionately count. Fifteen seconds seemed like an average. Then they would be wheeled to a recovery room, to lie with the others like children on a sleepover. It was called the ECT “Suite”, as if it was a splendid hotel room, and not a collection of iron single beds, a trolley, and a wooden box full of wires.


We had video training every week, when we would interview a patient and have our performance analysed by a proper grown up psychiatrist. To this day I can hear those critical voices when I find that I miss a cue, or ask the wrong question or stare out the window for too long in my own office. Then I sit up, and put on my calm psychiatrist’s face. It does not always work. “You are too soft to be a psychiatrist Pat.’ She was a patient in her twenties, with a drink and drug problem. She was from a medical family, and I knew some of them from years before. She had the scars on her arms that suggested childhood trauma, and I had let her out for the weekend. The consultant, an oldish young man with a row of coloured pens in his top pocket, had written in her chart that she was not to be let out, but her sisters had arrived and I could not see any reason to keep her in. 

Night flight, 1982

Nobody had a mobile phone back then and the consultant was away somewhere and could not be found. She managed to make it back without getting drunk or stoned or damaging herself or anyone else. She was, in fact feeling much better. That was when she told me that I was too soft as the Consultant, without comment, tippexed out my Saturday afternoon comments on his elusiveness on the Monday morning. He later confessed to me as he lit a cigarette with a shaking hand that he had not known that he was on call at all, and had little recollection of where he had been. He wasn’t the worst, poor chap. He discharged her on the Tuesday .She did well, as they say, and never looked or went back.

That same Tuesday, rushing from ECT to Outpatients, my first patient was a lovely man who had been discharged after 40 years inside. It was the height of Punk Rock and he told me how he had walked, for the first time in decades, down the streets of his small town while youngsters with multicoloured mohicans and safety pins in their faces stood at street corners. “And they locked ME up”, he said without rancour.

I spent two years in Psychiatry altogether. It now seems to me like a place where I once lived, and have not seen for years, and if I was to go back, would have changed so much I would hardly know it. The great institutions were already on their way out thirty years ago. The problem then was getting all the patients out; my problem now is getting them seen at all, and it is a very rare case who gets to stay even overnight, never mind sixty years.


Heavy weather, 1970 

It was a different world with different hairstyles and cars and music .There was little in the way of street drugs, and the old fashioned pint drinking alcoholic was a regular visitor. The hospital was a home for hundreds and a refuge for dozens. Misunderstood youths, fragile loners, bewildered spouses, weary parents and heartbroken heroes came and went and came back again. The nurses gave tea and orange juice and cigarettes from cartons and listened without judgement.

When I look back on those days I remember a Doctor’s Res on the top floor; the former residence of the generations of Chief Psychiatrists and their families; and the view through the Victorian windows of the fields and the high walls and beyond the towers and spires of the town which had turned its gaze away many years before.

And one final piece of art, with this image of Pat's home town of Nenagh. The artist is Chris McMorrow

Guest blog: Dr. Niall Byrne reflects on his Intern year

The guest blogs from four University of Limerick graduates over the past few weeks have provided fascinating insights into the different stages of training to become a Psychiatrist. 

Dr. Diarmuid Boyle focused primarily on starting off in Psychiatry and the Basic Specialist (BST) years:

https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-dr-diarmuid-boyle-on-making.html

Dr. Noreen Moloney reflected on those heady days of Higher Specialist Training (HST):

https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-dr-noreen-moloney-on-making.html

Then along came Dr. Kevin Lally, who has finished BST and a year as Psychiatry Clinical Tutor in UL and he had a trilogy of blogs on:

Telemedicine and Telepsychiatry: https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-part-1-of-dr-kevin-lally.html

and then two blogs on medical education during the COVID-19 pandemic: 

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-2-of-dr-kevin-lally.html

and

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-3-of-dr-kevin-lally.html

Then last week Dr. Frank McKenna, who has also completed BST and a year as Psychiatry Clinical Tutor in UL, reflected on teaching, research and the wide variety of career options within Psychiatry:

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-dr-frank-mckenna-year-in.html

This week I have great pleasure in welcoming Dr. Niall Byrne, yet another extremely bright, energetic and talented graduate of UL who is embarking on a career in Psychiatry while also cultivating a variety of other interests. And this week we are going back to the very beginning of postgraduate training, with Niall's very thoughtful and useful reflections on his Intern year and his hopes and plans for the future. Niall has also included two beautiful works of art to accompany his text. 

So thank you Niall and it's over to you...

Dr. Niall Byrne - biography

I am to commence the Psychiatry Basic Specialist Training (BST) sceheme in Dublin in  July, after completing the academic internship at Galway University Hospital. I graduated from the Graduate Entry Medicine programme at the University of Limerick in 2019. I am interested in innovation in medicine and research and hope to specialise in Child and Adolescent Psychiatry.  Beyond this I am interested in art and videomaking and I have recently made comedy medical voice over videos which has been circulated among the medical community across the country: https://www.instagram.com/medhumer/?hl=en

Reflections

As I reflect upon the past 12 months, I feel a sense of achievement having overcome the steepest learning curve of my life, but I am apprehensive for changeover. I was fortunate enough to achieve the only academic internship post to include a psychiatry rotation, which was based entirely in Galway University Hospital (GUH). My first three months were in general adult psychiatry and I was based mainly in the acute Mental Health Unit (MHU), which is an impressive two-storied newly built facility with over 50 in-patient beds.

I was split between two consultants and worked on the community mental health (CMH) team under Dr Brian Hallahan, attending weekly multidisciplinary team meetings as well as outpatient clinics. The CMH multi-disciplinary team understood the patient’s life beyond their diagnosis, something which is not afforded the same amount of discussion in other specialties, which is essential to that patient’s management. Moreover, I found out-patient clinics a particularly helpful means in developing my clinical acumen. As my confidence and knowledge base developed, I was seeing patients alone and making decisions and changes to patient’s management.

On Professor Colm McDonald’s team, we looked after the acute adult in-patients. I was given the opportunity to present case discussions and do full medication reviews as well as attend rounds and making adjustments to inpatient’s medical management where necessary. My perceptions of psychiatry practice prior to working quickly transitioned into reality and I was relieved by how much it lived up to my expectations. On one occasion I presented a complex case of refractory paranoid schizophrenia during the weekly case presentations, and together we devised a treatment plan. This was a rewarding experience. As a psychiatry intern, you get as much out of it as you invest. You can have minimal responsibility, or you can really get enthralled and maximize your learning. I tried to gain as much as possible as I was strongly leaning towards a career in this field for a number of years.

Rainy Day by Phan Tru Trang

The one major setback to commencing the intern year on a psychiatry rotation is having to do medical call with minimal exposure to acute medicine during the day job. When starting off on my extended days even navigating around the main hospital was challenging. On one of my first nights the medical registrar questioned why a psychiatry intern was doing medical call, when we both had to manage a deteriorating patient on one of the wards. However, he later apologized for the comment and admitted that he was stressed because it was his first day in GUH. I quickly learned that if people are difficult there is generally an underlying reason and you just have to give them the benefit of the doubt and not let it affect your own performance. Although if it is something more persistent or it hinders your patient’s care then it should be dealt with appropriately to avoid conflict, burnout or mismanagement.

After psychiatry I rotated onto vascular and general surgery. I enjoyed the level of responsibility being on such a small team. Surprisingly, there were several opportunities to develop my psychiatry skills. One episode that stands out was a middle-aged female patient who was admitted with painless jaundice. She needed a CT and my registrar informed me that she was 'too nervous' to go through with the scan. I insisted on carrying out a brief psychiatric assessment which revealed a long-standing history of generalized anxiety with progressive loss of function that was refractory to treatment. She also suffered a number of traumatic life events that she had not disclosed previously. I arranged for a liaison psychiatry review and she was commenced on treatment and would be followed up in the community. I taught her some basic mindfulness and prescribed a stat dose of alprazolam. She completed her scan and was discharged. She said this experience had saved her life and would make a great change going forward; she was so grateful that she gifted me with an angel statue during a follow up appointment.

My current rotation is in respiratory medicine, which brings with it a heavy workload, but the team were particularly easy to get on with and made the experience much more enjoyable. I found myself enjoying medicine a lot more than I anticipated and was particularly fond of acute management while on-call. Eventually I was making medical decisions on-call and during the daytime with confidence and my procedural and management skills developed rapidly.

When the COVID pandemic emerged, my team was at the forefront. However, I remained the only intern on the wards which brought with it additional responsibility. The respiratory inpatients at this time were highly specialized cases, mainly patients with cancer and cystic fibrosis. For a long period of time it was just me, the consultant and an SHO. I was arranging family meetings and breaking bad news to patients and families, which although was difficult, it was a great learning opportunity. As an intern we have the privilege of being able to re-visit patients who may have received bad news on a round or who don’t quite understand their management regimen, etc. Something I carry into my career was said to me by a dear friend of mine, who told me that when her mother, who is a nurse and suffered from acute leukaemia, said that sometimes all she needed was for someone that she can vent with. I would always take the time to see patients later on in the day and give them the time they needed, to explain or to simply lend an ear from person to person. In medicine there’s a tendency to launch towards a psychiatry referral for someone going through an acute adjustment reaction or who has psychosocial stressors without even enquiring about a psychiatric illness. I think offering these patients a psychiatry referral is insulting to both the patient, and the speciality, and it is a message I always stress, to avoid this from happening. A patient should not be labelled as requiring psychiatry input for experiencing human emotion.

Every intern will encounter a trauma or case that will affect them. Our resilience can only be stretched so far. GUH’s cohort of interns and staff in general are kind and willing to help one another and this sense of comradery softens the blow of the intensity of the intern role, a role which is diverse, challenging but rewarding. I am happy to say that I thoroughly enjoyed my job and found the year rewarding and eye opening.

I will commence the Psychiatry BST as an SHO as part of the UCD deanery in mid-July. I have mixed feelings as I have fallen in love with Galway and GUH and will miss it and many people dearly. At the same I am excited to begin my training as a psychiatrist, and I am confident that this is the right path for me having reflected upon my experiences. My goals are to bring about change for patients and for colleagues. As I specialize in this field, I will dedicate time to quality assurance, research and education. Most importantly I will carry the message to be kind to your colleagues and to always be an advocate for your patients.

After the Rain by Phan Tru Trang

Guest blog: Dr. Frank McKenna - A Year in Time: Reflection on a year as Clinical Tutor

This week I am delighted to welcome yet another graduate of the University of Limerick Medical School as a guest blogger. Dr. Frank McKenna has just completed a year as Clinical Tutor in Psychiatry with UL. During that year, Frank has become immersed in the worlds of medical education and research and his students have been lucky to have had such a talented, wise and dedicated teacher and guide. Frank has provided a very modest biography (see below) so, along with his wide range of accomplishments in his first few years in psychiatry, I must add that he is not just 'a writer of fiction' but an award winning author. For artistic accompaniment this week, Frank has suggested two of his favourites - Limerick artist Annemarie Bourke and Gibraltarian artist Christian Hook.

Frank's biography: 

Frank McKenna completed psychiatry BST in 2019 and will commence HST this July. He has spent the intervening time as a Clinical Tutor in Psychiatry with the University of Limerick (UL). A former Business and Information Systems graduate who worked in both IT and retail management, he completed Graduate Entry Medicine in UL in 2015. He has varied interests within psychiatry including Sports Psychiatry and Narrative Psychiatry. He is a writer of fiction, and avails of any opportunity to speak to a crowd. 

Evening on the Shannon (Annemarie Bourke)

George's Head, Kilkee (Annemarie Bourke)

A Year in Time: Reflection on a year as Clinical Tutor

Affect. I described it routinely. Congruent and resonant, appropriate and reactive, perhaps incongruent and blunted, or inappropriate and flattened, or some other combination of a limited collection of descriptors.

The lecture notes I inherited likened affect to the weather, in contrast to mood being the climate. The same simile was on the same slides when I went through my psychiatry rotation at the University of Limerick (UL) in 2015. I wasn’t sure about it then and I’m not sure about it now. But the night before I would first deliver this particular lecture – MSE: Mood, Affect and Risk – after a little thought, I came to enough clarity to think “I’ll run with it.”

 

Foxes Bow, Limerick (Annemarie Bourke)

From Clare to Here (Annemarie Bourke)

Climate and mood pervade in the background. They influence the likelihood of what will be visibly evident at any given time: the weather, or the affect.

By 11am the following morning weather and climate were out the window, where they bloody well ought to be. Eventually inevitable, this reaction was catalysed by the twenty-eight gazes that materialised incremental layers of glaze with each of my attempts to clarify what was becoming increasingly abstract in my own head.

There is a lot of focus in medical education theory on the value of feedback. I found that the best feedback is not sought, but evident in the students’ engagement and in the looks on their faces. This was my principal guiding force: Are they engaged?

I resorted to being less clever than my predecessors.

We ask two questions about affect:

(1)   How reactive (or resonant) is it?

(2)   How congruent is it with the patient’s mood?

The twenty-eight pleasant nods I received allowed me to think this had done the trick. The students’ first written case presentations at the midway point of their 6-week psychiatry rotation illustrated that the trick certainly had not been done. Patients’ affects were all manner of verbs and adjectives: “happy”, “crying”, “tense”, “laughing”. Some were even “good” or “bad.”

I had a few tries at this. In UL we teach the same course 5 times in the academic year as students rotate through the psychiatry placement. In the end I think I had it down, and this came with realising that, in the Mental State Exam, we are not asking “what is the patient’s affect?” The question we ask is “how good is their affect?” That is, how well does their affect represent their mood? Towards the end of the year, reactive and congruent affects began to stream in, and all was right in the academic world.

Shodo Series 2019 (Christian Hook)

The Ambush (Christian Hook)

In July I will start my first post as a Senior Registrar (SR), but for the last (almost) eleven months I have been outside of clinical training, working fulltime for UL, teaching psychiatry to medical students.

I applied for this job for many reasons, but mainly I wanted more teaching experience and I wanted to get a research boost prior to starting HST.

Teaching hours were not as many as I expected – guest lecturers deliver about half, leaving the other half to share between Kevin (my fellow tutor) and myself. Initially this was a tad disappointing. I was chomping at the bit to strut my stuff, impart knowledge to, and open the minds of, roomfuls of focused final years. I had notions. It did not take long to realise the teaching hours I had were plenty, even ideal; easily enough to maximise teaching skills, time to prepare well, time to ponder how best to get the content across and afterwards to reflect on to how to do better.

That is not to say that time is there to be spent staring out the window, thinking the long thoughts of youth (not quite applicable in my case anyway, I’m afraid). The tutors are there to ensure the course runs well. Kevin and I had the advantage of having both gone through the course as students. The problem-based philosophy in particular came naturally to us, but still, time fills up. Scheduling lectures, liaising with lecturers (mainly consultants and SRs), filling in at teaching when things crop up unexpectedly, takes a chunk every now and then. Assessment of students is a continual process – monitoring engagement, assessing written assignments, delivering feedback, identifying the rare struggler, preparing end of year exams, and not infrequently addressing students personal or interpersonal issues.

This year coughed up the particular challenge of creating a new online assessment to replace the clinical exam. The aim was, in some way, to confirm that this year’s graduates understand the subtleties of a psychiatric interview – but there is much more on that in my colleague’s previous posts:

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-2-of-dr-kevin-lally.html

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-3-of-dr-kevin-lally.html

A year free of clinical responsibilities is a huge opportunity, not just to boost research output but also to improve research skills. The former, for me, despite a lot of work, has been hindered by Covid-19, but I am hoping foundations are laid to produce results in the months ahead. My research skills, on the other hand, have vastly developed. Planning projects, proposing to supervisors, reviewing literature, discussing aims and methodologies, collecting data, analysing data, writing papers – there is probably no substitute for going through these processes, and this year I was able to supplement this work by availing of relevant and useful tutorials and short courses available to University staff. I am a latent powerhouse of research.

More than anything else, I have enjoyed the year. Whatever about its place on my CV, it has allowed me to develop as a teacher, into having a clue and having an opinion when it comes to research. It has made me continually question my knowledge, and thus has deepened and broadened my understanding of psychiatry. It also removed me from the blinkered path from intern to consultant and broadened the scope of where I think my career could go.

HST is waiting. I have not seen a patient in a year so in the first days there may be some toe dipping. Soon enough I will be sailing again, and a year as UL Clinical Tutor in Psychiatry has given me a greater understanding of the vastness of the ocean ahead.

Origins (Christian Hook)

La Nostalgia de Londres (Christian Hook)