Patient safety

Day 681

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About 5 months after Saagar’s passing, one of my close friends sent me a subtle message suggesting that I should be careful about what I write in my blog as a few of my work colleagues read it regularly and if I appear to be too fragile or vulnerable, it might have a negative impact on my professional life. I understood her concern. The medical profession is not known for its understanding and compassion for mental frailty in colleagues.

Dr Wendy Potts was a GP in Derbyshire who blogged about living with Bipolar Disorder on a regular basis. One of her patients read the blog and complained to her Practise. The doctor was suspended. A few weeks later she ended her own life.

Firstly, I don’t understand the basis of the complaint. Would patients complain if their GP had diabetes or cancer?

Secondly, I don’t understand the basis for suspension from work. If the doctor’s performance was not questionable, then there is no ground for that.

Ref : https://www.theguardian.com/uk-news/2016/aug/26/gp-found-dead-after-being-suspended-over-bipolar-disorder-blog?cmp=oth_b-aplnews_d-2

This is one of many examples of poor treatment of medical colleagues with mental health issues. I think we are a long way from seeing parity between physical and mental illnesses as the ones who are supposed to put that into practise are themselves caught in the stigma associated with mental illness.

(PS: apologies for not being able to insert the link to the article in a better way. The ‘link’ icon on my page doesn’t seem to work anymore. Any ideas? )

 

Day 655

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When I first came to the UK, a couple of myths in my mind about this country were busted within the first week.

  1. Education is free, so everyone must be literate and educated.
  2. The government looks after people who are unable to work, so everyone must be happy.

I was puzzled by the fact that at least 1 in 3 patients I saw before an operation were on regular antidepressants. Some patients took St John’s Wort. I had never heard of that before. Some didn’t admit to having any problems with their health but on a closer look at their notes, were taking antidepressants.

Over the last 10 years, the use of antidepressants has doubled in the UK. Some science tells us that these drugs have a history of proven efficacy and some other science tells us that the benefits are marginal and short term. Occasionally the effects are very harmful. One such effect is ‘Akathisia’, defined as a movement disorder characterised by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting. People with akathisia are unable to sit or keep still, complain of restlessness, fidget, rock from foot to foot, and pace.

‘The Pill That Steals Lives’ is a book written by documentary maker Katinka Blackford Newman. It is one woman’s terrifying journey to discover the truth about antidepressants.

In it she talks about one year of hell that she lived through after being started on Escitalopram(Lexapro). She describes the thoughts of violent acts that crept into her mind while on that drug. She got full blown delusions about having killed her two young children. She had to be hospitalised and was put on multiple medications that made her loose the ability to look after herself or her children.

More than 10 years ago America’s National Institute of Mental Health set out to measure the effectiveness of antidepressants. They found that only 26%of patients responded positively to these meds and at the end of one year only 6% were well. Conclusion: ‘the findings revealed remarkably low response and remission rates’.

Saagar was started on Citalopram (a drug used for unipolar depression and unsuitable for young people) 4 weeks before his death. The dose was doubled from 10 to 20 milligrams per day, 2 days before his death. The riskiest time is when they are started, when they are stopped and when the dose is changed. How much did these medicines contribute to his death? We will never know.

Day 650

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A brain surgeon, Paul Kalanithi got diagnosed with terminal lung cancer at the age of 36. Suddenly he found himself on the other side of the table. He wrote a ‘rattling, heartbreaking, beautiful’ book about his life as a doctor and then as a patient before he died. It is called “When breath becomes air’. In it he tactfully dissects the walls that exist between doctors and patients. Having found myself on either side of the table – first as a physician and then as the mother of a severely ill child, I can completely relate with this excerpt below.

“The reason doctors don’t give patients specific prognoses is not merely because they cannot. Certainly, if a patient’s expectations are way out of the bounds of probability – someone expecting to live to 130, say, or someone thinking his benign skin spots are signs of imminent death – doctors are entrusted to bring that person’s expectations into the realm of reasonable possibility. What patients seek is not scientific knowledge that doctors hide but existential authenticity each person must find his or her own. Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.”

“I had to face my mortality and try to understand what made my life worth living and I needed Emma’s (my doctor’s) help to do so. Torn between being a doctor and being a patient, delving into medical science and turning back to literature for answers, I struggled, while facing my own death to rebuild my own life – or perhaps find a new one.”

I cannot imagine what one’s options would be when diagnosed with a severe/ terminal mental illness. Saagar was unable to access his own life as he knew it and perhaps chose to find a new one.

Day 648

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Patient safety skills in primary care, a national survey of GP educators by Ahmed et al was published in 2014. This study aimed to determine the views of General Practice Educators regarding the qualities and attributes of a safe General Practitioner (GP) and the perceived trainability of these ‘safety skills’ and to compare selected results with those generated by a previous study of hospital doctors. This graph represents the perceived importance of safety skills:

12875_2014_Article_206_Fig2_HTML

It is interesting that 6 to 7 out of ten GP educators thought ‘leadership’ qualities to be unimportant or inconsequential. Being a good doctor means more than simply being a good clinician. Every day, doctors provide leadership to their colleagues, and vision for the organisations in which they work and to the profession as a whole.

The definition of leadership has undergone an evolution in recent years. We recognise that some doctors are formal leaders who are accountable for the performance of their team, department or organisation. However some confusion exists between the terms ‘leadership’ and ‘management’.

Hospital doctors often have clearly defined leadership roles as part of clinical teams at the frontline and also as part of clinical directorates at managerial level. This may make leadership in respect to safety a more recognised construct within secondary care.

Important but subtle differences exist between what primary care and secondary care doctors perceive as core safety attributes. As the burden of avoidable harm becomes better understood in primary care, such safety skills training will ensure that current and future GPs possess the necessary competencies to engage in efforts to enhance the safety of healthcare.

 

Day 647

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”No history of self harm” said the discharge summary from the Home treatment team to the GP. This sentence was one amongst many on the four page long letter.

Saagar was seen by at least 3 psychiatrists – 2 senior trainees and one Consultant and they all missed it. Did they ask him and he didn’t tell them the truth or was it an omission? The scars could easily be seen on his left forearm. They were clearly visible. Did they find the scars and questioned him about them? Did he make up a convincing story for them as he did for me? Or were they missed altogether? No one asked me about his history of self harm. He was mentally ill at the time and I don’t think I was.

At the Coroner’s inquest when this question came up, the psychiatric team said that the remark was made because Saagar never presented to the Emergency department with self-inflicted injuries. Is that a valid criterion?

Self harm is a personal and often a very private act. Given it is an important clue to the extent of a person’s emotional suffering, we as carers and professionals cannot afford to miss it.

“The only antidote to mental suffering is physical pain.”
– Karl Marx