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As a second-year clinical student, one of my attachments was with an Obstetrics and Gynaecology firm at a district general hospital. Students liked being placed away from the main London teaching hospitals, for they often got more hands-on experience. In large teaching hospitals, filled to the brim with consultants and multiple tiers of junior doctors and trainees, lowly medical students barely got a look in, let alone the chance to assist with an operation or suture a woman’s episiotomy cut, or perform an invasive procedure. Ward sisters were more like traditional matrons – barking at students if they came on the ward at an inconvenient moment, and making them feel totally unwelcome and complete idiots. Coupled with the humiliation one often received from consultants during ward rounds, it was a relief to be sent to an outlying district hospital. But it also meant hard work, and many hours at night shadowing the junior doctors on call, as they rushed from one job to another, their list of things to do piling up after each intrusive bleep.
On the antenatal ward, we were allocated to a patient and expected to follow the birth through from start to finish. Sometimes, the finish meant a normal delivery by the midwife; at other times it meant an assisted delivery by the medical obstetric team using forceps or a ventouse (suction cup to the baby’s head), and occasionally it led to an emergency caesarean section, often performed by the consultant, who was called in from home.
‘She’s 10 centimetres,’ the midwife proclaimed. ‘Get her in now.’
I was hovering about, not quite knowing what to do or what to expect. It was my first delivery, and I was hoping to witness this event in the reassuring knowledge that an experienced midwife would be present to deliver the newborn. But the midwife was called away and she sent me in – alone. The next few minutes were filled with terror, but I mustered enough common sense to tell the woman to concentrate on her breathing, panting, and pushing. She was in agony, having refused all forms of pain relief. She asked me how many babies I had delivered before.
‘Oh, not that many,’ I lied.
‘Don’t worry,’ she said, sweat painted over her forehead. ‘This is my fourth. It’ll be all right.’
And it was. By the time the midwife returned, the baby was born and I was retrieving the placenta, one hand firmly placed on the woman’s lower abdomen and other holding onto the cut umbilical cord. I hope such a terrifying experience is not a common occurrence for students these days, but it certainly was the bread and butter of our junior doctor years.
The asylum was on the outskirts of London. A porter’s lodge marked the start of a long driveway through avenues of historic trees and extensive lands. There was a calmness and tranquillity about the place, despite the imposing listed red brick building which dominated the landscape. An abundance of corridors, long and straight, with paint peeling off the walls, seemed incongruous to the majesty of the building and the acres of landscaped greenery outside. People were milling about everywhere; men and women who seemed to have aged prematurely due to a lifetime of potent drugs, their gait stiff and their features mask-like, their odd mannerisms accepted as the norm. The first-time visitor, however, would have noticed the ‘kangaroo-lady’ skipping along the corridor, making whooping noises as she went by, or patients wringing their hands together, licking the walls and talking to themselves.
When I first arrived at the hospital at the start of my psychiatric training, I wasn’t given any advice about personal safety as trainees are now. There were hidden corners everywhere in the hospital, and no panic buttons or alarms I can recall. I remember we had to campaign for months before we got staff to agree to stay in the room with us as we assessed a new patient in the middle of the night who had presented to the hospital distressed, psychotic and in need of an acute admission. More often than not they were brought in by police, for behaving bizarrely in a public place. Over lunch one day, a senior nurse told me how a female patient had attacked a male consultant with a knife a few years earlier, so severely that he still carried the scar on his forehead. Apparently he had been interviewing this patient and had scratched his forehead whilst talking to her. She interpreted this as him attacking her and playing with her clitoris, so she lashed out at him. Not sure where she got the knife from though; must have had it on her. Ever since, I have always been very aware of my non-verbal cues and body language when assessing acutely mentally-unwell patients.
The first consultant I worked with during my psychiatric training only ever appeared for ward rounds, when he heard about the patients under his care from his team of junior doctors and ward nurses. He never held his own clinic and very rarely set foot on the ward at other times, but it was obvious he trusted his ward sister completely. I don’t remember observing him interviewing a patient or conducting a mental state examination. One medical secretary commented at the time that he gave us so much rope we could have hung ourselves.
It was not surprising, therefore, that my first psychiatric outpatient clinic was fraught with anxiety, as I was so inexperienced. I often wonder how those patients would have fared were I to see them now; I remember being totally out of my depth, and left to handle every psychiatric emergency and complex case with the help of a junior colleague who was only slightly more experienced than myself. In those days it really was a question of ‘see one, do one, teach one’.
A woman in her early thirties came to clinic. She sat in the chair in front of me, much lower than I was, and launched into a detailed history of her schizophrenic illness. She had come for a routine review of her medication – a potent, powerful, major tranquilliser given by regular injections. She supplemented this with tablets, in order to control her symptoms. But before I could say anything about her medication, she pleaded with me not to take her symptoms away. Cliff Richard was the voice speaking to her, through her arm. He was the only company she had. Without him she felt she had nothing, and she did not want him taken away.
One evening, a woman in her 50s was admitted onto the ward, and as the duty psychiatrist I was called to clerk her in. She had been seen by my consultant, either in clinic or on a home visit, diagnosed with severe depression and sent into hospital for treatment, which was often medication and sometimes electroconvulsive therapy (ECT). Apparently her symptoms had started several weeks before, shortly after she discovered her husband’s infidelity. I was chatting with the charge nurse when she came into the room. Rather unkempt, and with signs of self-neglect, she wore a cardigan partially buttoned, although the buttons were misaligned. She looked much older than her age. As I chatted with her I noticed some mild dyspraxia; when I examined her eyes with an ophthalmoscope, I thought I saw swelling of the optic nerve, which is a sign of increased intra-cranial pressure. There were no other doctors around, I was in a psychiatric hospital far away from physicians and the nurses working with me were mental health nurses. Thankfully, I had only recently left my casualty officer post, so I was pretty clued up with physical healthcare. I phoned the local hospital and asked to speak with the registrar for neurology. Luckily, I had worked with him as a surgical houseman and we got on well together. He was a senior registrar in neurosurgery, and has since gone on to have a very illustrious career. We arranged to transfer her urgently, and she had a head scan that night, an investigation that was very difficult to get for psychiatric patients at the time. We discovered a 10-centimetre tumour in her frontal lobe, which luckily was benign and operable, and she made a good recovery.
I also remember assessing a young woman who had head injuries. I think she was found severely bruised and with multiple superficial lacerations, but it was unclear what had happened. There was nothing untoward in her behaviour whilst recovering on the ward, so I don’t recall in what capacity I was asked to see her. However, when I chatted with her she disclosed, for the first time, that she had been hearing voices for years, and that they had increased in intensity and frequency. She had not told anyone, but had been so distressed by them she was hitting and banging her head against a brick wall in an attempt to get rid of them. It struck me then how stigmatizing and isolating severe mental illness can be, and often we are oblivious to the suffering. I didn’t have anything to do with her aftercare, so this must have been a one-off assessment, but the encounter has stuck with me and shaped my clinical interactions.
As medical students, we were taught to take a comprehensive history when assessing someone for a possible mental health disorder, although it wasn’t the same when assessing for a physical health condition. Psychiatric history taking followed a prescribed format: history of presenting complaint; past medical history including hospital admissions, major illnesses and risk factors, key questions targeting the major systems of the body; past psychiatric history including hospital admissions and treatments; family history including relationships with significant others, mental illness or mental handicap (now known as intellectual disabilities); personal history including developmental milestones and schooling; psychosexual history; treatment history and current medication including allergies; use of tobacco, alcohol and illicit/other substances; contact with the police and social history including living circumstances, employment and relationships. We also asked them to describe themselves and their usual personality before the onset of their presenting complaint. These questions all preceded any physical or mental state examination. With experience these questions become more targeted and nuanced.
When I was working in a district general hospital, on my liaison psychiatry placement, I was asked to see a man who had been admitted onto a medical ward. He had become confused and staff were seeking a psychiatric assessment and advice on managing his delirium. It’s a common presentation, but when I saw him things didn’t quite fit. After speaking with him I did a neurological examination, including testing his cranial nerves and asking him to get out of the hospital bed to walk for me. He was ataxic (poorly coordinated), with a high-stepping gait that had been missed by the medical team who had just seen him in bed. I suspected tertiary syphilis, which turned to be the cause of his presentation.
At its peak, Claybury Hospital in Woodford Green on the outskirts of London was home to 4000 mental health inpatients. It had listed buildings and extensive land: 50 acres of ancient woodland and 95 acres of open parkland, ponds, pasture and historic gardens. I spent my early psychiatric training there, and was very aware of the asylum it offered to acutely unwell patients, as well as the segregated and protected institutionalised care for those with more chronic mental health problems who had lived there for years. The hospital has long been closed with the move to ‘care in the community’. I lived there in the doctors’ quarters when doing my nights on call, and remember a very supportive environment when I was the junior doctor assessing people brought in by the police, as well as covering the whole hospital and admission wards at night. Early in my psychiatric career I came across a woman on one of the wards. She was the exuberant star of the inpatient group I ran every morning with the senior nurse, where patients were encouraged to discuss how things were going, and to have the chance to bring up issues with staff. This small woman, with short-cropped hair and a rather stout frame, stood centre stage as if gracing us with her presence. With arms outstretched she proclaimed her special powers and divine spirituality. After the group, she would make a beeline for me, demanding why certain things had not yet been done and angered by the slightest comment. I was terrified of her, and she knew it. She stood in the main corridor of the ward, waiting for me, rosary beads in hand and talking to herself, whilst directing staff and other patients to do her will. She had been a very respected nun at her local convent and had been admitted only a few days before. In the weeks preceding her admission the other nuns had revered her, believing she had been truly touched by the Lord. She had spoken of visions and special blessings and genuinely appeared to them to be in receipt of something divine. During mass she often stood up and took over the service, and the nuns came to regard her as a holy woman. However, as the weeks went by her utterances became more bizarre; she began to leave her excrement out for the birds, believing the Lord wanted her to feed them with her body. It was at this stage that the nuns sought psychiatric help for her. She was diagnosed as suffering from mania, a condition characterised by grandiose ideas, hyperactivity and elation. Once her acute episode was treated, she turned out to be one of the loveliest, gentlest and warmest women I have ever met. As her mood stabilized I enjoyed chatting with her on the ward – she was an amazing woman.
On one occasion I was almost smothered by a patient who came over to where I was sitting, grabbed my head and held it to her breasts, her huge arms enveloped round me. I could hardly breathe. She wanted some of my hair, she said, so she could do something positive with it – in fact, she wanted to keep a part of me with her, always.
Halfway through my core psychiatric training, which lasted three years, I was lucky enough to work with a consultant psychiatrist who was also a psychoanalyst. His ward rounds were often challenging for patients and difficult for us to manage as he would confront them and say things that often resulted in raw emotions, explosive anger and physical aggression. He always sat at the opposite end of the room from the patient, with a whole staff team between them. One day, I witnessed him confront a man about his most bizarre symptoms. Then and there the patient suddenly exploded; his anger and stress totally transformed him. His face was bright red, his hair was literally on end and with his right arm flexed against his chest, he blew hot air like a steam engine. It was piercingly accurate. I did not believe it possible that a man’s face could mimic a steam engine in this way. On another occasion, I was convinced the patient was suffering from a physical illness we had yet to uncover and treat, as her physical symptoms and signs were so distressing and obvious. I kept thinking about other tests we could do, and referrals to a host of physicians. My consultant allowed me to pursue this but he also said that they were all psychologically driven. He was right. I learnt a great deal about mental distress and its physical manifestations on that training placement.
My consultant was one of the few practitioners using psychoanalysis and psychoanalytic frameworks in his everyday clinical practice, even amongst those with acute psychotic illness. He introduced me to the work of Wilfred Bion and Melanie Klein, and whenever he spoke it made sense to me why someone’s mental state might fluctuate from psychosis to depression, and the problems with a diagnostic label. He told me something I remember to this day. He told me it was very important for the sane part of us to stand up to the insane part within our patients. They desperately need to see that there is sanity around them.
Of course, implicit in that sound advice is the notion that there is both sanity and insanity within us all. Not only within us, by within the organisations in which we work and within the world in which we live.