Dr Grumble recently described young women who turned up in casualty after taking an impulsive overdose as “silly girls”. There was a predictable volley of screeching from the politically challenged, but Dr No was and is with Dr Grumble on this one. They are silly girls, and to call them otherwise is not only silly, but also downright dangerous.
The gist of the screechers’ argument was that Pappa Grumble, in calling these distressed womenfolk silly girls, was acting in an insensitive, patronising and dismissive manner. He was insensitive in not appreciating their distress, patronising in calling them girls, and dismissive in describing them as silly.
What these distressed womenfolk needed, said the screechers, most of whom clearly wore their heart on their sleeve, was sympathy and help in their hour of need. There was further right-on screeching about the need for care, respect, empathy and a patient-centered approach. It’s a wonder there wasn’t yet more screeching about ethnicity and diversity.
Now, this kind of self-important sanctimonious twaddle may go down well at Euston Towers, but for Dr No, it doesn’t wash.
It doesn’t wash because, in their zeal to be not only right-on, but to be seen to be right-on, the screechers have lost the plot. In their enthusiasm to be seen as caring, empathetic, patient-centered helpers, they are allowing their own self-interest, in wishing to be seen as such, to interfere with that which is really important – the best interests of the patient. They are as much treating their own need to feel caring as they are caring for their patient. That is why it gets dangerous.
Let us return to the girl on the trolley in casualty. Let’s make her 19 years of age. She has no history of mental illness. She’s pretty (doctors notice these things as much as anyone else), and can usually wrap her boy friends round her little finger. Only, last night she couldn’t. She got dumped. She got drunk and do what girls do when they get dumped and drunk. She took an impulsive overdose of paracetamol – enough, as it happens, to cause liver damage and so possible death. Her mother finds her, and takes her to casualty.
At casualty, she declines treatment. Pappa Grumble thinks “silly girl” and imposes treatment. Luckily she got to casualty in time, and she recovers. The acute medical crisis is over.
The crucial question is what happens next. Although she has no history of mental illness, the fact she has taken an overdose raises the possibility that she might in fact have one. And so, almost certainly, she will undergo a psychiatric assessment, and it is in this assessment that her future will hang in the balance.
Given the importance of getting this assessment right, it should rightly be done by an experienced doctor who will probably (no one is infallible) get it right. Unfortunately, in practice these assessments are more often done by very junior doctors, or, even worse, noctors. Noctors who are not only lacking in diagnostic skill, but also prone to wear their heart on their sleeve, to be caring, empathetic, patient-centered helpers who – even worse – like to practise “on the safe side”. Noctors who, when they are not noctoring, will most likely spend their time posting anonymous screeching comments on Pappa Grumble’s blog.
Noctors are usually rather keen on clipboards, a legacy from their nursing days, when the clipboard hung on the end of their patient’s bed, and recorded the patient’s vital signs. Today’s clipboard is somewhat different. There is no TPR chart. Instead, there is a 22 page Assessment Form. There are a lot of boxes to be filled in and ticked off, and ratings to be made.
Now, the combination of a nursing background and a protocol driven assessment is flawed. It is flawed because it is weighted towards caring, rather than diagnosis. And that is dangerous, because what this young woman who has recovered from her overdose needs is not care, but diagnosis. An expert diagnosis. There needs to be a decision as to whether she has an illness, and if she does, what it is. The care, if it is needed, comes after the diagnosis.
Unfortunately all too often the flawed assessment leads to a woolly view that the patient (for she has now become one) needs help. No one really knows what the diagnosis is, but the noctor thinks the patient needs help. The noctor, remember, needs to feel caring. So she offers an outpatient appointment, or, even, God forbid, an admission. At a stroke, the patient becomes a patient with a psychiatric history – something that is not, as many will tell you, a very helpful history to have. But hey, it’s OK, because the noctor feels good, because she has been caring. She’s offered help, just to be on the safe side.
The trouble with all this well-intentioned interference is that all to often it turns non-psychiatric problem (an impulsive overdose taken for personal reasons) into a psychiatric one, and an individual into a patient, with a history he or she does not need, and which will do nothing but harm.
What this unfortunate girl does need is not care, but a confident medical diagnosis – that she does not have a mental illness. She is instead a silly girl who has taken an overdose that might have killed her but thankfully did not. She is freed to get on with the rest of her life, without the encumbrance of an unnecessary psychiatric history.
This silly girl may or may not take another overdose. Whether she does, and what happens subsequently, will be influenced by her assessment outcome this time round. But that is another story, for another day.