Can you “cure ‘em”?

Funny or offensive?

 

This is a curious clip, and appears to have been produced by someone, maybe a behavioural neurologist, or neuropsychologist with considerable insight into NEAD and particularly patients views on their disorder. There is the bit towards the end with the head injury, and “crying wolf”, and then the recurrent leitmotif of the little dog (?wolf, ?seizure alert dog); before finally the theme switches to welfare benefits, and then she is then apparently cured by a new boyfriend. This was, I suspect, produced by a clinician with an interest in functional disorders, or possibly by a patient who had recovered from NEAD (Doctors.net.uk)

Worth a giggle. But it does raise a more serious point about the way we handle, and are taught to handle, psychogenic and psychiatric disorders.

We learn as students about the management of mental health conditions, the psychopathology behind why the patient feels and responds that way, and to look at the illness in a holistic, patient centered way. We consider the advantages and disadvantages of ‘labeling’ such patients, the social aspects of the etiology of their health condition and their care, and ways of reintegrating patients with severe psychiatric disorders into their community and employment. It’s all very nice, working for the patients, taking what they say seriously and applying clinical skills to make things better for them.

Then we get exposed to the patients by clinicians. We’re on post-take ward round with the consultant who brushes off the apparently fitting patient as, “just another one of her pseudo-seizures, leave her alone for half an hour then we’ll send her home”. We’re in A&E with the registrar who asks with a resigned sigh if you would “go find out what she’s taken this time” and pointed in the direction of the patient with borderline personality disorder who’s attended for the third time this month. It’s hard not to become convinced by the cynical approach of the experienced clinicians that they’re the ones who are right. The lectures are divorced from reality; On the front line, these people are untreatable, repeat offenders who waste our time, and as the healthcare assistant muttered as she walked past an apparently ‘cry for help’ suicide attempt, “you just can’t cure ‘em”.

It’s sad, in a way. I like to think of myself as having at least a little bit of desire to care for people, hence getting into this whole medicine jazz. And I have good friends, both in person but also online, who have these apparently ‘untreatable’ diagnoses applied to them. The majority do try and help themselves, working with the psychiatric teams, trying desperately to become ‘normal’. Jobs, friends, education – they manage, despite the obstacles that having this label throws in front of them. Sure, there’s the occasional relapse, but on the whole they are putting in a lot of the leg-work themselves, with support from the medical profession.

So why can’t I treat the person in the A&E bed the same, trying to give them the same support, rather than just counting down the minutes until their paracetamol levels come back safe and we can boot them out to clear up a trolley? Is it depersonalization, protecting myself from the draining effects that caring for someone in that condition can have? I treat my friends differently from my patients, and I think that’s only correct, but do we go too far the other way? Or am I learning to treat patients that way vicariously, following the examples of the doctors around us?

Perhaps it’s like all the jokes within hospital and the ambulance service about GPs. The reason primary care gets such a bad rep is that you only see and remember the bad ones. This blog is full of stories from when I was working in Yorkshire of grossly inappropriate jobs given out by GPs, but a disproportionate number were given out by the same few doctors. The majority of general practitioners do a good job, caring for their patients themselves, and only referring to the A&E pathway when absolutely necessary, and often with very clever and subtle catches. But you barely remember them: All that sticks in your head is the waste of time jobs, and those where the patient is on the verge of dying because that catch was never made.

Chronic mental health may be like that. The majority of people we see are the same patients over and over again. Perhaps they are the ones who don’t want to help themselves, the minority. There can’t be just one borderline patient, one NEAD in the city, but they’re the ones we see over and over again. One could argue that the issue isn’t their mental disorder, but something more fundamental about their personality. We shouldn’t apply who they are and the way they behave to everyone with that same label, the vast majority of whom are working hard to cope in the same way someone with a chronic physical illness like asthma or diabetes does.

But unlike the bad GPs, is it right that we write them off as uncurable? Or should we be applying the same, arguably unattainable, model of the perfect clinician doing everything for their patient, and still try to give them all the help we would someone actively trying to get better? Or is it a lost cause, the issue lying with them as a person, rather than their illness? Would our time be better served treating as mental health practitioners those who want to be treated, as emergency clinicians those people who’s illnesses or injuries are life threatening?

And more fundamentally, is the personality/illness distinction really our call to make?

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