Here is a piece I wrote for the RCPsych London division December Newsletter.  It’s about Triage ward on the Ladywell unit in Lewisham.

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Triage ward is one of five general adult wards serving the inpatient psychiatric needs of the Lewisham area.  It is based in Lewisham hospital and is part of the Ladywell Unit which in turn is part of the South London and Maudsley NHS Trust (SLAM).  Judging by the number of visitors we have had to the ward whilst I have been working here, there is a great deal of interest in the way we do things. 

Triage ward is part of an unusual model for managing psychiatric admissions, and one that is soon to be implemented across SLAM.  As a ward it acts as a single point of admission for all patients who enter the Ladywell unit.  It is aimed that patients will stay for a maximum of two weeks, whilst their needs are considered.  If, after this time, they need to continue as an inpatient for a further spell, they are then transferred to a longer stay ward.   This model contrasts to the established paradigm whereby ward allocation is sectorized, where patients are on admission immediately assigned to wards depending on their postcode or the location of their general practitioner and there is no envisaged limit on admission duration.  The impetus for establishing Triage was a desire to address common problems found within psychiatric in-patient units where wards are busy and overcrowded, leading to patient overspill into the private sector and a high staff turnover.  It was established in 2003 by Dr Martin Baggaley, who is now medical director of SLAM.

Triage is a mixed ward and its maximum capacity is 16 patients.  Asides having an airlock and being more secure, it looks much like any other inpatient psychiatric ward, although newer than some.  The provision of staff is generous compared to other sites and asides a contingent of skilled nursing staff, there are two CT1-3s doctors, a ST4 doctor, two part time consultants (full time equivalent), and a social worker. 

Triage’s aim is that, after admission, patients should have their needs met and be discharged to the community or another ward as quickly as possible and much of what we do has this goal in mind.  The turnover of patients is extremely high and amounts to 920 patients per year.  There can be as many as four new patients in a day across a wide ethnic mix.  Some patients seem to go before one has even met them and after a returning from a week’s annual leave the ward’s inpatients will have almost completely changed.  This constant flux means it’s difficult to form a rapport with any of the patients.   The life of a junior doctor is very busy and a recent new duty is a completion of an OPCRIT computer based diagnostic assessment for each patient.  Unlike other SHO jobs, time constraints mean that we don’t complete the patient discharge summaries and this responsibility is passed onto the ST4 trainees.  Fellow CT trainees on other wards are jealous of this concession!

A lot of my work is administrative, which can be dull but in compensation there is plenty of opportunity to learn at the consultant lead ward round, which is held daily to ensure swift patient movement through the system.  Here my role is to make interview and management plan notes and this is done on a computer terminal which is projected for all to read.  With two different consultants it is possible to observe different interviewing styles.  I have found interviewing more difficult than I expected and my ability to undertake a mental state examination has much improved.  The presentations of our patients are very varied and sometimes the ward rounds can be quite dramatic.  About half of our patients are under section at any one time and, much is as one might expect, depressive, psychotic and personality disordered presentations predominate.  We work closely with the local crisis resolution service and a member of their team is often present.  The downside of such regular ward rounds is that with senior doctors so regularly available, there’s little latitude for independent thought. 

Triage might perhaps appear foreboding to the uninitiated.  The ward and staff base can feel as busy and noisy as general medical wards post take, but there are plenty of calm periods too.  The staff base is shared between doctors and nurses.  This makes for good multi-disciplinary communication and although we’re short of computer terminals this is never a cause of friction.  I have however become resigned to our second printer being permanently broken.  There can be an air of unpredictability and the ward panic alarm is activated a lot.  I’ve never felt personally threatened, although it’s not unheard of for a member of the nursing staff to be assaulted.    

Patient treatment is predominantly medication based and I think it’s a shame that there are no psychologists on the ward, but there is a social worker available to address social needs, which oftentimes is the most important thing.    The air conditioning we have is a mixed blessing as patients often complain of being cold in bed at night.  The ward environment is rather boring for the patients, although there is a daily newspaper and a table tennis table; the nature of the disorders with which we deal means that some patients, who might wish for peace and quiet, are disturbed by other more vociferous residents. 

Overall my experience of working on Triage ward has been very positive.  On other wards on which I have been employed patients can sometimes be admitted for several days before they are seen by a consultant, an experience that can be very frustrating.  However on Triage ward, with its daily ward round, things move much more quickly and it is also hard not be impressed by the financial savings Triage has bought to the SLAM trust, as it is now almost unheard of for a Ladywell patient to be accommodated in the private sector.

Perhaps it’s the congestion charge or the increased provision of cycling lanes, or maybe we’re inspired by high profile cyclists Boris Johnson and David Cameron, but cycling in London has risen by a staggering 70 per cent since the year 2000. Corresponding with this newfound popularity, the profile of London cycling has risen dramatically and, previously, a pursuit for the foolhardy, the joys and tribulations of a daily bicycle commute are now a favorite dinner party conversation topics for the chattering classes.

One feels that the British capital’s roads would sport even more cyclists were it not for lingering concerns over safety. There has been a recent upsurge in cycle related injuries as well as collisions with pedestrians.  Stark reminders of the vulnerability of cyclists are the ‘ghost bikes’ which can be seen chained to railings at several major junctions across the city. If the amount of copy in national newspapers such as the Guardian is anything to go by, the lobbying power of cyclists is increasing and most of this is focussed on increasing safety. The majority of concerns are about careless driving and cycling organizations such as the CTC, the organisation formerly known by the rather quaint name of the Cyclists’ Touring Club, like to paint a picture of cyclists as a saintly breed, innocent victims of the negligence of others.  A website has recently been launched to address this issue, its title drawn from the allegedly popular excuse for a near miss: “Sorry mate I didn’t see you”.

Users of the site are invited to document instances of bad driving. And yet, individual cases aside, anyone who uses London’s roads knows that this vision of cyclists as entirely innocent does not bear scrutiny. Occupying as they do a dim and ill-defined hinterland somewhere between motorised vehicles and pedestrians, strict adherence to the Highway Code seems not to have caught on.  High visibility clothing and lights at night are eschewed. The conscience of the average London cyclist appears untroubled by flouting traffic lights and any visiting pedestrian will quickly learn, as residents already have, that many cyclists have no intention of stopping for crossings. One feels that the true motivation for some bike commuters are not those of pursuing alternative modes of transport, but rather that they could no longer go sufficiently fast in their cars.

The current distain shown by four wheels for two and two wheels for two legs can perhaps best be understood in two ways. Firstly as a competition between different groups for road space and speed, both scarce resources in an ancient and ‘un-designed’ cities like London and Dublin. It is a neat coincidence that when sociologists talk of the propensity of a societal group to mistreat those directly below it on the social ladder they talk of the ‘bicycling reaction’, so named as just like a cyclist the group bows to those in before it and kicks those below.  The treatment of pedestrians by London cyclists is not so dissimilar. Secondly, some of the quasi-conflict appears to have its roots in class. Cyclists are predominantly from higher socio-economic groups who can afford to live within cycling distance of work. Conflict, then, as much about people seeking to demonstrate their difference from – and superiority to – others as it is to getting anywhere quickly.

It would be nice to see people improving their behaviour without police crackdowns or yet more Government leglisation – and before the current cycling paradigm becomes so engrained that it is part of the Londoner’s character. Cyclists will certainly get no encouragement to change from the CTC, which has written in support of cycling on pavements.   Many seem to think that, simply by virtue of their being likely to come off worse from collision with a motorised vehicle, cyclists occupy the moral high ground. They do not. Cycling should be encouraged, but a sober reassessment of the behaviour of cyclists rather than blind support of their rights on the road would be the most appropriate.

Cycling has much in its favour: it is quick, cheap and increases fitness. As a result there are plans for a massive increase in cycling provision across Britain, but this will only work if cyclists begin to play by the rules.  Boring, I know.

Also published on Forth.ie

I went to a debate on complementary medicine recently, hosted by the KCL Social Medicine Society.  Despite being held on Guy’s Hospital Campus, a supposed stronghold of conventional medicine, the lecture theatre was awash with complementary therapists and when the pre-debate votes were taken the numbers were two to one against critics – like me – of complementary practice.

The speeches for and against the motion, although equally disadvantaged by the lack of anticipated audiovisuals, were, by and large, as I had expected as they rehearsed well known arguments on medical evidence and the primacy of double blind randomized control trials.  What I hadn’t been expecting was the degree of tension between the two viewpoints; for instance several audience members felt regularly moved to heckle Simon Singh, co-author of Trick or Treatment – a paean to evidence based medicine, not content that he is already subject to a libel lawsuit from the British College of Chiropractors.

After the addresses, relations deteriorated further when participation was invited from the floor.  It wasn’t just that some of the points made were verbose and closer to statements than actual questions, the vehemence of the complementary therapy supporters disagreement with a conventional medical approach was striking.  It was almost as if they felt that those opposing their view not only disagreed with them, but did so malignly with murderous intent.

Of course the sample of people I saw was self-selecting, but why would people feel so strongly that conventional medicine, and by extension doctors, wished them ill?  A partial answer as to the schism between complementary and conventional medicine is provided by Bad Science guru Ben Goldacre, who in his recent book lists reasons why ‘clever people believe stupid things’.  His argument is psychologically based: people are biased; see patterns where there is only random noise; see causal relations where there are none and overvalue and seek out confirmatory information.  From these beans a beanstalk grows all the way up to Matthias Rath.

I don’t doubt Goldacre’s assessment, but it cannot wholly account for the hostility which I witnessed.  The supporters of complementary medicine at the debate seemed to feel entirely disenfranchised by conventional medicine, and alienated even from cordial debate.  The root of this emotional intensity may be that although the majority of people tolerate the NHS’s faults and are basically satisfied with the service they receive, some people’s experience of conventional medicine can be poor.  Consider the people who feel unheeded by their doctor who can only allot them seven minutes, or those upset and resentful about their parent who died from the effects of chemotherapy; or those suffering from medicine side effects or whose operations lead to complications. For some, it won’t just be the message, but the messenger too: doctors nearly all come from a privileged swathe of society and our relative erudition and advantage will make some patients, whose achievements may on the face of it seem more humble, feel unpleasantly diffident.

Other factors against doctors are wired in from our training.  Despite modern efforts, it all too rarely leads us to heed that a patient’s experience of receiving their healthcare can be even more important than the healthcare itself and we still tend to see people in terms of aggregations of symptoms, ignoring that most of our patients come to see us for reasons only partially related to an identifiable disorder.  Although improvements have been made and medical schools have pulled up their socks, the MRCPsych and other membership exams give pitiful consideration to the cultural forces behind poor health.    Overall, and especially post graduation, our manner with our patients and our ability to help them in any way beyond a narrow biomedical confine it is not treated as central to what we do but rather something we are expected to pick up as we go along.

Could complementary therapy for its staunch adherents be then one in the eye to all the people like doctors who ‘think they’re clever’ and fail to adequately assess or understand patient difficulties?  Is it an inevitable outcome as the result of some people wishing for a more equal partnership for healing? For the disenfranchised, complementary medicine may be something that they can own, and a haven from the people whose education unfortunately makes them seem intimidating and unapproachable.

Addendum 4 June 2009:  In an earlier version of this email I used the spelling complimentary as in ‘to offer praise’ rather than the correct complementary as in ‘to act as an accompanyment’.  Gradually chipping away at my ignorance….  Indebted to TimA for his wise counsel.

Guardian A sceptical inquiry 9 March 2009

John Cale, Welshman, and former member of seminal rock band the Velvet Underground was interviewed in the Guardian this week.

… what about the night Andy Warhol got the Velvet Underground to play a convention of psychiatrists at Delominco’s steak house? The psychiatrists were appalled. “That was revenge – Lou’s revenge,” Cale says, “and I was all for it.” As a teenager, Reed had been given electric shock treatment to “cure” him of homosexuality. “Lou and I were going to put out a record with his psychiatrist’s letter on one side and my arrest record* on the other,”

The Velvet Underground were a band formed in the mid-1960s by Lou Reed and John Cale together with Mo Tucker and Stirling Morrison.  Although their lifespan was brief they combined the energy of rock with the sonic adverturism of the avant-garde.   Pop artist Andy Warhol was their manager and their first album famously featured a large yellow banana sticker and the instructions ‘peel slowly and see’.  Andy Warhol had been invited to speak at the annual banquet of the New York Society for Clinical Psychiatry and he decided to take the the band along with him as ‘a kind of community action-underground-look-at-your-self-film project’

The psychiatrists who turned out in droves for the dinner, were there to be entertained – but also, in a way, to study Andy. “Creativity and the artist have always held a fascination for the serous student of human behavior,” said Dr. Robert Campbell, the program chairman. “And we’re fascinated by the mass communications activities of Warhol and his group.

“I suppose you could call this gathering a spontaneous eruption of the id,” said Dr. Alfred Lilienthal. “Warhol’s message is one of super-reality,” said another, “a repetition of the concrete quite akin to the L.S.D. experience.” “Why are they exposing us to these nuts?” a third asked. “But don’t quote me.” source

I really wish I could have been there.

The second the main course was served, the Velvets started to blast and Nico started to wail. Gerard and Edie jumped up on the stage and started dancing, and the doors flew open and Jonas Mekas and Barbara Rubin with her crew of people with camera and bright lights came storming into the room and rushing over to all the psychiatrists asking them things like:

What does her vagina feel like?
Is his penis big enough? Do you eat her out?
Why are you getting embarrassed? You’re a psychiatrist; you’re not supposed to get embarrassed…. source

The New York Times reported on the event the next day under the heading, ‘Shock Treatment for Psychiatrists’

Excerpt of the performance

Addendum 17 May 2009:

I found a further account of this in the book Women’s Experimental Cinema by Robin Blaetz.  She’s talking about Barbara Rubin, an underground film maker and a player in Warhol’s factory:

On January 13 1966, Warhol was invited to be the evening’s entertainment at the NY society for Clinical Psychiatry’s forty thir- annual dinner, held at Delmonico’s Hotel. Bursting into the room with a camera, as the Velvet Underground acoustically tortured the guests and Gerard Malanga and Edie Sedgwick performed the ‘whip dance’ in the background, Rubin taunted the attending psychiatrists. Casting blinding lights in their faces, Rubin hurled derogatory questions at the esteemed members of the medical profession, including: ‘What does her vagina feel like? Is his penis big enough? Do you eat her out? As the horrified guests began to leave Rubin continued her interrogation: ‘Why are you getting embarrassed? You’re a psychiatrist; you’re not supposed to get embarrassed. The following day the NY Times reported on the event; their chosen headline, ‘Shock treatment for psychiatrists’, reveals the extent to which Rubin’s guerrilla tactics had inverted the sanctioned relationship between patient and doctor expert and amateur.

Addendum 18 May 2009: Mindhacks has featured this also

*Cale had been previously arrested for possessing chemical substances.

I almost fell off my chair today whilst reading Scarlett Johansson’s article ‘Skinny’ in the Huffington post.  Appalled by tabloid stories that she had lost fifteen pounds in preparation for her role in Iron Man 2, Johansson hit back, and very sensibly and eloquently too, with no talk of the alien religions that so enamour some of her kinsmen:

Since dedicating myself to getting into “superhero shape,” several articles regarding my weight have been brought to my attention. Claims have been made that I’ve been on a strict workout routine regulated by co-stars, whipped into shape by trainers I’ve never met, eating sprouted grains I can’t pronounce and ultimately losing 14 pounds off my 5′3″ frame. Losing 14 pounds out of necessity in order to live a healthier life is a huge victory. I’m a petite person to begin with, so the idea of my losing this amount of weight is utter lunacy. If I were to lose 14 pounds, I’d have to part with both arms. And a foot. I’m frustrated with the irresponsibility of tabloid media who sell the public ideas about what we should look like and how we should get there.

Needless to say, right next to this article was a link for a posting for a magazine printing nude pictures of celebrities.  Please spread the word Miss Johansson, the world needs more people like you.

Update: I’ve been thinking about this (but mostly other people have been telling me) that although SJ may have written this article she still has a body shape that adheres to the Hollywood ideal and has also critically undermined her credibility by having appeared in Vanity Fair’s 2006 cover shoot which severely objectifies the female form .

Sorry for anyone who came visiting and found something unexpected. It’s all over now, thanks Trev!