1052
In my
beginning
is my end
ALEX COMFORT I started end it as
independent medical practice as a locum and shall
The National Health Service declines-with it is true-to appoint consultants in psychiatry apologies, over age 65. But, by Zeus, it is glad of them to fill in the spaces left by conferences, holidays, and staff turnover, inefficient as it may be for the consultant to drive over a hundred miles there and back to see, perhaps, four patients in a clinic that has been run down ahead of an imminent one.
vacancy. The work has satisfactions and frustrations.
Apart from where one has the opportunity to meet and interact with students and residents, there are the childish satisfactions of smartening up others’ diagnoses, modifying or cancelling others’ prescriptions, and generally taking charge-but with the frustration that one will not be there long enough to see the revised diagnosis confirmed or the new treatment successful. The few patients-most of them longstanding depressives and consumers of tricyclics-who come back transformed by a change to a monoamine oxidase inhibitor (MAOI) or the addition of carbamazepine, are among life’s rare satisfactions. Doubts raised in the mind of the regular consultant where atypical psychotics have not had a trial of lithium before a sticky label ("schizophrenia"-more rarely "mania") is irrevocably affixed is another. I have yet to see a file where schizoaffective disorder was firmly diagnosed in Britain, common as it probably is. Thereby hangs a tale. Psychiatric practice is a great, possibly the greatest, generator of files as thick as a telephone directory. These records should give the newcomer a complete view of the patient’s illness, the investigations and treatments undertaken, and the response if any to those measures. They don’t. Aside from volume, one problem is legibility. One can read one’s own hand, disguising or distorting it so that the patient cannot, but it is dangerous to life and discourteous, to file notes and prescription sheets which occupy the time of your successor or substitute who tries to guess whether the language used is Hebrew or Tamil. If I were going to be in charge for long, I would ask the resident to summarise each file as it become active, or do it myself-but I am not in charge for long. One does not fix it if it works-but those very thick files on relapsing, not-quite-stable patients, or patients recovered from major depression who have not yet climbed the second stair of normality (they will have anergia, flatness, and view life in monochrome) do offer the opportunity of the new broom, the second opinion not fatigued by long familiarity. We treat depression by the seat of our pants because the drug regimen to which the patient will respond is not encoded in palmprints or ascertainable by any but therapeutic tests. To search for a more effective treatment, one needs to know what has been tried previously, and whether it was tried for long enough at an adequate dosage. There is no point in re-testing MAOIs if the patient has already had a trial and responded with hypotension or not at those
refreshing places
ADDRESS: Windmill House, The Hill, Cranbrook, Kent TN175AH. UK (Dr A Comfort, MB, DSc).
all. Can one learn this from the fardel of notes? Sometimes, and sometimes not. The patient had lithium for two weeks and was taken off it: why? The notes may or may not tell you. Here again, were I in charge, things would be otherwise because there would be a protocol for the treatment of moderate or mild depression, with a standard procedure for those who do not respond. One may try the addition of lithium, which often works faster than ECT, addition of an anticonvulsant, and even the possible addition of thyroxine or oestrogen after which there remain only prayer and the likelihood of eventual spontaneous remission. Or prompted by the fact that the depression is "atypical", associated with obsession, dream scintillations, or with migraine, one can go the MAOIroute, often with a quick result. Finally, the two routes merge in a trial of MAOI plus tricyclic (not clomipramine) under close supervision-a less risky
procedure, provided one uses phenelzine not tranylcypromine, than is commonly supposed.2 Others may have other routes based on their experience. The point is, there can and should be a flow-chart, and your successor or substitute can see where the patient stands. Five years on amitryptiline with no severe episodes but no complete recovery will not do. A flow-chart can also bear notes ("intolerant of phenelzine", "no response to lithium over adequate time and with adequate dose") that shorten the patient’s quest-and the locum’s. Those phonebook files, apart from the frustration that they contain, do also give satisfactions, but often these are of an historical rather than a practical kind. If they are fat enough they contain a history of psychiatry over the past twenty years. New drugs and new diagnoses, eruptions of zeal, for instance, behaviour therapy, even the bees in the bonnets of past consultants-they are all here in fossil form. Nobody should laugh; after all they were doing their best and we are doing the same. One can remember when, in America, "even a trace of schizophrenia is schizophrenia"’3 with grave results for manic, schizoaffective, and acute episodic psychotic patients. To study these chronicles when the clinic intervals between patients are long, as they often are for summer locums, gives one a crash course in humility. It is the residue of patients who have suffered much from many physicians, who have had compassionate support, who are not very ill but not very well, and who generate those files, who remain in the mind. They are, or should be, the psychiatric equivalent of the Five Noble Sights-a poor man, a sick man, an old man, a corpse, and a renounced ascetic-which caused Gautama to leave home in quest of an end for the human experience of suffering. Perhaps the lesson is sharpest for the peripatetic who sees many clinics, and many such folders. REFERENCES 1. Dinan TG, Barry S. A comparison of ECT with a combined lithium and tncyclic combination among depressed tricyclic nonrespnders. Acta Psychiatr Scand 1989; 80: 97-100. 2. Pare CMB, Kline N, Hallstrom C, Cooper TB. Will amitriptyline prevent the ’cheese’ reaction of monoamine oxidase inhibitors? Lancet 1982; ii: 183-86. 3. Lewis NDC, Piotrowski ZA. In: Hock P, Zubin J, eds. Depression. New York: Grune and Stratton, 1954.
In my
beginning
is my end
ALEX COMFORT I started end it as
independent medical practice as a locum and shall
The National Health Service declines-with it is true-to appoint consultants in psychiatry apologies, over age 65. But, by Zeus, it is glad of them to fill in the spaces left by conferences, holidays, and staff turnover, inefficient as it may be for the consultant to drive over a hundred miles there and back to see, perhaps, four patients in a clinic that has been run down ahead of an imminent one.
vacancy. The work has satisfactions and frustrations.
Apart from where one has the opportunity to meet and interact with students and residents, there are the childish satisfactions of smartening up others’ diagnoses, modifying or cancelling others’ prescriptions, and generally taking charge-but with the frustration that one will not be there long enough to see the revised diagnosis confirmed or the new treatment successful. The few patients-most of them longstanding depressives and consumers of tricyclics-who come back transformed by a change to a monoamine oxidase inhibitor (MAOI) or the addition of carbamazepine, are among life’s rare satisfactions. Doubts raised in the mind of the regular consultant where atypical psychotics have not had a trial of lithium before a sticky label ("schizophrenia"-more rarely "mania") is irrevocably affixed is another. I have yet to see a file where schizoaffective disorder was firmly diagnosed in Britain, common as it probably is. Thereby hangs a tale. Psychiatric practice is a great, possibly the greatest, generator of files as thick as a telephone directory. These records should give the newcomer a complete view of the patient’s illness, the investigations and treatments undertaken, and the response if any to those measures. They don’t. Aside from volume, one problem is legibility. One can read one’s own hand, disguising or distorting it so that the patient cannot, but it is dangerous to life and discourteous, to file notes and prescription sheets which occupy the time of your successor or substitute who tries to guess whether the language used is Hebrew or Tamil. If I were going to be in charge for long, I would ask the resident to summarise each file as it become active, or do it myself-but I am not in charge for long. One does not fix it if it works-but those very thick files on relapsing, not-quite-stable patients, or patients recovered from major depression who have not yet climbed the second stair of normality (they will have anergia, flatness, and view life in monochrome) do offer the opportunity of the new broom, the second opinion not fatigued by long familiarity. We treat depression by the seat of our pants because the drug regimen to which the patient will respond is not encoded in palmprints or ascertainable by any but therapeutic tests. To search for a more effective treatment, one needs to know what has been tried previously, and whether it was tried for long enough at an adequate dosage. There is no point in re-testing MAOIs if the patient has already had a trial and responded with hypotension or not at those
refreshing places
ADDRESS: Windmill House, The Hill, Cranbrook, Kent TN175AH. UK (Dr A Comfort, MB, DSc).
all. Can one learn this from the fardel of notes? Sometimes, and sometimes not. The patient had lithium for two weeks and was taken off it: why? The notes may or may not tell you. Here again, were I in charge, things would be otherwise because there would be a protocol for the treatment of moderate or mild depression, with a standard procedure for those who do not respond. One may try the addition of lithium, which often works faster than ECT, addition of an anticonvulsant, and even the possible addition of thyroxine or oestrogen after which there remain only prayer and the likelihood of eventual spontaneous remission. Or prompted by the fact that the depression is "atypical", associated with obsession, dream scintillations, or with migraine, one can go the MAOIroute, often with a quick result. Finally, the two routes merge in a trial of MAOI plus tricyclic (not clomipramine) under close supervision-a less risky
procedure, provided one uses phenelzine not tranylcypromine, than is commonly supposed.2 Others may have other routes based on their experience. The point is, there can and should be a flow-chart, and your successor or substitute can see where the patient stands. Five years on amitryptiline with no severe episodes but no complete recovery will not do. A flow-chart can also bear notes ("intolerant of phenelzine", "no response to lithium over adequate time and with adequate dose") that shorten the patient’s quest-and the locum’s. Those phonebook files, apart from the frustration that they contain, do also give satisfactions, but often these are of an historical rather than a practical kind. If they are fat enough they contain a history of psychiatry over the past twenty years. New drugs and new diagnoses, eruptions of zeal, for instance, behaviour therapy, even the bees in the bonnets of past consultants-they are all here in fossil form. Nobody should laugh; after all they were doing their best and we are doing the same. One can remember when, in America, "even a trace of schizophrenia is schizophrenia"’3 with grave results for manic, schizoaffective, and acute episodic psychotic patients. To study these chronicles when the clinic intervals between patients are long, as they often are for summer locums, gives one a crash course in humility. It is the residue of patients who have suffered much from many physicians, who have had compassionate support, who are not very ill but not very well, and who generate those files, who remain in the mind. They are, or should be, the psychiatric equivalent of the Five Noble Sights-a poor man, a sick man, an old man, a corpse, and a renounced ascetic-which caused Gautama to leave home in quest of an end for the human experience of suffering. Perhaps the lesson is sharpest for the peripatetic who sees many clinics, and many such folders. REFERENCES 1. Dinan TG, Barry S. A comparison of ECT with a combined lithium and tncyclic combination among depressed tricyclic nonrespnders. Acta Psychiatr Scand 1989; 80: 97-100. 2. Pare CMB, Kline N, Hallstrom C, Cooper TB. Will amitriptyline prevent the ’cheese’ reaction of monoamine oxidase inhibitors? Lancet 1982; ii: 183-86. 3. Lewis NDC, Piotrowski ZA. In: Hock P, Zubin J, eds. Depression. New York: Grune and Stratton, 1954.
