Christmas Reflections

Christmas, for many reasons, is a time of year when I always feel particularly contemplative. I'm not a religious person - I was raised in a "respecting all religions but following none of them" kind of household and seem to have continued along that path into adulthood - but there's still something about Christmas that seems special. There's no denying that, as a little girl, at least part of the excitement was about presents, but I think it's always been about more than that. My Daddy used to finish work at lunch time on Christmas Eve, we would probably see friends and cousins who we didn't see often, there would be lots of people visiting and, of course, no school for us or work for our parents, so we spent lots of time together as a family. Overwhelmingly, though, what sticks out in my memories of my childhood Christmases is that everyone was happy. It was simply a time of seeing the people you loved and enjoying being together.

During my teenage years, as many of you will know, I had a rather difficult time with my mood. A time when everyone was so cheerful, and the general attitude appeared to be "you should be happy, it's Christmas!" suddenly became difficult to cope with. The general tolerance for misery seems to drop at this time of year, and anyone who isn't feeling full of the festive spirit not only has to contend with their own difficulties, but also with accusations of bringing everyone else down and spoiling Christmas.

Now, as an adult, I enjoy Christmas again, but a combination of my teenage difficulties and work and family circumstances mean I'm all too aware of how difficult this time of year can be. I'm working again this year, but come Monday when I have some time off, I'll be heading up to see my parents and sisters before spending New Year with my boyfriend. I'm lucky to have not only a job that I genuinely enjoy and that pays me enough to be able to spoil the people I love, but (more importantly) people I love close by, happy and healthy.

Working over Christmas in a hospital is an odd experience which brings with it a strange combination of emotions. I still smile when I remember the sweet nonagenarian who burst into tears of happiness when Santa came around the ward and gave gifts to all the inpatients. The same day, I had to tell a lady that the symptoms her son had brought her to A&E with were likely due to metastatic cancer. Another year, I got a Christmas kiss on the cheek from a very mischievous older gentleman patient before discussing end of life care for someone else. Last year, I saw babies and children spending their Christmas in hospital - for some it was their first Christmas, for others it would be their last; for a few it was both.

Whatever you're doing this Christmas, spare a thought for those who aren't enjoying the festivities in the usual way. My colleagues in the health service, from the domestic staff keeping the wards clean to the consultant surgeons performing life-saving operations, will be there to ensure you and your family are well looked after. Those in the fire service and police force are making sure our streets and homes are kept safe. Thousands of hospitality workers are spending today serving up countless turkey dinners and glasses of prosecco to help other people have a merry day. To everyone working this Christmas - thank you.

If Christmas is a challenge for you, know that you aren't forgotten. Those struggling to get through the day without a loved one - be it for the first or the fiftieth time - I feel for you. If you're spending the day in the hospital, either as a patient or visiting a loved one, I hope Christmas is comfortable and that the New Year will be brighter. If you simply feel overwhelmed and are struggling, there are people who care and who will listen.

Merry Christmas, everyone, stay safe and I hope 2016 brings health and happiness to all xxx

There are a number of places you can get help should you need it. The services I've listed are free to call and open 24/7. A more comprehensive list is available through the NHS choices website, but not all services are free or open over Christmas.

If you're struggling today, or any day, the Samaritans are there to listen for free - call 08457 90 90 90.
Children and young people can contact ChildLine on 0800 1111 whilst adults who have concerns about a child can call the NSPCC helpline on 0808 800 5000.
If you feel in danger of hurting yourself and don't have a crisis plan, please call 999 or go to your local A&E department.
For those who need help with domestic abuse, contact Refuge on 0808 2000 247.
If alcohol is a problem, you can call Alcoholics Anonymous on 0845 769 7555.
If you need help with drugs, you can speak to Frank on 0800 77 66 00.

A Marathon Journey

Anyone who's read this blog before will realise that I'm a fan of a metaphorical journey - the journey from schoolgirl to doctor, the journey from messed up adolescent to semi-functioning adult, that sort of thing.

Well, recently I made what may turn out to be one of the most ridiculous decisions of my life so far - I decided I'd make the journey from lazy so and so to... marathon runner. Yes, that's right, marathon runner. On 24th April 2016, all being well, I will complete the London marathon.

To give you an idea of quite how huge a journey this is going to be, I'll give you some details on my current fitness levels and running ability. In 2010 I completed a 10k run for charity in a not-at-all-impressive time of 1 hour 20 minutes. I say run, I did minimal training and walked most of it. I haven't really run since. I intermittently get the gym bug and start building up my fitness, but I have always avoided the treadmill like the plague. I even had a personal trainer for a while, but whilst we did a lot of work to build up my strength, we did very little to do with running. Our sessions were mostly "interval" training, so I'd do short bursts on the cross trainer or bike, followed by 5 reps of dead lifts or similar. In February, I started a job with over an hour's commute each way and was so exhausted I basically stopped all forms of exercise. I've been saying since August that I'd start getting fit again, but until this week I hadn't done much about it. I've downloaded a 16 week beginner's training plan, and have just over 23 weeks to train. My plan is to use the C25k programme to get me able to run for 25 minutes or so over the next 7 weeks, and then to move on the the training plan (which seems to suggest you can start with no running experience at all, but includes 20 minute runs in the first week). It's going to hurt.

So, why on earth am I putting myself through this? Firstly, because I had been thinking for a while that it was about time I did something mad to raise money for charity, and secondly, because whilst I know I need to get fit, I'm absolutely dire at doing things without a specific target in mind.

I mentioned charity, and I am hoping to get some sponsorship for this. I've decided to raise money for the fantastic CLIC Sargent. As a paediatric doctor with an interest in oncology, I'm aware of the brilliant advances in science and medicine that mean we can now cure more children than ever of cancer. We're lucky enough to live in a country where the NHS means that families don't have to pay for treatment. Whilst there's still a long way to go, the treatment of children's cancer now is getting better and better. What I also know as a hospital doctor is that hospitals can't do everything. The emotional impact of a cancer diagnosis on a child or young person is enormous. The disruption to family life is huge. Parents may not have to pay for their child's treatment, but there is often a financial burden - be this travel to and from a treatment centre or having to temporarily give up work to care for a sick child. We are getting better and better at treating the physical disease state, but hospitals can't do everything. This is where charities like CLIC Sargent come in. They do an amazing job of helping children and their families cope emotionally, be this through formal counselling or just providing activities allowing them to spend time together without worrying about hospitals. They provide grants to families who are struggling with the financial impact of a childhood cancer diagnosis. They provide free accommodations for families who live too far from their treatment centres to reasonably be expected to travel. They supply a range of information aimed at children of varying ages so that their diagnosis and treatment is explained in terms they understand. In short, the care provided in hospitals is excellent and gets better year on year, but we couldn't provide the fantastic support required by our patients and their families without the help of charities like CLIC Sargent.

My training might hurt, but each time it gets tough, I'll just remind myself that it's nothing compared to a childhood cancer diagnosis.

If you'd like to spur me on with sponsorship, please go to https://www.justgiving.com/amanda-friend/

Thank you.

I'm Not A Lousy Doctor - But I'm A Lousy Friend

If you've read this blog before, you'll probably be aware that I'm a prolific tweeter. In fact, I'd be surprised if you were reading and had come across this post via anything other than seeing me tweet about it. One of the things I love about Twitter is that it makes the world a smaller place. One of my favourite Tweeters is the lovely @dr_ashwitt; although she is as far from me as is basically possible (Melbourne, if you were wondering), I frequently read her tweets and think "oh my God, me too!". Recently, Ash re-posted a link to a post she wrote a couple of years ago about her experiences of depression. She urged other doctors to post their own 140 character experiences of mental health issues, and #MH4Docs got a fair number of tweets which Ash has collated here. I haven't actually tweeted yet, but I've been pretty vocal about my own issues over the years and it's good to see that people feel they can open up about these things. The thing that really made me think, though, was the sentence she used to link to her blog.

"I have depression, but that doesn't mean I'm not a good doctor."

I think a big part of the reason that a lot of health care professionals (and non-health care professionals, come to think of it) are reluctant to open up about mental health issues is the fear that their abilities at work will be called into question. I know that one of my major fears when I "admitted" to having depression was that people might think I was unable to do the job I love and have worked for for a long time. 

My mental health problems don't mean I'm not a good doctor. I have a need to be busy which means that I will crack on with as much work as I can, and I'll find non-essential tasks which just "need doing at some point" to keep me occupied. Focusing on other people means I'm not thinking about myself and my own emotions, so I'm unlikely to slip into a spiral of despair. My lack of self esteem and constant impostor syndrome mean I'm keen to please and make an extra effort to be friendly and polite. Work makes me feel better and I think my own issues mean I will always work as hard as I can. Possibly I'm at risk of burnout, but it's nothing I've ever felt close to, and the other hobbies I've developed to occupy myself and prevent negative thinking mean I have outlets outside of medicine.

No, depression doesn't mean I'm not a good doctor. It does mean I'm not a good friend, though. Being nice and polite to people can be frankly exhausting. After a whole day smiling and engaging in banal conversation and generally giving the impression that I'm a functional human being, I am absolutely worn out. I very rarely agree to after-work plans because I know I'll be too tired to be good company. If I've made arrangements, there's a good chance I'll flake out at the last minute because I just can't face being around people any more. Finally living alone rather than with flatmates is a Godsend because it means I can have meltdowns in the living room and kitchen rather than being restricted to my bedroom. On nights out, I'm renowned for disappearing without telling anyone after being consumed by an overwhelming wave of misery and wanting to get away before I spoil anyone else's night. As for relationships, I am probably one of the worst girlfriends out there. I take insecurity and anxiety to ridiculous levels, any compliment is analysed repeatedly to ensure it isn't actually a heavily veiled insult and "I love you" is not infrequently followed not with "I love you, too" but "..really? Do you actually though?".

So yeah, I have depression, and that doesn't mean I'm not a good doctor. But it does mean I'm not a good friend. If you've stuck around anyway, thank you. I may not say it with nights out or long conversations, I may cancel half of our arrangements and you might feel like you're walking on eggshells when we talk, but you are loved and appreciated.

 

I'm A Paeds FY1... Get Me Out of Here!

With the much anticipated first Wednesday in August (for non-UK/non-hospital based folks, that's when all the junior doctors change jobs and our shiny new colleagues start their first roles as qualified doctors) fast approaching, I'm breaking from the EBM theme to write a #tipsfornewdocs type post for those who will be starting out in the crazy, scary, exciting world of paediatrics. I never actually did a paediatric rotation in FY1 but over the past year or so I've worked with numerous FY1 colleagues, some of them excellent and some of them a little less so. This is basically a list of the things I think really make the difference between the good ones and the rest.

If you're starting your first job as a doctor on paediatrics, lucky you! Whilst a lot of people are naturally anxious about working with children (yes, some of them are quite small, and they can be sticky and noisy, and worse than that, they come with parents attached!) you'll be working in a very well-supported environment with, on the whole, a very approachable group of senior colleagues. No one will expect you to be cannulating neonates or taking bloods from chunky toddlers on your first day! You also have the benefit, if you start in August, of working in a specialty with quite marked seasonal variation in admissions, so over the summer it should be relatively quiet on the wards and you'll have time to get your head around how things work before the winter chaos commences!

Paediatrics is a lovely, varied specialty with lots to learn. How much you do in terms of venepuncture, cannulation etc is largely up to you - if you aren't comfortable, no one will make you do it, but if you're keen then the SHOs and registrars will be more than happy to teach you. There should be lots of opportunity for getting involved in audit, if that's your sort of thing, and there's usually some kind of research going on if that's what interests you. So what makes a great paediatric FY1?

Be organised. This goes for every FY1 job out there, to be honest. If you know who your patients are, what's going on with them and when they might get home, you'll probably not go far wrong. If you know a patient might go home, get started on their discharge paperwork early. This is great for your patients, as it means they have less of a wait between being told they're fit for discharge and actually getting to go home. It also keeps the nurses happy, and frankly keeping the nurses on your side is one of the biggest things you can do to help yourself survive as a junior doctor!

Be interested. I get it, not everyone is keen on kids. For some of you, paediatrics will probably be your worst nightmare. We all do at least one job during our training we are not remotely keen on (FY1 general surgery, in my case), but these jobs still have plenty to teach you. The majority of you will end up having some contact with children during your future training, and even if you have your heart set on geriatrics from day one, there's a lot of opportunity for embracing multi-disciplinary working and improving your communication skills, which will be useful in any future career. You don't have to love it, but please don't treat your rotation as some kind of sentence which must be served.

Be able to spot a sick child. This is the biggest "clinical" thing expected of you if you're going to be involved in assessing children. Hopefully you'll get a chance to see new admissions to the unit and clerk them, as that's probably the best learning opportunity. No one will expect you to correctly diagnose everything you see, but it's important that you can recognise those children who look unwell and need senior review sooner rather than later. There is a really useful website called Spotting the Sick Child, which has elearning modules and videos of what to look out for and is worth doing if you aren't clear what a sick child looks like (you also get a certificate of completion which you can stick in your ePortfolio...). If in doubt, ask. Children can deteriorate quickly so if you aren't comfortable and feel something is wrong, get help sooner rather than later. Management priorities for someone acutely unwell follow the ABC approach, but you should never be in a situation where you're dealing with this by yourself. The DEFG (don't ever forget glucose) is particularly important in young children as they're prone to hypoglycaemia and it can have serious consequences.


Be friendly. Engaging well with a child can make a huge difference. Not everyone is naturally comfortable with children, but if you can chat about something that interests them, that's a great start. Knowing which characters frequently appear on t-shirts and pyjamas is useful, as clothes are a great starting point for conversation ("oh wow, that's Peppa Pig on your top, is she your favourite?"), as are toys and characters around the room. Frozen and Minions are particularly popular at present. If you can distract a child talking about whether they like Anna or Elsa best or how funny it is when the naughty Minions turn purple, you're much more likely to work out whether they have genuine abdominal tenderness, for example. Hi-fives after finishing an examination or procedure go down well, and if there are bravery certificates and stickers on the ward these tend to be good bargaining tools if you need to do something the child perceives as unpleasant (including looking at the throat; you would be amazed at just how much kids hate opening their mouths when you ask them to do it!).

Be professional. There's a fine balance between being child-friendly and being silly. Yes, parents want someone who's good with their child and knows how to communicate with them, but they also want a doctor. Being daft when you're examining and chatting to a kid is fine, but make sure when explaining finds and communicating plans to parents that you come across as the knowledgeable professional you are. This also goes for speaking with teenagers, who will be wholly unimpressed if you treat them like children.

Common things are common. Have a basic grasp of the common presentations and how to manage them. A lot of paediatrics is about simple things, done well. Wheeze and fever are probably the 2 most common presentations, so know your local investigation and management guidelines for these. You'll also probably see a a lot of jaundiced babies, rashes and gastroenteritis. If you can take a decent history, examine and work out which kids are the really poorly ones (see earlier point) you won't go far wrong.

Enjoy it! Paediatrics is fun and children are interesting. Plus, where else can you get baby cuddles, play with bubbles and watch cartoons whilst at work?!

Good luck!

Potential Pitfalls in Evidence Based Medicine

In my last post, I talked a bit about why we need to use evidence in medicine. However, much as I support using evidence wherever possible, I can also see that there are a number of things that can go wrong when using EBM approach. Most of these are not due, per se, to EBM, but are down to issues with its implementation. Nonetheless, I think they're worth discussing.

One of the biggest issues with evidence is knowing how to apply it. A study may say something that sound potentially interesting, but it's important to work out whether the result actually applies to the patient sat in front of you before changing your practise. Was the study you're reading carried out exclusively in 50 year old men with high blood pressure but no other co morbidity? That doesn't mean that the 65 year old diabetic women in front of you won't benefit from the intervention studied, but it does mean that the evidence is less applicable to her and you should think carefully about applying it to her case. Lots of studies look at extremely specific groups. This is to reduce the likelihood of "confounding variables" - things other than the intervention which may result in a difference in outcome between study groups. However, the flip side is that the study result may not apply to those who differ from the specific group looked at in the study. It's therefore well worth having a good look at the inclusion criteria for participants in trials and bearing in mind that the results might not automatically apply to all of the patients you see.

A related issue arises when we look at guidelines. Clinical guidelines are available for many, many conditions now, and provide advice on interventions, investigations, referrals etc. In the UK, most of these are issued by The National Institute for Health and Care Excellence and, in Scotland, the Scottish Intercollegiate Guidelines Network. Guidelines are usually devised by a group of professionals appraising the available evidence - basically, they've done the hard work for you and read through all the evidence to determine what the best thing to do is in a number of situations. They will usually reference the evidence they used, should you wish to read it for yourself, and also tell you how strong the evidence is behind each recommendation. However, they are not hard and fast rules, they don't replace clinical decision making and they certainly don't cover every eventuality. Use them, just don't do so without thinking.

An issue it's also worth talking about is the difference between clinically significant and statistically significant. Statistical significance in most medical (and other) science) is usually taken to mean p <0.05. This means that there is less than a 1 in 20 chance that the result occurred by chance; in other words, it's likely that any difference in outcome between groups was down to differences in intervention rather than just being coincidental. Statistical significance is important because it's how we know that our interventions have actually done something. However, this has no reflection on whether the difference in outcome will make any kind of difference to a patients health, well being or long-term risks. This is another important thing to bear in mind before advising or prescribing an intervention based on evidence; will the outcome matter to my patient? An example where this becomes important is when thinking about statins, a group of drugs which lower cholesterol. There is good evidence that (a particular group of) patients who take statins are significantly less likely to suffer a stroke or heart attack within 20 years than those who don't. This sounds great, but if you have an octogenarian sat in front of you, does this really matter? They are unlikely to live another 20 years, so is it worth adding to their drug burden, with all the risks of side effects and drug interactions this brings? I'm not saying don't, just that you should be realistic about what the benefits of this will be to your patient. Maybe discuss the risks and benefits with them and see what they think.

There are other important factors to think about too when looking at a paper/trial/study. Rather than go through all of them, it makes more sense to hand over to the experts at this point. There are really useful study appraisal checklists available on the CASP (Critical Appraisal Skills Programme) website, which guide you through the things you should ask yourself when you're considering the value of a piece of research.

I've hopefully discussed the main issues that occur when trying to implement evidence. In my next post, I plan to talk more about what we actually mean by "evidence" and how we can decide whether one piece of evidence is more or less worth using than another.

Why We Need Evidence in Medicine

I’m a self-confessed geek. I like learning. I like working things out. I like science. I did a science degree before going to medical school and I spend my spare time on such fun activities as post graduate certificates and systematic reviews. This doesn’t mean that I think of medicine as a science – I think there is definitely an art to lots of what I do – but I do think that it’s important for doctors to have a good understanding of scientific methodology so that they can interpret the vast amount of evidence they are presented with when making clinical decisions.

This is the first in a series of posts about evidence-based medicine. It's deliberately simplistic so that those outside of the medical field can understand it, but I hope it doesn't come across as patronising. The premise of this post is to explain why we need evidence in medicine. In later posts, I'll go on to talk about what constitutes evidence, problems we face in evidence-based medicine and ways in which we can use it to benefit patients.

I’ve heard numerous colleagues tell me that they “aren’t convinced by this evidence based medicine lark”. Their arguments usually centre around the fact that they have seen interventions work before and therefore are happy to use them again. On the surface, this is a reasonable argument. Someone is poorly. You give them some tablets. They get better. Next time you see someone who is poorly in the same way, you give them the same tablets. They get better too. The problem is, how do you know that they wouldn’t have got better anyway?

Let’s take a common example – a cold. If you have a cold and you take a course of antibiotics, you’ll probably feel better within 2-3 days. However, if you don’t take the antibiotics, you’ll also feel better in the same amount of time. That’s just how long it takes for a cold to get better, but if you gave every patient with a cold some antibiotics, you’d be forgiven for thinking you had found an excellent treatment. Observations like this are very useful in medicine. They’re the basis of a lot of important discoveries. They just aren’t the be all and end all.

So, how do you work out whether your treatment actually makes a difference? This is where trials come in. In very simple terms, if you want to know whether or not your treatment works, you need to randomly give it to half the people you see with a particular condition and not give it to the other half. If the half who get the treatment get better more quickly than those who don’t, that’s a good indicator that your treatment probably does make a difference. Of course it’s more complicated than that, but that’s the basic premise.

You might ask why I really care about evidence at this stage. After all, in the examples I’ve been giving, the patients all get better. There are two issues that we need to address here. The first one is side effects. No medication is risk free, so before choosing to give it to your patient, you want to be comfortable that the benefits of using it outweigh the risks. If you’d stopped at the first, observational stage, you wouldn’t know that your treatment didn’t offer any benefit over not treating, so you’d be subjecting all your patients to the risk of a treatment that might not actually make them any better. Remember, “first, do no harm”.

The next issue is about multiple treatment options. What happens when two people think their treatment works? We owe it to our patients to give them the best possible treatment, so we need to use trials and evidence to work out which option is “best”. This needs to take into account multiple factors, such as which treatments make more people better, which ones get people better more quickly and which ones have fewest side effects.

This has been a very brief run-down of why we need evidence. Without proper trials etc, we are left guessing whether or not things work and which things work best, and who wants medicine based on guess-work?

Survival Tips For Medical Students

Tonight I noticed a tweet asking for top self-care tips for medical students, and (unsurprisingly) I felt I had too much to say to fit it into 140 characters, so I thought it might be worth a blogpost. Being a medical student is an amazing experience, but it can also be incredibly difficult for lots of reasons. This post isn't supposed to be in any way comprehensive. I'm not an expert, by any stretch. This is just a collection of suggestions and ideas based upon my own experiences and those of people I know.

Work hard.
Medicine is hard work. Most of it isn't intellectually particularly stretching, but there's a vast amount of stuff to learn and the majority of people will have to do a reasonable amount of work to keep on top of it. I'm not advocating becoming a hermit, but going to most of your lectures, showing up on the wards and keeping up with reading will mean exam season is far less stressful. If you have to actually learn everything from scratch, rather than just revise it, you'll be giving yourself a far more difficult task than is necessary.

Play hard.
It's also important to make the most of being a student. Go to toga parties. Play pub golf. Go clubbing whilst dressed as a giant chocolate bar or do garlic and chili body shots from the Med Soc president. Or don't, if you'd rather not. But don't feel like doing an academically demanding degree means you have to  miss out on the student experience. A boss of mine once said "you can resit an exam, but you can't resit a party". I'm not sure that's the most sensible advice, but find a balance that makes you happy. Whether it's partying, music/sports/drama societies, volunteering or just reading novels and watching trashy TV, doing fun stuff is important. Keeping up with friends and enjoying yourself is an essential way of dealing with the stress you will feel from time to time. Speaking of friends, they're really important. Make sure you keep up with those outside of your course, too. Non-medics are brilliant for allowing you to properly relax and giving you a sense of perspective (medic friends are great and can relate to a lot of what you've experienced, but have an awful habit of talking shop so you don't truly escape medicine around them).

But don't forget to sleep.
Seriously, sleep is really important. When you're trying to balance partying and studying, sleep can seem like something you don't have time for, but it's essential. Everything seems worse when you haven't been sleeping well. As a medical student, you've embarked on a pretty awesome journey, but you need to be on top of your game to make the most of it.

Eat well.
OK, so it's boring, but it's another essential. If you're spending long days in lectures and then going out drinking, it can be tempting to sustain yourself on Pot Noodles and Red Bull, but there's no way you'll be at your best if you aren't getting a decent amount of vitamins, minerals, fibre etc. Sorry guys, your Mum is right about this one.

Exercise.
Similar to the above, exercise is useful for both keeping you physically at your peak and helping beat stress. As a naturally lazy person who would rather exercise by lifting a spoon from ice cream tub to mouth than go anywhere near a gym, I totally get that this is not top of some people's agendas, but it's amazing how much more energy you have after a swim or run. Even a brisk walk around the block is better than nothing.

Cry.
Sometimes you will see things that really resonate with you and upset you. This is absolutely OK. Allow yourself to be upset. Talk to a friend. Have a cry. I still get upset about cases from years ago (such as this one), Remember that if there ever comes a time when sad things don't bother you in the slightest, you probably want to think about a change of career.

Take a break.
OK, so this might go a little against what I said earlier about working hard, but it's important. Sometimes, things will get on top of you (see previous point). You might be unwell. You will have stressors in your life outside of medicine. If you're struggling, give yourself permission to take a sick day. There's no point dragging yourself in when you aren't going to be properly concentrating. Doctors are absolutely terrible for going into work when they're unwell. It does noone any favours. Learn now to spot when you aren't well and sort it out early. Even if you're cruising along fine, don't spend more time working than you have to. If your registrar says you can leave early, do. Don't spend the holidays in the library. Having time off is vital to your emotional and physical well being.

Don't let the b*st*rds grind you down.
There are horrible people everywhere. Some of them will be in your year, some will be your seniors, some will be non-medical colleagues. Giving you a dressing down if you're rude or you really don't know your stuff is fine, but nobody should be bullying you. If they are, report it. Snide remarks, sniggering behind your back, deliberately telling you lies about teaching sessions or criticising your appearance or personality is not acceptable. People who do this are, frankly, arseholes. They're probably covering up their own insecurities by pointing out yours. They may well be jealous of how awesome you are. Either way, it's not cool. Don't let it get to you. (But if you're actually being bullied, tell someone. There is help to stop this kind of thing from happening.)

Be the best you you can, not a second-rate someone else.
This is more general life advice I suppose, but in medical school where you're surrounded by brilliant people it's easy to constantly compare yourself to other people. Try not to. The people who may seem the best at uni are not necessarily the ones who make the best doctors. Focus on your weaknesses, by all means, and work on improving them, but don't assume that anyone who really understands the kidneys or can do a super-slick neuro exam is better than you at everything. Maybe you have a really lovely manner with confused old ladies or perhaps you know intricate details of the coagulation cascade. Whatever it is, you'll have something you're awesome at too. Remember what it is you do well, feel proud of it, and work on improving other stuff so that you become the best doctor you can be, not so that you can beat someone else in an exam.

That's a very brief run-down, but those would be my top "survival" tips. Most of all, remember to enjoy it. You're on your way to doing the best job in the world, and you're going to be awesome at it.

The Drugs Don't Work, They Just Make You Worse

From time to time, I find myself "borrowing" song lyrics to title my posts. This is in part because I'm not hugely creative and partly because I'm usually listening to music of some sort whilst I'm writing, but mostly because if someone else has said it well before, then there's little chance of me saying it better.

Trying to describe how depression feels is almost impossible. Years and years ago, when I'd never met anyone else who had depression in "real life" and my support network was almost entirely a (sadly long-gone) forum, we used to tell each other "for those who understand,  no explanation is necessary; for those who don't, none will suffice". It's cliched and horribly over-used, but there was an element of comfort in realising that you'd probably never fully make other people understand how you felt, so you were as well saving your energy and not bothering. One particular thread, however, which I recall over a decade later, was entitled "The Sounds of Depression". I don't recall exactly how it started, but we started to share song lyrics (as well as other literary sources) which summed up our feelings. We were unable to express exactly how we felt, but many of our musical heroes did a fine job of it. Years after I first heard them, I find some songs are still better able to describe my feelings than any words I could write. Tonight, I'm thinking of The Verve.

"All this talk of getting old
It's getting me down, my love
Like a cat in a bag, waiting to drown
This time I'm coming down"

Some days, this is exactly what it's like. You fumble through your existence, not ever being entirely sure what the point is. The inevitable drowning that you feel sure awaits means that attempting anything seems like a waste of effort. You won't be able to get out of the bag that encloses you, so maybe it'd just be easier to succumb. Settle down, drift off to sleep and let yourself gradually suffocate. The eventual result will be the same, only with less pain in the meantime.

It's no coincidence that, as well as summing up how I sometimes feel, these lyrics are from a song called "The Drugs Don't Work". Yesterday, I read a very well-written piece by the lovely @katiehodgie about cognitive behaviour therapy and how it doesn't always work, which got me thinking about my experiences of treatment.

I've mentioned this sort of thing in the past, but in different contexts. I described my first contact with mental health services in my post on adolescent mental health. If you happened to read (or hear) the grand round I gave on the same topic, you may recognise it. That's because it was copied and pasted directly from that blog. "Suzie" was, of course, me. I don't mind if people who heard the talk guessed, but I didn't want to just stand and talk about myself openly because it felt somewhat indulgent, and may have detracted from the fact that I wanted to emphasise the importance of understanding mental health for all of our current and future patients, not just myself.

You can see that my first experiences of the psychiatric team were less than ideal. Over the many years which have passed since that appointment, I have had numerous other attempts at treatment. The list of medications I've tried resembles the formulary of a major psychiatric unit. I went for CBT and tried seeing a psychologist. I've met several psychiatrists. Despite all of this, and despite being a qualified doctor, it sometimes takes me by surprise when I remember that depression is a chronic problem. I have to remind myself, and other people, that I might dip again. It's a bit of an apology and a bit of a warning, summed up by John Mayer.

"Suppose I said
I am on my best behaviour
And there are times
I lose my worried mind
Would you want me when I'm not myself?
Wait it out while I am someone else?"

I'm never sure when the best time is to explain that I may be "not myself" for a while. Does it put people off getting to know me? Possibly. Are some people none-the-less shocked by it and unable to cope with it? Absolutely. I think this experience of negativity is one of the reasons I find myself wanting depression to be a transient phenomenon. The idea that friends won't have to "wait it out" again is appealing. Sometimes, I even believe it will happen.

When I am in a "good" phase, I convince myself it was something that happened once before, but something I am now over; a dreadful nightmare from which I have thankfully awoken. When I'm at my lowest, I am like the aforementioned cat, trapped and suffocating in a bin liner wondering when the water will finally wash over and take it all away. But there is a middle ground. The days when I first suspect it might be back. The mornings I wake inexplicably early, feeling anxious about nothing in particular. The evenings I cannot focus on whatever book I try to read. The afternoons where I suddenly feel like going out with my friends later is an insurmountable task. These are the times when I start thinking there might be an answer. Maybe another pill. Perhaps a different kind of talking therapy. Eating better, exercising more, filling my time with positive things. Maybe, this time, it will stop. Sarah McLachlan explained it pretty well.

"Spend all your time waiting
For that second chance
For a break that would make it OK"

I wonder, during these days, what it will be that makes it OK. I live in a kind of limbo, hoping that eventually I'll find and answer. Someone, somewhere will snap their fingers and it will all be OK.

In my case, the drugs do work, at least a little. The appropriate dose does mean that my eating is under better control. I have fewer binges and feel less compelled to consume everything in sight. Although I have dips, it's a long time since I put myself in any real danger or tried to do myself any sort of major harm. So, they help a bit. The psychological therapies I've tried have given me a better understanding of myself and some of my quirks, but haven't really enabled me to deal with things in a different way or had much impact on how I live my life. I have no doubt that for some people, one or a combination of treatments will actually completely cure them. For most, though, I suspect things help a little, but never make it completely go away.

I sometimes feel like it would be easier if I never experienced the better days. There are times when I start to think happiness is a myth, that I will forever experience the world through a sort of grey fuzz. During these times, I start to accept the lowness. I forgive myself for having no energy and allow myself to wallow. I stop looking longingly at "normal" people and decide that's not how I'm supposed to be. I accept that a sort of ambivalence about whether I life or die isn't too bad.

And then there are the better days. I wake up as my alarm goes off, feeling like I've had enough rest. I genuinely enjoy the simple things - my morning cuppa, a sunny drive to work, chatting to an old friend. The fog seems to have lifted. I put the bad days behind me and get on with living. And then, out of nowhere, the black dog comes again. Happening at times when I can so vividly recall normality makes it all the worse; the sheer contrast with the way things have been is brutal. I'm stealing more lyrics now, this time from James.

"Now I've swung back down again
It's worse than it was before
If I hadn't seen such riches
I could live with being poor"

This is sometimes the worst thing of all. Those good days are reminders of what I'm missing. Without them, I could almost settle into the grey and accept things. It's those good days that make me wish for a magic wand, some kind of switch to make it all go away. Of course I don't wish I didn't have good days, but sometimes I think it would all be much easier not to be reminded that there's an alternative existence out there.

If you happen to meet me on a grey day, you may not notice. But if you do, if I seem distant or like I'm not listening, or if I make excuses not to meet you, please don't take it personally. Bear with me. I'll have another good day eventually. Matchbox 20 explain it better than I do.

"I'm not crazy, I'm just a little unwell
I know right now you can't tell
But stay awhile and maybe then you'll see
A different side of me"

Skinny Minnies

I've blogged in the past about eating disorders, both my own experiences and my thoughts as a doctor. I don't claim to be an expert at all, but from a combination of personal experiences, talking to friends and acquaintances who have had similar difficulties and encountering many patients with eating disorders at work, I've built up my own ideas about eating disorders and have also tried to read around the area to expand my understanding.

I make no apology for the fact that the forthcoming post may be a bit angry and ranty. I'm cross, and it was my annoyance and crossness which lead me to write. On reading it, I also appear to have used an awful lot of brackets. For that, you can have a bit of an apology I suppose (but only a bit).

A few days ago, I was casually scrolling through my timeline on a well-known social media site, when I saw a post which an acquaintance of mine had apparently showed some kind of appreciation for. The headline was "These 12 Anorexic Girls Look Stunning After Beating Their Condition". This annoys me for several reasons. Firstly, "desperately sick people look much better when they aren't ill anymore" is stating the obvious and is yet another reflection of (modern? Or has humankind always been so inclined?) society's obsession with appearance. Secondly, and more importantly, it demonstrates and perpetuates a deep and serious misunderstanding of what eating disorders are. Pictures of terribly sick, skeletally thin young women next to pictures of them looking healthier with captions like "no woman should ever be as thin as she was in the first picture, she looks much better with some weight on her" show just how flawed a perception many people have of eating disorders. I also find the use of the term "beating" to describe recovering from an illness unhelpful, but I'll elaborate on that in a separate post.

Would people write an article entitled "This Girl Who Had Cancer Looks Great Now She's Off Chemo"? How about "Man With End-Stage Liver Disease Looks Gorgeous Post Transplant"? Or "Check Out How Fit These Ladies Are Now They're No Longer In ICU With Overwhelming Sepsis"? I like to think not, unless the people in question were celebrities, in which case no doubt the first thing we're supposed to noticed when someone's been incredibly ill is whether their weight has changed or if they've got the energy to still do their hair nicely. But I digress.

What upset me most about this articles was that it perpetuates the myth that eating disorders are solely about how people look. The premise of the article appears to be "overly skinny is not hot". Now, whilst I have no problem with promoting a range of body shapes as attractive (although frankly I do wish we could all shut up about appearance), the suggestion that people (not just girls - they affect both genders and all ages) with eating disorders are driven purely by a desire to be as thin as possible is just wrong. Eating disorders are complex. Patients with eating disorders are diverse. Trying to suggest that all eating disorders occur because a person wants to be skinny is as wrong and as damaging as suggesting that all cancers are caused by excessive alcohol intake - both illnesses occur due to a variety of factors. In some cases, one of those factors may be a desire for thinness/excessive alcohol consumption, but this is only one of a number of elements which co-exist and allow the disease to develop. In some patients, this factor will be completely absent.

Now feels like a good opportunity to link to a post my lovely friend Jo wrote about her experiences of an eating disorder. Another helpful post is this one, from the website of Mind - a mental health charity. Their website has some useful information on eating disorders which may help anyone who either has an eating disorder or is supporting a friend or family member with one. As all these links stress, eating disorders are often about control and dealing with difficult situations and not just a vain desire to look thin.

This blog is explicitly about eating disorders, but more generally it's about the lack of parity of esteem between "physical" and "mental" health conditions. I use the inverted commas because personally I believe the terms create a false dichotomy. Physical conditions may well be worsened by emotions - we all know people who get more migraines when the pressure piles up, and there's now evidence that adverse events during childhood may play a role in the development of diabetes. The way our feelings and emotions affect our health is something we are only just beginning to understand. In the meantime, if we could all aim to be a bit more understanding and not jump to conclusions about people just because they have a particular diagnosis, the world may well be a brighter place. And if you're writing a headline about a "mental" illness, think about how it would look if you replaced it with a "physical" one. If it sounds voyeuristic, shocking or offensive, chances are you're best not using it.

P.S. I googled  "These 12 Girls With Cancer Look Stunning After Beating Their Condition". Surprisingly, noone's written that article.

Mad, Sad, Bad....

I recently gave a departmental grand round (i.e. a talk open to all members of the paediatric department where I work) on adolescent mental health. Various people have been keen to hear/see what I had to say, so I've posted a slightly edited version below.

It wasn't intended to be a comprehensive discussion of mental health issues by any stretch, but I wanted to at least mention some of the more common issues we encounter as paediatricians. Obviously every topic I spoke about is worthy of a talk in its own right, but hopefully this will have made people think a little bit and generated some useful discussion.

***Trigger warning*** Discussion of self harm, suicide and eating disorders.

"When I was first asked to give this talk, I had two reservations. The first - would anyone want to hear a grand round from such a junior member of the team? That was dealt with pretty swiftly, with assurances that training level didn’t matter so long as content was good. Hopefully that’s something I can achieve. The second, however, was more of an issue. Would people actually want to listen to a talk on adolescent mental health? The answer to that was less positive. In fact, it was a resounding “no”. And I think that's part of the problem, and it's exactly why I decided I should give this talk.

 

Imagine you're in your usual clinical environment, be that A&E, clinic, the assessment unit, general practice... You're examining a patient, and you find this...
 

 

How do you feel about your patient now? Don't focus on what you think the differential is, think about your reactions and feelings towards this patient. Are they wasting your time? Are you less inclined to take their other complaints seriously? Are they an attention seeker? This may sound dramatic, but we're all guilty at times of responding negatively towards issues such as deliberate self harm.

 

There are lots of different ways in which I could represent the distress caused by mental illness, but I think one of the most effective is to share the story of a young person I've been involved with, including some of her quotes.

Suzie is 15. She presents to her GP after being encouraged to attend by her form tutor. The consultation is difficult. After some encouragement, she says that has been experiencing low mood for the past 3 years. She does not feel she has any friends. She feels that she is unattractive and is not achieving at school. Her eye contact is poor and she has a blunted affect. On examination, she appears well. Some superficial lacerations are noted over her thighs and forearms.

This encounter is one Suzie still feels uncomfortable about. “I was pretty cross that I’d been made to see a doctor. It’s hard enough for people to get appointments without me taking them up. I actually felt quite guilty about using a slot which could have been given to someone who was actually ill. I was also really worried about admitting I cut myself. It seemed like people felt that that was something done for attention, so I wanted to hide it as much as I could; I didn’t want to be seen as an attention-seeker when actually I just did it to try to feel better.”

Suzie is referred to CAMHS, who commence an SSRI and offer CBT, which she declines.

Suzie vividly recalls her CAMHS appointment. “I was 15 and it was the Christmas holidays. The department was located in an old, probably Victorian, terraced house which hadn't been particularly well renovated. The room I was seen in was freezing. There were two people seeing me; a middle aged lady who was a social worker and a younger man who introduced himself as a "trainee doctor" - I suspect that he was a psychiatry registrar but at the time I was pretty convinced he was a medical student. They sat behind a desk for the whole consultation and the seats for us (my parents were with me) were a good few metres away from them. There was also a little window at the top of the wall where someone else was apparently watching what was going on. On the wall were several posters about how to deal with your child's difficult behaviour and advising against smacking. There were toys all over the floor.

My first impression was that they thought I was a child (which of course I was, at least legally, but what 15 year old doesn't think they're incredibly grown up?). I don't recall much of the discussion we had. I remember them repeatedly asking whether I'd ever been abused, and then later taking great delight in asking my parents to leave the room so that they could ask me again. Actually I only wanted my parents out of the room because I knew they'd be upset if they knew the extent of my depression, but the doctor and social worker seemed pretty desperate to uncover some horrific trauma which must have caused my problems.

I didn't go back after that first appointment. They put me on fluoxetine. They also wanted me to have CBT but I declined. In retrospect, I probably should have gone for it, but at the time the only time I could cope with being "mental" was to tell myself and everyone else around me that it was due to "a chemical imbalance in my brain". Taking medication to correct this was fine. To have CBT would have been admitting that my thinking was fundamentally flawed and that it was therefore some weakness of character resulting in my problems and not a "proper" illness. Of course I know now that that isn't true, but the explanation I got was such that that was what I believed at the time.”

Shortly after commencing treatment, Suzie attempts suicide by taking 64 paracetamol tablets.

Even now, Suzie finds it difficult to articulate exactly why she tried to end her life. “I was fed up of everything. Nothing I did seemed to have any point. I didn’t think I’d ever achieve anything. I saw how unhappy my Mum was, knowing I felt like this, and that made me feel incredibly guilty. I was sure I was making my whole family miserable and that without me there, they’d all be better off. I could just about believe that they might be initially upset if I died, but I really felt that they’d get over that and be far happier than they could with me around. I wanted to stop feeling miserable and I wanted to stop dragging other people down with me.”

Suzie recovers from her suicide attempt with no residual physical effects. She continues to self-harm by cutting herself with razor blades. In addition, she begins to struggle with food, going through periods of severe restriction followed by binges. She often induces vomiting and abuses laxatives.

Although diagnosed with bulimia, Suzie feels that her eating behaviour was closely linked with her mood. “Food made me feel better when not a lot else did, but after I'd stuffed myself senseless I'd feel so guilty and dirty that I'd have to make myself vomit... Some days, I just didn’t feel like I’d possibly emptied my stomach, so I started taking laxatives too. I knew it was dangerous but I didn’t care. I felt that I’d rather die than put weight on. Sometimes, after a purge, I didn’t feel the need to cut myself as much. It was like the vomiting was a kind of release, in the way that cutting was.”

Although all cases are very different, this is a fairly typical case. But so what?

What does this matter? What's the impact of self harm? Well, there is evidence to suggest that in young people like Suzie, who self-harm, risk of premature death is considerably higher than in the general population. Whilst, unsurprisingly, risk of completed suicide is up to 25 times higher than those who don’t self-harm, risk of accidental death is seven times and death from natural causes twice as high as the general population. Mean years of life lost was over 25 for both males and females (Bergen et al., Lancet 2012). Self-harm is also associated with poorer educational and employment outcomes, increased risk of mental health problems and increased risk of substance misuse in later life (Mars et al., BMJ 2014). The UK has one of the highest rates of self-harm in Europe (at

400 episodes per 100 000 population) (Hawton et al, Lancet 2012)

So what can we do about it? How can it be treated? Although self-harm within itself is not a diagnosis, the majority of young people who self harm will have an affective disorder, most commonly depression, although anxiety, eating disorders and psychotic disorders such as schizophrenia may also occur. The only licensed anti-depressant for under 18s is fluoxetine. Paroxetine (Seroxat) in particular has been linked with increased risk of self-harm and suicide after initiation of therapy, but there is some risk with all anti-depressants. There are multiple theories as to why this is, but it may be to do with returning energy levels and drive once treatment is commenced. It's therefore important to ensure that any young person commenced on anti-depressant therapy have regular follow-up and support. The evidence base for any therapy is limited, although psychological therapies are being increasingly developed and investigated.The current recommendation is that moderate-severe depression is treated with a combination of an SSRI and CBT, although resources mean that this isn't always available.

There are a number of reasons why people attempt suicide. Life stressors, such as financial worries and relationship breakdowns are particularly common precipitators, as are psychiatric symptoms. However, many people who attempt suicide do not realise that their symptoms are due to an illness (Lim et al., Journal of Affective Disorders, 2014). This is important because it means that the first time people present to medical services will be with a suicide attempt. They often won't seek help for their underlying psychiatric symptoms because they don't realise they have an illness which can be treated. Over 10% of young people experience suicidal ideation and around 4% will attempt suicide at some point before the age of 25. Suicide is the third commonest cause of death in 10-24 year olds. Suicide attempts are more common in girls and those with a diagnosis of depression (Grudnikoff et al., European Journal of Child and Adolescent Psychiatry, 2014). 

Eating disorders are a huge topic and obviously worthy of a whole talk within themselves. However, I felt it was worth mentioning them because they commonly co-exist with affective disorders. One study found that 18.5% of patients referred for anxiety or depression had problematic eating, with 7.3% met the diagnostic criteria for an eating disorder, with those who were younger, female and having a history of self-harm most likely to be affected (Fursland and Watson, Eating Disorders, 2013). It's therefore important that we are know to look out for these things, because anorexia nervosa in particular has a high mortality rate.

So, what can we do about this? Well, they key is to listen. A recent report published by the Royal College of Psychiatrists, and endorsed by our royal college, the RCPCH, suggests that simply listening and taking a sensitive history has therapeutic benefit. Groups such as Cello and Young Minds, who do a lot of work with young people affected by these issues, find again and again that doctors do not feel comfortable dealing with mental health issues in young people. They do not feel they have the necessary skills to help and they don't know what they're supposed to do. However, the evidence shows that actually, something as simple as just talking about the issue in a sensitive way helps. We all have the skills to take an history and listen to someone. It isn't difficult or complicated, yet it helps to reinforce a positive image of healthcare services in a young person's mind and means they are more likely to engage with services in the future.

That's been a brief overview of adolescent mental health issues. Hopefully it's made you think about how you might deal with these issues, and reinforced that all of us have skills which will help us to deal with them.



I don't usually put references at the end of blogs, but in case anyone is interested, these are some of the papers I read whilst I was preparing this talk.

BERGEN, H., HAWTON, K., WATERS, K., NESS, J., COOPER, J., STEEG, S. and KAPUR, N., 2012. Premature death after self-harm: A multicentre cohort study. The Lancet, 380(9853), pp. 1568-1574.

CELLO, YOUNG MINDS, 2012. Talking Taboos: Talking Self Harm. Cello Group

FURSLAND, A. and WATSON, H.J., 2014. Eating disorders: A hidden phenomenon in outpatient mental health? International Journal of Eating Disorders, 47(4), pp. 422-425.

GRUDNIKOFF, E., SOTO, E.C., FREDERICKSON, A., BIRNBAUM, M.L., SAITO, E., DICKER, R., KANE, J.M. and CORRELL, C.U., 2014. Suicidality and hospitalization as cause and outcome of pediatric psychiatric emergency room visits. European Child and Adolescent Psychiatry, .

HAWTON, K., SAUNDERS, K.E.A. and O'CONNOR, R.C., 2012. Self-harm and suicide in adolescents. The Lancet, 379(9834), pp. 2373-2382.

LIM, M., KIM, S.-., NAM, Y.-., MOON, E., YU, J., LEE, S., CHANG, J.S., JHOO, J.-., CHA, B., CHOI, J.-., AHN, Y.M., HA, K., KIM, J., JEON, H.J. and PARK, J.-., 2014. Reasons for desiring death: Examining causative factors of suicide attempters treated in emergency rooms in Korea. Journal of affective disorders, 168, pp. 349-356.

MARS, B., HERON, J., CRANE, C., HAWTON, K., LEWIS, G., MACLEOD, J., TILLING, K. and GUNNELL, D., 2014. Clinical and social outcomes of adolescent self harm: Population based birth cohort study. BMJ (Online), 349.

ROYAL COLLEGE Of PSYCHIATRISTS, 2014).Managing Deliberate Self-Harm in Young People (College Report CR 194). Royal College of Psychiatrists