My name is Ross Dunne and I have the best job in medicine. I am a consultant psychiatrist for the over 65s working in one of the most diverse and disadvantaged areas of Britain – North West Manchester. I care for both inpatients and outpatients, and I deal with a range of illnesses including the “bread and butter” of psychiatry like depression and schizophrenia, but also dementia. The demands of these two aspects of the job are wildly different. This range of illness stretches my expertise from neurological examination to cross-cultural communication, from breaking bad news to the intricacies of psychopharmacology, and everything else in between.
Wednesday morning means home visits. This morning I was invited into the home of an Asian lady who has suffered a manic episode and needed to be admitted to our inpatient unit a few months ago. She recovered well and went home to her family. Now, as is so common in bipolar disorder, she has become profoundly depressed. When I last saw her, she was in despair. She was rocking in her chair, wringing her hands and chanting Qu’uranic suras alternating with obscure Punjabi phrases under her breath. Her son translated some of her utterances, which turned out to be iterations of and variations on “I’m so bad – I cannot help it, I am no good”. I was reminded that whether one is from the sleepiest corner of Rawalpindi, or darkest Kent, the depths of psychic pain are often extraordinarily similar.
Now, although better, she still feels hopelessness and distress, agitation and despair, not mere sadness. Thanks to an attentive extended family, this lady is still eating and drinking, and she is taking her prescribed medication, which has been having some effect since this episode started 4 weeks ago. She is less distressed, but still not rising from bed. Her recovery has been a slow road for her, for her family, and frankly, for me too. I have seen her every week, supervising increasing lithium doses and checking blood-levels, ferreting out written information in Urdu and weighing inpatient versus outpatient treatment. She does not want to come back to the hospital. I can understand this – nobody speaks her first language; the food is different – it is an alien environment even for white Britons at the best of times.
Her family suggest electroconvulsive therapy, which has worked for her in the past. We talked about this before. She, looking hopefully at me, nods her agreement. We discuss what outpatient treatment would mean. She would have to come to the hospital twice a week, have a cannula placed in her arm and be given a muscle relaxant and a general anaesthetic. She would be asleep for 3-4 minutes while a small, measured amount of charge was applied to her brain. This would be only just enough to cause a generalised seizure, but because of the muscle relaxant, she would not thrash like in the films, merely twitch a little. Enough for us to know it was working. The EEG seizure would last about 30 seconds, and then she’d gradually wake up. When her vitals were all normal she could go home in the company of her family. She might need six treatments as before, but at the end she is 90% likely to be remitted – to have no symptoms at all.
My job is a privilege. My job is different. I have to think about the whole human being – I think of stroke risk factors, falls risk, bone protection, and all of the other problems that beset the elderly. I think about language and culture. I think about biology, psychology and the social aspects of life.
I struggle daily against societal norms that pretend the elderly don’t exist. And, in spite of all that, I haven’t forgotten my medicine – I flex those mental muscles every day and I need to know the latest NICE guidance on hypertension as well as that on dementia. In the future, my job will be even more amazing – new drugs are in the pipeline for dementia; we have begun talking to rheumatologists – who do such magic routinely – about how to run “biologics” clinics for administering potentially curative anti-dementia antibodies; cures for dementia are around the corner.
I believe it will be my privilege to watch dementia emerge from the deafening silence that surrounds it to be one of the great success stories of 21st century medicine.
I have the best job in medicine. You might want to think about it as a career. If you do, take a look at the website of the Royal College of Psychiatrists, or drop me an email at firstname.lastname@example.org. You could sit in on a few clinics or try to arrange an elective. Whatever you do, if you have a curious mind, I promise you, you won’t ever be bored.
Dr Ross Dunne