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Thursday, October 20, 2016

Making of a Child Psychiatrist: (53) Moving towards General Practice (2)

My last day of working at King’s was 20th September 1969, and we were due to move into the flat at Margate General in mid October ready for me to begin work.  Our little East Dulwich first family home had to go back on the market to make us a small profit and pay off the bank. The in between was a flurry of activity, sorting furniture and transporting it down to Kent in a van driven by my brother in law Jim, husband to Jan’s older sister Wendy. Luckily the summer seasons at Kingsmead were over, and Jan’s father had begun to convert the hotel into apartments. So there was temporary storage space for our belongings as well as us. I know that Jan’s parents, having always been family oriented people, were utterly delighted we were moving to Kent and would be living and working just up the road. Jan was delighted to be coming home, even though she had been forced to give up her job with all the respect it gave her as a professional. We created upheaval, but nobody seemed to mind. I guess that is the wonderful thing about family life.
We also had some family news. Jan had missed several periods, and was certain she was pregnant, with our new family member due in early April. So everything was new and full of promise. We no longer had a house to call our own, but that could be organised during my time at Margate.
One of four in the block, our ground floor flat was functional, sparsely furnished in a simple utilitarian way, and it had its own small fenced garden and a car park.  Jan did not enjoy it. Perhaps it was not ever to be a part of ‘us’. She was pregnant, and it was too empty and clinical to ‘nest’. Unfortunately there was also a constant smell of curry permeating the entrance hall and our flat. Both Jan and I love a good curry from time to time, but the couple of doctors upstairs were from Pakistan, and so curry seemed to be on the menu every day. Add in Jan’s pregnant state, a hyperawareness of smell, and my absence during working hours, and she preferred to be elsewhere. The problem was that she did not yet drive confidently and independently, so she had to catch the bus into Westgate to be with her parents or with an Auntie Kate, who was to be very supportive over many years.
The entrance to Maternity was a short 100 metres away from the flat. So I was able to get back to the flat for lunch when Jan was there, and was also home early after work, even if it was a bit too convenient for staff in need of a doctor urgently – even when I was not on call.
The Director of Obstetrics was Dr. Jean Burton-Brown (‘Miss Burton-Brown’, as she was known), who came from an august family of eminent surgeons who had served England and the Empire over generations, with a great grandfather in the Bengal Medical Service, a grandfather who was a Brigade Surgeon in the army, and a father who had been a surgeon in the navy. She had qualified somewhat late at the age of 32 and been a doctor during the London Blitz, gaining her membership of the College of Obstetricians and Gynaecologists in 1944.
She had an immense reputation for her gynaecological and obstetric work in Kent where, for over 20 years, she had developed the services against the odds, and overseen the building of the Maternity unit. She was highly esteemed by nursing staff who were certain she would always be there to back them up. But I suspect that when I joined the staff in 1970 (when she was only three years away from retirement), she had had her fill of jumped up young men who knew very little. She had high expectations, could be dictatorial if you did not listen, did not follow protocol or were a bit uppity. She could be scathing, and in the early days I came in for several dressings down when I had not completed a task to her liking or to her standards. I learned rapidly to toe the line. Luckily, given my experiences in Plymouth and at King’s, in the day to day business I was always ready to learn from nursing staff, and not embarrassed to get something checked out. I was also happy to refresh my obstetric knowledge through my ever present Brudenell textbook. Given my past experience of surgery, I don’t know how I would have managed as her Gynaecology house officer. But, Obstetrics is almost always a happy process with positive outcomes, despite occasional human interference. So although there were clinical panics from time to time, the staff were a happy constructive lot, and the 6 months from the work point of view passed very happily.
In retrospect, and although I would not have been conscious of it at the time, I am certain that my psychiatric experiences played a role. Most births are not traumatic in a long term sense, but if things begin to go wrong, the possibility of lifelong trauma is a serious issue. I knew that people survived trauma much better if their anxieties could be soothed. So there were several pregnancies that just did not want to go into full-blown labour, despite hours of waiting and special drips. Sitting, listening to life stories, soothing anxieties and keeping a positive demeanour certainly did no harm, even if you could not measure the good. Sitting with, and listening to, anxious or angry husbands who were demanding action where none was appropriate, seemed to help everyone. It was a form of abreaction without the use of Ether or intravenous injections. I was often threatened with violence because I was somehow seen as responsible for a circumstance. “You’re the doctor; you should be doing something!” But although there had been stories bandied about, violence to person or property did not occur during my time.
I found myself having the most ordinary of conversations while masked and begowned, completing necessary sutures. Similarly on two occasions, I had to complete manual removals of recalcitrant placentas. Here you are doing the most odd procedure, and listening to the most ordinary of discussions about the future plans for a woman and her new family.
I was never to be in charge of a caesarean section, given my youth and inexperience, but I was always happy to assist. In those days it was not a lifestyle choice, it was an emergency procedure to save the lives of both mother and child. They were such joyous occasions, and there was always that sense of having beaten the odds.
Our second child was due to be born in the maternity unit on 6th April. The issue was that if he was born prior to April the 5th, we would recoup a whole year of tax. So what, I hear you say. Never muck about with nature. Just let life take its own course. We discussed it again and again. We certainly could do with the money. The word from several of my midwife friends was that a dose of caster oil would create strong bowel movements, and that this in turn would prompt labour if Jan and the baby were ready. We decided to take the risk on 31st March, and with a mix of excitement and concern Jan swallowed her medicine.
Early the next morning, we both woke to an audible thump, and Jan had a strong urge to go to the toilet. Within minutes, there was a cry of need from the bathroom, and Jan announced she was in labour and frightened she would deliver down the toilet. We moved her step by step back to the bed and gathered her ‘ready’ bag. I raced across the tarmac into Maternity, grabbed a wheelchair, and charged back to the flat. We then raced back up the slight incline, through the doors and down to the delivery suite where our Roderick was born about 20 minutes later – our April Fool son, apparently no worse for his precipitate journey. So the whole labour was about 45 minutes from ‘thump’ to a newborn’s cry. I was so glad I was working in the unit, so glad we had a flat so close, and so grateful to the midwives at 6.15am on April 1st. I wished we had not challenged nature. There is always a cost to such manipulation.
Part of the cost was that Jan had a slight perineal tear, which may have been avoided if the skin had had time to stretch. I phoned Jan’s consultant, an older man usually very amiable. He refused pint blank to drive all the way from Canterbury at that time in the morning just to do a few stitches. Suggesting that I had had loads of experience and should do it myself, he put the phone down. I was appalled, and just could not bring myself to do something that I felt was not quite right. We organised one of the nursing staff with some prior experience and I supervised the process, still seething. Jan was to stay on the unit for the next 10 days, in part because that was the routine, but also because Rod became quite jaundiced after 2-3 days, and his bilirubin levels rose to the kind of levels the paediatrican thought might need transfusion. Luckily I had followed protocol and taken a sample of cord blood. So we were prepared. Jan was advised to give up the attempt to breast feed because there might be a sensitivity to breast milk. She had been so keen, and was deeply saddened and somewhat affronted. Rod stayed in neonatal intensive care for several days under bright lights, on a drip, and wearing eyeshades to protect his eyesight. He was to have food sensitivities throughout childhood.
There was a grand sense of closure to my six months, and Miss Burton-Brown took me aside about a week before I finished up. She actually thanked me and showed a faint smile; I have to say I was immensely grateful for her tutoring. However, she had to have the last word. I was going up to London the following day to do my Diploma in Obstetrics exams. I had been growing (what I thought of as) a very hip young man’s beard since my time in psychiatry (don’t all psychiatrists have beards?) She had told me on several occasions that beards were filthy things, harbouring germs likely to infect pregnant women and their newborns. She had never reached the point of demanding I remove it, but certainly had maintained the battle line. She told me forcibly that if I tried to do my Dip. Obst. with a beard, I would be failed. I asked her if she was serious, and she repeated herself, turned on her heel and stalked off. The following morning I shaved off the beard, but felt quite denuded throughout the journey. I attended the College, wrote the paper, had my oral examination, and that evening returned home feeling I had probably done fairly well. The following morning I began to re-grow my beard.

Wednesday, October 19, 2016

Making of a Child Psychiatrist: (52) Moving towards General Practice (1)

As I have mentioned before, I have an Uncle Tony, a younger brother to my father. He is a vague memory from my past as a small child about the age of 3-4yrs. He was studying psychology at St. Andrew’s University in Scotland, and spent some of his holiday time in Westgate staying in Cuthbert Road, visiting my mother in her isolation. He was a quiet and thoughtful man, with a dry sense of humour, obviously focused on his studies and the future. But I imagine there were stories that we were never to hear. He, like his brothers and his father had been in the RAF during the war. Tony had been a navigator in a Catalina flying boat. He has never talked about it during the few times we have met up over the years, but I imagine he was in grave danger much of the time and must have seen appalling sights. Flying boats were used in anti-submarine patrols, and had the ability to land on the sea to rescue downed airmen.
Tony used to go for what he called his ‘constitutional’ walk at about 3pm each afternoon, and would sometimes return with molluscs and other animalia found on the beach. I have a memory of him dissecting one of these on our kitchen sink wooden drainer in the small flat at Cuthbert Road. His response to my question about what he was doing, was an amused ‘”trying to find out how it all works”, and this must have been my introduction to dissection long before I did biology at school. How understanding molluscs was related to psychology, I have no idea; perhaps it was just a representation of scientific curiosity.
The only other memory from about that time is an episode when I fell into the toilet. I have no idea how long I had been using the big toilet, but there I was standing on the mat. As I finished, I leaned forwards to pull the chain, and the mat slipped from under me, sending me head first into the toilet in the process of being flushed. I must have made quite a noise, because both Tony and my mother were there to rescue me. I was dried off, changed and cuddled. Tony’s wry comment was: “Only Graham could fall down the toilet and come up smelling of violets.” I understand the joke went round the Martin family, and I was affectionately known on and off for several years as ‘Violets’. I quite like the name; it does represent what I feel overall about my life. I have been fortunate, and even when things have appeared to go seriously wrong, they do seem to come back to an even keel in the end.
Sadly, I was to see little of Tony even though I have felt a lifelong affinity, always wishing I could have more in the way of serious professional discussions. There was to be a small disaster the next time we met. Tony had emigrated to the United States many years ago, married and settled down with his family of three children in Connecticut. He was an organisational psychologist, and rose to prominence working for a large management consultancy company called Rohrer, Hibler and Replogle (RHR International), based in Illinois. Tony did well in the US, even writing a book on transformational change in management systems circa 1965 (sadly, I have not been able to find a copy).
We met up with him in 1967, when he was on a business trip. He was staying at the Hilton on Park Lane in London, and invited Jan and I for lunch. We met up and Tony took us up to the Roof Top Bar of the Hilton, where we sat and ordered pre lunch drinks. An obsequious waiter crept up behind Tony, saying: “I am sorry sir, the young man cannot be served drinks in the bar; he does not have a tie.” “Tony’s response was something like: “That’s fine, we will just sit here quietly.” To which the response was: “I am sorry sir, the young man cannot stay in the bar; he does not have a tie.” “Do you have a spare tie the young man can borrow?” “No. sir.” We left, perplexed and slightly huffy, and went elsewhere. Tony was not amused. We apologised, but he remained somewhat offended and distant; I guess we had embarrassed this rather formal and important man in public. Neither Jan nor I had given much thought to mode of dress, although I had (and still have) a number of formal ties. We were casually attired given it was a weekend; as I remember I was in grey slacks, a shirt and a light brown button up men’s cardigan. Despite our embarrassing Tony we did enjoy our discussion and, at the end of it, he invited us to stay with him and the family if we were ever in the United States.
The opportunity for us to travel did occur in 1969, when Jonathan was about 18 months old, and I was finishing my year in psychiatry. Early in our student lives, we had had contact with Jan’s cousin Michael who was studying science and mathematics at university. Mike’s father had worked for the Hoover Company, and his grandfather had been part of the team who developed the rubber tyre at Dunlop, so I guess science was in the blood. Sharing a grandfather, Jan and Mike had always felt a bond even though the families rarely got together. So it was always great to catch up a number of times with Michael and his partner Pauline. She was an absolute livewire, a go-getter, also studying at university until she fell pregnant with their son Dean born in 1965. After Michael had gained a job in Canada, they emigrated and contact was restricted to occasional cards. They seemed to be settled in Montreal, and the offer was there for us to stay with them in their well-heated apartment.
So we planned a trip to Canada for a week, followed by travelling to the US to stay with Tony, Myra and their children across the border in Connecticut. Everyone was happy except Jonathan who at 18 months found it difficult to settle to sleep on planes and in strange environments. It was all our fault. He had had a lightweight knitted shawl since being very tiny, and this had become a constant companion: his ‘bye-byes’ which settled him often with only three or four deep sniffs of its familiarity – a mix of smells from both he and Jan (perhaps more than me). The smell of course could be disrupted if ‘bye-byes’ ever went into the wash, and Jonathan always knew, even if we connived to do it while he was asleep. I was learning about the crucial importance of the ‘transitional object’ for little people, even before I read any of the work of Winnicott. Anyway, we had been staying in Westgate and, in our rush to catch the train to Heathrow, we forgot this crucial object. Jonathan was distraught; as we were just about to become! We phoned from London airport while waiting for our flight, and Jan’s mother promised to send the shawl airmail. Long story short, it arrived several days later, but there were two new problems. Jan’s mum Bobbie being a pragmatist had washed the slightly grey object for the sake of cleanliness. Secondly, she had noted that the edges of the shawl were frayed, so she removed them before sending. The initial problem of a clean ‘bye-byes’ was overcome quickly as Jonathan’s relief flooded his senses. Sometimes we did wonder whether he looked at his ‘bye-byes’ with a slightly perplexed frown. However, when we got him back to the UK, we were to find that the spare pieces had not been thrown away! So ‘bye-byes’ became a triptych, and all three pieces had to be found each night for several months.
Anyway Montreal was fun, borrowing outer clothing to stay warm when we left the apartment, sightseeing the city and climbing Mont Royal, driving 250 Kms to sightsee Quebec, eating and speaking French again, and then on two of our last days, the 650 Kms to Niagara Falls (an extraordinary experience of white noise at its loudest contrasted with black macs and headgear to match the black wellington boots). We managed the closeness of the apartment well, never stopped talking, and the only slightly sour note was that Dean had ownership of his parents and his bedroom, but seemed anxious to reassert that from time to time. Jonathan collected a few bruises, and shed a few tears, and we had slightly bitten lips. We coped, and were incredibly grateful for how much they had put themselves out.
Myra picked us up from John F Kennedy Airport after our short 2 hour flight from Montreal, and proudly showed us ‘the fall’ colours of the trees and the architecture all the way to Connecticut, while we caught up on family. They had a large New England home on what seemed to us to be a park. Once inside we were introduced to the Nanny maid, and we settled into spacious accommodation, while Myra went for her afternoon nap. Later we met our cousins Susan, Renna and Chris when they returned from school, and Tony who always took the train into the city and needed to be picked up from the station. I guess we were overwhelmed and slightly awed at the strangeness of wealth and the American ways. It was a wonderful time, and everyone was generous with time and space. Tony took us on a business trip to Boston where we became re-acquainted with the grand Hilton style, but enjoyed our tours and the sense of history left by the founding fathers.

Myra generously offered to look after Jonathan for the day while Jan and I went into Manhattan, toured the United Nations, the Guggenheim Art Gallery, and the circle line tour by boat under the bridges of New York. We then had one of those bizarre experiences in life that remind you the world is a small place, and humans have an odd connectedness across place and time. We took the lift to the top of the Empire State Building and stood on the viewing platform watching the sun begin to set, and the lights of New York appear. For a moment I was distracted by the crunch of a young woman eating from a packet of chips. Perhaps I was beginning to be hungry. Then I looked again, thinking: “I know that person. She was a physiotherapist at King’s”. I introduced myself, and then her husband joined us from the other side of the platform – none other than Dr. John Sutton–Coulson, the man who had helped Jan deliver our son some eighteen months prior. How can such a moment occur? Across all that time and distance and in such a spectacular place? Surreal! We chatted, caught up on mutual contacts and then, because they were hungry too, we phoned Myra to delay our return home and went out for an early dinner, and continued our animated conversation. Sadly we went to a ‘Zum-Zum’ bar and the meal was later to cause quite painful diarrhoea. I am sure it was that; I am sure I was well over my ambivalent feelings toward John - who, after all, had ensured we gained one of Life’s greatest gifts. I was never to find out if they were as indisposed as we were. But it underscored the memory of the event.

Tuesday, October 18, 2016

Effectiveness of Australian youth suicide prevention initiatives

Another freely downloadable article (open access) on the Effectiveness of programs for Youth Suicide in Australia.

Monday, October 17, 2016

Making of a Child Psychiatrist: (51) Training in Psychiatry (4)

There were certain advantages to being a senior house officer rather than a registrar in psychiatry. I was not deemed to be experienced enough to be on call, so essentially the job was 9am to 5pm, even if I had to do the occasional weekend. As you would now have guessed, the work was intense and somewhat wearing. Not only was I learning how to manage a wide range of fairly serious disorders but there was also an expectation of doing a fair amount of introspection. I have never shied away from that, and understood from early on the importance of it in relationships with people who were struggling. The phrase ‘Primum non Nocere’ (first do no harm) took on a very special meaning.
I was also on a very steep learning curve at home. As I have noted before, we had moved into our first true home in about April 1968, with Jonathan born in the February. By the time I took up the psychiatry job in October, he was getting on for nine months, and able to sit and begin to take in the world. He provided endless fascination and nappies. Jan seemed to have taken on the tasks of parenting so naturally, but I was a learner and paediatric training in medicine does not provide you with much in the way of skills to be a parent. We had both had siblings about 7 years younger. Jan had always been fascinated by her little sister and her development, and took an active part in helping whenever she could. In contrast, as a boy, I had very little interest in my baby sister; she was just a noisy nuisance taking up all my mother’s attention, and doing that embarrassing breast-feeding thing. I was happy to be roaming around with my friends outside the house.
So, I know I was not a very competent parent to begin with; rather, I was a rank beginner on a steep learning curve. Jonathan was not easy to settle down at night, so we often had to stay awake till late, or get up repeatedly. Even so he was a joy and, like every set of new parents, we were fascinated with each tiny developmental advance, overjoyed by each smile. I guess I was also taking a professional view of his development. Was he on track? Was he normal (whatever that means)? Who would want a doctor and proto-psychiatrist for a parent?
There was also a lot to be done in our new home home. While the outside of the house had been renovated and appeared modern by comparison with the rest of the street, we wanted to decorate the inside to our taste. Like all new homeowners, we wanted to make it ours. So we painted walls and ceilings, organised carpets, and built simple bits of furniture.
Jonathan was getting too old to go into work with Jan, so we had a compromise to make, and were both unhappy about it. Jan found a day care situation with a woman she quite liked, where Jonathan was duly parked each day at the block of flats to allow Jan to go into work. She was very torn, but got into a rhythm of dropping him off each morning with his pram for morning naps, then walking the remainder of the 2 miles on to King’s for her half time job. She was relieved when she returned each lunchtime to find him still in one piece.
There were also, of course, times of great anxiety. One evening when Jonathan was about fourteen months old, he developed a fever and was literally ‘burning up’ with a temperature in excess of 100 degrees Fahrenheit. We tried cooling him down, gave him some infant aspirin, but it went on and on. My paediatric skills were not helpful when I was so personally involved. Late that night we decided we had no choice but to take him down to King’s Casualty. We got clerked in, and watched in horror as our little bloke was stripped down to nothing, and sat disconsolate on a cold metal trolley inside our screened cubicle, while nurses wiped him down with cold wet flannels. Jan was desperate because we would have done nothing like that at home and it seemed so brutal. I was outraged because I feared he might develop pneumonia, if that was not already the problem. We were turned from professionals into scared parents, and felt that sense of helplessness that everyone must feel when you become a number, just another case. He was seen by a paediatric registrar and had an Xray of his chest. All good apparently! Eventually his temperature did come down, he was given a dose of penicillin, discharged, and we dressed him and took him home – not all that impressed, and vowing to never repeat the experience.
The house was very close to Peckham Rye Common, so when weather allowed we would go down to the park and enjoy being a family. We have photos of sunny days, and all of us smiling, as well as one glorious one of Jonathan in a pushchair with his curly hair, pudgy baby face covered in ice cream. We were just an ordinary family out having fun; just as it should be.
My year in psychiatry was coming to an end. It did not matter how well I had done, how many apparent successes we could count, how much I had enjoyed the experience, or how much I was liked; there was no immediate prospect of a registrar position at King’s. I looked elsewhere, but just could not find a job in the medical journals; all very depressing. For the last six months I had become increasingly anxious about what to do next. I discussed my career with consultants and registrars but no leads began to appear, and our little family needed financial security. I know I became increasingly morose, and not much fun to live with.
And fate stepped in. Jan’s father had from time to time played golf with a couple of general practitioners in Kent, and had discussed our situation. Apparently an elderly GP Dr. Alan Bowie, who had completed 35 years of medical service in Birchington (the town of our old drama group, and early courting days), was about to retire. His junior partner, Dr. John Hayden, was now looking for another doctor. Jan and I spent days discussing the option. It meant moving on from psychiatry, and moving house again; but what could be nicer than a beachside and rural practice, only 2 miles from the town where we had both grown up? What could be nicer than moving close to family? What could be nicer than almost trebling my current salary?
I met up with John Hayden for a discussion one weekend, and we got on well. The job sounded manageable. In addition to John, there was one other long-term doctor (Dr. Denis Merritt). The practice overall had just over 10,000 patients, but with some new council estates being built, the numbers were growing. My flock would be about 3,000 people in Birchington and perhaps some in Westgate, as well as the surrounding farming communities of Thanet including St. Nicholas at Wade, Sarre and Pluck’s Gutter in one direction, Acol and Minster in another. I would be expected to look after a Dr. Barnardo’s home with about 100 children, and be on call for the whole practice one week in every three. I had no concept of what that might entail, but John assured me it was not overly taxing, and I would not take long to grasp the whole thing.
John suggested I would be well advised to complete 6 months of Obstetrics training before beginning, given the number of births each year in the practice and surrounding villages (about 200 a year). Given my joy in my student midwifery training, that sounded good. John had heard there might well be a senior house officer job coming up at Margate Hospital (where I had worked very briefly as a nurse assistant 10 years before); he said he would find out more. I put together a brief curriculum vitae, and wrote to the Director of Obstetrics at Margate Hospital, discussing the plan to move into General Practice, and noting I would like to work towards a Diploma in Obstetrics. The response was rapid and positive, so I guess there had been few other applicants (if any) for this small hospital outpost on the tip of Kent. There was a bonus. A ground floor hospital flat in a small block almost next to maternity would become free shortly after I began work. Would we be interested in moving into that? How fortunate could we be?

Sunday, October 16, 2016

Free download of Suicide Prevention 5 year Outcome Study

This study reviews the Mates in Construction Suicide Prevention Program, comparing 5 years of the program with the 5 years before the program began.
It is rare to find such longitudinal outcome studies.

Martin, G., Swannell, S., Milner, A., & Gullestrup, J. (2016). Mates in Construction Suicide Prevention Program: A Five-Year Review. Journal of Community Medicine & Health Education. 6: 465. DOI: 10.4172/2161-0711.1000465 

The paper is free to download from the OMICS site (i.e. OPEN ACCESS)