Doctors cure, nurses care?

Seaneen has written an interesting and very thoughtful piece giving her relative views on psychiatrists and mental health nurses. Seaneen prefers the nurses to the doctors, and feels more understood by them.

The debate that follows in the comments thread is also quite interesting. Some people agree with Seaneen. Others report the opposite - that they’ve preferred the psychiatrists to the nurses (Mental Patient About Town fits into this latter category - don’t worry, we won’t hold it against you).

I think I’ll attempt to join in this debate by adding a few thoughts of my own about the relative roles of doctors and nurses in mental health.

Psychiatry is a rather un-doctory form of doctoring, and child and adolescent mental health (where I work) is the least doctory of them all. Child psychiatrists have acquired a reputation in recent years of being drug-obsessed fiends trying to put the nation’s kids onto methylphenidate. This is a little unfair, since child psychiatry probably uses less medication than any other field of medicine you care to name. The only childhood mental health problems for which medication is the first-line intervention are ADHD, psychosis and Tourette’s Syndrome. For everything else - mood disorders, autism, conduct disorders, attachment disorders - the first line interventions are psychotherapy (CBT, problem-solving therapy, social skills training, family/systemic therapy, a small amount of psychodynamic therapy) and psychosocial interventions (parent training, liaising with schools for educational support, signposting to youth services in the voluntary sector).

Because of this, it’s probably no surprise that child and adolescent mental health is seen as an unattractive career option by a lot of doctors, and an attractive one by a lot of mental health nurses.

A lot of psychiatric SHOs seem to find it frustrating to be unable to use a lot of their medical skills when they come to us. Understandable really, if you’ve spent 5 or 6 years training in the intricacies of human anatomy and physiology, only to find yourself in a role where that training isn’t massively relevant. There’s not even a lot of sectioning decisions being done, because with the few children we detain, it can usually be done by acting in loco parentis under the Children Act rather than the Mental Health Act. The SHOs rotate into CAMHS, wind up feeling like they should have done a degree in psychology or social work instead, and then rotate out again to scurry off to somewhere like elderly psychiatry, where they at least get to pick up a stethoscope.

A few psychiatrists do seem to thrive on child and adolescent psychiatry - mainly the more psychosocially-oriented doctors who perhaps may have got through medical school and wished they’d done that psychology/social work degree after all. You do also, unfortunately, get some time-servers who just seem to have latched onto CAMHS as an easy option. A place to get a comfy 9 to 5 job where you can get away with not doing a great deal of hard work. It may not be a coincidence that it also seems to be these lazy-arse ones who are the most ready to reach for the prescribing pad and dish out the methylphenidate at the drop of a hat.

By contrast, nurses are often a lot more keen on CAMHS. This is probably due to the greater emphasis that a mental health nursing course places on the psychosocial dimension (those dreaded sociology lectures!) Quite a few student nurses (myself included) come to CAMHS for a placement and instantly fall in love with it. Of the students in my mental health class, 30% went to CAMHS when we qualified. A high figure for what is still a fairly small (but growing) speciality within mental health services.

So, what are the two professions good for? Well, the doctors (and Dr Crippen will probably jump for joy to hear me say this) are better than nurses at doing the diagnostic work (though the nurses often play a vital role in evidence-gathering for this, by doing school observations and so on). And of course, they’re more expert at medications - or at least those few that we use (ADHD medications like methylphenidate and atomoxetine, flouxetine for depression, melatonin for sleep problems, some use of antipsychotics like risperidone). They’re also vital for spotting organic pathologies masquerading as mental disorders. Some kids initially believed to have ADHD, for example, have turned out to have glue ear.

As for the nurses - well, they’re good at doing what nurses are meant to do, which is spend time with patients and develop a therapeutic relationship with them. A lot of our patients are lucky if they get to see the doctor once a month, and often it can be a lot longer than that. A nurse might be able to see them once a week or once a fortnight - or in the case of some of the more severely ill kids, it can be every day at times.

Seaneen commented on the fact that nurses are often closer to the patients in terms of social class, and this can make it easier to develop that relationship. I think there’s a degree of truth to that. Doctors, no disrespect to them, are by definition upper-middle class professionals and often come from upper-middle class upbringings - therefore it’s no surprise if the nurse might find it easier to relate to a single mum on benefits than the doctor. This will sound shockingly arrogant, but I consider myself better at working psychotherapeutically with children and adolescents than my consultant child and adolescent psychiatrist. Though in fairness this is mainly to do with the fact that my consultant has all the wit and charm of Gordon Brown on lorazepam. Not that there aren’t nurses out there with bad people skills too.

It’s sometimes said that doctors cure and nurses care. CAMHS may not much resemble healthcare in its conventional sense, but overall I’d say this distinction is still a valid one.