Thursday, March 30, 2017
Making of a Child Psychiatrist: (66) The General Practitioner (11); A bit more Child Psychiatry +
While Ken Munro Fraser was senior in experience, I was to find out he was flexible and open to new ideas. He allowed discussion, and I decided to keep quiet and listen. I had done enough damage with my ‘foot in mouth disease’. Or perhaps not! Over the next few weeks there followed a general airing of ideas about assessment and choosing appropriate therapies for any given child and family. Ultimately, even though I was only there once a week to join in the subsequent clinic discussion, I found out there was a decision about a changed process, with cases allocated within limits on a roster to any of the professionals. The idea was that the ‘case manager’ would gain the best understanding of the case that they could, and then bring that to a team meeting where the next steps in the assessment could be organised, and appropriate therapy planned. It sped the assessment process up, and took pressure off the social workers who often had to ‘hold’ a case until a psychiatrist or psychologist was free to complete their assessment. Of course Ken retained overall control over the decisions, given he was the Director and therefore would have to face the music if anything went wrong.
The reports I heard were that the process was quicker, with professionals able to begin some intervention during or after a first or second interview session, without having to wait for the main team meeting, so patient families felt they were getting some ideas and strategies almost from the beginning. Of course additions or changes could be made if the meeting consensus suggested something. From a personal perspective, it meant I could see cases for whom I had some ‘ownership’ and responsibility for diagnosis, process of assessment, therapy and reporting back to the team meetings. Luckily I was having some supervision each week from Ken to ensure I was looking at my own reactions to families and children, but also learning new skills. He was always suggesting some reading to help this, and would sometimes provide me with an article copied his secretary. So my one session a week, would often entail me spending another couple of hours a week in the evenings. Far from onerous, I found the process exhilarating.
Not that my work in the practice had lost any of its lustre, and there always seemed to be something new happening. We had a social work student approach John Hayden to seek a placement in the practice. Her expectations were that she might get to sit in on clinics, but also spend time around the practice with midwives, our district nurse, and even my visits to St. Nicholas at Wade. She was pleasant, enthusiastic, and careful not to intrude if patients were unhappy for her to be present. Jean had an assignment to complete prior to finishing, and we discussed ideas in the tearoom and while driving.
Two of my clinic patients at St. Nicholas were middle aged men who had each spent many years working as miners at Chislet (until it closed down in 1969) and then Betteshanger coal mines. Jean thought it would be a really interesting experience to go down a mine, facing some of the trials that miners put up with every day. These days, I suspect, all sorts of bureaucratic blocks focused on occupational health and safety might have been placed in our path. But when Jean approached her mentor to gain permission to shape part of her general practice report around the experience of miners, she thought it was a creative idea. When Jean approached the hierarchy at Betteshanger, they welcomed the idea of having real life health professionals gaining experience of working conditions.
And so, with only minimal discussion at home and in the practice, foregoing my three piece suit for some older somewhat daggy clothing one Wednesday afternoon I found myself descending into the depths in a wooden cage dressed in miner’s dungarees, borrowed boots, a helmet and a slightly flimsy facemask. Jean was very excited and kept the miners talking about their experiences. I was less enthusiastic, if not increasingly anxious. I am not sure what I had expected; perhaps a mini-presentation from a miner or supervisor, a visit to the wooden cage, and then a tour of the onsite museum followed by a cup of tea. No such luck!
I realised they were actually going to take us down the 1600 feet or so in the cage (which was noisy and appeared rickety to my untutored eye). I felt unable to say no. I was not being gallant for Jean’s sake; she was thrilled by the whole event and did not need that a mere male to support her. I just felt a bit embarrassed to wimp out, so I gritted my teeth and smiled while Jean went enthusiastically through her lengthy list of questions about mining.
After a shaky, rattling descent that felt longer than it actually was, we landed and the cage door was opened to the dim lighting of a cavern. We were met by the driver of a primitive underground electric train with open seating on narrow gauge rails. I have no idea how far we travelled, but the rounded ceiling seemed to get lower, and the walls closed in. Jean kept up her tirade of excited questions. How did the air stay fresh so far down? (Everything had begun to taste of coal of course, despite the facemasks). Were they still using the pit ponies about which she had heard? Not any more. Had there been any serious accidents? Not for many years. At the end of the line, we were told that to view the coal face we would have to crawl along a passage under what looked like wooden trestles maybe four feet high. Jean had already accepted the challenge and I had little choice but to follow. Lights were strung on the trestles, but the view either side was limited. The track was not really wide enough to turn around even if I had no-one behind me; the forty yards of crawling felt like an eternity. We arrived at a more open area and could see the open face, with miners drilling holes into rock. I tightened my facemask, and wished I had earplugs. The holes would eventually hold an explosive charge, the idea being that the whole face of coal would crumble down ready for transit. There was what felt like interminable discussion of the intricacies of explosive charges. These were men who knew what they were doing, given their lives depended on not making mistakes. There was pride in what they did, and trust and strong bonding between them. You smiled, and asked rather obvious questions; the miners smiled back and give rather obvious answers. I was struck by their acceptance of this dark reality of their work lives, and the tolerance for extreme working conditions. In contrast I felt a hint of shame in my own rapidly building need to return to the surface. I wasn’t sure I could get out quick enough to maintain the shreds of my dignity, and the return journey seemed endless.
I suspect there was endless discussion and a series of stories and jokes between mates in the pub about these two odd professionals needing to explore their work lives. Later I was to meet the two miners who lived in St. Nicholas, and was pleased that they (being blokes) were happy to come to the doctor to discuss often quite intimate problems. Separately, they both asked (with twinkling eyes) if I had enjoyed my visit to the mine, and whether I had recovered from being at the coalface. Obviously the story had got around.