The woman is sitting in front of me, patiently waiting for me to finish what I was doing.
– So… what happened to you? What brought you into contact with psychiatry?
She looks at me a bit fearful. She doesn’t understand the question… or she seems not to understand what I want from her… I repeat my question.
– I came for the prescription of my pills.
– Okay, but what are you suffering from?
She remains silent.
– What’s your disease? What’s the name of your mental disorder?
– I don’t know.
– What are you taking this medication for?
– Doctors have said I have to.
– But what for?
– So as to be well.
– What makes you feel unwell?
– Are you sick?
– How do you know you’re sick?
– Doctors have told me that I am.
– But you… how do you feel your disease?
– How do you feel that you are not well?
– But I feel good.
– But why do you take the medication then?
– Because doctors told me to take it.
– What happens if you don’t take the medication?
– I feel unwell.
– And in what exactly consists this fact of being unwell?
– I can’t really say…
– What exactly does the medication block from happening?
– What the drugs prevent to appear? What symptom is blocked by the pills?
Silence. The patient looks blankly at me. And at this point the nurse who is with me in the office is triggered:
– Ma’am, you suffer from a disease. You’re taking drugs to feel better. What are you suffering from, for God’s sake?
– I… feel well now… I guess… Am I?
Being a psychiatrist is perceived as otherworldly. Most of us have a phenomenal patience. Instead of being infuriated, I notice an opportunity to be creative. I mean, how can I make the patient talk about her and her issues? What strategy to use? I choose to be directive, as I remember I am limited by time.
– You’ve got voices in your head?
– Are you or were you sad?
– Not really.
– Are you afraid of something?
– Actually yes… people used to look at me and judge me… they harassed me…
– And what you did with that?
– I tried to kill myself. I couldn’t stand that.
All the time I had before my eyes her file and I know she is suffering from a psychotic disorder with paranoid ideas that led her to a suicide attempt a couple of years ago. She looks stable now but I see her for the first time so I need to get to know her and exchange a couple of words so as to be sure she’s not decompensated. I often let the patients talk a bit or we have a small conversation when we meet for the first time, while I scan them for worrying symptoms or other “surprises”. That’s how I work.
The patient looks fine. Well, she has cognitive issues and a quick glance at the current prescription explains why: heavy sedating and addictive medication, although the psychosis itself can explain as well the cognitive decline. I renew the prescription and I give it to the patient while I keep talking with her for a while.
– I need to say something, doctor.
– Never in the many years since I suffer from this disease had I talk with a doctor for so much time… You do seem to be a good doctor.
– But I’m just doing my job!
– Yes, but everyone else before you just gave me the prescription without talking to me or asking how I’m doing.
I stop a bit. It’s my turn to be wordless. I pull myself together in a couple of moments.
– I guess each doctor has his or her own style of seeing the patients…
– No, doctor, it’s not true and you know it. They’re only after money and as little effort as possible.
I smile and remain silent. I don’t want to continue a debate I might lose.
Quality used to be rare a couple of years ago. Now, it is exceptional. I do what I do out of conviction and education. I do talk with the patients; I’m not just handing them a medical prescription. I’m still interested in their anamnesis, that is, their medical history. But I am – as I like to mention many times, practically every week – a “dinosaur”. Today’s medical system is based on a bureaucratic view of life, where there are vacancies to be filled and the continuity of service (read: the night shifts) to be assured. Nobody, however, is watching for the quality of the service. In a medical system “forever in crisis”, “forever underpaid”, it is lucky to have doctors in the public service, so “having the numbers” is good enough. And this is not a French problem; it’s likely a worldwide problem.
I received a couple of days ago an e-mail from the United Kingdom where I used to be GMC registered as a specialist doctor but couldn’t find a job so I never practically worked. The recruitment companies however have my contact details and the e-mail was advertising locum positions for a fixed period of 3-4 months. This is bureaucratic in the deepest sense. It’s a plan or an agenda that can’t be filled, so people are open to recruit “anybody” so as to fill the gaps. It doesn’t matter the fact that in psychiatry (and in other specialties as well, but particularly in psychiatry) you need to build what is called “a trusting relationship between the patient and the doctor”. How can someone build such a relationship during a period of 3-4 months – when you probably see the patient once or maximum twice – or when the doctors are replaced every 3-4 months? Rhetoric question, of course. Ironically, those positions were from Scotland, from exactly the same place I applied to years ago and I got rejected because, you know, I don’t speak English good enough… that was the stated reason… I guess I became “good enough” today, with my extra French background, – or the system is in such a dire situation that I’ve become desirable – but anyway, I digress…
All these – lack of quality, lack of planning and lack of strategy for the future – have one name: short-termism. The bureaucrat is someone who suffers from a disease called “tunnel-vision” or “into-the-box thinking” (as opposed to the “out-of-the-box thinking”). The bureaucrat is concerned only about making a plan, that is, filling the gaps, and is concerned about doing this now, in the present moment, as fast as possible and as easiest as possible, using as little resources as possible for economic reasons (because – everybody knows – there is always a crisis and money is scarce; alternatively, it is good to prove you did something “of impact” with maximum efficiency and little money). So the bureaucrat will never look at the quality of the employee, but only at his or her existence or availability. They will probably assess “the profile” and see if that profile fits what is required “now”, in the “short-term” – in other words, a good profile has a lot to do with what is presently needed and little to do with what that profile can potentially offer. Then, the bureaucrat will never think about the future, about ways to keep good employees in the system (that has a name, it’s called “employee retention”). Why? Because the bureaucrat lives in the present moment and not in the future; he or she is a down-to-earth entity, with difficulties when it comes to imagination, especially since he or she, the bureaucrat, will also dream about changing his/her own job in a couple of months because, as everybody knows, you need to advance in your career. And finally, the bureaucrat will not look at a system in general and understand how it functions; he or she will look only at his precise responsibilities inside his own department, excluding from the “working memory” the other aspects of the system; “it it’s not your company, you don’t care what happens to it”.
Short-termism employed for many years has led to what we see today: a public service in disarray everywhere in the Europe I know. Quality can either be found in private or it has completely disappeared because those who cared to do quality stuff are enjoying their retirement or are already dead. There are only some very distant unconnected “islands of quality & common-sense” left.
Encountering this patient, who was genuinely shocked that I spoke to her, to the point that she didn’t know what to say or how to present her problem, was an opportunity for me to encounter the effects of this short-termism. It still creates echoes in my soul, as I know that sooner or later I will get old and sick and I will need myself to see a doctor. The question is: am I going to see a doctor or am I going to see only his/her prescription? It might be an AI (artificial intelligence) who will play the role of a doctor… who knows? But then… where’s going to be that “human factor”, that “human touch”, dare I say, that “humanity”? Or… am I asking for too much?!