That’s a wrap: Medfest 2014 comes to a close

The 30th and final Medfest film event of 2014 took place last week. I had the privilege of being this year’s national lead, and wanted to take this opportunity to review the festival and to thank everyone.

Medfest is an annual series of evening events held at medical schools across the UK each spring. It’s funded by the Royal College of Psychiatrists and organised by trainee psychiatrists. A programme of medically-themed short films, clips and animations are shown and discussed with panels of distinguished names from psychiatry and related disciplines, with the aim of getting medical students interested in mental health.

Through our theme for the year, the catchy yet mysterious “Medicine from Cradle to Grave”, we aimed to show how film portrays medicine impacting upon the lives of people of all ages.

Our poster, for the third consecutive year, was designed by the marvellous David Shillinglaw.

finalposterMF2

Gradually, we found trainee psychiatrists and medical students all over the country who were interested in organising an event in their local medical school. Though we weren’t able to host an event everywhere, our final total of 30 events was an exponential increase on the previous years of 9, 16 and then 21 events. We also found no shortage of amazing pannellists, with the likes of Claire Gerada, Norman Lamb MP, David Nutt, Simon Wessely and Raj Persaud more than happy to give up their time to chat about how the various clips affected them.

We were lucky enough to find some wonderful films, which together formed a vibrant, varied programme:

Our first section, the health of children, was led by Shane Koyczan’s animated spoken-word poem To This Day, a viscerally eloquent tour through the hell of being bullied and the lifelong after-effects. The poem touched many audience members personally, but equally, some panels found that it tried too hard, or was even unnecessarily scary or defeatist.

To this day

We also compared two clips on Polio. The 1946 public education film His Fighting Chance, narrated by Eleanor Roosevelt and a real child of its time, was contrasted with the slick computer generated imagery of a commercial from the Bill and Melinda Gates Foundation called Polio’s Last Percent. There were so many ways to compare the films – social attitudes, film making techniques, medical progress – it was a fertile ground for discussion. Overall, though audiences enjoyed watching both films they also remarked that they felt equally disingenuous, covering up aspects of the truth for different aims (morale and money).

Polio                             Polio2

In the second section, the heath of adults, we compared two more films. In a brave gamble we decided to include Dr Easy, a science fiction short about a robot doctor dealing with a mental health crisis. The dystopian tale and its unsettling ending left many an audience member torn – did they feel comfortable with liking the film in spite of its artificiality, and could they accept what it had to say about our own, supposedly uniquely human, communication skills?

In direct contrast, we showed a collection of clips from the recent Channel 4 series Bedlam. Lloyd, a man recently diagnosed with schizophrenia, was shown coming to terms with his diagnosis and the image of madness that he assumed society would now have of him. The audience comments on this film were far more widely appreciative, but also sometimes pessimistic – is this all good mental health care can really achieve?

   Dr Easy                Bedlam

In our final section, health in old age, we showed two more short films back to back. Irene, the story of a 92 year old Scottish lady suffering with Alzheimer dementia preparing for a week in respite care, was shot by her granddaughter director Lindsay Goodall. It was compelling, heart warming and truly brought out the personality of the titular character as she resiliently lived her life. Flatline, in a directly opposing style, was a brash American short film showing two pioneering heart surgeons recount their implantation of the first prosthetic heart into a human. Though no less captivating, audiences noticed that it lacked a rich narrative of the patient – something Irene did fantastically.

Other areas of discussion including whether Irene could give informed consent to be filmed (which Linday Goodall herself, as a pannellist in Edinburgh, assured us that she could), the increasing demonisation of the unavoidable process of death, and the need to consider a sick person in a social context.

Irene                     Flatline

Packed into around 2 hours, the programme was quite a challenge to co-ordinate and I’m sure many a local lead will have been glad when the time came to hand out the feedback forms and get started on the cheese and wine.

As reports came back to us from up and down the country, it was clear that thankfully, our hard work had paid off.  Films were hated and loved, but the pattern of attitudes varied across each event. We’d split people’s opinions, made them think and got them talking about mental heath.

Overall, the feedback we had was highly positive, which is very rewarding. It appears that well over 1000 medical students attended, and they seemed genuinely more attuned to mental health and more likely to consider it as a career as a result. You can read far more articulate reviews than mine by Desmond O’Neill in his BMJ blog and Anna Taylor in her Bristol University Psychiatry Society blog. We were also the cover feature of the most recent edition of Junior Dr magazine.

Clearly, the job of leading the whole festival was far too much for one person, certainly for me. The first thing I did after being given the role was to advertise for willing (naïve) helpers, and I need to thank them profusely – I was lucky enough to find an amazing group of committee members, and I owe them a huge debt of gratitude for all their hard work.

Alex Blackman, under the nominal title of secretary, was a firm hand on the tiller of our website and co-ordinated the distribution of posters and DVDs with effortless precision.

Daniel Meek and Duke Nzekwue, as my co-leads, took a substantial amount of stress off my hands by liaising with a proportion of the local leads, and they also found extra sponsorship.

Louise Murphy, along with Helen Hutchings, organised a phenomenal art exhibition at the Royal College. It was the first time we’d branched out into art, and Louise and Helen took hold of our theme for the year brilliantly by displaying work from patients of all ages.

Kat Levick was our music lead, lending a hand to the team at the National Student Psychiatry Conference in organising their Medfest:Music night, and also putting together a night of medically-related music on a boat on the Thames too.

Karina Beinerte, our international lead, scoured the globe for potential host cities outside of the UK, and came up trumps with Canberra, Melbourne and Riga. Next year we’re looking good for Canada and more of Europe too, which is very exciting.

I also need to thank everyone who helped out at local events, everyone who sat on a panel, and of course, everyone who turned up to an event. I’m also grateful to The Royal College of Psychiatrists for funding the events, and I hope they agree that they’ll make their money back in terms of improved recruitment!

Medfest will be back for another round of mental health-inspired film, art and music in 2015. We don’t know the theme yet, we don’t even know who’ll be taking charge of it, but one thing is for sure – it’ll be bigger, brighter and better than ever. Lights, camera, action.

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Continuity of Care: Why we need to build services around therapeutic relationships

This month’s British Journal of Psychiatry includes a lovely qualitative study by Bilderbeck et al on how patients experience being assessed for a mood disorder.

I think we can learn so much more from a good qualitative study than we ever could from a study on genetics or a drug RCT, both as professionals and as mere members of the human endeavour, so it was great to see a high-impact journal publishing the paper.

One of the recurring themes that Bilderbeck et al identified in their interviews with patients really leapt off the page at me. As well as wanting an explanation for their feelings, wanting to feel listened to and involved, the patients wanted consistent and continuous care. 

In short, the patients wanted to meet the same doctor each time they attended. In the trade we call this continuity of care.

Continuity of care

Bilderbeck et al noticed that patients felt more comfortable and able to discuss sensitive, personal events if they’d met the doctor before. Conversely, if the doctor they were meeting was new, they felt more anxious and were generally less able to use the relationship to heal:

‘There’s never any consistency. It really bothered me… Virtually a different doctor every time I went back… it’s just like going back to a stranger and I don’t really, it’s not helping me at all.’ 

In fact, one quote illustrates how seeing a new doctor at each visit can be nothing more than a waste of time, like a clinical Groundhog Day:

‘I’d like to see the same doctor all the time. See one, than have to explain myself again and again and again.’

 

Widespread problem 

This is by no means a chance finding in a small group of participants. A lack of continuity is raised again and again by patients who feel let down by the system.

This is because getting to know a mental health professional, and letting them get to know you back, is the most powerful treatment we have. The therapeutic bond formed between the professional and the patient is taught to be worth more than the effect of any tablet, and responsible for the majority of the effect of any talking therapy.

In most other medical specialities, meeting a patient for the first time and taking a history (asking them all about their main problem, past problems, personal life and family history) is largely nothing more than a simple transfer of information. The patient gives the doctors facts about his life and current state, and the doctor uses these facts to decide on a treatment. If the same doctor turns up again the next time then that’s nice, and saves a bit of time, but if a different doctor turns up they can just read the notes the carry on fairly easily where the previous doctor left off.

In mental health, however, talking to a patient about their problems for the first time is more than just an exercise in gathering facts. It is the foundation for a lasting and potentially healing relationship, built on the trust that the patient’s disclosures imply. It isn’t always easy but it’s the first part of recovery.

Later meetings between the professional and the patient continue this healing – building on the previous meetings and delving deeper and wider into the problems, with growing nuance and understanding. To meet a different doctor at this point would be, in a way, to restart the largest aspect of the whole healing process and risk the patient feeling rejected.

What’s more, a doctor who already knows you is far less likely to make a mistake, like misdiagnosing you or sectioning you when you’re actually no worse than you usually are.

Stifling continuity

Often a lack of continuity is unavoidable – doctors have to take it in turns to cover the hospital at night, for example – but often we build services in such a way that continuity is stifled from the start.

We’ve brought in Triage wards, to which patients are admitted for a few days before either being discharged or admitted to a longer stay ward. Triage wards have their own team of doctors and nurses, with whom patients somehow have to miraculously form a relationship in just a few days, when seriously unwell, before being moved on to tell their story again elsewhere.

If the patient is admitted to a longer stay ward, the chances are that their consultant won’t be the same consultant that they see in the community. These days, consultants are moving towards solely doing either inpatient or outpatient work for the sake of “specialisation”. Therefore, another person to tell your story to.

Even on discharge, you might not end up under the care of your old consultant. Depending on your diagnosis you might end up under an Early Intervention team, or any number of other crisis resolution or brief treatment teams. They might be specialists, but they’re not mind readers – it’s time to tell your story again. 

And don’t forget that you might have to see a Home Treatment Team in the meantime (tell your story) and even a separate Drug and Alcohol team, because your own team can’t deal with that (tell your story).

Of course, you might not see any of these teams – they might all be burnt out and hideously understaffed because getting to know new patients all the time is hard work. Treating patients you know can be thoroughly fulfilling, and building on those relationships can make your job worthwhile, but a constant turnover of new and subsequently worrying cases can be enough to wear anyone out.

Where from here? 

So how do we bring continuity of care back to the forefront of psychiatric practice?

Sometimes it’s easy. We need to make sure that when a patient is re-referred to a service, someone who already knows them takes their case again. If a patient is readmitted to hospital, they need to go back to the ward where the staff know them best. It sounds obvious but so often, it doesn’t happen.

Of course, this also means keeping enough beds open so patients don’t need to be transferred hundreds of miles away when they need an admission, and paying for enough staff to be available to cater for all the patients on a long term basis.

But how do we ensure continuity past the obvious?

For me, the first step seems to be proving that it’s important. That means more qualitative studies on patient experience in high-quality journals. In general, we need to listen to what patients feel is important more often – we need to judge quality of care not just by abstract outcome markers like “readmission rate”, “medication adherence” and “employment” but by what patients think about how much we helped.

Ideally, we need to prove that continuity of care is somehow cost effective too. This is certainly true, but also certainly difficult to demonstrate. If different doctors see the same patient three times, they’ll each repeat a lot of the work, generally take longer and make more mistakes – all costing time and money.

Next, we need to use that evidence to design services with continuity in mind. Ideas could include:

  • switching consultant posts back to a mix of community and inpatient work
  • cutting down on unnecessary or unproven specialist teams
  • developing service policies on continuity on an individual and service level
  • turning Triage wards back into longer stay wards, or linking them better with the patient’s long term consultant
  • being more flexible about keeping a patient under a team’s care when they change GP or move house

Continuity of care is at the core of every positive change we make in mental health and we need to protect it at all costs. As always, I’m eager to hear your thoughts.

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