The doctor, the psychiatrist and the patient

In less than two months’ time, I shall be completing my formal training as a psychiatrist. After five years of medical school, two years general medical training and six years psychiatric training, I will finally be able to take up my long coveted job as a consultant psychiatrist. While I am excited about moving forwards, I would be lying if I said I was not a little nervous as well.

As November approaches, I have found myself reflecting on what I have achieved, but also where I find myself and my future plans. Going to medical school was a fairly last minute decision, psychiatry was one of just a few options during my training, and I certainly had never heard of the specialty of Learning Disability Psychiatry until just a few years ago now. How I have gotten to this point in my career has had a fair amount of fortuitous happenstance, but it seems to have worked out well so far.

Those of you not directly involved in the medical profession may not have any idea what I mean when I say I am a Learning Disability Psychiatrist, and I suspect a fair few colleagues may be unclear what it is I do as well. If I am honest, there are even times when it is not clear to me, so I thought this post would be a good chance to explore this further.

“And what do you do?”

When I first left medical school, if I was asked what I did for a job when meeting new people, I would say of course that I am a doctor. For some people this might have been a shock, I was only 23 at the time and may not have looked like a typical doctor, but once people accepted what I was, the next question was almost inevitable “can you have a look at this rash?” People know what a doctor is, even to the extent their normal social boundaries fade away.

When I began psychiatric training and I was asked what I did for work, my response would depend a little on the company. I might have still said I am a doctor and then expand upon this if asked, but more often than not I would tell them proudly “I’m a psychiatrist”. At this point, there were really only two responses I would get. The first would see the person I was speaking to become suddenly fascinated in refilling an already full glass before disappearing into the crowd, or else they would suddenly open up about the most personal and detailed aspects of their life and mental health, social boundaries once more evaporated.

Over the last couple of years, if given the opportunity I have clarified that I am a psychiatrist working with people with learning disabilities, to which the usual reply is “a what?”

Disabilities or Difficulties?

You will almost certainly have heard the term Learning Disability before, even if you are not quite sure what it means. You may also have heard of Learning Difficulties, and just to complicate matters if you are outside the UK you might well have heard of Intellectual Disability.

To briefly clarify what each term means, someone with a Learning Disability has a below average IQ from childhood and struggles with various aspects of day to day life, from shopping and paying bills through even to washing and dressing themselves. Around 2% of the population has a Learning Disability, although nowhere near everyone will need to see me and colleagues for help. Intellectual Disability is another term for the same concept, and while not as common in the UK, technically it is the term we should now be using.

Learning Difficulty is a different concept altogether, although many people will use them interchangeable. Examples of Learning Difficulties include conditions such as dyslexia, and while people might for example have difficulties with reading or writing, the vast majority of people will have an average or above average IQ and require no help beyond their specific difficulty.

LD Psychiatry

Notwithstanding the difficulties people with Learning Disability can have with day to day life, they are also more susceptible to mental health problems as well. In the general population around 1 in 4 people will develop a mental illness in their lifetimes, if you have a Learning Disability this rises to around 2 in 5 people, or 40%.

When someone with a Learning Disability develops a mental health problem, it might well appear different to the general population, it might be harder to diagnose because of communication difficulties, and if you can diagnose mental illness it can be harder to treat. Having a Learning Disability puts you at risk of a myriad of disadvantages in life, and none more so than with their mental health.

It is for these reasons and more that the specialty of LD psychiatry exists. We recognise people with Learning Disability are more likely to be ill, more likely to have difficulties being diagnosed and treated, and so people like myself have trained especially to work with, diagnose and treat them.

My week

On the face of it, my week looks much like any other psychiatrist, and very much like other doctors as well. I have outpatient clinics, where I will see patients and review how their health and treatment are doing. At times I will visit them at home, particularly if they struggle to leave the house. I attend meetings, to discuss patients with colleagues and other professionals like social workers, but also meetings which discuss and plan changes to the services we provide. I attend teaching sessions, both as tutor and pupil. I spend a little more time than I like completing paperwork.

Where my job differs I feel from other psychiatrists is predominately in the interactions I have with my patients. It can be challenging at times. My patients may struggle to communicate verbally, if at all. They might use Makaton or other communication aids to help get their thoughts across. I often have to rely on family and carers for additional information. I no infrequently have to rely on behaviour alone to reach a diagnosis.

Once I have made a diagnosis, I then have to be cautious with treatment choices, giving smaller doses of medications, and the patient being more likely to get side effects even if I am cautious. Treating mental illness is a fine balance at times, treating people with Learning Disabilities can seem like the most challenging tight rope.

And while we walk this tight rope, the world of Learning Disability Psychiatry is changing rapidly as well. You may well have heard about the abusive outrages which occurred in places like Winterbourne View and more recently Whorlton Hall has seen a drive towards discharge people from hospitals across the country and moving them closer to home. This is of course the right thing to do, but it comes with its own challenges, not least actually finding houses for people to move into.

The future

I have completed my training at an interesting point for Learning Disability Psychiatry. Yes much of the work I do will remain the same, in the clinic and beyond, but much will change as well. As I reflect on what an LD psychiatrist is, I think I know what it is I do, and hopefully you will have a better understanding too.

How we support and treat people with Learning Disability is and will continue to change, something I find exciting if not a little daunting. While I may have an understanding of my job now, who knows what the next thirty years or so before retirement brings.