I was working a particularly busy evening shift covering two medical wards at the general hospital as well as the mental health unit across the road. Whilst in the middle of managing an acutely unwell patient, I received a page requesting a clinical review from mental health. When I had a moment, I returned the page and the nurses revealed that the clinical review was for chest pain. I requested an ECG and headed across the road.
When I arrived, the staff were anxious; chest pain wasn’t something they routinely dealt with and they were concerned that they might not have the experience and expertise to manage the situation on a low acuity ward. The woman I was asked to see was even more anxious. I found her sitting up in bed, clutching her chest and breathing quickly. She reported a sharp, stabbing pain at her left ribs that was worse on deep inspiration. Although she often experienced pain and shortness of breath with a panic attack, it had ‘never been this bad before’. The pain was reproducible on palpation of the chest and manipulation of the left shoulder. The ECG showed sinus tachycardia.
At this point it would have been easy to attribute the pain to another panic attack, but I couldn’t ignore the woman’s cardiac risk factors: she was obese, diabetic and a smoker. I called the medical registrar who agreed that she deserved a chest x-ray and serial troponins. He requested that I document my assessment and our discussion, and said that he would follow up the results. We were later reassured that the pain had self-resolved and the investigations were normal.
That night when we discussed the case at handover, I was surprised by how dismissive my colleagues were of the situation. The moment they heard ‘mental health unit’ and ‘chest pain’ in the same sentence, they switched off. As I attended more handover meetings throughout the year, I began to notice a tendency for medical and surgical teams to instinctively attribute a psychological basis to the presence of physical symptoms in a patient with a history of mental illness.
The following year I elected to do a term in psychiatry. When my colleagues heard this, their responses could be collectively summarised as either ‘Oh, how did you get stuck with that?’ or ‘I didn’t realise you wanted to be a psychiatrist!’ Very few of them seemed to recognise the value of experience in mental health regardless of your planned career path. I embarked on the term with an open mind and a goal to learn as much as I could in the short ten weeks I had. As anticipated, I learnt new skills in dealing with a range of clinical encounters related to mental illness. But I also learnt skills in the management of physical illness, because as it quickly became apparent, people with mental illness suffer the same physical illnesses as the rest of the population.
Management of physical illness on the mental health unit wasn’t always easy. There were at times frustrating encounters with medical and surgical teams who preferred to defer seeing a patient until all psychiatric issues had been resolved. But this idea of segregated health care failed to recognise that many of the individuals on the mental health unit lived with comorbid mental and physical illness that would persist well beyond discharge home. Additionally it appeared that some teams had a genuine fear of managing patients with a history of mental illness. It wasn’t uncommon for acute physical problems to be managed on the mental health unit simply because the medical or surgical team did not feel comfortable having someone with a history of mental illness on their ward.
With all the education that doctors receive in medical school and beyond, why are we still afraid of mental illness? The observations I have made are not new, and indeed there is a body of literature that highlights irrational beliefs that doctors have towards mental health and psychiatry. However it is thought that these stem from emotional rather than cognitive processes, similar to those that lead to stigma against mental illness in society. Much of the fear that doctors have of looking after patients with mental illness arises from lack of experience. But if all doctors had greater experience in mental health, perhaps we could better appreciate the co-existence and interaction between mental and physical health to provide holistic patient-centred care.
Today marks the start of Mental Health Week. There is increasing motivation in Australia to address mental illness: recognising discrimination against those who suffer from it, and empowering them to seek help. Within the discipline of medicine, it is important to remember that mental illness can affect anyone and at any time. We each probably know someone affected by it, whether it is a partner, family member, friend or colleague.
We must recognise that people with mental illness face enormous stigma in the community and because of this they are often reluctant to seek medical attention. We as medical professionals are enormously privileged to be able to work with and help this vulnerable population and we should strive to make the experience as positive as possible or else we risk individuals refusing to engage with health services in the future.
People with mental illness also suffer from physical illness. This may be associated with their mental illness or occur independently. We should always review and manage physical illness with respect and dignity regardless of comorbid mental illness, and not reflexively attribute physical symptoms to mental illness, which can have a hugely negative impact on the individual and their loved ones. We must respect the people who work with and care for people with mental illness. They possess invaluable skills and are always willing to work as part of a team to optimise holistic patient-centred care.
What strategies does your workplace use to reduce discrimination against mental illness?