The US healthcare system is at a dramatic fork in the road | Adam Gaffney

The US healthcare system – and with it the health and welfare of millions – is poised on the edge of a knife. Though the fetid dysfunction and entanglements of the Trump presidency dominate the airwaves, this is an issue that will have life and death consequences for countless Americans.

The Congressional Budget Office’s (CBO) dismal “scoring” of the revised American Health Care Act (AHCA) on Wednesday made clear just how dire America’s healthcare prospects are under Trump’s administration. But while the healthcare debate is often framed as a choice between Obamacare and the new Republican plan, there are actually three healthcare visions in competition today. These can be labelled healthcare past, healthcare present, and healthcare future.

Let us begin with healthcare past, for the dark past is precisely where Republicans are striving to take us with the AHCA. The bill – narrowly passed by the House on 4 May – is less a piece of healthcare “reform” than a dump truck sent barreling at high speed into the foundation of the healthcare safety net.

Wednesday’s CBO score reflects the modifications made to the AHCA to pacify the hard-right Freedom Caucus, changes that allowed states to obtain waivers that would relieve health insurers of the requirement that they cover the full spectrum of “essential healthcare benefits”, or permit them to charge higher premiums to those guilty of the misdemeanor of sickness, all purportedly for the goal of lowering premiums.

In fairness, the CBO report did find that these waivers would bring down premiums for non-group plans. This, however, was not the result of some mysterious market magic, but simply because, as the CBO noted, covered benefits would be skimpier, while sicker and older people would be pushed out of the market.

In some states that obtained waivers, “over time, less healthy individuals … would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all”. Moreover, out-of-pocket costs would rise for many, for instance whenever people needed to use services that were no longer covered – say mental health or maternity care.

Much else, however, stayed the same from the previous reports. Like the last AHCA, this one would cut more than $ 800bn in Medicaid spending over a decade, dollars it would pass into the bank accounts of the rich in the form of tax cuts, booting about 14 million individuals out of the program in the process. And overall, the new AHCA would eventually strip insurance from 23 million people, as compared to the previous estimate of 24 million.

It’s worth noting here that Trump’s budget – released Tuesday – proposed additional Medicaid cuts in addition of those of the AHCA, which amounted to a gargantuan $ 1.3tn over a decade, according to the Center on Budget and Policy Priorities.

The tax plan and budget – best characterized as a battle plan for no-holds-barred top-down class warfare drawn up by apparently innumerate xenophobes – would in effect transform the healthcare and food aid of the poor into bricks for a US-Mexico border wall, guns for an already swollen military, and – more than anything – a big fat payout to Trump’s bloated billionaire and millionaire cronies.

What becomes of this violent agenda now depends on Congress – and on the grassroots pressure that can be brought to bear upon its members.

But assuming the AHCA dies a much-deserved death – quite possible given the headwinds it faces in the Senate – we will still have to contend with healthcare present.

Last week, the Centers for Disease Control released 2016 results from the National Health Interview Survey, giving us a fresh glimpse of where things stand today. And on the one hand, the news seemed good: the number of uninsured people fell from 48.6 to 28.6 million between 2010 and 2016.

On the other hand, it revealed utter stagnation: an identical number were uninsured in 2016 as compared with 2015, with about a quarter of those with low incomes uninsured last year (among non-elderly adults). It also suggested that the value of insurance is declining, with “high-deductible health plans” rapidly becoming the rule and not the exception: for the privately insured under age 65, 39.4% had a high-deductible in 2016, up from 25.3% in 2010.

Healthcare present, therefore, is an unstable status quo: an improvement from healthcare past, no doubt, but millions remain uninsured and out-of-pocket health costs continue to squeeze the insured.

Which takes us to the third vision, that of healthcare future. As it happens, another recent development provided a brief glimmer of hope for that vision. As the Hill reported, the Democratic congressman John Conyers held a press conference yesterday (Physicians for a National Health Program, in which I am active, participated) to announce that his universal healthcare bill – the “Expanded & Improved Medicare For All Act” – had achieved 111 co-sponsors, amounting to a majority of the House Democratic Caucus and the most in the bill’s history.

This bill – like other single-payer proposals – is the precise antithesis of Paul Ryan’s AHCA. Rather than extract coverage from millions to provide tax breaks for the rich, it would use progressive taxation to provide first-dollar health coverage to all.

Which of these three visions will win out is uncertain, but the outcome of the contest will have a lasting impact on the country. We can only hope that the thuggish, rapacious vision championed by Trump and his administration does not prevail.

The US healthcare system is at a dramatic fork in the road | Adam Gaffney

The US healthcare system – and with it the health and welfare of millions – is poised on the edge of a knife. Though the fetid dysfunction and entanglements of the Trump presidency dominate the airwaves, this is an issue that will have life and death consequences for countless Americans.

The Congressional Budget Office’s (CBO) dismal “scoring” of the revised American Health Care Act (AHCA) on Wednesday made clear just how dire America’s healthcare prospects are under Trump’s administration. But while the healthcare debate is often framed as a choice between Obamacare and the new Republican plan, there are actually three healthcare visions in competition today. These can be labelled healthcare past, healthcare present, and healthcare future.

Let us begin with healthcare past, for the dark past is precisely where Republicans are striving to take us with the AHCA. The bill – narrowly passed by the House on 4 May – is less a piece of healthcare “reform” than a dump truck sent barreling at high speed into the foundation of the healthcare safety net.

Wednesday’s CBO score reflects the modifications made to the AHCA to pacify the hard-right Freedom Caucus, changes that allowed states to obtain waivers that would relieve health insurers of the requirement that they cover the full spectrum of “essential healthcare benefits”, or permit them to charge higher premiums to those guilty of the misdemeanor of sickness, all purportedly for the goal of lowering premiums.

In fairness, the CBO report did find that these waivers would bring down premiums for non-group plans. This, however, was not the result of some mysterious market magic, but simply because, as the CBO noted, covered benefits would be skimpier, while sicker and older people would be pushed out of the market.

In some states that obtained waivers, “over time, less healthy individuals … would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all”. Moreover, out-of-pocket costs would rise for many, for instance whenever people needed to use services that were no longer covered – say mental health or maternity care.

Much else, however, stayed the same from the previous reports. Like the last AHCA, this one would cut more than $ 800bn in Medicaid spending over a decade, dollars it would pass into the bank accounts of the rich in the form of tax cuts, booting about 14 million individuals out of the program in the process. And overall, the new AHCA would eventually strip insurance from 23 million people, as compared to the previous estimate of 24 million.

It’s worth noting here that Trump’s budget – released Tuesday – proposed additional Medicaid cuts in addition of those of the AHCA, which amounted to a gargantuan $ 1.3tn over a decade, according to the Center on Budget and Policy Priorities.

The tax plan and budget – best characterized as a battle plan for no-holds-barred top-down class warfare drawn up by apparently innumerate xenophobes – would in effect transform the healthcare and food aid of the poor into bricks for a US-Mexico border wall, guns for an already swollen military, and – more than anything – a big fat payout to Trump’s bloated billionaire and millionaire cronies.

What becomes of this violent agenda now depends on Congress – and on the grassroots pressure that can be brought to bear upon its members.

But assuming the AHCA dies a much-deserved death – quite possible given the headwinds it faces in the Senate – we will still have to contend with healthcare present.

Last week, the Centers for Disease Control released 2016 results from the National Health Interview Survey, giving us a fresh glimpse of where things stand today. And on the one hand, the news seemed good: the number of uninsured people fell from 48.6 to 28.6 million between 2010 and 2016.

On the other hand, it revealed utter stagnation: an identical number were uninsured in 2016 as compared with 2015, with about a quarter of those with low incomes uninsured last year (among non-elderly adults). It also suggested that the value of insurance is declining, with “high-deductible health plans” rapidly becoming the rule and not the exception: for the privately insured under age 65, 39.4% had a high-deductible in 2016, up from 25.3% in 2010.

Healthcare present, therefore, is an unstable status quo: an improvement from healthcare past, no doubt, but millions remain uninsured and out-of-pocket health costs continue to squeeze the insured.

Which takes us to the third vision, that of healthcare future. As it happens, another recent development provided a brief glimmer of hope for that vision. As the Hill reported, the Democratic congressman John Conyers held a press conference yesterday (Physicians for a National Health Program, in which I am active, participated) to announce that his universal healthcare bill – the “Expanded & Improved Medicare For All Act” – had achieved 111 co-sponsors, amounting to a majority of the House Democratic Caucus and the most in the bill’s history.

This bill – like other single-payer proposals – is the precise antithesis of Paul Ryan’s AHCA. Rather than extract coverage from millions to provide tax breaks for the rich, it would use progressive taxation to provide first-dollar health coverage to all.

Which of these three visions will win out is uncertain, but the outcome of the contest will have a lasting impact on the country. We can only hope that the thuggish, rapacious vision championed by Trump and his administration does not prevail.

Charlie Gard doctors can stop providing life support, court rules

A couple who want to stop doctors taking their baby son off life support so they can take him to the US for treatment could take their case to the supreme court.

Appeal court judges ruled on Thursday that doctors could stop providing treatment nine-month-old Charlie Gard, who is being kept on a ventilator at Great Ormond Street hospital in London.

Chris Gard and Connie Yates had sought to keep their son alive long enough to travel with him to the US for experimental treatment that may prolong his life.

Lawyers representing the couple told appeal court judges that they would like the supreme court to consider the case.

Connie Yates and Chris Gard.


Connie Yates and Chris Gard. Photograph: Gareth Fuller/PA

Charlie, who was born on 4 August last year, had a form of mitochondrial disease that causes progressive muscle weakness and brain damage. He can only breathe through a ventilator and has been fed through a tube.

Lord Justice McFarlane, Lady Justice King and Lord Justice Sales analysed evidence at a court of appeal hearing in London. A high court judge last month ruled against a trip to the US, and in favour of Great Ormond Street doctors who said they believed it was time to stop providing life support for Charlie.

Richard Gordon QC, who led Charlie’s parents’ legal team, told the appeal court judges that the case raised serious legal issues, including the possibility that Charlie might be being unlawfully detained and denied his right to liberty.

“They wish to exhaust all possible options,” Gordon said in a written outline of Charlie’s parents’ case. “They don’t want to look back and think ‘what if?’. This court should not stand in the way of their only remaining hope.”

Gordon said judges should not interfere with the exercising of parental rights and added: “What is really at stake in this case is the state, on a massive scale, intruding in your right to private and family life.”

But Katie Gollop QC, who led Great Ormond Street’s legal team, suggested further treatment would leave Charlie in a condition that gave him “no benefit”. The therapy proposed in the US was “experimental” and would not help Charlie, she said.

“There is significant harm if what the parents want for Charlie comes into effect,” she told the appeal judges. “The significant harm is a condition of existence which is offering the child no benefit.”

Gollop said nobody knew whether Charlie was in pain, “because it is so very difficult because of the ravages of Charlie’s condition. He cannot see, he cannot hear, he cannot make a noise, he cannot move.”

After the judges upheld the ruling, Lord Justice McFarlane praised Charlie’s parents for their composure and dignity, and said: “My heart goes out to them.”

Charlie Gard doctors can stop providing life support, court rules

A couple who want to stop doctors taking their baby son off life support so they can take him to the US for treatment could take their case to the supreme court.

Appeal court judges ruled on Thursday that doctors could stop providing treatment nine-month-old Charlie Gard, who is being kept on a ventilator at Great Ormond Street hospital in London.

Chris Gard and Connie Yates had sought to keep their son alive long enough to travel with him to the US for experimental treatment that may prolong his life.

Lawyers representing the couple told appeal court judges that they would like the supreme court to consider the case.

Connie Yates and Chris Gard.


Connie Yates and Chris Gard. Photograph: Gareth Fuller/PA

Charlie, who was born on 4 August last year, had a form of mitochondrial disease that causes progressive muscle weakness and brain damage. He can only breathe through a ventilator and has been fed through a tube.

Lord Justice McFarlane, Lady Justice King and Lord Justice Sales analysed evidence at a court of appeal hearing in London. A high court judge last month ruled against a trip to the US, and in favour of Great Ormond Street doctors who said they believed it was time to stop providing life support for Charlie.

Richard Gordon QC, who led Charlie’s parents’ legal team, told the appeal court judges that the case raised serious legal issues, including the possibility that Charlie might be being unlawfully detained and denied his right to liberty.

“They wish to exhaust all possible options,” Gordon said in a written outline of Charlie’s parents’ case. “They don’t want to look back and think ‘what if?’. This court should not stand in the way of their only remaining hope.”

Gordon said judges should not interfere with the exercising of parental rights and added: “What is really at stake in this case is the state, on a massive scale, intruding in your right to private and family life.”

But Katie Gollop QC, who led Great Ormond Street’s legal team, suggested further treatment would leave Charlie in a condition that gave him “no benefit”. The therapy proposed in the US was “experimental” and would not help Charlie, she said.

“There is significant harm if what the parents want for Charlie comes into effect,” she told the appeal judges. “The significant harm is a condition of existence which is offering the child no benefit.”

Gollop said nobody knew whether Charlie was in pain, “because it is so very difficult because of the ravages of Charlie’s condition. He cannot see, he cannot hear, he cannot make a noise, he cannot move.”

After the judges upheld the ruling, Lord Justice McFarlane praised Charlie’s parents for their composure and dignity, and said: “My heart goes out to them.”

‘Writing about Beethoven helped me come to terms with my own hearing loss’

As someone who makes a living as both a soprano and a playwright, I should find Beethoven an obvious subject of interest. Even more so now, as 18 months ago I was diagnosed with a hearing loss condition called acoustic neuroma or vestibular schwannoma, which will eventually lead to complete hearing loss in my right ear. I already often sleep through my alarm if I have my good ear jammed into my pillow.

One in six people suffer some form of hearing loss. There is no reason to suppose musicians are magically exempt from that statistic. Yet you wouldn’t know it. That fear of admitting to hearing loss hasn’t changed since Beethoven’s day. It is still simply too risky. Hearing is an essential tool for a musician, and human beings are not very good at understanding subtleties: that it is possible to have hearing loss, yet still hear enough to continue being a musician.

But I almost certainly wouldn’t have chosen to write a play about Beethoven were it not for Krysia Osostowicz, leader of the Dante Quartet. We met shortly after my diagnosis, ostensibly to discuss fundraising for the quartet’s tour of Japan. But instead we ended up talking about their plans to perform the entire cycle of Beethoven’s 16 or 17 string quartets (depending on how you count them) over six concerts. Krysia had ideas for combining the quartets with readings and narrative. I told her about the positive reactions to my work with the Marian Consort for their performances of my concert-cum-play Breaking the Rules, about 16th-century composer and murderer Carlo Gesualdo.

[embedded content]
The Marian Consort perform Breaking the Rules

“Would you be interested in writing a narrative for Beethoven to accompany the series?” Krysia asks.

I hesitate. One of the reasons I hadn’t considered writing about Beethoven is that in some ways it felt too personal. The one thing everyone knows about Beethoven is that he was deaf. It would be impossible to write a piece without tackling his hearing loss, and that would mean looking at my own journey full in the face. I wasn’t sure I was ready for it.

For a start, my hearing loss wasn’t common knowledge. I was careful who I told at first. I had always been complimented by other musicians on my intonation, and it was a source of pride. I was desperate to hang on to that skill and mostly, so far, I have learned to adapt, making good use of my left ear.

soprano Clare Norburn.


Challenge … soprano Clare Norburn. Photograph: Robert Piwko

Practising on my own is easy. Working with other musicians – for me the true joy of being a musician – is more challenging. It’s because you hear both inwardly and outwardly when you work with others. In your inner ear you are loudest of all, and when half of the source of your information from the outside world (about how to blend, tune and balance) is by degrees cut off, it’s hard.

But mostly it’s about fear – of what others will think. And this is an experience that I clearly share with Beethoven, although his deafness was so much more devastating than mine. And his response to deafness is simply extraordinary – an inspiration.

It was in summer 1801, when he was 30, that Beethoven first admitted in a letter to his increasing deafness. A year later came his “dark night of the soul” moment. Beethoven suffered not only from increasing deafness but from what specialists think may have been hyperacusis – a rare condition where pain is caused by loud noises, accompanied by hearing loss. His physician suggested he move from the noise of the city to give his ears a rest. So the composer went to Heiligenstadt, a village now on the outskirts of Vienna. There he penned his Heiligenstadt Testament, in which he wrote frankly about the effect of his increasing deafness. He admitted how isolated he felt, how he had withdrawn from society because he could not hear, and how, as Vienna’s foremost pianist and composer, he could not admit to his deafness.

He admitted to considering suicide. “Only my art, that is all that held me back,” he wrote. And from that moment of true despair came an extraordinary hope, an artistic commitment: “It was impossible for me to leave this world until I had brought forth everything that was within me.”

This really resonated with me. As I have come to terms with my hearing loss, it too has ultimately been a call to action. Today suddenly has such potency. Who knows what I will be able to hear tomorrow? I must write, must sing, now. No more putting things that matter on hold for an uncertain future.

[embedded content]
The Dante Quartet perform Beethoven’s String Quartet No. 16

So I said yes to Krysia and the Dante Quartet. And, as I wrote a funding application to Arts Council England and researched Beethoven’s life, I realised that making this a first-person narrative was an opportunity to shine a light on some of those hearing loss nuances, and to shout loud about Beethoven’s extraordinary achievements.

The words I put into Beethoven’s mouth speak for me, for all musicians who silently suffer hearing loss: I’d always been gauche at those society soirees. So imagine me now. I mean, there’s a limit to how many times I can ask people to repeat themselves without giving myself away.

“I am a musician, a composer. Hearing is all – it defines me. The pricking of my skin shows me the future. Society is unthinking. There is black and there is white. Hearing. Deafness. And nothing in between.

“But the truth is sometimes grey. I have not lost my critical faculties overnight. I can still hear when the tenor is flat, when the horn comes in a beat late.

“Yet I fear that the great and good of Vienna will think: poor Beethoven. He has lost his edge.”

The extraordinary thing about Beethoven’s hearing loss journey is that he found a way forward at every stage. Once he accepted his deafness at Heiligenstadt, it was no longer a source of shame, and he was open about it from then onwards. Even for the last 10 years of his life, when he could hear nothing, he kept composing. Many people will know the story of his conducting what seems to be an orchestra in his head at the premiere of his 9th Symphony. Eyes still shut, he had to be stopped and shown the smiling musicians, the appreciative audience applauding.

He had clearly found a way of hearing in an inner soundscape, which gave me an idea for a way into my series of six concert-plays for the Beethoven Quartet Journey. Dante are the string quartet Beethoven hears in his head. My Beethoven explains this to the audience: The music in my head. It’s flawless. Perfectly in tune. Each articulation lifted clean off the page.

David Timson as Beethoven in Clare Norburn’s Beethoven Quartet Journey.


David Timson as Beethoven in Clare Norburn’s Beethoven Quartet Journey. Photograph: Nick Harries

“My very own imaginary quartet … they play newly minted movements perfectly.

“And they are blessedly silent. None of that moaning that my music is unplayable!

The narrative is about much more than Beethoven’s hearing loss. Writing six concert-plays means a big canvas, and I wanted to balance the script to cover both the man and his music. One of the most enjoyable aspects of the collaboration with the quartet has been finding ways to provide an accessible and lively narrative, to explain what Beethoven does musically in a way that makes the works understandable for non-musicians, but also brings insights even for those who know the quartets well.

Ultimately, I learn from Beethoven that I am lucky. He shows me that hearing loss in one ear is nothing, even for a musician. “Find your own way,” he tells me. “And keep finding it. The time is not tomorrow. The time for action is now.”

12 Jours review – a devastating glimpse into broken souls

A young woman stares across a table at the judge who is reviewing her case. Her gaze is both searingly intense and curiously blank. Holding herself preternaturally still, muscles tensed against the turmoil of emotions, she pleads to see the two-year-old daughter who has been removed from her care. “Not all the time, I accept that. But just to change her diaper, to love her.” If there’s a more achingly sad moment in any film of the 2017 Cannes film festival, it’s hard to imagine what it could be. For 12 Jours, veteran documentarian Raymond Depardon (Modern Life, Journal de France) turns his lens on to the desperate, broken souls of the patients who have been involuntarily committed into the care of a Lyon psychiatric institution.

By French law, anyone admitted into the hospital without their consent must be seen by a judge within 12 days. The cases of long-term patients are also assessed on a regular basis. The patient, accompanied by a lawyer, sits on one side of a table in a hospital office; the judge on the other. And the conversation between them will determine whether they can be allowed to take personal responsibility for their own liberty.

Depardon protects the identities of the subjects by changing their names and other details, but their faces are shown. The extraordinary level of access and intimacy begs the question, if someone is not deemed fit to leave a psychiatric ward, can they really agree to participation in a documentary? It’s a legal and moral conundrum and it is part of a larger issue which looms over any factual film which focuses on the most vulnerable members of society. However empathetic the approach and honourable the intent, questions of consent and the spectre of exploitation lurk at the edge of the frame.

Moral questions notwithstanding, this is a remarkable piece of work. A brittle woman, voice choked up by the tears that fall as soon as she starts to talk, is stretched to breaking point by her work. She is glad to stay in the hospital, acknowledging that she needs to heal. “I’m an open wound,” she gasps.

All the other patients ask to leave. One, a young woman hollowed out by a lifetime of loneliness, wants to go home to kill herself. Another says he has a political party to start, funded by Bernie Sanders, which is going to “wipe out psychiatrists”. Another, a hollow-eyed 20-year-old man who slurs through a list of paranoid delusions in agonising slow motion, ends the interview with a promise to become a professional footballer when he gets out. The camera rests on the face of the judge for a moment as he looks into a future which is likely to include many things, none of which will be professional soccer.

The distressing momentum of scrutinising shattered psyche after shattered psyche is broken up, firstly by slow shots that roll through the corridors of the hospital like a gurney, and secondly by three sections of wrenchingly lovely music, composed by Alexandre Desplat. It’s a quietly devastating film.

Charlie Gard doctors can stop providing life support, court rules

Doctors can stop providing life-support treatment to a sick baby who is being kept on a ventilator at Great Ormond Street hospital, appeal court judges have ruled.

The decision comes after a legal battle by Chris Gard and Connie Yates, who had sought to keep their son, Charlie Gard, alive long enough to travel with him to the US for experimental treatment that may have prolonged his life.

Connie Yates and Chris Gard.


Connie Yates and Chris Gard. Photograph: Gareth Fuller/PA

Charlie, who was born on 4 August last year, had a form of mitochondrial disease that causes progressive muscle weakness and brain damage. He can only breathe through a ventilator and has been fed through a tube.

Lord Justice McFarlane, Lady Justice King and Lord Justice Sales analysed evidence at a court of appeal hearing in London. A high court judge last month ruled against a trip to the US, and in favour of Great Ormond Street doctors who said they believed it was time to stop providing life support for Charlie.

Richard Gordon QC, who led Charlie’s parents’ legal team, told the appeal court judges that the case raised serious legal issues, including the possibility that Charlie might be being unlawfully detained and denied his right to liberty.

“They wish to exhaust all possible options,” Gordon said in a written outline of Charlie’s parents’ case. “They don’t want to look back and think ‘what if?’. This court should not stand in the way of their only remaining hope.”

Gordon said judges should not interfere with the exercising of parental rights and added: “What is really at stake in this case is the state, on a massive scale, intruding in your right to private and family life.”

But Katie Gollop QC, who led Great Ormond Street’s legal team, suggested further treatment would leave Charlie in a condition that gave him “no benefit”. The therapy proposed in the US was “experimental” and would not help Charlie, she said.

“There is significant harm if what the parents want for Charlie comes into effect,” she told the appeal judges. “The significant harm is a condition of existence which is offering the child no benefit.”

Gollop said nobody knew whether Charlie was in pain, “because it is so very difficult because of the ravages of Charlie’s condition. He cannot see, he cannot hear, he cannot make a noise, he cannot move.”

I worried about working in psychiatry but one patient taught me how to listen

In medicine, psychiatry isn’t seen as glamorous. As a student and while training, you fight with your colleagues for the sexy jobs in cardiology, intensive care or on the frontline. When the crash call goes off, it’s dramatic; chest compressions, ventilation, trying to be the hero you see depicted on television. A job in psychiatry wasn’t my first choice, if there was a crisis, what would I do? Come running with my pen and notebook? Not exactly Oscar-winning stuff.

I had my reservations as I was about to embark on 91 days as a doctor in an adult inpatient psychiatric unit.

My first patient was a middle-aged woman with chronic depression and schizophrenia. Sandra* greeted me with a look of suspicion. Abused as a child, she had lived on the streets for most of her adult life, during which time she’d been through harrowing experiences. My first task was to take bloods from her. With every attempt over the next four months, I was met with the resistance of a combat warrior.

In my interactions with patients I wondered whether I was talking a different language. I had never been rejected by so many patients so much – the common answer to most of my questions being met with a firm “No!”.

After weeks of failing at any kind of meaningful interaction with patients, I decided to change tack. I stopped being the doctor in the white coat and softened my somewhat rigid attitude. Rather than judging their resistance towards me I decided to dig beneath their exterior. Connecting with my patients on an even playing field was going to be my biggest asset – but more importantly it was going to change my understanding. With Sandra, meanwhile, I had to earn her trust. Slowly, over the weeks, I learned more about what made her the person she was and the experiences that had shaped her life. She was letting me into her world, and with time she would give me her arm to take those bloods.

At first I was perhaps too naïve. I soon began to realise that if a patient was suffering from a manic episode and running around the ward naked, it wasn’t funny, but undignified. Psychotic symptoms were no longer just a list I had memorised for my medical finals exams, but instead a detachment from reality which gave patients the powers to feel like a God – indestructible. They would jump out of a window because they believed they were a superhero. I was fighting to keep them alive and protect them from the dangers of the outside world – imaginary wings will not make you fly. They will bring you crashing down to earth, hard and fast.

I started to see beyond patients’ bizarre delusions, wild disinhibition and somewhat entertaining personalities. Instead what I saw in front of me were people whose lives were consumed by the cruel fate of mental health problems. I was seeing how such a distressing illness could leave them as an empty shadow of their former self. Disabled by these crippling illnesses, their vulnerability and risk put their lives in my hands more than ever.

One day on the ward, my bleep (or, technically, in this setting, a personal protection alarm) began sounding like a siren to draw my attention to an urgent incident. Sandra lay slumped with blood pouring out from her wrists. Self harm and suicide is talked about almost too readily in the news. Seeing it in front of you is a whole different ball game.

A lone junior medic in a psychiatric hospital, I was the most senior (year two out of medical school) and experienced medical doctor. I longed for a team to come running to my aid – as is the norm in a hospital when those alarms sound. With little equipment and assistance we were able to stabilise her and wait for the bleeding to stop. Although Sandra’s wounds in time would heal, her psychological scars remained etched even deeper.

People like Sandra have taught me a lot about myself. I’m walking out with invaluable experience.

In its own right, psychiatry is a complex integration of theories and experience. No physical test will give you an explanation for the patient in front of you. Maybe that’s why the rest of the medical profession remains baffled – as a cohort we like to work with numbers and hard evidence. Instead, with mental health you must talk, listen and observe – skills that take years to acquire.

*Not her real name and some details have been changed

  • In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here

If you would like to contribute to our Blood, sweat and tears series about memorable moments in a healthcare career, read our guidelines and get in touch by emailing sarah.johnson@theguardian.com.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

I worried about working in psychiatry but one patient taught me how to listen

In medicine, psychiatry isn’t seen as glamorous. As a student and while training, you fight with your colleagues for the sexy jobs in cardiology, intensive care or on the frontline. When the crash call goes off, it’s dramatic; chest compressions, ventilation, trying to be the hero you see depicted on television. A job in psychiatry wasn’t my first choice, if there was a crisis, what would I do? Come running with my pen and notebook? Not exactly Oscar-winning stuff.

I had my reservations as I was about to embark on 91 days as a doctor in an adult inpatient psychiatric unit.

My first patient was a middle-aged woman with chronic depression and schizophrenia. Sandra* greeted me with a look of suspicion. Abused as a child, she had lived on the streets for most of her adult life, during which time she’d been through harrowing experiences. My first task was to take bloods from her. With every attempt over the next four months, I was met with the resistance of a combat warrior.

In my interactions with patients I wondered whether I was talking a different language. I had never been rejected by so many patients so much – the common answer to most of my questions being met with a firm “No!”.

After weeks of failing at any kind of meaningful interaction with patients, I decided to change tack. I stopped being the doctor in the white coat and softened my somewhat rigid attitude. Rather than judging their resistance towards me I decided to dig beneath their exterior. Connecting with my patients on an even playing field was going to be my biggest asset – but more importantly it was going to change my understanding. With Sandra, meanwhile, I had to earn her trust. Slowly, over the weeks, I learned more about what made her the person she was and the experiences that had shaped her life. She was letting me into her world, and with time she would give me her arm to take those bloods.

At first I was perhaps too naïve. I soon began to realise that if a patient was suffering from a manic episode and running around the ward naked, it wasn’t funny, but undignified. Psychotic symptoms were no longer just a list I had memorised for my medical finals exams, but instead a detachment from reality which gave patients the powers to feel like a God – indestructible. They would jump out of a window because they believed they were a superhero. I was fighting to keep them alive and protect them from the dangers of the outside world – imaginary wings will not make you fly. They will bring you crashing down to earth, hard and fast.

I started to see beyond patients’ bizarre delusions, wild disinhibition and somewhat entertaining personalities. Instead what I saw in front of me were people whose lives were consumed by the cruel fate of mental health problems. I was seeing how such a distressing illness could leave them as an empty shadow of their former self. Disabled by these crippling illnesses, their vulnerability and risk put their lives in my hands more than ever.

One day on the ward, my bleep (or, technically, in this setting, a personal protection alarm) began sounding like a siren to draw my attention to an urgent incident. Sandra lay slumped with blood pouring out from her wrists. Self harm and suicide is talked about almost too readily in the news. Seeing it in front of you is a whole different ball game.

A lone junior medic in a psychiatric hospital, I was the most senior (year two out of medical school) and experienced medical doctor. I longed for a team to come running to my aid – as is the norm in a hospital when those alarms sound. With little equipment and assistance we were able to stabilise her and wait for the bleeding to stop. Although Sandra’s wounds in time would heal, her psychological scars remained etched even deeper.

People like Sandra have taught me a lot about myself. I’m walking out with invaluable experience.

In its own right, psychiatry is a complex integration of theories and experience. No physical test will give you an explanation for the patient in front of you. Maybe that’s why the rest of the medical profession remains baffled – as a cohort we like to work with numbers and hard evidence. Instead, with mental health you must talk, listen and observe – skills that take years to acquire.

*Not her real name and some details have been changed

  • In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here

If you would like to contribute to our Blood, sweat and tears series about memorable moments in a healthcare career, read our guidelines and get in touch by emailing sarah.johnson@theguardian.com.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

Digital autopsies should be standard for probable natural deaths, says study

Digital autopsies should be the first-line approach in postmortem investigations of probable natural death, and should be offered free of charge to families, researchers have said.

About 90,000 autopsies requested by coroners are carried out in England and Wales every year, with the majority of deaths found to be a result of natural causes.

A switch to body-scanning techniques could prove valuable, say researchers, since a traditional autopsy can be upsetting for the bereaved and a number of religions, including Islam and Judaism, teach that a body should be buried quickly and not violated after death.

“The main benefit is about avoiding the autopsy,” said Bruno Morgan, co-author of the research from the University of Leicester. “The autopsy is not just a simple operation, it is opening [the body] up fully, taking all the organs out and slicing them all into pieces.”

CT scans have long been used to aid postmortem investigations, while more recently studies have explored targeted coronary angiography – another CT scanner-based technique that involves inserting a catheter into an artery and is used to reveal whether blockages are present in the coronary arteries, and to investigate the heart itself.

The latter is a major step forward, since one limitation of digital autopsies has been the difficulty of standard CT scans in establishing causes of death such as coronary heart disease.

[embedded content]

The latest study offers a large-scale comparison of the accuracy of the combined CT techniques to traditional autopsy.

“This paper is the first one that has come out and says this is as accurate as autopsy is in this setting. It works and therefore it is a valid alternative,” said Morgan.

Writing in the Lancet, researchers led by a team at the University of Leicester describe how they studied 241 cases of adults who had died suddenly and unexpectedly of natural causes or had died a non-suspicious unnatural death.

Each was assessed by a postmortem CT scan, with targeted coronary angiography successfully carried out in 85% of the cases. Standard autopsies were then carried out for each case, with the pathologists not told about the findings from the body scans.

After excluding 31 cases, including 24 cases for which the cause of death was clearly traumatic, such as a gunshot wound, the team found that the body-scan approach gave a cause of death, based on “the balance of probabilities”, in 92% of cases.

In 11% of this group, results from either the scans or the autopsy were at odds with findings from a combination of the two. Further analysis revealed that these discrepancies were evenly split between errors in the body-scan approach and errors in the traditional autopsy.

The team say the gold standard for postmortem is the use of both traditional autopsy and body scans, but say the findings support a move to using digital autopsy as the first-line technique in cases of probable natural death. Should more evidence be required, they add, a traditional autopsy can subsequently be carried out.

The public are already allowed to request – usually at a cost of about £500, typically paid by the family – that digital autopsies are used for postmortem investigations where appropriate.

But Morgan says that option should be made available free of charge – a service currently only offered by a small number of councils.

“If you don’t want an invasive autopsy on yourself or on your family, you should be raising the debate and saying why can’t the council pay for this?” he said. “It strikes me that it is wrong that we should make people pay for something that is a statutory obligation,” he added.

Dr Mike Osborn, a fellow of the Royal College of Pathologists, said that postmortem investigations are vital in understanding why people die, as well as improving understanding of disease. But he acknowledged that autopsies can be distressing and clash with religious beliefs.

The development of digital autopsies, including those based on CT scans, he added, was exciting and important. While Osborn noted that some conditions still require a diagnosis from a traditional autopsy, he welcomed further research in the field to reduce the number of traditional autopsies required. “The accuracy of cross-sectional imaging postmortem has improved over the last 20 years and is likely to continue to do so,” he said. “The College fully supports further research in this area while reinforcing the need for thorough and robust governance in this emerging field.”