Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground. You can read the rest of the series here, and here.

One of the pharmacists at the Training Ground wasn't interested in his job. Not at all. An ideal shift, for him, would be involve a technician to do all the dispensing. That way, all he had to do was check the 'script before it went out. And read the newspaper.

He read the Sydney Morning Herald, in its entirety, each and every shift. Quite an impressive feat. And potentially disastrous.

The Newspaper Pharmacist (NP) prioritised reading above everything except checking prescriptions, and in doing so, compromised his patients. He didn't counsel on new medications. He didn't give opinions regarding the most appropriated Pharmacist-prescribed medicines. He left the shop assistants to fend for themselves. He was thrilled that I could dispense, albiet at a lethargic pace.

The NP was a good bloke; he was intelligent and had wide ranging and interesting views on the world. Unsuprisingly, he was well informed on the state of the world, and we had discussions about everything from Casey Martin in the USPGA tour, to unfolding events in Israel, to the state of the Health system in Australia, New Zealand, the UK and the US. I became a better world citizen from my chats with NP.

It helped my pharmacy, too. Every time I worked with NP I would be thinking "He needs to talk to this patient." Or, "I don't think that's the right stuff." All this was sharpened by my idealistic student way of thinking. I was horrified at the lack of interest the NP gave to his work, more so given the poor quality of shop assistant (more on that next time).

From a tangible point of view, NP wasn't doing anything wrong. It was NP's failure to act, counsel and frankly, to care, that left me gobsmacked. By the end of the Summer, I'd firmly resolved never to be a newspaper pharmacist.

This was the consultant's opening gambit in a tutorial about dementia. We went on to discuss this idea and noted characteristic observations of an elderly dementing driver at an intersection,and the differences compared inexperienced drivers.

Younger drivers usually have superior reaction times, their mental processing can usually identify risks. However, inexperienced drivers may respond somewhat inappropriately to the perceived risk, resulting in "close calls" and situations that could well be described as a "lack of judgment".

A kid getting their license for the first time is excited; they feel great, and are often lauded by their peers and parents alike. They have achieved a new level of independence, and are becoming a fully functioning adult.

Conversely, dementing drivers have markedly slowed reaction times, and their mental processing is overwhelmed by the mass of information. Their inability to integrate large amounts of complex information in a very short space of time, and act accordingly, is the crux of the problem. The medical term is "executive function"; in dementia it is compromised.

Often though, the demented driver has some coping mechanisms in place. They may hesitate before selecting a gap, may stay close to home and avoid highways. Taking a license away from this person will leave them trapped and house-bound. They may feel demeaned and wronged, because they've never had a crash in their life. Their independence will be curtailed, and their outlook on their life may suffer.

Additionally, driving delirious or drunk is a bit like practicing medicine drunk; you put others at huge risk unnecessarily due to the short-term compromise in your executive functioning. Simply put, if you drink and drive, you're a bloody idiot.

These principles seem to echo into medicine;

We celebrate getting our license, we don't work or drive drunk and we're aware that as we get older, whilst our coping mechanisms and experience grow sharper, at the end of our careers our processing skills and executive function may diminish.

Then what? Do we continue to practice? Do we wait for the proverbial 'tap on the shoulder' from authorities? Or do we wait for an ambulance to pick up the pieces of our accident?

Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground. You can read the full series introduction here.

At the Training Ground, there were four full-time shop assistants, and I, as a student, slotted into the fifth spot. Four would work each day, with one opening at 6am and the rest trickling in before 8am. The four girls, between them, had established that the 'opener' would make the pharmacist breakfast each day.

This was a pretty sweet gig for the boss as the 'script trade was rarely overly intense, and the assistants, in addition to the usual order and stock managment, cleaned the shop from top to bottom each day, removing entire bags of breakdust.

On my first opening shift, I blearily arrived at the appointed 5:45 am and helped open the store. As rush hour began to subside, I asked Syd what he'd like for breakfast.

Syd laughs and says to me,

"Mate, you don't have to make me breakfast. And they don't either. Always remember that. Making meals or fetching food is something that's outside your assistant's job description, and you should never expect it."

Meantime Lillian, the older and more assertive of the team, has typically asserted herself, and whipped up the usual peppered tomatoes on rice-crackers.

Syd elbows me gently in the side and in a low whisper says,

"Remember, if they're even offering you food, that's a really good sign... Unless it's poisoned."

Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground.

The store was located in one of Australia's busiest station, a meagre 40 metres from the barriers. As a result, the shop was endlessly covered in a layer of brakedust. There was an open-style shopfront and no air-conditioning, so stale, rancid summer air wafted at the behest of the lazy ceiling fans. These too, were coated with an inch in black on all surfaces, and at their worst resembled startled bats, flying in circles.

The dispensary, too, was choked thick with black dust. A key job of the pharmacist or assistant was to wipe every item, not only so the label would stick better, but so the box could actually be read and checked!

The pharmacy was staffed by four assistants, myself and the pharmacist owner. In the afternoons, the pharmacist would be relieved a few afternoons a week by one of this two pharmacist mates.

The owner, Syd, (and consequently, his mates) was in his mid sixties. He was, at that time, my archetypal pharmacist; wise, banterous, compassionate and unflappable.

I also learned some really good skills from several of the Pharmacists who worked there, especially when it came to staff management. The lessons I learned were partly though necessity, partly through dumb luck but mostly from kind and honest teaching. This series looks at some of the lessons from the Training Ground.

I'm well and truly into the thick of Psyche Rotation, and true to my word, I'll not be bringing you any patient stories.

All in all, I've found psychiatry a potentially overwhelming area; it's not that the theory is gargantuan or the hours are terrifying or even that it's diagnostically mind-boggling.

The challenge, I feel, is that, for each and every patient under the Specialist Psychiatry teams, their issues pervade through every single aspect of their lives. There's no aspect that seems to escape the ravages of severe mental illness;

Physical Health
Interpersonal relationships
Education
Sociability
Sense of self
Money management
and more.

It all gets absolutely totaled. And it's all such a synergistic failure. Without most aspects of a person's life functioning, they're so vulnerable to falling, as my friend James would say, in a screaming heap.

I understand the management principles and theories for vulnerable patients, and I can see these being applied relatively consistently to a variety of situations. I, like the majority of staff, have great, realistic, hope for the patients, their management plans and their prospects. It's so frustrating when one of, say, fifteen aspects of a plan doesn't work the way it should and the patient's back to square one.

It's astonishingly precarious. And, I guess, when you apply that idea to patients in moderate and milder situations, that any one event or stressor can tip them into a severely dysfunctional state, it's pretty worrisome.

So, in a nutshell, that's my experience in psychiatry; overwhelmingly precarious. Oh, and one of the Fat Man's laws;

4. THE PATIENT IS THE ONE WITH THE DISEASE.

I'm not a violent man, but sometimes I really have the urge to yell at people. On this day, I kept it under control. Barely.

She was getting in my face. If that's possible to do behind an inch-thick glass screen.

Man, was I tired. The flight had been at least ten hours, and Singapore Airlines aren't really built for 6 foot four Barbudans who are used to lounging about. Well, not in economy class, at least. Still, the food had been exceptional; a welcome relief from the three solid weeks of curries I'd endured through Goa and Tamil Nadu.

But now I'm standing at customs, trying to get home for a sleep, and this woman asks me what my business is.

"I been on holiday."

She looks me up and down, looks at my well-worn passport. I'm proud of it, y'know. For a start, it's a Barbudan passport, even though I'm an Aussie. Plus, there's about twenty five, maybe thirty countries in there. Some weird ones too, like when I went to visit my mate Nas in Botswana.

Anyway, the uniform behind the glass starts leafing through my stuff pretty intently. And she says, matter-of-factly,

"And how did you get the money to pay for your trip?"

Who asks that? Since when do customs care how punters bankroll their holiday. That really pissed me off. She's asking me because I look different. I got smart;

"I stole it of course."

And the cow calls her boss. He waddles over in his grey knit jumper and starts giving me a dressing down. He asked what I'd said to the customs woman to get him over there. It told him that it wasn't cool to ask where someone got their money. So he asked me.

"And where did you get the money?" What an arsehole.

I told him.

I'm a cabbie. Y'know. I work hard for my money. I don't mean this nine to five white collar crap. I'm talking hundred hour weeks, sometimes a hundred and ten. I drive for four different blokes, at all hours of the night. I work my ring off. And now this cow with a sprayed-on uniform asks where I get the money to travel. Maybe I'm just one of those guy who attracts attention for the wrong reasons.

He keeps asking me questions, and making me repeat myself. He says he can't understand my accent. How dumb is that. I mean, I can only speak english.

Eventually, they let me go.

We all knew that she wouldn't have asked if I was white.