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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 2.

An “informal curriculum” refers to lessons that are not explicitly taught. In medicine, there are skills doctors learn that are rarely recorded in textbooks or overtly discussed during rounds or lectures. However, these are important skills that doctors need so they can work effectively with patients and colleagues. Lessons in the informal curriculum include how to present patient information to other doctors, how to discuss end of life care with the families of patients, etc.

Contrast this with the “formal curriculum”, which focuses on topics such as anatomy, physiology, and using the language of the field. Contrast this also with the “hidden curriculum”, which can include topics like how to hide medical errors, beliefs about the utility (or lack thereof) of different types of physicians, etc.

In this series, I will share some lessons from the informal curriculum about interviewing patients.[1. Back when I was a medical student, psychiatrists were still considered the artisans of the clinical interview… and not just dispensers of psychiatric medications.] I usually teach these lessons to medical students. Other physicians, psychiatrists or not, may find them useful. If for nothing else, this provides an opportunity for all of us to consider how physicians can improve interactions with patients.

I am purposely omitting the first recommendation for now because it is paramount, the most difficult to define, and often challenging to implement.

My second recommendation: Orient patients to the interview. Patients often don’t know what to expect during an initial visit with a doctor. It takes less than 60 seconds to explain the ground rules of the game of the clinical interview. Doing this can help dispel some of the anxiety patients may have about the meeting. It also gives physicians the opportunity to shape the interview before it begins.

Make introductions. Tell people your name. Ask patients for their name (and how they would prefer to be addressed). Though a power differential exists between doctor and patient, you’re both human beings. Good manners go a long way in building a strong working relationship. The person in front of you is not just a patient: He is a person with hobbies, strengths that you may not have, and a name. Acknowledge the person and at least learn his name.

Tell patients how much time you have together. In outpatient settings, most patients generally know how long appointments will last. In inpatient settings, the schedule is less clear. In both locations, however, patients may have expectations that you will spend much more time with them than you actually can. Explicitly announcing the amount of time available can help establish and maintain focus on the presenting problem.

Tell patients what will happen during the interview. You don’t have to present a detailed itinerary, but do give patients a general idea of what to expect. If you’ll be asking a lot of questions, say so. If you’ll be performing a procedure, explain what will happen. People generally don’t like surprises. Do your best to give patients enough information so they can prepare themselves for what’s next.

Tell patients that you might interrupt them. Sometimes, some patients may start telling you things that they think you want to know. Sometimes, this information is irrelevant. Because you only have limited time together and you may need information that patients may not think to tell you, tell patients that you might interrupt them before you ever do.

When I first meet patients, my preamble goes something like this:

Hi. My name is Dr. Yang and I work as a psychiatrist. We have about 45 minutes together. I’ll be asking you a lot of questions, some of which might make you wonder, “Why is she asking me that?” If you find me interrupting you, I’m not trying to be rude; I just want to make sure I get the right information.

It takes less than 30 seconds to say that. As a result, however, I have essentially let the patient know:

  1. We have time together, but it is limited. We’ll both try to stay focused on your concerns.
  2. You might find some of my questions weird. Humor me.
  3. I intend to be courteous, but I might be impolite because I might need information that you may not think to tell me.

Without this orientation, patients might end up telling me unnecessary information. They might feel vexed when I start asking questions they don’t expect (like when I ask about menstrual cycles, HIV status, or where they live). They might find my manner rude if I interrupt them to stay on track.

This is expectation management. And this can be one of the more important things we can do for patients.

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Homelessness NYC Observations

Memorial.

Two weeks had passed before I learned what happened.

I hadn’t seen him in several months. At our last meeting, the trees were full of red and orange leaves. He, as usual, was not interested in talking to me. He was sitting in front of a closed shop.

“Hi. How are you?”

“Fine.”

People in the neighborhood took care of him. Surrounding him were several plastic bags holding neatly stacked styrofoam containers filled with soup. Another bag held several pastries, most of them still wrapped in clear cellophane. Another bag contained many empty, crushed water bottles.

“Anything new happening?”

“No.”

He was old enough to be my father, though he looked like he could be a grandfather. Time had taken away some of his teeth. The joints of his fingers were knobby. Crescents of dirt were caked underneath his nails. He was wearing a different coat.

“You got a new coat.”

“Yes.”

He previously wore a blue windbreaker; now he was wearing a puffy black jacket that was three sizes too big for him. His thin neck poked out above the collar. The jacket was unzipped and showed the soiled white tee shirt he wore underneath.

“Any more thoughts about going inside for the winter?”

“Not now.”

People were starting to gather around us. In that particular neighborhood, passersby routinely stopped and gawked whenever I spoke with people who appeared obviously homeless. They were staring at us, their mouths hanging open, their faces perplexed.

“Can I help you?” I barked at them, doing nothing to mask the irritation in my voice.

In response, they closed their mouths, turned away, and walked on. (Related: One of the fastest ways to get people in New York to stop looking at you is to say, “Hello!”)

“Where are you sleeping now?”

“In the park.”

Sometimes he slept in a box. He usually slept on a flattened box, and it often wasn’t in the park. People had seen him underneath nearby construction scaffolding. Others saw him in the subway station, though he didn’t seem to use the subways at all.

He said that he had been outside for “a while”. Records from the shelter and from concerned citizens in the neighborhood suggested that he had been outside for at least 20 years.

“I know you’ve heard this before, but just humor me: You don’t have to stay outside. You can stay in a small studio apartment where they serve two meals a day, you can store your belongings there—”

“I’m okay.”

I felt for him. I wouldn’t want to talk to me if I were him.

When homeless people disappear from their usual locations, I wonder: Have they moved to a different neighborhood? Were they arrested and now in jail? Did they find a place to live? Are they in a hospital?

I often never find out.

This man had died. He contracted pneumonia and was in an intensive care unit for about a week. Was there a code? Did the physicians withdraw care? If so, who made that decision? Was anyone with him when he died?

There was no funeral. There was no memorial. Did anyone from the neighborhood notice that he was gone? Did any of those people who gawked at us notice his absence? Did people assume that he ultimately agreed to go into housing, that he finally changed his mind?

Did anyone think that he had died? Did anyone miss him?

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Education Observations Reading

Reading.

In an effort to resume the habit of writing regularly:

I finished Reynolds’s excellent Constructive Living earlier this month and am nearly through Morita’s Morita Therapy and the True Nature of Anxiety-Based Disorders. Several thoughts related to this:

1. People may believe that psychiatrists approach patient care from generally the same theory.

This is untrue.

I am not well versed in Freudian ideas or related “psychodynamic” hypotheses of mind. This is due to my inability to understand psychodynamic writings. Example from Heinz Kohut’s The Restoration of the Self (page 15):

In the analysis of those narcissistic personality disorders where working through had on the whole concerned a primary defect in the structure of the patient’s self, resulting in a gradual healing of the defect via the acquisition of new structures through transmuting internalization, the terminal phase can be seen to parallel that of the usual transference neuroses.

That single sentence has 58 words.[1. Courtesy the Word Count Tool.] I had to read the sentence three times before I understood Kohut’s idea. (“The treatment in narcissistic personality disorder focuses on a primary problem of the patient’s character. The patient integrates new ideas about himself and other people to correct this problem. When treatment is ending, patients will demonstrate similar reactions to the therapist as they did earlier in treatment.”) Because I find it difficult to read and understand this kind of writing, I am less inclined to read it.

Furthermore, I do not agree with some (many?) of the psychodynamic hypotheses of mind. I do not believe the Oedipus complex metaphor (and sometimes I’m not sure if it is meant to be a metaphor). I do not believe in the “good breast” and “bad breast” (see object relations theory).

I readily agree that I may lack the sophistication to grasp these concepts.

(That being said, I do believe that dynamics exist amongst people: There are reasons why some people are compelled to assert their superiority in a group. There are reasons why some people have difficulties leaving abusive partners. I do not believe, however, that these reasons are due to penis envy or castration anxiety.)

As a result, I read literature that I can understand: Cognitive Behavioral Treatment of Borderline Personality Disorder. Cognitive Behavioral Therapy for Severe Mental Illness. Japanese books about anxiety disorders.

2. These two texts highlight the importance of accepting emotions, versus changing them. As a result, the focus is more on behaviors. (Or, it is not possible to will ourselves to feel different emotions. What we can will, however, are behaviors.)

Some Western formulations of psychology also highlight the acceptance of emotions (mindfulness based cognitive therapy and acceptance and commitment therapy). It is not surprising that many of these formulations are based on Eastern philosophies. I have been impressed, however, with Morita’s repeated emphasis on the importance of accepting emotions. He argues that patients often experience anxiety symptoms because they are unwilling to accept what is actually there (or what is not there). All of us, to some degree, do not accept certain aspects of reality. That lack of acceptance can result in suffering.

In some ways, these Eastern philosophies directly contradict Western, psychodynamic ideas of mind. If indulging the extremes of psychodynamic hypotheses, nothing is ever what it seems. You dreamed about a dog eating flowers (“manifest content”), but what that actually means is you hope your father will die (“latent content”). Morita might argue that you might be paying too much attention to your dreams.

Two further reading recommendations:

David Healy’s blog. I had noted earlier that all psychiatrists (and patients taking antidepressants) would benefit from reading his book, The Antidepressant Era. He’s bringing related information online.

Mad in America. The posts are stimulating counterpoints to information from mainstream psychiatry.

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Lessons Observations

366 Days.

Happy new year!

The first day of the year is nearly over. How did you spend it?

Think forward to Monday, December 31, 2012. On that day, when you reflect back on the year, what will you say?

What goals will you have accomplished?

Will you have tried new things?

Will you have invested in your health?

Will you have told your friends and loved ones on a regular basis how much you care about them?

Will you have been generous? kind? compassionate?

May 2012 bring you good health and many blessings. May you be alive on December 31st, 2012, and have the opportunity to express gratitude for the year.

Tomorrow is the second day of the year. Use the time wisely.

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations Policy

Red Herring: Epilogue.

I encourage you to read the entire Red Herring series before reading this post. Consider this your “spoiler alert”.

The patient really is fine.

She returned to the gastroenterology clinic several times for treatments to widen her esophagus. (It’s a neat procedure: The GI doctors insert a small balloon into the esophagus. They gently inflate the balloon to stretch the stricture a few millimeters. With repeated stretching, the esophagus will remain open.) The patient ate more. She stopped vomiting. Her weight increased.

For the sake of flow, I did not include two complications that occurred during the course of events:

Medication problems. Although I had written a letter to hospital staff that included the patient’s history and list of medications, the psychiatrists in the first hospital omitted one medication from the patient’s regimen. As a result, the patient developed distressing symptoms consistent with schizophrenia. (In some ways, this was a blessing, as this omission confirmed her diagnosis. As the patient had demonstrated minimal symptoms of schizophrenia as an outpatient, I would have been tempted to taper off medications… which could have resulted in an “unnecessary” hospitalization.) I suspect this error prolonged her hospitalization.

Transfers of care from outpatient to inpatient settings (and vice versa) are fraught with problems that often adversely affect the patient. People have proposed universal health records, care managers, and other devices to help minimize this potential for harm. For now, most of us continue to do the best we can with the current system.

Decisional capacity issues. After the patient was hospitalized the second time, the gastroenterologists had concerns about the patient’s ability to consent to the procedure to evaluate her esophagus. While she could communicate a choice, they had doubts that she could appreciate her condition and understand the risks and benefits of intervention. Her worker ended up going to the hospital to discuss the procedure together with the patient and physicians. We were fortunate that he was available to do this.

I wanted to share the tale of the Red Herring for three reasons:

All physicians are subject to bias. Patients can suffer as a result. Patients with psychiatric diagnoses sometimes do not receive appropriate medical attention simply because of diagnostic labels. This can occur even if patients are not demonstrating psychiatric symptoms at the time of the encounter. Physicians, including psychiatrists, may assume that these patients exaggerate or misreport medical symptoms. Alternatively, physicians may assume that medical symptoms are due solely to psychiatric conditions.

According to Wikipedia (not the best source of medical information, but anyway…), the prevalence of esophageal strictures is 7 to 23% in the US. The prevalence of schizophrenia is less than 1%. The prevalence of bulimia in the US is about 5%. Though esophageal strictures are more common than either psychiatric condition, we all somehow believed that the latter was the culprit in the case of the Red Herring.

We all often forget that people are not simply mind or body. People with psychiatric conditions still have physical bodies that can bleed, break, and hurt.

Physicians need time to provide good care. 15 minute appointments maximizes profits for organizations and physicians in private practice. 15 minute appointments often do not maximize benefit and value for patients. (To be fair, organizations and individuals need money to maintain clinics. If clinics go bankrupt, everyone loses.)

If I saw this patient for only 15 minutes, once a month, it would have taken me much longer to build a relationship with her. Without that relationship, I could not have directed her to go to the hospital. She would have (accurately) experienced that as coercion. Furthermore, my understanding of her symptoms and condition would have been limited.

If I only had 15 minutes a month with this patient, I would not have been able to advocate for her as I did. If we want our physicians to provide this level of care, we all must recognize that physicians need time to do so. (My patient was enrolled in a program for individuals with severe psychiatric conditions. My “caseload” of patients was purposely kept low; this allowed me to spend a flexible amount of time with people and to see them on a more frequent basis.)

Physicians must advocate for their patients. For those patients who are able to advocate for themselves, we must encourage them to do just that. Helping patients obtain the services they need to lead healthy, independent lives with limited contact with medical establishments should be one of our primary goals. This is particularly true in psychiatry: we should do what we can to get people out of the mental health system so they can get on with living their lives.

For those patients who cannot advocate for themselves, we must advocate for them. They otherwise will not receive the care and interventions they need to maximize the chances that they can lead healthy, independent lives. We have all read articles citing the enormous financial costs associated with undertreated or untreated medical problems. Furthermore, we will have failed our moral obligation to promote beneficience.

Thank you for reading the Red Herring. I appreciate your attention.