Category: Consult-Liaison

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Consult-Liaison Informal-curriculum Lessons Medicine

You Don’t Have to Like Everyone.

You don’t have to like everyone under your care. And you probably won’t, which is okay.

Own how you feel. If you insist on telling yourself that you should like someone when, in fact, you don’t, it will come out in other ways: The tone of your voice, the expressions on your face, the way you position your body.

There might completely understandable reasons why you don’t like the person under your care. Maybe he never seems to hear what you say. Maybe he doesn’t follow any of your recommendations, but he blames you for lack of healing. Maybe he expresses opinions you find offensive. Maybe he calls you racial slurs. Maybe he’s thrown things at you. Maybe he threatens to rape you. Maybe he’s told you that he will kill you and your family.

People do things like that for reasons that make complete sense to them. You may disagree with or misunderstand their reasons, but despite that, they are still people. Even though you may dislike some people under your care, you must still recognize that they are still human beings. The moment you refuse to recognize the humanity of the other person, you are at risk of inflicting violence upon them. Violence can manifest in many ways, including neglect.

First, do no harm.

It is possible to dislike someone and do no harm.

When we don’t like someone, it is much easier to assign blame entirely to the other person (e.g., “He’s an annoying @$$hole”). While it is possible that the problem has nothing to do with you and everything to do with the other person, that doesn’t change the fact that you cannot control other people. You can’t make someone less of an @$$hole. You, however, can make yourself view the situation in a different perspective.

Own how you feel. Let’s say he is, in fact, an @$$hole—something you cannot change. What if you focused instead on yourself?

“I really don’t like him. I feel dread whenever I have to see him.”

The reasons behind your dread make complete sense to you. When you acknowledge your dread and dislike to yourself, you give yourself more options as to how to proceed. You now have more control over the situation.

When you don’t like someone who is under your care and you acknowledge this, you can:

  • get support from your trusted colleagues. You can tell them how much you don’t want to see this person, how anxious and annoyed you feel about having to do this, and how much you don’t like this person. Get it out of your system ahead of time so you can be the professional you want to be when you actually see this person.
  • activate your internal coach. You can take some deep breaths and say a silent prayer before the interaction begins. You can rehearse some evacuation plans in case things start to run off the rails. Your internal coach can recruit your internal cheerleaders afterwards if the conversation goes well.
  • pause and remind yourself of your purpose. Your job does not include judging or shaming the person under your care. Your job isn’t to like the person under your care. Your job is to help the individual improve his health. Sometimes the people you care for have terrible life circumstances that contribute to the behaviors that you don’t like.
  • ask a colleague to see the individual so you don’t have to. Sometimes it is clear that the clinical relationship won’t work out at this time. We can’t be effective with 100% of the people we see (though we can try). Sometimes, the best way we can help the people under our care is to remove them from our care. (Sometimes, though, this isn’t an option.)

It’s often helpful to focus on the behaviors of an individual. When you focus on behaviors, you are more likely to remember and respect the person’s humanity. This keeps us professional and kind, even if we aren’t warm and smiling.

Indeed, he may do things that you don’t like… but he may also do things that you do like. And when we offer genuine thanks to people when they do things we like (e.g., “Thanks for your patience while I was asking you all of those personal questions,” “Thanks for summarizing your story quickly for me,” “Thanks for not calling me names today”[1. I have actually said, “Thanks for not calling me names today!” to people under my care and, no joke, the vast majority of them never address me with bigoted phrases ever again.]), people are almost always going to do those things more often.

You don’t have to like everyone under your care. Once you start owning how you feel, though, you might find that, most of the time, you do.

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Consult-Liaison Education Medicine Systems

The Social History.

From the notes I read, it seems that other medical specialties limit “social history” to whether or not someone uses tobacco, drinks alcohol, or uses drugs.

“Social history” is meant to get a sense of the context in which people live. Where do they live? Who do they live with? How did they come to live there? Where did they grow up? What sort of work do they do? How much school have they finished? What do they do for fun? What are the important relationships in their lives? etc.

I almost always start my clinical interviews with the social history. There are several reasons why I do this:

One, it’s a more neutral place to start. My hope is that it will help the person feel more comfortable talking to me. Most of these questions are easy to answer, since many of them overlap with social conversation: Where do you live? How long have you lived there? This is also an opportunity to communicate through non-verbal communication: The nodding, the eye contact, and all the other behaviors that show that I’m paying attention and worthy of trust. (“See, it’s not so bad to talk with a psychiatrist.”)

Two, it puts the information the person shares with me into context. If people don’t have a stable place to live, then they have good reason to feel anxious about their safety and exhausted from poor sleep. If someone lives with other people who are struggling with substance use or are often fighting, then this person may not be able to recruit them to help with the tasks of daily life. They may not even feel safe staying with them, but don’t have other choices. One can’t expect someone to take medication on a regular basis when they don’t have enough money to buy food.

Three, if people don’t want to talk to me for whatever reason, the way they stop the conversation is useful information. Sometimes people are paranoid for a variety of reasons—some based in reality, some not—and they shut down the interview. Sometimes people want to talk to me, but they’re exhausted and ask me to come back later. Sometimes people don’t like something about me: my hair (it’s noteworthy how some people respond to my hair), my ethnicity, my clothes, my sex, the way I talk. I can’t change most of those things, and how people respond to all that tells me (1) how I can better interact with them in the future and (2) what might be going on that is causing them to respond this way. And sometimes people don’t want to talk to me because I’m not conducting the interview in a skillful way: Maybe I’m coming across as cranky, uncaring, or judgy.

Four, and most importantly, I want the person to know that I view them as a human being. I wince whenever someone immediately launches into their mental health history: “Okay, I have a diagnosis of schizophrenia and I take Zyprexa and Cogentin….” This tells me that this person got the message over time that no one is interested in him as a person; people only want to know his diagnosis and medications. But people aren’t their diagnoses or their medication regimens. All people have hopes and dreams; they have things they want to do and people they want to be. While a summary statement might make the interview more efficient, it matters whether this person volunteers at the animal shelter every week because he loves dogs or whether he stays at home and watches TV all day. This information is valuable, regardless of his diagnosis.

It takes time to get a social history. Short appointments, though, are short-sighted. It’s much faster to generate diagnoses from labs and studies; it’s much faster to write prescriptions than to listen to patients. If physicians don’t get an accurate history, then physicians are more likely to generate wrong diagnoses. Wrong diagnoses, along with no information about the contexts in which people live, lead to wrong interventions. Did anyone then actually save any time?

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Consult-Liaison Education Medicine

Thoughts about the Digital Pill.

Reader and stellar nurse Natalie[1. I know Natalie is a “stellar” nurse because we used to work together.] wondered about my thoughts about the digital pill.

My initial reactions were similar to several of those who were interviewed for the article. The digital pill, which provides electronic information to confirm whether someone has ingested the medication, has great potential to become a tool of coercion. Aripiprazole (Abilify) is classified as an antipsychotic medication, which is often prescribed to people who have beliefs that machines and other surveillance tools are in their bodies. Why would the nascent technology of a digital pill make its debut for this population?

I have several other concerns about this digital pill:

(1) The purported mechanism of action for aripiprazole (Abilify) involves hand-waving, which is yet another reason why its debut as a digital pill is perplexing. To the manufacturer’s credit, the package insert for arpiprazole is blunt: “The mechanism of action of aripiprazole in schizophrenia or bipolar mania, is unknown.” (Section 12.1.) The explanation in the scientific papers, though, gets those hands waving all over the place (warning: technical language fast approaching):

The development of D2 partial agonists is a logical strategy for the treatment of schizophrenia because the pathophysiologic mechanism of schizophrenia is thought to be based on too much dopamine activity in some regions of the brain and too little dopamine activity in other regions. A D2 partial agonist can act as a functional antagonist in areas of high levels of dopamine, such as the mesolimbic pathway, but not in areas of normal dopamine levels, such as the nigrostriatal and tuberoinfundibular pathways. Thus, a D2 partial agonist is expected to reduce the positive symptoms of schizophrenia without producing movement disorders or elevated prolactin levels. In regions of low dopamine concentration, such as the mesocortical pathway, a D2 partial agonist will show functional agonist activity.

Put into plain language, what all that means is aripiprazole might stimulate specific receptors in one part of the brain, but block those same receptors in other parts of the brain. The concentration of dopamine might determine whether aripiprazole stimulates or blocks those receptors.

I’m skeptical.

That’s like an antibiotic that only kills one specific type of bacteria in one part of the body, but doesn’t kill that same specific bacteria in other parts of the body.

How does that work? Especially since science has yet to determine the underlying causes of psychotic disorders, such as schizophrenia?

So, in sum, this is a digital form of a medication that has an uncertain mechanism of action for a disease that we don’t fully understand.

What?

(2) The focus on adherence to medication assumes that the ingestion of medications is the most important aspect of treatment. This may be true for some individuals, but does not apply to everyone. Psychiatry focuses on maximizing function and quality of life. Sometimes people can attain both without taking digital pills daily.

(3) Most people under my care don’t have access to technology like smart phones. Some of these individuals also have the most severe symptoms and are the most likely to benefit from a variety of interventions: Skills coaching, housing, nutrition, exercise, art, and talk and behavioral therapies, in addition to medication.

(4) I don’t know how the data from this digital pill will actually change care. Psychiatry, for now, still relies on the observation of thoughts, emotions, and behaviors of people. Whether someone is taking their medications or not may not actually change treatment plans.

For example, say Natalie is under my care and takes a digital pill. I learn that Natalie takes this medication five days out of seven. All sources report that she’s doing okay: She’s getting along with her family, is going to school or work, is keeping up with her rent, and continues to follow the blogs she likes. Do I encourage her to take the medication every day? What more gains might she make? What if it detracts from her quality of life to have to take a medication every day, particularly when she’s doing okay?

Or, what if the digital pill tells me that Natalie hasn’t taken medications at all since I prescribed them to her? And Natalie continues to experience significant symptoms? I guess it’s helpful to have confirmation that Natalie isn’t taking medication, but, if I have sufficient rapport with Natalie, she’ll straight up tell me that she’s not taking it. Why use a digital pill when I can get the information from someone directly? Particularly when she can tell me the specific reasons why she doesn’t want to take it?

Or, what if the digital pill tells me that Natalie is taking the medication everyday, but she also continues to demonstrate significant symptoms? Again, the confirmation that she’s taking her medications could be helpful, but if I have rapport with her and she continues to suffer from symptoms, it’s likely that she would tell me this information, anyway.

If physicians want people to trust them, then physicians must show that they trust the people under their care. There are easier and more compassionate ways to get accurate information without resorting to a digital pill.

(5) Lastly, who are we actually treating with this digital pill? Who is going to feel better with the data the pill generates?

This data won’t tell individuals anything they don’t already know. They will know if they took their medications or not. (And savvy patients will figure out a way to subvert this digital pill reporting: Maybe they will give the meds to a pet or to another person.) This data is meant to help physicians feel better, not patients.

If the goals of psychiatry are to help reduce suffering, improve function, and help people live the lives they want to lead, we cannot rely on medications alone to achieve this, particularly for those individuals with significant symptoms. Even if the data shows that someone is taking medications daily, that process measure is meaningless if the person’s overall function and quality of life remains poor.

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Consult-Liaison Observations

Status Game Strategy.

How do you introduce yourself when you greet people, particularly those you don’t know?

Yes, your answer might depend on who you’re meeting. But what’s your general approach?

I try to emanate warmth: I make eye contact and smile. I do what I think will make the person feel comfortable. I listen and try to speak less than the other person… unless it becomes clear that the other person wants to listen more and speak less, too.

This strategy has worked for me: It helps me form and maintain relationships. This approach has produced few, if any, negative consequences.

Some people use a different strategy when they interact with others: They assert their superiority. They say things like they have “one of the great memories of all time” and “I went to an Ivy League college… I’m a very intelligent person.”

The other way to assert superiority is to denigrate others, such as commenting that others are “weak”, “lightweight”, and “fake”.

This, of course, is a status game. Who has higher status? Who should have higher status? And if I should always have higher status, how can I make sure that everyone around me recognizes that?

Sometimes people use this status game strategy because it’s the only way they know how to interact with other people.

Maybe they learned long ago that the people in their life only paid attention to them when they said something that asserted their high status. People only took interest in them when they said things like, “I’m a very rich person.” The attention of others makes them feel worthy, seen, and valued. It’s nice to have a lot of money, but some people crave a wealth of attention.

Asserting high status, though, becomes a vicious, reinforcing cycle. After a while, people won’t care when they hear things like “I’m a very rich person”. They’ve heard that before and won’t react the way they once did. So it escalates: Soon, these individuals have the best memory, the highest IQ, and the best words.

Even though these statements are false—and verifiably false!—it doesn’t matter. Remember that outrage and indignation are still forms of attention. And some people are never satisfied with the amount of attention they receive.

This status game strategy works for some people: It helps them form and maintain relationships. For whatever reason, it has produced few, if any, negative consequences.

There are other ways, of course, to interact with people. However, it takes time and practice to do something different. Why change what you’re doing if it’s worked for you for so many years?

People who behave this way don’t need our pity. Pity doesn’t help anyone. One wonders, though, what happened to them in the past. Despite being over 70 years of age, they still don’t know how to interact with people without elevating themselves or putting others down.

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Consult-Liaison Education Medicine Policy Systems

Online Screening for Depression?

Inquisitve reader Amy asked me if I had any opinions about online screening for depression. The British Medical Journal recently published a debate on this issue.

What an excellent question, Amy! I read the opposing arguments and these are my thoughts:

First, I see two different issues. The first is whether the 9-question Patient Health Questionnaire (PHQ-9) is an appropriate tool to use to screen for depression. The second is whether the public should trust Google to administer the PHQ-9.

Before I do delve into that, though, let’s take a step back and consider the purpose of screening tools. Screening tools help physicians figure out how much more we should learn about a person. For example, asking for a person’s biological sex is a screening tool. The moment I learn that the person before me is female, I will ask her questions about menstruation and pregnancy history. I’ll skip those questions if the person is male. Similarly, if a person tells me that he smokes cigarettes, then I will ask more questions about how much and how often he smokes, what he gets out of smoking cigarettes, and if he thinks smoking causes him any problems. This helps me assess potential risks to his psychological and physical health. It also helps me assess if he has any interest in changing his smoking behaviors. Screening tools help us sort and gather information to generate diagnoses and interventions.

The literature states that the PHQ-9 was developed both to diagnose and measure the severity major depression. The PHQ-9 was modeled after the criteria for major depression in DSM-IV. Thus, the problems with the PHQ-9 for diagnosis are the same as the problems with the DSM for diagnosis: Context is completely missing. The authors of DSM argue that the situation and underlying causes of major depression don’t matter; they state that the presence of certain symptoms determine whether the diagnosis applies.

Long-time readers know my refrain: Context does matter. Major depression is “comorbid” with many other psychiatric conditions, meaning that someone experiencing the symptoms of major depression often experience symptoms of other psychiatric conditions. For example, bipolar disorder, by definition, includes episodes of major depression. People with diagnoses of post-traumatic stress disorder (PTSD) and schizophrenia often experience major depression. Some people who take drugs, whether prescribed or obtained from illict sources, experience symptoms of major depression. Sometimes the symptoms of major depression are actually due to a medical condition, such as certain cancers, infectious diseases, or thyroid conditions.

There are several papers that make the case that the PHQ-9 is a useful tool in the screening for and diagnosis of major depression. Given that major depression is comorbid with other conditions, a positive PHQ-9 result is useful to help get people into care. A professional can then help clarify symptoms, determine possible diagnoses, and suggest treatment and other interventions. Recall that the purpose of diagnosis is to guide treatment.

Here is where we get into the second issue as to whether the public should trust Google to administer the PHQ-9. Most task forces agree that there is no point in performing screening tests if you can’t do anything with the results. If you can’t refer someone with a positive PHQ-9 result to a professional who can clarify diagnosis and provide treatment, then why bother? You’re potentially causing more problems and distress for the person seeking help. Thus, the question is whether Google will direct people with positive PHQ-9 results to helpful resources.

There is a shortage of psychiatrists and other mental health professionals in the US. One wonders if an online depression screening tool will lead people to believe that they are “majorly” depressed, when they are not. They will then seek services that are hard to find. If these individuals are able to get into primary care services, those medical professionals may not be able to determine if someone has depression because of bipolar disorder, or depression due to the recent death of a loved one. Wrong diagnosis often results in wrong treatment or overtreatment. Recall that we should first do no harm.

However, it is clear that people seek information about depression and other psychological experiences on the internet. The questions on the PHQ-9 can educate the public about the differences between major depression and having a sucky day. The more information and education we can provide to the public, the more empowered the public can feel about not only what isn’t going well, but also what they can do to improve their health and wellness. I do not view my work as a psychiatrist as a guild secret. The more understanding and communication we have in our communities, the more we can address our psychological health on individual and societal levels.

The other reaction I had to that BMJ debate was related to a comment that Dr. Duckworth made under “attitudinal barriers”. He noted that a “key reason may be that people with mental health conditions perceive that they do not need treatment. Studies show that they report attitudinal barriers to seeking care much more often than structural or financial barriers.”

I don’t see how the PHQ-9 is related to “attitudinal barriers”. Screening tests don’t reduce stigma. Sure, people may avoid treatment for depression because they don’t know that they are depressed. However, I suspect that more people avoid treatment for depression because of the stigma associated with psychiatric conditions and treatment. If we want to reduce and remove “attitudinal barriers” related to depression, we must help share stories that remind everyone that people with depression are, first, people. The PHQ-9 is not a means to that end.

I don’t know the workings of Google well enough to comment more about whether we should trust Google to administer the PHQ-9. Others with more knowledge about online security, marketing, and data mining can say more about whether Google will use PHQ-9 results for good or evil… or both. There are likely other unintended consequences that I don’t know or understand.

Thanks for the question, Amy!