Category: Informal-curriculum

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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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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.

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Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.

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Education Homelessness Informal-curriculum Observations Policy

Medicators.

Two recent events inspired this post:

1. My husband and I had dinner at Farestart, which is

… a culinary job training and placement program for homeless and disadvantaged individuals…. As members of [this] community are placed in housing, the need for job-training will play a critical role in ensuring the self-sustainability of these individuals.

While eating the tasty food and learning about the mission of Farestart, I reflected on my experiences working with the homeless. I have encountered them outside of the health care system, in emergency rooms and psychiatric hospitals, and in medical hospitals as a psychiatric consultant.

I realized that, as a group, psychiatrists are skilled at prescribing medications for the homeless. Unlike Farestart, however, we offer little to help the homeless help themselves.

2. Since starting my new job in Seattle, several patients have come to me with the chief complaint[1. “Chief complaint” is a medical phrase that refers to the reason why a patient has come to see a physician. It is not a sardonic comment.] of wanting to stop their psychiatric medication(s).

One of the greatest pleasures of my job is helping people taper off of their medication(s).[2. To be clear, there are instances when I actively discourage people from tapering off of their medications, as some people end up in psychiatric hospitals when they stop taking medications. A personal goal of mine is to help keep patients out of hospitals.] My colleagues and I have all seen patients who are taking large numbers of psychiatric medications for unclear or invalid reasons. There is also data to suggest that certain classes of people are more likely to receive psychiatric diagnoses that may not be valid, which results in prescriptions for medication that they don’t actually need.[3. African Americans are more likely to be diagnosed with schizophrenia. Anecdotally, I’ve worked with several African American patients with diagnoses of schizophrenia who were taking antipsychotic medications, though neither the diagnosis nor the medications seemed indicated. We gradually tapered off the antipsychotic medication and nothing happened. They were fine. Which makes me wonder.]

Some people eventually come off of all of their medications without incident. Some people significantly reduce the number of medications they take. And, unfortunately, a few people end up in the hospital during the tapers.

That never feels good.

I realized, again, that psychiatrists are skilled at prescribing medications, but we know little about stopping medications. (In my brief review of Pubmed, I found only one article that offers suggestions about stopping medications.) Furthermore, as a group, we lack the knowledge about treatments other than medications and psychotherapy.[4. Psychiatrists in private practice are more likely to offer both psychotherapy and medication services. Psychiatrists who work in medical centers often only provide medication services due to the institutions’ financial systems.]

Perhaps this is due to the belief that patients who come to see psychiatrists have already tried everything else. They have gone through trials of exercise, counseling, deep breathing, meditation, naturopathic medications, etc. Because none of that has been helpful, they come to see a psychiatrist as a last resort.

That could be true.

This may be a function of our training. Contemporary psychiatry, for better or for worse, follows the medical model. The medical model focuses on biological causes of illness and disease. Current medical treatments (i.e. medications) aim to correct the presumed underlying biological causes.[5. The underlying biological causes of psychiatric conditions remain unclear. Discussions about “chemical imbalances” are still hypotheses, not theories. Psychotropic medications are primarily empirical treatments.] Thus, psychiatrists end up prescribing medicine because that is what we were trained to do. Furthermore, patients often expect us to prescribe medication. (Like other human beings, psychiatrists sometimes feel the pull to “do something”, even though “doing nothing” may be the most prudent choice.)

Psychiatrists, often rightly so, have reputations as “medicators”. A friend of mine works as a psychiatrist in Canada. She came to the US for fellowship training. An administrator told her that her role in the American clinic was that of “the medicator”. My friend was horrified. Because of the funding system, Canadian psychiatrists routinely provide both medication management and psychotherapy services. She could not believe that her role would be limited to the prescription of medication.

“What? You believe in the biopsychosocial model? You think context matters?” the American fellowship cohort dryly commented.

If the knowledge and practice of psychiatrists is limited solely to medications, of course the general public will believe we are simply “medicators”. This is problematic, as we have incomplete knowledge of how psychotropic medications work. (All psychiatrists should read Healy’s The Antidepressant Era. Healy does not outright dismiss antidepressant medication, but he provides data that strongly argues that antidepressants are not as effective as the public believes.)

I cannot speak for all psychiatrists, but I believe most of us did not choose to enter this field to become “medicators”. Thankfully, many psychologists were involved in my education. I’d like to think that, as a result, I am less inclined to pursue medications as the sole mode of treatment. I must admit, though, that I am unfamiliar with the literature for non-pharmacological treatments. (I am familiar with the literature for housing as treatment…. but what is the evidence—or lack thereof—for exercise? meditation? diet changes?)

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Education Informal-curriculum Lessons

The Value of Interruptions.

That interview didn’t go well at all. The patient wouldn’t let me get a word in! That little old lady just kept talking and talking and talking. It’s like she thought we had all the time in the world to talk about her children.”

“It was hard to interrupt, huh.”

“Yeah! It seemed like she really wanted to tell me about her kids. I didn’t want to be rude.”

“Of course it feels rude to interrupt people. We’re taught to wait our turn and listen when other people talk.”

“Yeah.”

“When you’re interviewing patients, though, it’s not a usual social conversation. Social skills are still important, but the context is different.”

“What do you mean?”

“Do you routinely ask your friends if they’re in pain? Have you asked your medical school classmates if they’re passing gas? How about your parents? Do you know if they’re taking their medications as directed?

“Oh….”

“Even though we might use our usual words and gestures in conversations with patients, we’re not having routine social interactions with them. You need to get as much accurate history from patients as possible. Accurate histories[1. “Listen to your patient, he is telling you the diagnosis.”] lead to accurate diagnoses, which lead to proper treatment.”

“Right.”

“To be clear, you don’t want to be a jerk when interrupting patients. Practicing and learning the skill of interrupting, while you’re still a student, will serve you well in the future.”