For psychiatrists who practice dance therapy: dealing with falls

[erg923]

Ok. Is there informed consent of said "frame?" I can't imagine grandma in this originally posted situation consented to such a thing?

Anyways, "ground rules" simply sounds like my typical 3 and half minute informed consent spiel at the beginning of each intake I do. We need to give a fancy name, now do we? Smells of Freud to me. Fishy...

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[xlithiumx]

Ok. Is there informed consent of said "frame?" I can't imagine grandma in this originally posted situation consented to such a thing?

Anyways, "ground rules" simply sounds like my typical 3 and half minute informed consent spiel at the beginning of each intake I do. We need to give a fancy name, now do we? Smells of Freud to me. Fishy...

I don't know that ground rules are "Freudian" or equivalent to "informed consent." I don't imagine that treatment relationships are formulaic or fully proscribed at the outset. I think a treatment relationship develops over time and the "rules" of that relationship are malleable. All therapeutic modalities have a "frame."

 

[novopsych]

Ok. Is there informed consent of said "frame?" I can't imagine grandma in this originally posted situation consented to such a thing?

Anyways, "ground rules" simply sounds like my typical 3 and half minute informed consent spiel at the beginning of each intake I do. We need to give a fancy name, now do we? Smells of Freud to me. Fishy...

Robert Langs, not Freud

If it's a spiel (which comes from the word game), it's not really a frame. The frame is everything—even something as obvious as the environment in which you meet.

Edited to add: It's not contractual per se, in my opinion. The ways in which people attempt to leave the frame can be instructive.

 

[jakeislove]

The patient is everything.

Nothing comes before or is more important than the patient.

 

[novopsych]

The patient is everything.

Nothing comes before or is more important than the patient.

I agree 100%. Everything in my practice is in service of the patient.

Look, if I were a football coach (and I really don't know much about football, so bear with me), I would run my players hard. It might hurt, but it would be in service of them. If a football player fell and was languishing on the ground, how would he perceive me if I started tending to his wounds? The frame dictates who does what. It is in service of the patient that I could not render medical care for whatever caused her to become immobile on the floor.

In the same way, if I were a football player and sustained an injury that ended my career, I wouldn't want my last memory of lying on the field with my coach coddling me. I would want my last memory to be of him riding me hard, pushing me to my limits. It wouldn't be his job to tend to my leg. That's not part of the "frame" of being a coach, to extend the metaphor. That's what an EMT does.

I know the metaphor doesn't work perfectly, but it's to try to help explain the vantage point of someone trained in psychiatry, psychotherapy, and dance therapy.

 

[Ceke2002]

I agree 100%. Everything in my practice is in service of the patient.

Look, if I were a football coach (and I really don't know much about football, so bear with me), I would run my players hard. It might hurt, but it would be in service of them. If a football player fell and was languishing on the ground, how would he perceive me if I started tending to his wounds? The frame dictates who does what. It is in service of the patient that I could not render medical care for whatever caused her to become immobile on the floor.

In the same way, if I were a football player and sustained an injury that ended my career, I wouldn't want my last memory of lying on the field with my coach coddling me. I would want my last memory to be of him riding me hard, pushing me to my limits. It wouldn't be his job to tend to my leg. That's not part of the "frame" of being a coach, to extend the metaphor. That's what an EMT does.

I know the metaphor doesn't work perfectly, but it's to try to help explain the vantage point of someone trained in psychiatry, psychotherapy, and dance therapy.

So obviously acting like a decent human being isn't part of your frame. FFS, you're not bundling this old woman up in snuggie blankets and offering to tend to her needs night and day in the comfort of your own home if you do something as basically decent as, you know, actually blanking helping her as a medical 'professional'.

 

[novopsych]

So obviously acting like a decent human being isn't part of your frame. FFS, you're not bundling this old woman up in snuggie blankets and offering to tend to her needs night and day in the comfort of your own home if you do something as basically decent as, you know, actually blanking helping her as a medical 'professional'.

Context is everything. She was fine, save the hip fracture. Her presenting symptoms were fussing in a way that was not atypical to previous history. She had a history of somatoform complaints, and in general with such patients, it is healthier to ignore the complaints, or better yet remind the patient that in the context of therapy, physical maladies can't be addressed anyway so there's no use in discussing them. That in this case she happened to have what seemed to have possibly been an actual physical malady is why I allowed my secretary to tend to her. This was a unique situation in which she was not righting herself, and while I had known the patient to be histrionic, I appropriately allowed the possibility of another explanation. It turned out an alternate explanation existed, yet I still believe the underlying somatoform disorder exacerbated the manner in which she chose to present.

A decent human being sees something better for their patient than what the patient can currently see for themselves.

By the way, my secretary has delivered foals for me.

 

[erg923]

Do you have any empirical evidence or any kind of explanatory model for the frame "being everything?"

What tole does this have in producing behavior change? What evidence do you have to support this?

 

[Ceke2002]

Context is everything. She was fine, save the hip fracture. Her presenting symptoms were fussing in a way that was not atypical to previous history. She had a history of somatoform complaints, and in general with such patients, it is healthier to ignore the complaints, or better yet remind the patient that in the context of therapy, physical maladies can't be addressed anyway so there's no use in discussing them. That in this case she happened to have what seemed to have possibly been an actual physical malady is why I allowed my secretary to tend to her. This was a unique situation in which she was not righting herself, and while I had known the patient to be histrionic, I appropriately allowed the possibility of another explanation. It turned out an alternate explanation existed, yet I still believe the underlying somatoform disorder exacerbated the manner in which she chose to present.

A decent human being sees something better for their patient than what the patient can currently see for themselves.

By the way, my secretary has delivered foals for me.

Yes I'm sure the agony of that broken hip as she fussed on the floor in great pain, and probably watched on in an increasingly panicked state wondering why her own Doctor was ignoring her to continue the dance was a truly cathartic moment that lead to great breakthroughs and insight on the patient's behalf. Bravo.

</sarcasm>

I support dance therapy and many other 'complementary' treatments as an adjunct to more traditional Psychiatric practices. I do not support the way you are choosing to treat certain patients under your care. Somatoform complaints or not, you don't leave an elderly woman lying on the ground after a fall whilst you dance off in a corner somewhere.

 

[michaelrack]

In the same way, if I were a football player and sustained an injury that ended my career, I wouldn't want my last memory of lying on the field with my coach coddling me. I would want my last memory to be of him riding me hard, pushing me to my limits. It wouldn't be his job to tend to my leg. That's not part of the "frame" of being a coach, to extend the metaphor. That's what an EMT does.
.

Actually, that is part of the frame of being a coach-not coddling but providing basic first aid- and deciding whether the player (or patient) could continue on in the game (or dance) or whether further medical care needed to be obtained.

Novopsych, from your posts on this thread it is obvious that you don't perceive yourself as a real doctor (and I definitely don't consider you a real doctor). Even though you may technically be a psychiatrist, you may get a better perspective on "the dance" by posting in the psychology forum (and I mean absolutely no disrespect to psychologists, and bet that most psychologists would have handled the fall differently than you did).

 

[jakeislove]

Football coaches are employed by a team's owner to win games.

Perhaps staying "in frame" was a way for you to avoid dealing with her injury.

 

[xlithiumx]

Football coaches are employed by a team's owner to win games.

Perhaps staying "in frame" was a way for you to avoid dealing with her injury.

jakeislove FOR THE WIN!

 

[erg923]

Actually, that is part of the frame of being a coach-not coddling but providing basic first aid- and deciding whether the player (or patient) could continue on in the game (or dance) or whether further medical care needed to be obtained.

Novopsych, from your posts on this thread it is obvious that you don't perceive yourself as a real doctor (and I definitely don't consider you a real doctor). Even though you may technically be a psychiatrist, you may get a better perspective on "the dance" by posting in the psychology forum (and I mean absolutely no disrespect to psychologists, and bet that most psychologists would have handled the fall differently than you did).

That forum is generally filled with fairly stringent scientist-practitioner Ph.Ds (such as myself) and would be lambasted (much as I am doing) for medical negligence, poor critical thinking, and poor science supporting this as an efficacious treatment. To assert such things (the dance is everything, the frame is everything) with absolutely no outcome data/studies or evidence-based explanatory model to back any of it up is pretty unreal. Such thinking was slapped down hard in my program. But then again, the person does not seem to view herself/himself as physician or a mental health professional. Perhaps a dance gypsy or something. They obviously don't seem concerned about Hippocratic oaths, licenses, or evidenced based therapy/psychiatric medicine.

 

[smalltownpsych]

I also referred to this as being the practice of a crackpot and as a psychologist, I do take offense at the implication. Furthermore, the public tends to lump us together so a crackpot psychiatrist or a crackpot psychologist is equally damaging to our professions.

 

[jakeislove]

It's doubtful the public or professional impressions of psychiatry and psychology will change much. That being said, it's unreasonable for practitioners to run or dance away from unintended ramifications of therapies they prescribe.

 

[smalltownpsych]

It's doubtful the public or professional impressions of psychiatry and psychology will change much. That being said, it's unreasonable for practitioners to run or dance away from unintended ramifications of therapies they prescribe.

I am not sure of your logic. Obviously, one crackpot more or less won't change perceptions much, so should we not call it out as such? What would be the end result of that?

 

[novopsych]

Do you have any empirical evidence or any kind of explanatory model for the frame "being everything?"

What tole does this have in producing behavior change? What evidence do you have to support this?

I just realized a source of miscommunication. When I said the frame is everything, I didn't mean that in terms of importance. I meant that the frame is not one thing, such as a spiel. The frame is the appointment time, the position of a sofa, etc. "Everything"—not the most important thing.

 

[jakeislove]

I am not sure of your logic. Obviously, one crackpot more or less won't change perceptions much, so should we not call it out as such? What would be the end result of that?

Generally, I tend to believe labels are only to make us feel better. I'm of a mind that a specific patient exists for almost any therapy someone could imagine. If people weren't amenable to (or feel better) after dance therapy, the practice would go away.

If dance gypsies can heal people, it definitely wouldn't take a medical education to do the job.

 

[michaelrack]

I also referred to this as being the practice of a crackpot and as a psychologist, I do take offense at the implication. Furthermore, the public tends to lump us together so a crackpot psychiatrist or a crackpot psychologist is equally damaging to our professions.

sorry, didn't mean to imply that the OP would get better acceptance from psychologists, or that psychologists accept crackpot theories. I brought up psychologists because 1) they don't have the same medical obligation as psychiatrists (when dealing with a fall, etc) and 2) may know something about dance therapy, which I had never heard of before.
While I am skeptical about dance therapy, I don't know enough about it to judge it, I just know enough to judge the OP.

 

[hamstergang]

no, I can't diagnose a broken hip from across the room. I'm a psychiatrist. That's about about as far removed as diagnosing broken hips as you are going to get.

Ok good, so then you should have problem realizing that when you say "she had a broken hip, what could the psychiatrist have done that other random people couldn't?" it's not really the right question to be asking because when the patient falls, we don't yet know it's a broken hip.

 

[novopsych]

Ok good, so then you should have problem realizing that when you say "she had a broken hip, what could the psychiatrist have done that other random people couldn't?" it's not really the right question to be asking because when the patient falls, we don't yet know it's a broken hip.

Exactly. I didn't know either. All I knew was that I had a patient with a history of being extremely fussy (official diagnosis: somatoform disorder), who refused to right herself and was more fussy than usual.

If I had handled the situation purely from a psychiatric point of view, I would have continued ignoring her until she righted herself and began dancing again. It was my professional judgment that due to her advanced age and greater than usual whining, something more might have been going on. While I never would have predicted a hip fracture, my judiciousness was spot on. There was nothing I could have done for her that my secretary couldn't in terms of assessing an observable physical malady. The secretary called 911, I never had to leave frame, and the patient left frame less than she would have otherwise, and all-in-all the situation couldn't have been handled any better than it was.

Remember that I am trained in general medicine, psychiatry, and the dance. That doesn't necessarily make me an MVP in an emergency. Part of being a good doctor is knowing when to defer to others. My secretary delivers both miniature and full-size foals, whereas some psychiatrists would struggle to take an accurate blood pressure reading. My secretary could surely tend to a woman on her side who was healthy enough to coherently complain non-stop, and she did.

Let me put this another way. You're at a swimming pool and suddenly start drowning. Do you want a 14-year-old 70-lb girl who has her official lifeguard license to save you or a 200-lb man who isn't certified but happens to be nearby?

It's not a perfect metaphor because I could have done everything my secretary did. I'm not saying I couldn't have. I'm saying she was as qualified as me in this particular instance, and it was better for her to handle it than me so that the patient's therapy frame could be respected. But as my metaphor shows, sometimes people officially less qualified are actually better qualified to help. You can't just go on bureaucratic assessments. Not every 18-year-old is an adult. And not every secretary is incapable of aiding an elderly woman.

 

[xlithiumx]

Exactly. I didn't know either. All I knew was that I had a patient with a history of being extremely fussy (official diagnosis: somatoform disorder), who refused to right herself and was more fussy than usual.

If I had handled the situation purely from a psychiatric point of view, I would have continued ignoring her until she righted herself and began dancing again. It was my professional judgment that due to her advanced age and greater than usual whining, something more might have been going on. While I never would have predicted a hip fracture, my judiciousness was spot on. There was nothing I could have done for her that my secretary couldn't in terms of assessing an observable physical malady. The secretary called 911, I never had to leave frame, and the patient left frame less than she would have otherwise, and all-in-all the situation couldn't have been handled any better than it was.

Your incompetence and lack of capacity for learning from your mistakes is truly staggering.

May I ask where you trained? I have occasion to interact with medical students, and I wouldn't want to point them in the direction of whatever institution "trained" you.

 

[notdeadyet]

A physician ("even" a psychiatrist) who defers a medical emergency to a secretary because she delivers foals? The medical competence, professionalism, and malpractice awareness are in a race to the bottom here...


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[erg923]

How does it make you feel when those outside and inside the profession read your posts and think you're an idiot?

 

[Armadillos]

Im convinced the existence of novopsych and vistaril in our forum are not independent, although it would seem like an awfully committed trolling scheme even by vistaril standards

 

[OldPsychDoc]

Exactly. I didn't know either. All I knew was that I had a patient with a history of being extremely fussy (official diagnosis: somatoform disorder), who refused to right herself and was more fussy than usual.

People with "official diagnoses" of panic disorder occasionally have actual myocardial infarcts. For their sake and yours, I hope they're not in one of your sessions when it happens.

 

[michaelrack]

Let me put this another way. You're at a swimming pool and suddenly start drowning. Do you want a 14-year-old 70-lb girl who has her official lifeguard license to save you or a 200-lb man who isn't certified but happens to be nearby?

It's not a perfect metaphor because I could have done everything my secretary did. I'm not saying I couldn't have. I'm saying she was as qualified as me in this particular instance, and it was better for her to handle it than me so that the patient's therapy frame could be respected. But as my metaphor shows, sometimes people officially less qualified are actually better qualified to help. You can't just go on bureaucratic assessments. Not every 18-year-old is an adult. And not every secretary is incapable of aiding an elderly woman.

I would want the 70-lb licensed lifeguard. A panicked swimmer (someone who is drowning) can easily take down an untrained rescuer with him. Your metaphor sucks.

 

[novopsych]

How does it make you feel when those outside and inside the profession read your posts and think you're an idiot?

It makes me think they didn't read the title of the thread. So far, not one psychiatrist who practices dance therapy has responded, and it was that population's opinion I was seeking.

 

[Ceke2002]

You know this totally reminds me of this one time when my Psychiatrist was leading a meditation session and I had a sudden asthma attack, so naturally not wishing to acknowledge my non meditating behaviour he went and lotus positioned himself in the corner until finally my audible wheezing behooved him to om mani padme hum his way out of the office, where upon he relayed the situation to his medically untrained secretary via a series of Buddhist chants...

...Oh, no, wait, that's right, my Psychiatrist isn't a prancing self absorbed malpractice suit waiting to happen, that must be someone else I'm thinking of.

 

[Armadillos]

In other news Vistaril has been trolling the path forum super hard lately it seems, this guy is a beast.

 

[Leo Aquarius]

This whole thread must be a joke. Novopsych must be joking about relegating the emergency to a secretary. There's no way...

 

[erg923]

Or it could mean you are are medically negligent, resistant to feedback, and resistant to science/evidence based practice.

I mean for goodness sakes, my wife is a schoolteacher and thinks you are look likea babbling idiot. My best friend is a CPA and read your post and thinks psychiarty is a complete joke. You think this is what the public wants to see when they see the face of psychiatry-some lady going on about the dance inquisition of 1508?! You want this to be the how psychiatric medicine is presented to the public?!

 

[OldPsychDoc]

It makes me think they didn't read the title of the thread. So far, not one psychiatrist who practices dance therapy has responded, and it was that population's opinion I was seeking.

I'm thinking it's not a population that's not well-represented here, to say the least.

 

[vistaril]

Ok good, so then you should have problem realizing that when you say "she had a broken hip, what could the psychiatrist have done that other random people couldn't?" it's not really the right question to be asking because when the patient falls, we don't yet know it's a broken hip.

well it really depends on the situation.....I don't know the situation in which the pt fell, but if everyone was dancing I doubt it was a situation where there was a person down of complete unknown etiology. IOW, there is usually some msk issue/collision/whatever that would be noticed by someone and then the pt goes down. In that case, it's not like heart attack, stroke, etc is really going to be on the differential.

But let's not act like we are in a real position to work things up anyways. The right thing to do is go see the person and decide whether they need actual medical care. That's true for a psychiatrist, a secretary, another member of the dance group, etc....

 

[vistaril]

Or it could mean you are are medically negligent, resistant to feedback, and science/evidence based practice. Perhaps Occams razor applies here?

I mean for goodness sakes, my wife is a schoolteacher and thinks you are a babbling idiot. My best friend is a CPA and read your post and thinks psychiarty is a complete joke. You think this is what the public wants to see when they see the face of psychiatry-some lady going on about the dance inquisition of 1508?! You want this to be the how psychiatric medicine is presented to the public?!

honestly though, is it worse than a lot of other current practices that are presented to the public on a daily basis?

 

[Tizoc]

In the same way, if I were a football player and sustained an injury that ended my career, I wouldn't want my last memory of lying on the field with my coach coddling me. I would want my last memory to be of him riding me hard, pushing me to my limits. It wouldn't be his job to tend to my leg. That's not part of the "frame" of being a coach, to extend the metaphor. That's what an EMT does.

Having seen coaches come out to comfort seriously hurt players from the high school level to the professional level, I can tell you know nothing about sports or compassion.

 

[michaelrack]

honestly though, is it worse than a lot of other current practices that are presented to the public on a daily basis?

Maybe not (and I don't excuse those practices) but it makes us, as a profession, look worse.

 

[Armadillos]

All this debating about the handling of the broken hip is kind of silly. Any medical professional is going to be better than a non-medical professional and most physicians are going to handle this about the same. Its not like an orthopod is going to have bone screws on hand and be ready to operate on the floor, (s)he is going to call an ambulance and get the patient somewhere where they can get imaging.

On the other hand, all physicians will be able to do useful things, the most important of which is keep people calm and reassure the patient by the mere presence of having a MD nearby. Just because a physician can't fix or even adequately rule out a broken hip without a hospital (imaging) doesn't mean physicians have nothing to offer.

 

[hamstergang]

well it really depends on the situation.....I don't know the situation in which the pt fell, but if everyone was dancing I doubt it was a situation where there was a person down of complete unknown etiology. IOW, there is usually some msk issue/collision/whatever that would be noticed by someone and then the pt goes down. In that case, it's not like heart attack, stroke, etc is really going to be on the differential.

But let's not act like we are in a real position to work things up anyways. The right thing to do is go see the person and decide whether they need actual medical care. That's true for a psychiatrist, a secretary, another member of the dance group, etc....

MI isn't really on your differential when an elderly patients physically exert themselves?

Deciding what level of medical care is needed is something you should be better at than the general public if you're actually a doctor.

 

[vistaril]

MI isn't really on your differential when an elderly patients physically exert themselves?

Deciding what level of medical care is needed is something you should be better at than the general public if you're actually a doctor.

MI isn't on my differential if I saw a pt go down due to what I describe above(a collision injury or obvious msk injury)....no.

And no, deciding what level of care is needed for such situations is not something psychiatrists should be good at.

 

[vistaril]

All this debating about the handling of the broken hip is kind of silly. Any medical professional is going to be better than a non-medical professional and most physicians are going to handle this about the same. Its not like an orthopod is going to have bone screws on hand and be ready to operate on the floor, (s)he is going to call an ambulance and get the patient somewhere where they can get imaging.

On the other hand, all physicians will be able to do useful things, the most important of which is keep people calm and reassure the patient by the mere presence of having a MD nearby. Just because a physician can't fix or even adequately rule out a broken hip without a hospital (imaging) doesn't mean physicians have nothing to offer.

the first point is what anyone(physician or otherwise) can do...an othorpod, pm&r, sports med doc, etc....they could probably add something if there is some sort of manipulation can be done(where there isn't a break but is some other msk injury)

and no, 'keeping the pt calm by having an md nearby' provides no tangible value. I can just imagine some of you guys on an airplane rushing to help when someone asks if a dr is present and then the looks on their faces when you tell them you're a shrink.

 

[MacDonaldTriad]

Is Vistaril a Shrink or not?
I have answered a few” is there a doctor on board” calls. I have been unimpressed with the performance of other physicians in some of these circumstances: A dermatologist trying to sort out a TIA, an orthopedic surgeon dealing with abdominal pain. Once the airline MD on the phone asked to have me put back on the line.

 

[vistaril]

Is Vistaril a Shrink or not?
I have answered a few” is there a doctor on board” calls. I have been unimpressed with the performance of other physicians in some of these circumstances: A dermatologist trying to sort out a TIA, an orthopedic surgeon dealing with abdominal pain. Once the airline MD on the phone asked to have me put back on the line.

hey more power to you if you have some bona fide medical skills. I just know that I certainly wouldnt feel comfortable answering such calls, and would gladly defer to non-physicians who do have more medical experience(for example a nurse who works on medicine floors). And it's been fewer years since I did the medicine months than most.

 

[OldPsychDoc]

the first point is what anyone(physician or otherwise) can do...an othorpod, pm&r, sports med doc, etc....they could probably add something if there is some sort of manipulation can be done(where there isn't a break but is some other msk injury)

and no, 'keeping the pt calm by having an md nearby' provides no tangible value. I can just imagine some of you guys on an airplane rushing to help when someone asks if a dr is present and then the looks on their faces when you tell them you're a shrink.

Hey when someone's trying to blow up their underwear, or more commonly, has been overserved in the airport lounge--there's no one better to break open the med kit and start giving the IM lorazepam.

 

[smalltownpsych]

MI isn't really on your differential when an elderly patients physically exert themselves?

Deciding what level of medical care is needed is something you should be better at than the general public if you're actually a doctor.

lol Is Vistaril really a doctor? People will say that a psychologist is not a real doctor but at least I know that when an old person falls to the floor I might want to consider a) heart attack b) stroke

Nevertheless, that is all moot because I would think that the correct response is to call 911 regardless of what the diagnosis is or who the provider is when a patient falls and can't get up.

 

[hamstergang]

And no, deciding what level of care is needed for such situations is not something psychiatrists should be good at.

hey more power to you if you have some bona fide medical skills.

Hmm so it seems that the problem is that you're just not a very good doctor. It might surprise you to know that some of us made sure to learn how to be a doctor in med school and residency. We're not just prescribing psychologists.

 

[hamstergang]

Nevertheless, that is all moot because I would think that the correct response is to call 911 regardless of what the diagnosis is or who the provider is when a patient falls and can't get up.

Well, if you have an AED available, you might need to use that ASAP. Also, if you can provide information to the EMTs/paramedics, it can help them out and save time.

 

[Armadillos]

Hmm so it seems that the problem is that you're just not a very good doctor. It might surprise you to know that some of us made sure to learn how to be a doctor in med school and residency. We're not just prescribing psychologists.

Vistaril has consistently stated he didn't have the skill, aptitude or interest to excel in other fields of medicine. I think he projects that on everyone else and he assumes everyone is like him. He literally doesn't know what its like for all you psychiatrists who are strong, well rounded physicians because thats such a foreign concept to his own skills and experience.

 

[vistaril]

Vistaril has consistently stated he didn't have the skill, aptitude or interest to excel in other fields of medicine. I think he projects that on everyone else and he assumes everyone is like him. He literally doesn't know what its like for all you psychiatrists who are strong, well rounded physicians because thats such a foreign concept to his own skills and experience.

the hyperbole from you and hamster here is off the charts.....

 

[Armadillos]

the hyperbole from you and hamster here is off the charts.....

You have probably said 5+ times you didn't have the skills/interest to possibly be good at specialties besides psych, thats not true for most of the posters here.