Psychological intelligence

[Delphine]

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Do you think that it is the job of a physician to, at the very least, be informed about psychological issues and how they create real obstacles for patients' health?

Or do you believe that that is the job of a psychologist? Or perhaps a psychiatrist?

I ask because I have met many doctors who are thoroughly ignorant about psychological distress or what a basic understanding of psychology might contribute to their practice. In fact, they don't even want to be bothered by such notions. I wonder why?

The relationship between a doctor and their patient is a powerful one. I believe that failure to understand and respect psychology often hinders the doctor's role. (NOTE: clearly not in the role of prescribing antibiotics...or the like.)

Thoughts?

 

[Exalya]

I personally feel it's extremely important, for a number of reasons. I really think that doctors should be better at identifying psychological illness--I was abused by my mother because no one noticed for 15 years that she had borderline personality disorder. How nice it would have been if someone medical (the OB, the pediatrician... anyone...) could have caught on to that. I also believe that psychological health affects the body, so keeping tabs on a patient's mental well-being is good both physically and emotionally.

I've met a lot of doctors and pre-meds who are ignorant when it comes to psychological disorders as well. One of the people I had an internship with even spouted off about how suicidal people belong in jail and people with post-partum depression are just "fakers." Needless to say she got a mouthful from me. Certainly the psychologist/psychiatrist is the one who has to treat the mental illness, but at very least I feel that other doctors should be sensitive to mental disorders. People with mental illnesses don't often just *go* to get therapy, in my experience. Someone else has to have the insight to see that there's a problem, and doctors are in a particularly prime place for that, given the close contact and ability to observe patients.

 

[TexasTriathlete]

Y'all know they have doctors who do this very thing, right?

 

[spicedmanna]

Yes, I think I agree with you. To be ignorant of a patient's presenting state of mind (and how it might impact his or her health and the management of it), any new onset or existing mental conditions, and some very general aspects of his or her ongoing psychosocial wellbeing, is to be incomplete in assessing the patient. Can you be more specific about what you mean by psychological distress or psychological issues?

The assessment of mental status and psychosocial wellbeing is part of a normal Hx. If a 30 y/o woman, a working, single mother of two, who just started dating again, comes in to the office presenting with obvious distress about her worsening fatigue and trouble sleeping, which started about a week or two ago, you are going to take everything into account in taking your history, in making your differential, and consider it again when forming your plan. Let's say a 16 y/o woman comes in complaining of hoarseness, fatigue, dizziness, and pain in the center of her chest; you note that when you ask her to change into the hospital gown she seems overly concerned about her weight and when you ask about her family history, she looks very distraught about her parents getting a divorce. Yeah, I'm going to definitely take that into account. Isn't that normal? Or do you mean something else?

You use the example of prescribing an antibiotic, but as the physician creating the treatment plan, you need to be conscious of the patient's social and mental status to understand whether your patient is going to be compliant enough to take them as indicated, and if not, what alternative drugs might better treat the patient. Also, you are going to want to know what else you are going to have to do or consider in your plan.

For example, if a 50 y/o homeless alcoholic male presents to the ER with dysuria and painful, purulent penile d/c, the presumptive dx being chlamydia urethritis (do the usual workup w/ LFT and a metabolic panel, a NAAT for chlamydia, culture for gonorrhea, screen for other STI's, and consider Hep Panel), I'm not going to give him 100mg Doxy BID for 7 days. I'm going to give him the 1g Zithromax in the office and watch him take it and also give him a single IM injection of Ceftriaxone for gonorrhoea. I'd probably also give him, presumptively, a shot of B3 while I'm at it. I'm probably going to offer resource for social support and support for his addiction, if you he is ready for it. I may take a different approach with a 56 y/o male, married, recently retired, presenting with similar symptoms, and again, a different approach with a 14 y/o male with a similar presentation.

 

[slim78]

We take human behavior (taught by psychiatrists) our first and second years here at AZCOM that address these very issues. I think that some schools are actually doing a lot to help educate their students about the psychological aspect of health.

 

[Krisss17]

Y'all know they have doctors who do this very thing, right?

True...but many patients have both psychological issues and medical issues. I think it is important for all doctors to realize that caring for the body (or mind) without thought of the other is sorely limiting themselves.

One of the philosophical tenets of osteopathic medicine is to treat the "whole" pt and that takes into effect not only their body, but also their mind and spirit. An imbalance of one can surely create an imbalance in another.

 

[Krisss17]

Yes, I think I agree with you. To be ignorant of a patient's presenting state of mind (and how it might impact his or her health and the management of it), any new onset or existing mental conditions, and some very general aspects of his or her ongoing psychosocial wellbeing, is to be incomplete in assessing the patient. Can you be more specific about what you mean by psychological distress or psychological issues?

The assessment of mental status and psychosocial wellbeing is part of a normal Hx. If a 30 y/o woman, a working, single mother of two, who just started dating again, comes in to the office presenting with obvious distress about her worsening fatigue and trouble sleeping, which started about a week or two ago, you are going to take everything into account in taking your history, in making your differential, and consider it again when forming your plan. Let's say a 16 y/o woman comes in complaining of hoarseness, fatigue, dizziness, and pain in the center of her chest; you note that when you ask her to change into the hospital gown she seems overly concerned about her weight and when you ask about her family history, she looks very distraught about her parents getting a divorce. Yeah, I'm going to definitely take that into account. Isn't that normal? Or do you mean something else?

You use the example of prescribing an antibiotic, but as the physician creating the treatment plan, you need to be conscious of the patient's social and mental status to understand whether your patient is going to be compliant enough to take them as indicated, and if not, what alternative drugs might better treat the patient. Also, you are going to want to know what else you are going to have to do or consider in your plan.

For example, if a 50 y/o homeless alcoholic male presents to the ER with dysuria and painful, purulent penile d/c, the presumptive dx being chlamydia urethritis (do the usual workup w/ LFT and a metabolic panel, a NAAT for chlamydia, culture for gonorrhea, screen for other STI's, and consider Hep Panel), I'm not going to give him 100mg Doxy BID for 7 days. I'm going to give him the 1g Zithromax in the office and watch him take it and also give him a single IM injection of Ceftriaxone for gonorrhoea. I'd probably also give him, presumptively, a shot of B3 while I'm at it. I'm probably going to offer resource for social support and support for his addiction, if you he is ready for it. I may take a different approach with a 56 y/o male, married, recently retired, presenting with similar symptoms, and again, a different approach with a 14 y/o male with a similar presentation.

👍 Well said, spicedmanna!

 

[Delphine]

Yes, yes of course Slim and Spiced and TT.

I was talking more in line with what Exalya wrote.

It is hard for me to understand why some doctors give up bedside manners or look down upon a persons mental state...or talk smack about a patient who is having a hard time of it... or turn their shoulder.

Of course I am walking a fine line here. Professionals need their boundaries.

Yet outside of extreme cases, within the shades of grey of primary care and prevention- it humbles me to see a physician letting their own defenses get in the way of helping their patients. Having their own issues get in the way or stop them from seeing or being truly proactive on their patients behalf...

Oh I dont know - maybe I am just rambling today.

Moreover I think that Doctors sometimes forget how helpful kindness can be when dealing with patients... who are going through health issues- and it is hard for me to understand how something which is so fundamental can be forgotten- I suppose I will find out soon enough.

 

[TexasTriathlete]

Here's the deal. Docs are going to be good at what they practice. You can get an extra class or something on psych in med school, and you can read about this stuff, but only once you've seen it a lot will you really get good at it. That is why they have residency training.

An OB/GYN who looks at crudded-up hooties all day is probably not going to be that great at diagnosing you with borderline personality disorder, any more than your psychiatrist is going to be able to tell you why you have green ooze coming out of your vagina.

A lot of residency programs, such as EM and family med, will have you spend some time on psych, and other relevant services, but ultimately, you're going to be best at what you do the most.

 

[loveoforganic]

They don't have to be able to diagnose borderline, or any other specific mental disorder for that matter. What any doctor should be able to do is, upon looking at a patient, either be able to provide them with an effective treatment or refer them to someone who is better trained in the services the patient needs. This would include being able to recognize someone presenting with a psychological disorder and referring them to a psychiatrist/psychologist.

 

[TexasTriathlete]

But that may not be obvious over the course of a visit that might last 10 minutes. Or less.

 

[loveoforganic]

If you're the PCP, even if it's a short visit, it's going to be multiple short visits. You should eventually be able to notice an abnormal trend of behavior, if they do in fact have a psychological disorder. Sure, if you're an EM doc and the CC is "flu", you're probably not going to pick up on anything in your 5 min visit unless the patient is psychotic, in the middle of a manic episode, etc.

 

[Exalya]

I obviously was not inferring that they should have been able to diagnose it. Not in any way. I'm saying that there were clear signs of physical neglect and strange behavior that I would think any sane individual would have raised an eyebrow at. Instead, no one asked questions. I suppose every 11-year-old continues walking for miles on a sprained ankle voluntarily, I don't know >.> It's a matter of sensitivity, not specificity. I may never be able to diagnose a personality disorder on the spot, but I'd like to think I would ask a few questions when something was so obviously off about a person. I can only speak from my own experience, and in my experience, doctors have been too busy and disinterested to notice glaring psychological issues.

 

[beckhunter116]

I agree with Exalya that the point we are getting at is sensitivity as opposed to actual diagnosis.

My background is in psychology,since I was little I have always loved to observe behaviors and was fascinated in why people make the decisions they make, ect. My point is that I will bring this background and thought process with me everyday to the job no matter if I'm a FP, IM, EM, or Psych.

Obviously, we each have unique backgrounds that we bring to medicine.