Which patients do you find most difficult to deal with?

[solumanculver]

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i find it so strange that folks continue to view psychotherapy and psychopharm as an either/or proposition...

Just because a person wants to do the prescribing and not the talking doesn't make it either-or... It seems unreasonable to insist that psychiatrists should want to do psychotherapy, we don't require orthopedic surgeons to do physical therapy... we have physical therapists for that.

 

[erg923]

Seems I have hit a nerve here 😉, are you one of those willing to 'just talk' and feel pharmacology is just an eye wash and waste ? I want to see you talking and analyzing one of the aggressive patients in your Office - when he is Off his meds and has history of bursting open heads. TALKKKKKKKKKKKKKKK TO MEEEEEEEEEE

No no, I''m in clinical psych, so we have a bit of a different take I suppose. And I don't work with acutey agitated or violent patients, so I understand that. It wasn't directed at you or anything, but when so many of my patients complain about how poor their relationship is with their psychiatrist, how they feel unlistened to, and are basically made to feel like a black box full of symptoms.....it just bugs me when I see this attitude manifested and justified by psychiatrists. I just think the minimization of importance you put on listening and speaking with your patients would make some patients cringe if they read it. Even if you are not the one providing it, I sincerely hope you realize the value and importance of talking and emotional catharsis if you are in this field.

 

[sunlioness]

I agree, erg923.

 

[solumanculver]

so many of my patients complain about how poor their relationship is with their psychiatrist, how they feel unlistened to, and are basically made to feel like a black box full of symptoms.....it just bugs me when I see this attitude manifested and justified by psychiatrists. I just think the minimization of importance you put on listening and speaking with your patients would make some patients cringe if they read it. Even if you are not the one providing it, I sincerely hope you realize the value and importance of talking and emotional catharsis if you are in this field.

Hi Erg,
Do you think that psychiatrists are treating their patients as a "black box full of symptoms" to a greater degree than other physicians, or just to a greater degree than psychologists? Do you think those patients are just complaining that their psychiatrists aren't listening to them because they have an expectation about what a psychiatrist is supposed to be that isn't fulfilled by their psychiatrist. Maybe that same patient is treated the same way by his internist and doesn't notice it because he doesn't expect his internist to be his emotional confidante...

I'm interested in becoming a psychiatrist and I intend to listen to my patients, but it doesn't seem like a good use of time to listen to them say things that won't affect clinical decision making. Of course, catharsis is good, but I don't want to be the one providing that... Do you have to provide catharsis whenever you meet with a patient?

 

[erg923]

Hi Erg,
Do you think that psychiatrists are treating their patients as a "black box full of symptoms" to a greater degree than other physicians, or just to a greater degree than psychologists? Do you think those patients are just complaining that their psychiatrists aren't listening to them because they have an expectation about what a psychiatrist is supposed to be that isn't fulfilled by their psychiatrist. Maybe that same patient is treated the same way by his internist and doesn't notice it because he doesn't expect his internist to be his emotional confidante...

I'm interested in becoming a psychiatrist and I intend to listen to my patients, but it doesn't seem like a good use of time to listen to them say things that won't affect clinical decision making. Of course, catharsis is good, but I don't want to be the one providing that... Do you have to provide catharsis whenever you meet with a patient?

Yea, I agree sort of. But the fact is, the patient population is different and people seeing a psychiatrists are in need of that "talk" more than "psychiatrically normal" people seeing an internist. The internist is not overly concerned with the patient's mental status and emotional well being, the psychiatrist is (or should be), and patients expect them to demonstrate that interest through their behavior (rightly so).

Regarding the highlighted section: Then I think you will have trouble establishing a sound therapeutic rapport with your patients, and they will complain to me about you..... Seriously though, I understand where you are coming from, but I find that patients will view the attitude of "I only listen to what I want to listen to" as uncaring and/or condescending. I just hope you will cut patients off from their stories very delicately, and clearly articulate the difference between what you are doing and what a therapist does, so they do not get too offended. Additionally you have to think about more than your clinical decision making here. Again its a human, not a box of symptoms. Research into the split treatment model overwhelmingly demonstrates that patients are more wiling to comply with treatment regimens when the psychiatrists presents as an allie in treatment, not just a diagnostician. It makes sense if you think about, I mean psych patients are the not the run of the mill medicine patients. Many are gonna be obstinate or paranoid, why would they take a medication just cause you say so? But demonstrate to them that you truly care, that you are their allie in treatment, and they are more willing to trust, and thus comply. So some good ole small talk that shows you care about them as individuals is in the best interest of your patients, and your reputation as a good psychiatrist.

And no, of course no one is gonna force you to do alot of long talking of formal psychotherpay with your patients in psychiatry. Maybe in residency some though. But, if you use your common sense and innate human compassion, would it be better to only ever talk symptoms, or occasionally sit down and take 5-10 minutes to inquire about an upset persons day, and give them that proverbial pat on the back that can really make their day? Patients get a big kick out of someone just showing an interest in their lives (not just symptoms), even if its just for a few minutes. Know what I mean? Occasionally, when I have had a bad day at school or the clinic, I will pass one of our janitors in the hall. I don't know the guy that well, we're not friends or anything, but he has made my day on more than one occasion by just saying "why the long face, wanna talk about it?" 5 minutes is all it ever takes. He always ends with this funny story that I doubt is really true, that really brightens my day. I know its not your job per say to do therapy and alot of small talk, but it is your responsibility as human to show consideration and compassion, and your job as a physician to do the best you can for your patients.

 

[billypilgrim37]

it doesn't seem like a good use of time to listen to them say things that won't affect clinical decision making.

It might not affect your clinical decision making, but it will certainly affect theirs. Patients are much more willing to take medications from a psychiatrist who they perceive as their partner-in-health than from the psychiatrist who doesn't connect with them at least on a minimal level.

And that's true in internal medicine. It's even true in surgery, if you've ever watched a vascular surgeon manufacturer resistance against quitting smoking.

I'm pretty sure there are a not-insignificant number of PVOD patients who keep smoking just to piss off their vascular surgeons. So wonderfully Freudian.

 

[Floyd78]

Just because a person wants to do the prescribing and not the talking doesn't make it either-or... It seems unreasonable to insist that psychiatrists should want to do psychotherapy, we don't require orthopedic surgeons to do physical therapy... we have physical therapists for that.

Since you are interested in becoming a psychiatrist but don't want to do psychotherapy, you should be aware of this:
In 2001, The Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) for Psychiatry added specific requirements, as follows, in section VI.B.2, which focuses on "Internal Evaluation": "The program must demonstrate that residents have achieved competency in at least the following forms of treatment: a. brief therapy; b. cognitive behavior therapy; c. combined psychotherapy and psychopharmacology; d. psychodynamic therapy; and e. supportive therapy."

 

[solumanculver]

Yea, I agree sort of. But the fact is, the patient population is different and people seeing a psychiatrists are in need of that "talk" more than "psychiatrically normal" people seeing an internist. The internist is not overly concerned with the patient's mental status and emotional well being, the psychiatrist is (or should be), and patients expect them to be (rightly so).

Hi, Of course I agree with that. Evaluating a patients mental status and emotional well being is important to clinical decision making. I mean that just being around to be some sort of cathartic outlet for the patient is not a good use of time.

Regarding the highlighted section: Then I think you will have trouble establishing a sound therapeutic rapport with your patients, and they will complain to me about you..... Seriously though, I understand where you are coming from, but I find that patients will view the attitude of "I only listen to what I want to listen to" as uncaring and/or condescending.

I don't mean that I plan on being tactless, but there is only so much time you have to see a patient... It's not inappropriate to direct a discussion to clinically relevant details rather than act as a cathartic sink, right?

Research into the split treatment model overwhelmingly demonstrates that patients are more wiling to comply with treatment regimens when the psychiatrists presents as an ally in treatment, not just a diagnostician.

What does it take to be considered an ally? It seems like when I see a physician there is a certain amount of small-talk that goes on... about a minute, I think. Of course, a physician should do as much small-talk as is required for the patient to be comfortable complying with the treatment plan, but is that different from any other branch of medicine?

It makes sense if you think about, I mean psych patients are the not the run of the mill medicine patients. Many are gonna be obstinate or paranoid, why would they take a medication just cause you say so?

Hi. Yeah, it seems like a psychiatrist should engage in enough small talk to get the patient to follow the treatment, but I take that to be different from being a cathartic outlet. Is it the same, you think?

But demonstrate to them that you truly care, that you are their ally in treatment, and they are more willing to trust, and thus comply. So this is in the best interest of your patients and for you, and your reputation as a good psychiatrist.

Yeah, the truth is that I do care, that's why I'm interested in psychiatry. But my interest is in medicine, not social work or therapy. I think that developing a doctor-patient rapport is important, but where do you draw the line?

And no, of course no one is gonna force you to do alot of long talking of formal psychotherpay with your patients in psychiatry. Maybe in residency some though.

Sure, that's a requirement that I'm not looking forward to. As a psychologist, what do you think about split treatment?

 

[erg923]

"I mean that just being around to be some sort of cathartic outlet for the patient is not a good use of time."

I think you would be surprised. Outcome studies demonstrate that the overwhelming majority of variance in successful psychotherapy (almost 70% on average) is accounted for by nothing more than good ole Dr.-patient relationship/rapport. Just "being there" for someone is more important than we often realize. Remember what I said about giving that upset patient that proverbial pat on the back? It just takes an extra few minutes. I'm sure you have had someone make your day once or twice just by showing an interest, or giving some kind and reinforcing words. I think one should strive to do this with all their patients. But, of course you should never sacrifice the necessities of clinical symptom assessment and mental status to only be a cathartic sink.

"It's not inappropriate to direct a discussion to clinically relevant details rather than act as a cathartic sink, right? "

Correct! But remember your audience here. This is not always the most rational, intelligent, or insightful population. Whether its truly inappropriate often is not the issue. The real issue is how its how its perceived by the patient. I understand its not inappropriate because I know exactly what you do, and understand you are trying to get as much meaningful information in the short time you have. Many psych patients will not understand this, at least not initially anyway. So it is certainly understandable that they might feel unlistened to, or neglected as an individual if you only talk about symptoms, and ignore or abruptly cut them off in the middle of something. You cant assume patients are gonna have such rational and insightful thought processes about what you are doing and why you are doing it. I would also add that, with all due respect, you sound very "me" focused when talking about your clinical work. (i.e., what you deem is relevant info, what you prefer, wanting to do the bare minimum of interaction to get them to comply with a treatment regimens). Again, these aren't regular medicine patients, they are different. They have come to you because they are in pain (emotionally). When you form this rigid hierarchy of "I am the expert and decide whats important, you are the just the patient" you are setting yourself up for disaster in psych (although I realize that mentality has to be exercised in certain inpatient cases). Psych patients often need a little more talking to, a little more understanding, a little more compassion, a little more time than that guy who presents with a broken arm. Instead of thinking about all this from a "what would I have to do" approach...try to actually enjoy talking and learning from your patients. I would think people who don't enjoy above the minimum amount of human interaction necessary, and view it as a chore rather than a pleasure, would not enjoy being clinicians. Instead of always approaching it from a "physician should do as much small-talk as is required for the patient to be comfortable complying with the treatment" attitude, try-"a patient deserves a physician who views the patients needs as primary, and is wiling to take the time and effort to make them feel comfortable. I think this phrasing is little more more idealistic and aspirational, and less "what is the bare minimum I can get by with" sounding.

"As a psychologist, what do you think about split treatment?"

I think the real question should be what do patients think of the split treatment model, and what does the literature say about its effectiveness? In theory, it has some potential advantages over an integrated model. Unfortunately, the literature (which is scant and needs to be updated) does not bare these out in most cases. However, at this time, I do not have a realistic viable alternative.

 

[crippledoc]

The patients that psychiatrists find most difficult to deal with are the normal ones. They just can't stand the fact that someone could survive without their intervention.

 

[nitemagi]

The patients that psychiatrists find most difficult to deal with are the normal ones. They just can't stand the fact that someone could survive without their intervention.

could someone please ban this troll.

 

[alpha62]

could someone please ban this troll.

If you plan on making a career of dismissing every person who accuses you or your profession of charlatanism, you are in for a very lonely couple of decades.

Grow a thicker skin or perish. 🙄

 

[whopper]

If you plan on making a career of dismissing every person who accuses you or your profession of charlatanism, you are in for a very lonely couple of decades.

Having a thick skin is different from banning a troll. Internet trolls in case you haven't noticed, even with a thick skin are a waste of time & bandwith.

And just what exactly is the problem with saving bandwith & time?

 

[Ritz]

No no, I''m in clinical psych, so we have a bit of a different take I suppose.

And I don't work with acutey agitated or violent patients, so I understand that. It wasn't directed at you or anything, but when so many of my patients complain about how poor their relationship is with their psychiatrist, how they feel unlistened to, and are basically made to feel like a black box full of symptoms.....


it just bugs me when I see this attitude manifested and justified by psychiatrists. I just think the minimization of importance you put on listening and speaking with your patients would make some patients cringe if they read it. Even if you are not the one providing it, I sincerely hope you realize the value and importance of talking and emotional catharsis if you are in this field.

I wont be too bugged by what other people are doing - but I feel for my patients when they say that their doctor they used to see for therapy told them Medication causes a decrease in their sperm count ! 😛

 

[erg923]

I'm not sure I understand your post...are you referring to a misinformed psychiatrist, or psychologist, or some other therapy provider (LCSW)? Obviously I would agree that passing on false information about medication side effects is not a good thing, doesn't matter who the source is.

 

[alpha62]

Having a thick skin is different from banning a troll. Internet trolls in case you haven't noticed, even with a thick skin are a waste of time & bandwith.

And just what exactly is the problem with saving bandwith & time?

So now I’m curious how you respond and deal with paranoid delusions of persecution at your office then.

In my office they’re not called trolls, they’re called revenue stream.

 

[whopper]

I've been on several boards & internet forums.

All of them turn up some troll sooner or later.

You just simply cut their account.

Nuff said.

Of course if you have a different philosophy for a board & want to tolerate them, while they take up hundreds of posts, tick off lots of people who will then go to boards where the moderators cut out the trollers you can have that as well.

An analogy between that & the "persecution" issue you brought up is different. An internet troll is different from someone with SCPT. That an analogy isn't even close.

 

[Ypo.]

This thread has been thoroughly derailed from it's original purpose. Closed.