The Shrinklady Demystifies Psychiatry - Chapter 1
Chapter 1: Common Sense and Artistic Flourishes
General Notes from the Shrinklady
Read the disclaimer before
you go on please.
FOR STARTERS: Psychiatrists are physicians (medical
doctors) with additional specialized training in the interface between
the mind and body. Psychologists are not medical doctors. I wish
that authors of fiction and scriptwriters would get that straight.
· You'll notice that I use the word "we" rather than "I" most
of the time when I talk about coming to treatment decisions throughout
this book. That's because unless you and your patient (and his loved
ones) truly feel that you're all working together as a team, the
odds of successful treatment are going to be much slimmer.
· Unless you're totally clueless, you'll also notice that
I use lots of cliches. Not only do they convey the message I want
the patient to understand efficiently, they make me sound like a
real, accessible person rather than a cold, scary "doctor".
· Incorporating a sense of humor into your dealings with
patients helps cut through the emotional tension inherent in this
kind of work. You'll also be demonstrating the use of humor as a
coping skill. It's good to laugh with your patients. Laugh
about ironies and goofy situations and avoid anything that could
be misinterpreted as making fun at the patient's expense.
Now, to illustrate this and the preceding point, which message will
be easier for your patient to understand and remember?
A. "The ability to identify humor under duress dissipates emotional
tension."
B. "Finding something to laugh about in a stressful situation makes
it easier to deal with."
· Look at the underlined and in the preceding section. I
highlight the use of the and to teach you the important skill of
gently confronting people about actions or behaviors that get in
the way of improvement. For example: "Mrs. Jones, I'm so proud
of you for doing such a wonderful job taking your medicine consistently
(pause to let this sink in) and I wonder why you still have/haven't
_____________."
If but replaces and , the patient will only hear the second part
of the sentence and discount the first. The word " but" serves to
negate what comes before it.
The late Dr. Mary Cerney was one of my instructors during residency
training at Karl Menninger School of Psychiatry in Topeka, KS. A
clinical psychologist and Catholic nun with a serene, Madonna-like
bearing, she was able to laser right into the issue without causing
much collateral damage.
Clinical Pearl: She taught me that you can more
comfortably share an unpleasant truth with just about anyone by phrasing
it in an "I wonder". For example: "I wonder if you realize that
undesirable behavior/failure to follow medical advice , problem being
caused ."
Examples that may apply to your work are:
· "I wonder if you realize that continuing to drink alcohol
XE "alcohol:abuse" against my medical advice indicates that
you have an alcohol XE "alcohol:abuse" problem."
· "I wonder if you understand how much it inconveniences
my staff and other patients when you show up late for every appointment." (In
this situation, you may want to evaluate for adult ADHD. See chapter
9.)
Confronting Mules
When I encounter patients who are stubborn and uncooperative, I
scoot my chair up next to them, place my hand on top of theirs, drop
my voice, smile and ask them, "Were you born in Missouri?" Their
usual response is "No, why do you ask?" to which I respond, "Because
you remind me a lot of a Missouri mule." At this point, they smile
and usually become more cooperative. I've never had a patient
become angry with me about this.
Words of Wisdom from Dr. D
· Clinical Pearl: Smile and shake hands
with the patient and whoever accompanies her to the visit. At the
end of the visit, shake her hand again and say, "You're a good person,
Mrs. Jones."
Leonard Dumonceaux, MD, my former clinical instructor and office-mate
shared this simple secret of treatment success with me 15 years ago.
Dr. D's patients adored him and followed his advice, to their great
benefit. He pointed out that some of our patients haven't heard a
kind word in years, if ever. Don't be surprised if your patients
are moved to tears on occasion when you praise them.
My favorite memory of working with Dr. Dumonceaux was his way of
preparing for his walk to the inpatient unit across the courtyard:
he put on his overcoat and old-fashioned fedora, while announcing, "I'm
off to stamp out disease and pestilence." Dr. D frequently told me, "Between
soap operas and country music, we'll be in business forever."
The Shrinklady's Words of Wisdom
· The power of suggestion is too powerful to waste. I take
advantage of it all the time when I speak with patients: to facilitate
rapport, compliance, development of coping skills, hope and self-esteem.
My running chatter is liberally sprinkled with comments such as:
· "Let's get busy and get you feeling better."
· "We'll find a way to deal with it." = the answer to any 'what
if?' question.
· "I'll be surprised if you don't look better the next time
I see you." Then point out the increased facial and vocal animation
and lessening of worry lines that are usually evident after several
weeks of treatment.
· "Let's come up with a good plan to take care of this problem."
· I assign a lot of responsibility to patients and their
family members to "do their homework" and learn about the illness.
I praise them lavishly when they follow through on the assigned responsibility.
· I place great stock in what patients and their families
tell me about symptoms and medication effects.
· I apologize to patients if I inadvertently inconvenience
them in any way.
· Since I'm not inside the patient's skin, and every patient
is different, I tend to prescribe minimum and maximum ranges for
p.r.n. (as needed, rather than routine) medications. I ask patients
to start low, then "experiment" (under my guidance) to determine
the most effective dose in various situations.
· In an ideal world, I would have fewer patients, but would
be able to see them more frequently. I would like to
see each patient 2 weeks after I start them on medication, then monthly
until their symptoms are in remission, then every other month for
a year or so, then every 3 months.
Demand for my time being what it is, the reality is that
it is usually 4 weeks before I can see a patient for the first follow-up
visit and that follow-up visits during the active treatment phase
are spaced about 6 weeks apart. In addition, many patients are afraid
of losing their jobs by taking off work frequently for doctor's visits.
Also, it doesn't help kids who are already struggling with bad grades
to miss school. That's why I ask patients/parents whom I believe
are capable of reliably monitoring symptoms and reporting problems
to take that responsibility. If I don't think the patient/family
is capable of this, I schedule them into my hidey-hole, whenever
this is possible.
· I'm an independent contractor with several clinics, so
it can be difficult to instill this concept into all the scheduling
secretaries I work with, but if you practice in only one location,
this should be easy to accomplish:
Clinical Pearl: Establish a hidey-hole of 30-60
minutes toward the end of your workweek during which no patients
are scheduled unless you specifically approve it. That's
where you can stick new or follow-up patients for whom you would
have to miss your lunch or extend your day, or who would have to
wait weeks to see you otherwise. Trust me, that "hurtin' gator" slot
will always get filled.
· Here's the fasting lab work I like to see on every patient
initially and at yearly intervals:
CBC with differential count
Comprehensive Metabolic Panel
TSH
UDS (Urine Drug Screen) if I suspect a drug abuse problem
· I don't find getting a routine UA to be of much benefit.
I only order a urinalysis
if the patient is symptomatic.
· On the lab order, I request that the results be sent to
me and to any other
medical providers, if the patient is agreeable. This minimizes hassle
and
expense and improves communication.
· I don't order brain imaging routinely, because the yield
is so low. I only order a CT or MRI under the following circumstances:
· New onset of psychotic symptoms
· Abrupt mental status change of undetermined etiology
· Classic brain tumor symptoms (The one time I suspected
this, I was right, unfortunately for the patient.)
· As part of a dementia evaluation
· Other neurological symptoms
· I diagnose tons of sleep apnea among my patients. It's
amazing what a little oxygen to the brain can do to improve psychiatric
symptoms, in conjunction with other treatment measures.
· I use duplicate prescriptions and keep the carbon-less
carbon, taping it to the bottom of my SOAP (Subjective, Objective,
Assessment, Plan) note.
· When clinically appropriate, I incorporate a "cushion" refill
into the prescription. For example, if I plan to see a stable patient
for routine follow-up in 3 months, I'll write for a one month supply
with 3 refills. That way, if something comes up and the appointment
has to be rescheduled, neither your staff or the patient has to be
inconvenienced playing "phone tag".
· As is the case with so many psychiatric medications, many
of them are prescribed "off-label". This means that while the medications
have been FDA-approved, the approval was granted for treatment of
a different medical condition. Pharmaceutical companies are not likely
to seek new indications for a medication whose copyright is soon
to expire. The "mother may I officially call myself a treatment for
condition X?" process takes so long and is so expensive that the
manufacturer would never recoup their investment.
It's perfectly legal to prescribe medications off-label if the patient
or parent/guardian consents to its use after discussion of your rationale
for using it and its potential risks/benefits. Just make sure that
you document your reasoning process for suggesting off-label use
of the medication. If a malpractice suit were ever to arise in regard
to treating a patient with an off-label medication, a jury is likely
to look favorably upon a physician who works to tailor the choice
of medication to the needs of the patient and family in the short
and long-term.
· You should be able to obtain a current pocket-size copy
of the DSM-IV-TR from a drug rep fairly easily, if you're not sufficiently
familiar with the officially-recognized diagnostic criteria for psychiatric
disorders.
· My favorite reference for medication issues is the well-organized
and practical Clinical Handbook of Psychotropic Drugs , 12 th revised
edition, Hogrefe & Huber Publishers, ISBN 0-88937-258-6.
· You'll notice that I repeat key points several times in
different areas of the book to beat it into your head…um, facilitate
learning.
Reminder: Stop reading right now if you can't accept the terms
in the incredibly long disclaimer located
in the introduction. Don't put my friend's health at risk! |
