Today I posted a piece on the Positive Medical Blog about how my views of forgiveness have evolved over the years, mostly as a result of hearing the life stories of many patients.

Since it’s a topic that would be entirely appropriate for this blog as well, I wanted to share it with you. Please click here to read the article.

PATIENT:

adjective: bearing pains or trials calmly or without complaint

noun: an individual awaiting or under medical care and treatment

from Merriam-Webster Online

Photo by frances 1972

Nobody likes to wait.

But, like it or not, the world is filled with situations where we commonly have to do so. Sometimes the waits are excusable and even predictable, and other times they are not. At most doctors’ offices, one can expect to wait to varying degrees beyond their scheduled appointment time. It’s predictable. But is it excusable?

As a doctor who has done plenty of outpatient work, I am well aware of both sides of this coin.

Patients very understandably assert that their time is valuable, too. They often see it as arrogant on a doctor’s part when they are made to wait. Disrespected is how these patients usually feel. “How dare that doctor believe that his time is more important than mine!” is the mantra.

While I can sympathize with this viewpoint, the situation is more complicated than one might assume. And it’s not usually personal or intentional even though it may feel that way to patients.

Some of the primary reasons that doctors run behind schedule include emergencies, patients’ visits taking longer than anticipated, and patients (ironically) arriving late to their appointments. Most of these situations are beyond physicians’ control. Doctors also must return phone calls, speak with pharmacists, and fill out many forms.

I suspect that many patients do not realize that these issues can be frustrating and stressful for doctors, too. Speaking for myself, I am a conscientious person. It bothers me to be running behind. I truly don’t want to inconvenience anyone or waste their time.

So I do try diligently to stay as close to on-schedule as I can. But if I’m to be a competent, conscientious physician, I absolutely cannot make this my first priority. Avoiding or trying to repair train wrecks is more important than the train schedule.

If my first priority is the clock, then I will be more likely to appear rushed or insensitive, not listen carefully, miss important clinical findings, or maybe minimize the importance of something that warrants attention. Patients matter, and their clinical needs, which are often unpredictable, must come first.

Since so much is beyond doctors’ control, should we all just give up and not worry about staying on schedule?

Absolutely not. There are some ways that physicians can improve timeliness. For example, there are methods for improving efficiency and workflow in clinics.  American Medical News recently published an article to help physicians reduce wait times by addressing such issues. Doctors’ offices also can hire consultants to help them with the task.

What can patients do?

Arrive on-time (I know that sounds like a double standard, but one late patient can result in many more patients having to wait). Be organized–come with a concise list of questions. Be realistic–do not expect a doctor to be able to address several issues in one brief follow-up appointment. Finally, remember that your doctor may be behind because he needed to spend extra time with a patient in need. Next time it might be you–be glad if your doctor is willing to take the extra time when it really matters.

What do you think about this issue? In particular I’d really like to know how long you believe is a reasonable wait in a doctor’s office.

Great doctors listen to their patients. They start out by asking open-ended questions, and unless patients get too far off-track, they don’t typically interrupt them. Despite having limited time for appointments, they have an unhurried manner. They make eye contact with their patients and do not bury their heads in charts and computer screens. Their patients leave their appointments feeling respected and heard.

Of course no doctor is likely to be able to do all of these things all of the time, but some come closer to this ideal more consistently than others.

But great doctors additionally have a “sixth sense.” They can “read between the lines.”

It’s vital that physicians listen to their patients, but human beings are complicated and sometimes do not say what they mean or mean what they say. Or, they may not even know for sure how they feel. Therefore, listening to a patient’s words alone is not enough.

Exceptional physicians have honed the skill of reading non-verbal cues as well as easily-missed subtleties of spoken language that help them to interpret their patients’ histories with greater accuracy. Ultimately, since they are able to connect with and truly understand their patients better, they have the potential to provide superior care.

But, wait. There’s an invaluable clinical pearl that physicians can borrow from the world of psychotherapy to help them to better hone this “sixth sense.”

I’ll explain.

Have you ever been around a negative, depressed person for too long? Or too many negative, depressed people in a short period of time?

How did you feel?

Let me guess–you probably felt depressed or “blah” yourself.

What about someone who was in a very happy and joking mood?

Did you want to smile and maybe laugh?

And that’s the “secret”–it’s actually quite simple: The feelings that others elicit in you are often reflections of their own internal mood states. So, how you feel in the presence of someone very well might be similar to what they are feeling.

I’ve seen this occur from being around people experiencing other emotional states as well.

An anxious, obsessive, fearful person often creates a sense of anxiety, tension, and unease in those around him.

An untrusting or even paranoid person often causes others to feel suspicious.

The list of possibilities goes on and on.

And while this “window” into a patient’s emotional state is not always reliable, it often is. It’s potentially important “information” that shouldn’t be ignored, regardless of a doctor’s specialty.

In addition to providing a clue about the patient’s own feelings, there is another reason that I believe it’s helpful for doctors to be tuned into our own emotions. Our emotional state can impact patient care.

As physician blogger, Dr. Rob, points out, the doctor-patient interaction involves two humans. He states:

Patients forget that doctors have bad days, get depressed, are sometimes sick, and can be as irrational as patients. We are forgetful at times, don’t always think of things that may be obvious, and even get distracted at times. Sometimes our kids annoy us, sometimes our marriages are bad, some of us have our own past trauma, and sometimes the patient immediately before your appointment was very difficult.

With regard to being “irrational,” that’s exactly what can happen when we have strong emotional reactions to our patients: We doctors can easily lose our objectivity. Making diagnostic and treatment decisions when in an overly emotional state can jeopardize good patient care.

So, what can physicians do?

We can try to pay more attention to how we feel when we’re with our patients. If we notice ourselves having strong emotional reactions, whatever they may be, we should remind ourselves that they may mirror our patients’ mood states. By simply getting ourselves in the habit of being more mindful of our emotions, I believe we’re less likely to allow them to inappropriately sway our clinical judgment.

“Everyone wants to tell you what to do and what’s good for you. They don’t want you to find your own answers, they want you to believe theirs. I want you to stop gathering information from the outside and start gathering it from the inside.”

from the Way of the Peaceful Warrior by Dan Millman

Photo by h. koppdelaney

Progress.

Inevitably it means change and supposedly inventing better ways of doing things. And as a society we’ve done just that. But there have been side effects.

Since we’re more “human-doings” than “human-beings,” we’ve focused on utilizing our advances to cram more work into our day instead of using our new-found efficiency to create more time to spend with our families and friends and to pursue volunteer and recreational activities.

Take technology for example. We now live in an “always-connected” culture. We can be virtually anywhere in the world and remain in uninterrupted contact with others. That’s amazing! And it’s great at times but not so great at others.

Without the constant ability to send and receive phone calls, text messages, e-mails, and social media status updates, many people feel lost and experience a restless unease.

Taking a quiet walk in nature while temporarily out of contact with the rest of world is good for the soul. But it’s also becoming something that some of us have forgotten how to do. We all could benefit from truly learning the art of doing nothing once in a while–just learning “to be.”

Despite the drawbacks of progress, I wouldn’t want to give up the internet or some of the other technological advances I’ve witnessed in my lifetime, but once in a while I fantasize about what life would be like without all of it. I imagine it’d be quieter, more peaceful, maybe less rushed.

Then I think of my own field of psychiatry.

Psychiatry has been getting quite a heavy dose of criticism lately. Yes, it’s far from perfect and could be improved in many ways. We’ve become too reliant on medications and have moved too far away from knowing our patients well where we really understand them thoroughly. Despite these still-needed improvements, if I compare the treatments that patients with mental illness have available to them today to what was available 30 or 40 years ago, there’s no doubt in my mind that there has been “progress.”

And, just as I said I would not want to return to the dark ages before technology, I also would not seriously want to turn back time on the field of psychiatry. I still want to see it improved, but I wouldn’t want to give up the new tools we have acquired along the way.

But, a small part of me similarly wonders what it’d be like to practice without being encumbered by all of the modern issues such as productivity concerns and time pressures. The big one, though, that I wonder about (and never hear anyone discuss) is the expectation that the psychiatrist always has something external to give the patient that will somehow make the patient’s life better.

In other words, the implicit assumption is that the patient has a life problem, and the answer to that problem lies outside of the patient. The patient does not have within him or herself either the answer or the means of finding the answer. Of course this assumption is untrue and disempowering to patients. (Just to be clear, for the moment I’m not talking about patients with serious mental illnesses who may also need medications. I’m talking about patients with any of a number of different things about themselves and their lives they want to improve–situations that theoretically should be within the purview of psychiatry.)

But, the other problem with the psychiatrist presumably holding the “keys” to a better life for the patient is the conflict it creates in the psychiatrist-patient relationship. Other than maybe feeling disrespected or not heard, the most common reason I believe patients get angry at psychiatrists is their not receiving some external thing that they feel the doctor is withholding from them. It could be a medication, advocacy for receiving disability, a work excuse, or any other perceived relief from suffering the psychiatrist could potentially offer.

I’ve always enjoyed reading about Eastern religions and philosophy. And in many such traditions exists the concept of a “guru.” Not meaning guru as in “expert.” Rather, loosely defined, a guru is often a great master who serves as a teacher to others. Those seeking enlightenment often connect with a guru to help them move along their own spiritual paths. And, it’s crystal clear the guru is not giving the follower anything external. The guru challenges the student’s thinking and habits, and the path to enlightenment or the answers to the student’s problems eventually become self-evident. Gurus do not give their students anything external, but they help them to find their own ways. Now psychiatrists never really have been the same as gurus; I realize that, but there still are some similarities between the two roles. It’s just that as psychiatry has progressed in some ways, it unfortunately has moved farther away from psychotherapy and therefore even farther from anything resembling a “guru” role.

I usually get along well with most of my patients, even those who are incarcerated. But when conflict arises, I sometimes think of the guru-student relationship with a bit of envy. It’s the power (and sometimes illusion of an external solution) of what a psychiatrist can give a patient that creates the conflict–the conflict that sometimes alters or damages the psychiatrist-patient relationship. And it occurs in the context of a culture where all have been led to believe that there is an external solution to every problem.

Psychiatrists treating patients who can’t talk: Sounds fishy, doesn’t it?

Well, I do it 2-3 days per week, and as strange as it may sound, it makes perfect sense.

Let me explain.

I provide psychiatric consultation services in a facility for people with intellectual and developmental disabilities. (Intellectual disability is the newer term for mental retardation.) Some of my patients are short-term admissions from the community, and others are long-term residents of the facility. Over the past couple of decades as community living has become the norm, many long-term residents have moved to the community. Those who are left are quite fragile and very medically complex. About 70% have seizure disorders. Most have severe or profound intellectual disabilities and are completely non-verbal. Being dependent on others for assistance with activities of daily living is the norm.

One of the old myths about persons with intellectual disabilities (ID’s) is that they cannot develop mental illnesses. You may have heard the term “dual diagnosis.” Usually that term refers to persons who have both mental illness and substance dependence. However, in the field of developmental disabilities it also refers to persons who have both an intellectual disability and mental illness. Patients with any level of ID, including those with no expressive communication skills, can develop mental illness.

Since these severely intellectually disabled individuals who can’t talk can develop mental illness, how does one determine whether mental illness is present and which diagnosis is most likely?

Not the traditional way that medicine is practiced in the U.S.

It takes a multidisciplinary team approach and careful data collection. Our team is comprised of primary care, psychiatry, nursing, psychology, occupational therapy, physical therapy, speech and language pathology, dietary, pharmacy, social work, Qualified Mental Retardation Professionals, recreational therapy, vocational services, and direct care staff (CNA’s).

The good news is that not only do we have access to all of these disciplines, but every team member is experienced in evaluating and treating intellectually disabled patients who have minimal communication skills.

One of the advantages of being in a system without fee-for-service medicine is that we can seamlessly involve as many disciplines as necessary without having to deal with administrative or reimbursement barriers. For example, as a psychiatrist, I can contribute my expertise (and learn a great deal as well) to cases that do not strictly involve mental illness. And my involvement transcends prescribing psychiatric medications.

When evaluating a new patient, our team will review outside records and then meet with the patient’s stakeholders from the community: parents/guardians, case managers, group home staff, etc. We will all sit around a table together and have an admission staffing meeting, a rare entity in health care these days.

The various disciplines will perform their assessments. If there are problem behaviors identified, then psychology will perform a functional assessment of the behavior. They will collect objective data of the relevant behaviors throughout the patient’s stay.

As a psychiatrist, I rely a great deal on the patient’s history as reported both in outside medical records and at the admission meeting. Then I consider the results of the assessments of the other disciplines with significant attention to the primary care physician’s and psychologist’s workup.

Many behavioral problems in this patient population are caused or exacerbated by non-psychiatric medical issues. Constipation and pain are a couple of common examples. Patients with such issues may begin to exhibit or show an increase in already-present behaviors such as agitation, yelling, aggression, or self-injurious behavior.

It is crucial not to be too quick to make a psychiatric diagnosis–one does not want to make the mistake of treating pain with psychiatric medication, for example.

Once I am able to consider the patient’s history and clinical signs in the context of the other team members’ assessments and objective behavioral data, I determine whether the clinical picture resembles established psychiatric diagnoses. This is where understanding “the art” of psychiatry and having previous experience treating verbal, developmentally normal patients is vital.

The longer I have to work with a patient, the better I am able to make an accurate diagnosis. Sometimes the diagnosis is fairly clear on the day of admission, but in some cases (such as with some of the long-term residents), it may take a couple of years or more.

When I do make a diagnosis, if I believe medication is warranted, then I typically prescribe very cautiously, starting only one medication at a time, using low doses, and making only one change at a time. If psychology wants to try a behavioral intervention, then that is considered a change. If primary care wants to start a medication for pain or reflux, then that is considered a change. Working collaboratively it is usually possible to stick to the “one change at a time” approach.

We all rely on the objective data that psychology tracks combined with each other’s observations of the patient to track the patient’s progress and to guide our treatment. This integrated approach allows me to provide much higher quality psychiatric care than I could in the traditional outpatient setting of the fragmented U.S. health care system.