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Understanding The Subtext Of The Therapeutic Relationship

When we talk about psychotherapy, one aspect of what we look at is the process of what occurs in the therapeutic relationship.  This is an important part of psychodynamic-based psychotherapy, meaning psychotherapy that is derived from the theories put forth by Freud.  Psychoanalysis (the purest form of psychodynamic psychotherapy) includes an emphasis on events that occurred during childhood, and a focus on understanding what goes on in the relationship between the therapist and the patient, including the transference and counter-transference.

In some of our posts, our friend Jesse has commented about how it’s important to understand what transpires in the mind of the patient when certain things are said and done.  Let me tell you that Jesse is a wonderful psychiatrist, he is warm and caring and attentive and gentle, and he’s had extensive training in the analytic method, he’s on my list of who I go to when I need help, so while I want to discuss this concept, I don’t want anyone, especially Jesse, to think I don’t respect him.  With that disclaimer…..

On my tongue-in-cheek post on What to Get Your Psychiatrist for the Holidays, Jesse wrote: Read more »

*This blog post was originally published at Shrink Rap*

The Stigma Of Psychiatric Treatment And Its Inclusion In The EMR

For a while now we’ve been talking about issues related to psychiatry and electronic medical records.  Roy is very interested in the evolution of EHR’s.

I don’t like them.  I think they have too many problems still, both in terms of issues of efficiency and time, and how they divert the physician’s attention away from the patient, and they focus medical appointments on the collection of data– data that is used in a checkbox form: patient is not suicidal and I asked, whether it was clinically relevant or not– and will therefore serve as protection in a lawsuit, or demographic information used by insurers, the government, who knows.

From a privacy standpoint, I think they are appalling.   If you are a patient in the hospital where I work, you get Read more »

*This blog post was originally published at Shrink Rap*

Therapy Is About Having An Honest Relationship, But Is Lying Ever OK?

We’ve been having a great discussion over on the post Tell Me…. An Ethical Dilemma.  The post talks about a young man who wants to know if he can check “no” to a question about whether he has a psychiatric disorder if his illness is not relevant to the situation.  The comments have been fascinating — do read them– and very thought-provoking.

One reader asked, ” If a patient asked if they were boring you, and they were, would you say yes?”

This is a great question, and of course the right thing to do is to explore with the patient what meaning the concern has to him.  But is that all?  I’m not very good at doing the old psychoanalyst thing of deflecting all questions, and mostly I do answer questions when they are asked of me.  This can present a really sticky situation because one can not think of any clinical scenario in which it would be therapeutic to have a therapist tell a patient, ‘Yes, you’re boring, OMG are you boring,’ or ‘No, in fact, I don’t like you.’  And not answering could be viewed as negative response by the patient –if you liked me, you’d tell me, so clearly you don’t like me.  So if the exploration of the question doesn’t take care of the issue, and the patient continues to ask, what’s a shrink to do? Read more »

*This blog post was originally published at Shrink Rap*

Why Don’t Psychiatrists Like To Show Patients Their Notes?

Please see my post on Clinical Psychiatry News and yesterday’s post What’s in a Note? along with the reader comments.

One reader asked why it’s weird to want to see your shrink’s notes and why shrinks refuse to show them on the grounds that they may distress the patients.  Another reader asked why doctors write “patient denies” as though they don’t believe the patient.  These are both great questions worthy of their own post.

Why don’t psychiatrists like to show patients their notes?  Are they really going to “harm” the patient?  There are a few reasons why a psychiatrist may not want to show a patient her notes.  Here is my list of thoughts as bullet points. Please feel free to add to it. Read more »

*This blog post was originally published at Shrink Rap*

A Shrink Considers The Effectiveness Of Her Scheduling Method

I’ve been at it a long time, and one thing (of many things) that I still have not gotten down is scheduling.  I seem to have a method to my own madness, but somehow I imagine it’s not how other people do this.  I’ve heard other shrinks say, “I’m booked for the next 4 weeks” or say they aren’t taking any new patients.  Some people put a “no new patients” message on their answering machine.  Wait, so no appointments for 4 weeks?  What if a patient calls and needs to be seen very soon? Like this week?  If you can’t wait, go to the ER?  I thought the point of having a private doc was that you didn’t have to go to the ER unless something couldn’t be handled safely as an outpatient.  And if you tell the world that you don’t take new patients, then don’t people stop referring to you?  It seems to me that patients will come in and announce, “I’m doing better and want to come less often,”  “I’m moving,”  “I’m done,” or they will cancel an appointment, not call back, and not be heard from again for weeks or months.  Sometimes it all happens on very short notice and life can be very unpredictable.

In my pre-shrink days, I thought that psychiatry worked such that patients came every week (or twice a week, or whatever) and had their own slots.  Tuesday at 1, that’s me!  So a psychiatrist had every slot full with patients this way, and could be “full,” until a patient finished and stopped coming, and then another soul was let in to the Tuesday at 1 slot.  Gosh that would be nice, but it doesn’t seem to work that way. Read more »

*This blog post was originally published at Shrink Rap*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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