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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Difficult Patient Key Feature 7: Take steps to end the physician-patient relationship when it is in the patient’s best interests. Skill: Professionalism, Patient Centered Phase: Treatment Key Feature 8: With a difficult patient, safely establish common ground to determine the patient’s needs (ex: threatening or demanding patients). Skill: Patient Centered, Professionalism Phase: Treatment Schizophrenia Key Feature 1: In adolescents presenting with problem behaviours, consider schizophrenia in the differential diagnosis. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 3: In all patients presenting with psychotic symptoms, inquire about substance use and abuse. Skill: Clinical Reasoning Phase: History Key Feature 4: Consider the possibility of substance abuse and look for it in patients with schizophrenia, as this is a population at risk. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 5: In patients with schizophrenia, assess and treat substance abuse appropriately. Skill: Clinical Reasoning Phase: Treatment Violent/Aggressive Patient Key Feature 1a: In certain patient populations (ex: intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Anticipate possible violent or aggressive behaviour. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 1b: In certain patient populations (ex: intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Recognize warning signs of violent/aggressive behaviour. Skill: Clinical Reasoning Phase: Diagnosis Key Feature 1c: In certain patient populations (ex: intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Have a plan of action before assessing the patient (ex: stay near the door, be accompanied by security or other personnel, prepare physical and/or chemical restraints if necessary). Skill: Clinical Reasoning Phase: Treatment Key Feature 2: In all violent or aggressive patients, including those who are intoxicated, rule out underlying medical or psychiatric conditions (ex: hypoxemia, neurologic disorder, schizophrenia) in a timely fashion (i.e., don't wait for them to sober up, and realize that their calming down with or without sedation does not necessarily mean they are better). Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation Key Feature 3: In a violent or aggressive patient, ensure the safety (including appropriate restraints) of the patient and staff before assessing the patient. Skill: Clinical Reasoning, Professionalism Phase: Treatment Key Feature 4: In managing your practice environment (ex: office, emergency department), draw up a plan to deal with patients who are verbally or physically aggressive, and ensure your staff is aware of this plan and able to apply it. Skill: Professionalism Phase: Treatment Yesterday, I spent my first full day on call for Psychiatry in the Emergency Department of St Paul's Hospital. I was shown what the quiet rooms in the ED looked like when I was oriented to the Acute Behavioural Stabilization Unit (ABSU) on a tour of where I would be working at the start of my week, but yesterday was the first day I actually went in to interview patients in this area. At one point I had a mission to obtain some history from two patients with psychosis who were in quiet rooms; there were three security guards and the attending physician by my side. First of all, how intimidating is that for any patient, let alone one who is floridly psychotic? Working at SPH means I have exposure to some very complex and unfortunate patient stories. Many of these patients have serious medical issues, perpetuated and exacerbated by their dire psychosocial circumstances. It feels as though patients without substance use disorders are the exception rather than the norm, and has helped me solidify asking about substance use as a routine part of all of my patient histories, especially those presenting with psychotic symptoms. It can be quite challenging to tease apart primary from secondary drug-induced psychosis, and many patients may have one or both. This fact is all the more true in a young patient presenting with psychosis, as this may be a newly evolving primary psychotic disorder such as schizophrenia, or it may also very well likely be a secondary drug-induced presentation. The possibility of primary psychosis and separate substance use that does not induce psychosis is also a possibility as well. (For example, I once encountered a patient with psychosis who had a substance use disorder but who was found to have neurosyphilis and psychosis secondary to that.) It is always important to ask, and obtain collateral information, which is generally important no matter the psychiatric presentation. It is also important to treat any substance use disorder much as treatment that may be offered to patients without a psychotic disorder (see this previous blog post). And, like with all my patients, I had hopes of gathering this information from the patients in the quiet room with psychosis. I started in a gentle open-ended fashion, introducing myself, and asking if they could tell me a little about what had brought them into the ED. Instantly I was faced with irritable - and what could really have been quite violent - reactions had I not had the security presence hovering around me. One of the two patients started to make threats, and so my attending physician asserted that the team needed to be treated with respect, and if not, we would not be able to engage with the patient to help them. The conversations ended quicker than they started, and I left the quiet room area feeling entirely unproductive. I looked at my attending once we were out of the area and bluntly said, "What the heck?" He responded by saying, "You have a lot to learn, little one!" He went on to explain to me that with particularly difficult patients, you have to start off by gaining their trust a little bit, of which they tend to have very little toward authority and healthcare figures. If you first focus on their primary needs being met, and in so doing building rapport, you're much more likely to get what you need to help them medically. I have learned this concept as it relates to pain in particular: In the patient who presents writhing in pain, you are just not going to be able to get a good history until you provide them with some pain relief. To do so is also just the humane thing to do. Much as these patients with poor self-care, with a string of unhealthy relationships, and who may be starving and exhausted from sleeping on concrete steps, they need their basic needs to first be met: to be fed, to be rested, to feel like their immediate suffering is the priority in the interaction. Of course, this would always have been my intention and hope, but I hadn't really thought about how, in these initial moments with such difficult patients, ones who are likely difficult because they are truly suffering, starting off by first making attempts to meet their basic needs is in fact the most patient-centered and productive way of helping them. As I write this paragraph, it is now a day later than when I wrote the above parts. I have since been reflecting on boundaries of the physician-patient relationship. As part of my learning objectives, I am supposed to learn to "Take steps to end the physician-patient relationship when it is in the patient’s best interests." While I expect to infrequently encounter patients who are as challenging to work with as the ones I met in the quiet room the other day, I will certainly have patients who are challenging to work with. There may even be patients who make threats, which would warrant ending the physician-patient relationship for safety concerns to myself or other people in the place of care delivery. But it was stumping me to come up with a situation for which ending a physician-patient relationship could ever be in the patient's best interest. Today in clinic, I clarified with my attending psychiatrist that ending a physician-patient relationship in the context of a threatening patient is certainly on grounds of patient and staff safety, but also in consideration that a therapeutic relationship cannot take place for the patient in this context, and therefore it is in the patient's best interest to terminate this relationship. I hope I will never have this happen in my practice, and if it does, I hope there can be enough rapport built to establish common ground and create more effective communication. But, in the setting of serious risk of harm to myself or coworkers, it is in the best interest of all parties to end the physician-patient relationship. This might not mean forever, but while the patient is upset or unpredictable (such as when acutely intoxicated or experiencing psychosis), or if they have a past history of violence/aggression in the health care setting, it does mean at the very least anticipating that the encounter could trigger a violent/aggressive response. It also means being able to recognize warning signs of impending violence/aggression (ex: increasing volume of voice, clenched fists, etc.) and having a plan of safety when engaging with a patient in whom you anticipate possible risk of physical harm (such as having security guards present in the ABSU, always having an exit that is not blocked by the patient's position, and if worst comes to worst, having the means to employ physical or chemical restraints as necessary). In the clinic setting, where there aren't security guards on stand-by, it's important to have policies in place to ensure all staff members are prepared to deal with verbally or physically aggressive patients.
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Difficult Patient
Key Feature 1: When physician-patient interaction is deemed difficult, diagnose personality disorder when it is present in patients. Skill: Clinical Reasoning Phase: Diagnosis Key Feature 2: When confronted with difficult patient interactions, seek out and update, when necessary, information about the patient’s life circumstances, current context, and functional status. Skill: Patient Centered Phase: History, Diagnosis Key Feature 5: When confronted with difficult patient interactions, identify your own attitudes and your contribution to the situation. Skill: Professionalism Phase: Treatment, Diagnosis Key Feature 6: When dealing with difficult patients, set clear boundaries. Skill: Professionalism Phase: Treatment Personality Disorder Key Feature 2: In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.) Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 5: When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions. Skill: Clinical Reasoning, Selectivity Phase: Diagnosis, History Today I spent the afternoon in the Acute Behavioural Stabilization Unit (aka the Psychiatry assessment area) in the St Paul's Hospital Emergency Department. After I came back from assessing a particularly challenging patient, my attending physician said to me, "How did that patient make you feel?" This reminded me of something I was once told by an attending physician in the past: when I leave a patient encounter feeling like it was just "off" or that the patient seemed strange, it is possible they have a personality disorder. I don't think this is an evidence-based screening tool for personality disorders, but I do think it is a clinical pearl. If your spidey senses are tingling, it's probably for a reason. In these settings, inquiring about what's been going on in a patient's life (aka gathering a social history) may reveal significant psychosocial stress that could be contributing to a short fuse or leading to avoidance to say much about personal issues. And although people with personality disorders may have increased psychosocial stress, it takes knowing a patient for an extended period of time (or at least gathering an extended history of an extended period of time ideally with collateral information) to make this diagnostic call. Despite the requirement of needing to have a strong understanding of patients' longstanding behaviours, clinicians tend to hold strong suspicions about patients having personality disorders based on initial consultations. This is particularly true when patients present with features in keeping with Borderline Personality Disorder, which we tend to see more frequently than other personality disorders in healthcare. (Note that it is important to not just take another clinician's word for a diagnosis of a personality disorder, as this diagnosis is sometimes made prematurely, and incorrectly labelling patents with personality disorders can have real and negative consequences if it is an inaccurate description for them.) Patients with this Borderline Personality Disorder can at times be manipulative, including with the assessing physician, and can cause a countertransference reaction that is what my attending physician today was referring to today. This attending went on to explain the importance of clear reasoning and firm, caring boundaries in the management of patients with this diagnosis, because otherwise you may find yourself getting pushed into providing care in a way that is not what you think is actually most suited for the circumstances. The patient today, for example, presented with thoughts about self-harm, but had a strong relationship with a psychiatrist in the community, and it was highly unlikely that an admission to hospital would've provided any benefit (in fact, more likely the opposite). When she found out the psychiatrist who did her intake consultation today deemed her fit for discharge and close follow-up care in the community, she began saying she was more suicidal than before. Hmmmm.... That being said, patients diagnosed with personality disorders tend to face much discrimination; they are often seen as frankly difficult patients with multiple complaints and issues, at times compromising thorough and indicated assessment for specific concerns. It takes a heaping amount of good intention and experienced clinical judgment, but patients with personality disorders develop other psychiatric and non-psychiatric conditions unrelated to their personality disorder. It is not always easy to have the patience or knowledge to distinguish these, as I have seen first-hand, but it is important if we value the dignity and humanism underlying good medical care. According to the DSM-V, "A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment... The personality disorders are grouped into three clusters based on descriptive similarities. Individuals with Cluster A personality disorders often appear odd or eccentric. Individuals with Cluster B personality disorders often appear dramatic, emotional, or erratic. Individuals with Cluster C personality disorders often appear anxious or fearful." In medical school, I was taught of these clusters as the "Mad, bad, and sad" personality disorders, respectively. According to the DSM-V, there are 10 different diagnosable personality disorders, which are as follows:
While I won't get into all of the details of each personality disorder, the general diagnostic criteria per the DSM-V for personality disorders is as follows:
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Chronic Disease Key Feature 4: In patients with chronic disease, actively inquire about:
Phase: History Difficult Patient Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times. Skill: Patient Centered, Professionalism Phase: Treatment, Follow-up Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain). Skill: Selectivity Phase: Hypothesis generation, Diagnosis Disability Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present. Skill: Clinical Reasoning, Patient Centered Phase: Diagnosis, Hypothesis generation Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family). Skill: Patient Centered Phase: History Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration. Skill: Patient Centered, Professionalism Phase: Treatment Multiple Medical Problems Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:
Phase: Treatment, Follow-up Stress Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor. Skill: Clinical Reasoning, Communication Phase: Hypothesis generation, History Key Feature 2: In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress). Skill: Patient Centered Phase: History, Diagnosis Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress. Skill: Patient Centered, Clinical Reasoning Phase: History The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications. There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient. In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life.  |
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