Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

Growing into My White Coat: Improving the Patient-Provider Relationship Through Diverse Patient Interviews

The “Patient Diversity” assignment is an integral component for all medical and other health care professional students rotating through the Surgery clerkship at the Yale School of Medicine. Students are instructed to interview a surgical patient who is of a varied social or cultural background to identify how psychosocial factors impact patient coping strategies. In the process, students often appreciate how health care providers’ own social and cultural backgrounds similarly shape their sentiments and reactions in patient care. In this interview with a 26-year-old surgical patient, one student strives to come to terms with her personal insecurities in patient interactions and seeks to overcome them through open conversation and honest introspection. By working to acknowledge and understand patient diversity, health care providers can enhance understanding of their patients’ conditions and form more trustful and empathic relationships with both their patients and colleagues.     

MILK LET-DOWN—The Use of Intranasal Oxytocin for Nursing Mothers

A study was carried out to determine whether intranasal spraying with a solution of oxytocin was an effective way to increase flow of milk in mothers who wished to breast-feed their babies.A hundred such women were given the drug intramuscularly for two days before they were to begin nursing. Then administration by that means was discontinued and 50 of the hundred were given oxytocin nasal spray kits for use at home. In general the patients receiving the spray kits were those who were apprehensive about sufficient lactation, those who had had previous difficulty and those who had flat, inverted or tender nipples.Results were not much different between the 50 women who used the spray and the 50 controls, but since the former group included the “difficult” cases, some benefit may be attributed to the aerosol therapy. Ninety per cent of those who used it said they would be willing to use it again.     

After 2 years of a pandemic,students are struggling to find strong reference letters

Writing and receiving reference letters in the time of COVID. Subject Categories: Careers

“People influence people. Nothing influences people more than a recommendation from a trusted friend. A trusted referral influences people more than the best broadcast message.” —Mark Zuckerberg.

I regularly teach undergraduate courses in genetics and genomics. Sure enough, at the end of each semester, after the final marks have been submitted, my inbox is bombarded with reference letter requests. “Dear Dr. Smith, I was a student in your Advanced Genetics course this past term and would be forever grateful if you would write me a reference for medical school…” I understand how hard it can be to find references, but I have a general rule that I will only write letters of support for individuals that I have interacted with face‐to‐face on at least a few occasions. This could include, for example, research volunteers in my laboratory, honors thesis students that I have supervised, and students who have gone out of their way to attend office hours and/or been regularly engaged in class discussions. I am selective about who I will write references for, not because I am unkind or lazy, but because I know from experience that a strong letter should include concrete examples of my professional interactions with the individual and should speak to their character and their academic abilities. In today''s highly competitive educational system, a letter that merely states that a student did well on the midterm and final exams will not suffice to get into medical or graduate school.However, over the past 2 years many, if not most, students have been attending university remotely with little opportunity to foster meaningful relationships with their instructors, peers, and mentors, especially for those in programs with large enrollments. Indeed, during the peak of Covid‐19, I stopped taking on undergraduate volunteers and greatly reduced the number of honors students in my laboratory. Similarly, my undergraduate lectures have been predominantly delivered online via Zoom, meaning I did not see or speak with most of the students in my courses. It did not help that nearly all of them kept their cameras and microphones turned off and rarely attended online office hours. Consequently, students are desperately struggling to identify individuals who can write them strong letters of reference. In fact, this past spring, I have had more requests for reference letters than ever before, and the same is true for many of my colleagues. Some of the emails I have received have been heartfelt and underscore how taxing the pandemic has been on young adults. With permission, I have included an excerpt from a message I received in early May:Hi Dr. Smith. You may not remember me, but I was in Genome Evolution this year. I enjoyed the class despite being absent for most of your live Zoom lectures because of the poor internet connection where I live. Believe it or not, my mark from your course was the highest of all my classes this term! Last summer, I moved back home to rural Northern Ontario to be closer to my family. My mom is a frontline worker and so I''ve been helping care for my elderly grandmother who has dementia as well as working part‐time as a tutor at the local high school to help pay tuition. All of this means that I''ve not paid as much attention to my studies as I should have. I''m hoping to go to graduate school this coming fall, but I have yet to find a professor who will write a reference for me. Would you please, please consider writing me a letter?I am sympathetic to the challenges students faced and continue to face during Covid‐19 and, therefore, I have gone out of my way to provide as many as I can with letters of support. But, it is no easy feat writing a good reference for someone you only know via an empty Zoom box and a few online assignments. My strategy has been to focus on their scholarly achievements in my courses, providing clear, tangible examples from examinations and essays, and to highlight the notable aspects of their CVs. I also make a point to stress how hard online learning can be for students (and instructors), reiterating some of the themes touched upon above. This may sound unethical to some readers but, in certain circumstances, I have allowed students to draft their own reference letters, which I can then vet, edit, and rewrite as I see fit.But it is not just undergraduates. After months and months of lockdowns and social distancing, many graduate students, postdocs, and professors are also struggling to find suitable references. In April, I submitted my application for promotion to Full Professor, which included the names of 20 potential reviewers. Normally, I would have selected at least some of these names from individuals I met at recent conferences and invited to university seminars, except I have not been to a conference in over 30 months. Moreover, all my recent invited talks have been on Zoom and did not include any one‐on‐one meetings with faculty or students. Thus, I had to include the names of scientists that I met over 3 years ago, hoping that my research made a lasting impression on them. I have heard similar anecdotes from many of my peers both at home and at other universities. Given all of this, I would encourage academics to be more forthcoming than they may have traditionally been when students or colleagues approach them for letters of support. Moreover, I think we could all be a little more forgiving and understanding when assessing our students and peers, be it for admissions into graduate school, promotion, or grant evaluations.Although it seems like life on university campuses is returning to a certain degree of normality, many scholars are still learning and working remotely, and who knows what the future may hold with regard to lockdowns. With this uncertainty, we need to do all we can to engage with and have constructive and enduring relationships with our university communities. For undergraduate and graduate students, this could mean regularly attending online office hours, even if it is only to introduce yourself, as well as actively participating in class discussions, whether they are in‐person, over Zoom, or on digital message boards. Also, do not disregard the potential and possibilities of remote volunteer research positions, especially those related to bioinformatics. Nearly, every laboratory in my department has some aspect of their research that can be carried out from a laptop computer with an Internet connection. Although not necessarily as enticing as working at the bench or in the field, computer‐based projects can be rewarding and an excellent path to a reference letter.If you are actively soliciting references, try and make it as easy as possible on your potential letter writers. Clearly and succinctly outline why you want this person to be a reference, what the letter writing/application process entails, and the deadline. Think months ahead, giving your references ample time to complete the letter, and do not be shy about sending gentle reminders. It is great to attach a CV, but also briefly highlight your most significant achievements in bullet points in your email (e.g., Dean''s Honours List 2021–22). This will save time for your references as they will not have to sift through many pages of a CV. No matter the eventual result of the application or award, be sure to follow up with your letter writers. There is nothing worse than spending time crafting a quality support letter and never learning the ultimate outcome of that effort. And, do not be embarrassed if you are unsuccessful and need to reach out again for another round of references—as Winston Churchill said, “Success is stumbling from failure to failure with no loss of enthusiasm.”     

Psychiatric assessment of patients with “20th-century disease” (“total allergy syndrome”)

“Twentieth-century disease”, or “total allergy syndrome”, is a condition attributed to hypersensitivity to the environment that may sometimes be seen as so serious that the patient is incapable of living in the modern world. Although the popular media frequently carry stories about it, there is little scientific literature. It is diagnosed by clinical ecologists, who maintain, among other theories, that susceptible individuals experience an overload in assaults by artificial materials in the environment. The patients usually have multiple ill defined symptoms for which no organic cause can be found, but they vigorously resist psychiatric referral, as they attribute their symptoms to allergy. A group of 18 patients who were purportedly suffering from 20th-century disease were referred to a university psychiatric consultation liaison service. They virtually all had a long history of visits to physicians, and their symptoms were characteristic of several well known psychiatric disorders. The case histories and management of three of them are presented. Although this group of patients may have been atypical in that they had more severe psychologic symptoms, the experience indicates that a psychiatric diagnosis ought to be considered. The symptoms of 20th-century disease have much in common with other conditions known to physicians for centuries.     

THE USE OF A MEDICAL INTERVIEWER—An Assistant Who Saves the Physician Time and the Patient Money

For dealing economically yet effectively with patients who are being made sick by psychic burdens rather than by “simple” organic disease, a trained interviewer who follows a formal outline in obtaining information from patients, can be of great assistance.The physician who makes use of the services of such an interviewer should select a person with good qualifications for the job and then train her for it. It is also up to the physician to get the patient to accept the idea of interview by such an assistant.After the interview, the interviewer prepares a typewritten summary for the physician for use as a guide in discussing means of treatment and prevention of psychosomatic illness with the patient.The method saves the physician much time, the patients much money, and has resulted in many gratifying therapeutic successes.     

Culture and Disability Behavior

A substantial amount of literature suggests that illness behavior in the United States is a product of a patient''s core culture; equally credible findings do not support this contention. Most students and graduates in the health care professions believe that illness and disability behavior are affected by a patient''s culture, but they are hard put to find convincing examples of that relationship. In experience with medical students studying the social and cultural bases of illness behavior, with patients who are disabled and with persons who claim disability in the absence of physical disease or disabling psychopathology, I observed no deviant disability behavior that was typical for the members of any cultural group, and no behavior was displayed by the members of one cultural group that was not seen in members of other cultural groups. No cultural stereotypes were upheld. I did find evidence that disability behavior is influenced by personality factors, social situations and the gains derived from the disability status. Evolving concepts of “entitlement,” which are closely related to socioeconomic status, also have a significant influence. The impact of feedback from others in a person''s many social and medical subcultures is a more crucial determinant of illness and disability behavior, except in those for whom illness and disability behavior is determined by the limitations imposed by the disease or by a personality structure resistant to cultural expectations and social feedback.     

Patients' accounts of being removed from their general practitioner's list: qualitative study

Objective To explore patients'' accounts of being removed from a general practitioner''s list.Design Qualitative analysis of semistructured interviews.Setting Patients'' homes in Leicestershire.Participants 28 patients who had recently been removed from a general practitioner''s list.Results The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were “good” patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services “appropriately,” were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These “bad” general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner''s list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising.Conclusions Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with “difficult” patients.     

The frequency of genetic disease and congenital malformation among patients in a pediatric hospital

A sample of 12,801 admissions to a pediatric hospital was surveyed in 1969-70 to determine the prevalence of disease which could be classified as “genetic” in origin or related to “congenital malformation”.“Genetic” admissions accounted for 11.1% of the total while 18.5% were for congenital malformations; about 2% (unknown group) were probably genetic. Therefore about one third of all admissions represent the effect of abnormal gene-environment interrelations at some point in the development or life of the patient.The “genetic” patient is admitted more often to a medical service while the patient with congenital malformation usually goes to a surgical service; the former stays 7.3 days and the latter 8.6 days. A disproportionate number of patients staying longer than 10 days were found in the group with congenital malformations. Seventy percent of the patients with multiple admissions (3.2% of all admissions) have genetic illness or congenital malformation.     

SOME VIEWPOINTS ON CHILD PSYCHIATRY

There is a great tendency in recent years to seek psychiatric answers to well-nigh all kinds of child problems. This tendency is seriously questioned. The average child has splendid capacities to solve his own growth problems, within the limits of home, school, neighborhood. Evidence accumulates that the average parent who seeks counsel has done a rather respectable job; that in his fear of setting limits because of “how the child will feel,” there is more of psychological threat to the child than in daring to comfortably move ahead and make some mistakes.Psychiatric treatment of a child implies that the child is unable to meet situations as adequately as other children. Such treatment should be reserved, in the main, for use in situations in which the psychiatrist and parents are willing to underwrite the implications of treatment. Treatment aimed at the vague goal of making the child “happier” is dubious. Treatment by a psychiatrist is presumably medical treatment and carries with it the advantages and disadvantages inherent in this fact. When given without carefully defining the reasons for it and the goals at which it is aimed, within medical framework, it is potentially an undesirable procedure.     

Production of Artificial “Case Histories” by using a Small Computer

This paper describes a method of producing artificial “case histories” by using probability theory and clinical data from a series of 600 patients with acute abdominal pain. A series of 12 such cases were distributed to clinicians, medical students, medical secretaries and technicians, and members of the general public. For each “case” most clinicians concurred with the intended diagnosis. So did the medical secretaries and technicians; indeed this group were more confident of their chosen diagnoses than were the clinicians.It is suggested that clinicians are concerned to a large extent with the consequences of a diagnosis as well as its accuracy, and are motivated to some degree by a fear of the consequences of failure. They may be justified in adopting this policy, for when “errors” in diagnosis are harshly penalized the clinicians were infinitely more effective than any of the other groups.     

Who Needs Cream and Sugar When There Is Eco-Labeling? Taste and Willingness to Pay for “Eco-Friendly” Coffee

Participants tasted two cups of coffee, decided which they preferred, and then rated each coffee. They were told (in lure) that one of the cups contained “eco-friendly” coffee while the other did not, although the two cups contained identical coffee. In Experiments 1 and 3, but not in Experiment 2, the participants were also told which cup contained which type of coffee before they tasted. The participants preferred the taste of, and were willing to pay more for, the “eco-friendly” coffee, at least those who scored high on a questionnaire on attitudes toward sustainable consumer behavior (Experiment 1). High sustainability consumers were also willing to pay more for “eco-friendly” coffee, even when they were told, after their decision, that they preferred the non-labeled alternative (Experiment 2). Moreover, the eco-label effect does not appear to be a consequence of social desirability, as participants were just as biased when reporting the taste estimates and willingness to pay anonymously (Experiment 3). Eco labels not only promote a willingness to pay more for the product but also lead to a more favorable perceptual experience of it.     

Mothers' experiences of induction

Mothers of a random sample of 2182 legitimate live births were interviewed about their experiences of pregnancy, labour, and delivery. Of these, 24% reported that their labours were induced, and data about this from a subsample of mothers tallied with information obtained through the doctors in charge in 88% of cases. All but 3% of the mothers who were induced perceived some medical reason for the induction. The proportion of inductions in the 24 study areas ranged from 6% to 39%. A relatively small proportion of labours in “teaching” hospitals, small hospitals with less than 100 beds, and GP maternity hospitals were induced, but a comparatively high proportion of private patients had an induction. There was no clear association between induction and the mother''s age or parity. Despite being given more pain relief, those who were induced reported similar intensities of pain during the first and second stages of labour to those whose labour started spontaneously; they also reported that they had “bad pains” for a similar period. The period they had contractions was shorter for the induced than for those starting spontaneously, and the intensity of pain at delivery was rated somewhat less by those who were induced.There was no difference between induced babies and others in the proportion who were held by their mothers immediately after their birth. Two-fifths of the mothers who were induced would have liked more information about induction; and a similar proportion said they had not discussed induction with a doctor, midwife, or nurse during their pregnancy. Only 17% of the mothers who had an induction said they would prefer to be induced if they had another baby. This contrasts with 63% of those who had epidural analgesia who would opt for the same procedure next time, while 83% of those who had had a baby in hospital, and 91% of those having had a home birth, would want their next baby in the same type of place.     

Effect of Dosage Form Properties on Therapeutic Efficacy of Tolbutamide Tablets

The rate of gastrointestinal absorption and the physiologic availability of tolbutamide are functions of the dissolution rate of the drug in gastrointestinal fluids. This property can be modified markedly by pharmaceutical formulation factors. The in vitro dissolution rates of clinically efficacious and clinically inefficacious tolbutamide tablets have been determined, and it has been found that the former dissolved considerably more rapidly than the latter. Once diabetic patients have been “titrated” with a particular brand of tolbutamide they should not be switched to a different brand without “retitration.” There is need to establish an adequate in vitro test to assure the physiologic availability of tolbutamide from commercial tablets.     

Clinical Diagnostic Process: An Analysis

An analysis of observations made during 1,307 diagnoses by a total of 28 clinicians (503 diagnoses in real life, and 804 on simulated patients) concerned primarily the interview of patients suffering from abdominal pain. Interviews ranged from 10 to 35 questions, and from “stereotyped” procedures, in which identical (and often irrelevant) questions were asked to each patient, to “adaptive” interviews, in which specific relevant questions were put to each patient. Senior clinicians tended to ask fewer, more relevant questions than their junior counterparts; and urgent cases were dealt with in a more adaptive fashion than routine cases in outpatients. Disappointingly, there was considerable difference between real-life and simulated situations. From these results it is suggested (a) that the “diagnostic process” does not exist, (b) that any automated diagnostic system must be flexible to accommodate the wishes of a variety of clinicians, and (c) that studies based on artificial clinical situations should be treated with extreme caution.     

“HIDDEN” ALCOHOLICS—Medical Implications of Undiscovered Addiction

“Hidden alcoholics”—those who drink surreptitiously to keep their addiction secret—far out-number the overt habitues of skid rows. The former rather than the latter should be considered “typical” alcoholics. Even though they have severe problems, they maintain fairly good employment stability and stability in marriage. Yet they steadily deteriorate.Often “hidden” alcoholics go to physicians because of symptoms referable to alcoholism but contrive to conceal their addiction and so make diagnosis difficult. Hence, physicians observing certain kinds of symptoms that cannot be attributed to a readily observable or demonstrable pathologic change should make searching inquiry as to the patient''s drinking habits. For not until the proper diagnosis is made in such cases can there be hope of effective treatment.     

The Selection of Medical Students in Western Canada

The methods employed in the selection of medical students for the 1964-65 class of freshmen at the four Western medical schools are described and recommendations are made for improving the procedure. The structure and functions of the various selection committees varied from school to school but their prime purpose was the same—the selection of “good students” who would later become “good physicians”. Not surprisingly, academic achievement and confidence in estimating this ranked highest in importance, and while non-intellectual characteristics ranked almost as high, committee members had no confidence that they could evaluate these qualities.It is suggested that the ideal selection committee would be a “high-priority” committee consisting of six to eight members who would meet at least twice a year, have tenure of at least four years, be trained in interviewing applicants, consider Medical College Admission Test scores, review applications before each meeting, and establish research committees to investigate the students they choose.     

Canadian Applicants to Medical Schools in Canada for 1965-66

An examination of applicants to Canadian medical schools for 1965-66 revealed that 4660 applications were received by the 12 schools for approximately 900 places available; 2852 of these were from Canadians, but because many applicants applied to more than one school, these 2852 applications represented only 1767 individuals. Evaluations made by the schools concerning the acceptability of these applicants showed that only 36 persons rated as “acceptable” by one or more schools failed to gain admission to any Canadian school for 1965-66. Furthermore, 66 “marginal” applicants were accepted, as were 130 multiple applicants who were rated as “acceptable” by one school but “marginal” and/or “unacceptable” by one or more other schools. Of the 464 multiple applicants, only 40% received the same evaluation from all schools to which they applied. If those multiple applicants who were rated as acceptable by all schools to which they applied are added to single applicants rated as acceptable, the pool of these clearly acceptable candidates (40% of all Canadian applicants) is sufficient only to fill 78% of places available. It was thus concluded that it is erroneous to speak of a surplus of well-qualified Canadian applicants at the present time.     

Characteristics of Attempted Suicide by Patients with Schizophrenia Compared with Those with Mood Disorders: A Case-Controlled Study in Northern Japan

Recent reports suggest a lifetime suicide risk for schizophrenia patients of approximately 5%. This figure is significantly higher than the general population suicide risk consequently, detection of those at risk is clinically important. This study was undertaken to define the characteristics of suicide attempts by schizophrenia patients compared with attempts by patients with mood disorders. All patients were diagnosed using the ICD-10 criteria. The study population comprised 65 patients with F2 disorders (schizophrenia, schizotypal and delusional disorders), i.e., “the F2 group”, and 94 patients with F3 disorders (mood disorders), i.e., “the F3 group”, who presented in the clinical setting of consultation-liaison psychiatry. The F2 group had a significantly younger mean age and significantly higher ratios of ‘past/present psychiatric treatment’ and ‘more than 3 months interruption of psychiatric treatment’. In contrast, the ratios of ‘physical disorder comorbidity’, ‘alcohol intake at suicide attempt’ and ‘suicide note left behind’ were significantly higher in the F3 group. The F2 group attempted suicide by significantly more serious methods. Furthermore, ‘hallucination-delusion’ was the most prevalent motive in the F2 group and was the only factor that showed a significant association with the seriousness of the method of suicide attempt (OR = 3.36, 95% CI: 1.05–11.33).     

SENSORY DEPRIVATION ON AN EYE SERVICE—Its Significance and Management

In a detailed investigation of 174 patients who wore patches over both eyes after ocular operations, some 35 per cent were observed to have one or more symptoms of mental aberrations. In a smaller group who had repair of retinal detachment and therefore had to wear eye patches for a much longer time, the incidence of mental symptoms was 100 per cent. A common symptom called “noncompliance” was found which has hitherto been regarded simply as lack of cooperation by the patient.The incidence of postoperative complications was considerably higher in patients who had symptoms of mental disturbance than in those who did not.In these circumstances it would appear worth while to prepare the patient mentally for operation, to give him assurances beforehand, and to take measures to reduce his “isolation” while he has to wear patches.