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.     

From Chattel to Consenter: Adolescents and Informed Consent: 2009 Grover Powers Lecture

Angela Holder was to give the Grover Powers Memorial Lecture at the weekly Grand Rounds conducted by the Yale Department of Pediatrics on Wednesday, May 27, 2009, but unfortunately, she died one month earlier, on April 22, leaving behind her prepared address, “From Chattel to Consenter: Adolescents and Informed Consent,” which she had regarded as the pinnacle of a remarkable career, much of it spent at Yale. As the Grover Powers honoree, the department’s highest honor, Ms. Holder was only the fourth woman of 46 recipients and the first who was not a physician. On the date scheduled for her address, tributes were presented by her son, John Holder, and her longtime colleague, Dr. Robert Levine, co-founder of Yale’s Interdisciplinary Bioethics Center. Their comments follow Angela Holder’s completed but undelivered Grover Powers address. — Myron Genel, MD, Professor Emeritus of PediatricsUnder the common law of England and in the early years of the United States, a minor (defined as anyone under 21) was a chattel or possession of his or her father [1-4]. A father had the right to sue a physician who treated his son or daughter perfectly properly but without the father’s permission because such an intervention contravened the father’s right to control the child. Beginning in the early years of the 20th century, by the end of World War II and into the 1950s, the notion that a 16-year-old was a legally different entity from a 6-year-old gradually became law in all states.¹ The first hospital unit for adolescents was created in 1951 at Boston Children’s Hospital, and the concept of “adolescent medicine” was born [5].As the law in this area currently defines “adolescent,” we are discussing someone 14 or older who may be (1) living at home with his or her parents; (2) Not living at home but still dependent on parents (i.e., a 16-year-old college freshman living in a dorm); (3) an “emancipated minor” who is married, emancipated by a court order, or a parent (other than in North Carolina), living away from home and self-supporting; or (4) a runaway or throwaway. At any time in this country, there are about 200,000 adolescents living on the streets with no adult supervision or involvement [6].Regardless of the age of the patient, informed consent consists of five elements: (1) An explanation of what will happen; (2) explanation of the risks; (3) explanation of the projected benefits; (4) alternatives (including doing nothing); and (5) why the physician thinks it should be done, which I interpret as a right to know one’s diagnosis. While the doctrine of “therapeutic privilege” means that in rare cases a physician may withhold some information from an adult patient if she or he believes the patient cannot “deal with the information,” there can never be any withholding of information from an adolescent. If the patient can’t deal with the information to be presented, then parents have to be involved and give permission to treat the adolescent.In some cases, when parents are involved, they do not want their adolescent to know his or her diagnosis. While this is usually not a good idea, it normally falls under the rubric of “professional judgment,” and the physician has every right to decide to follow the parents’ instruction if she agrees with it. In some situations, however, the adolescent must be told what his or her illness is, whether parents like it or not. For example, if a teenager is HIV positive, he or she must be told, must be instructed about safe sex, and must be asked to divulge the names of any sex partners. Parents who say, “Oh, no, don’t tell him, he would never do anything like that, so it doesn’t matter,” should be tactfully but firmly led to accept the fact that he may well have and if he hasn’t yet, he will certainly in the future. There has been at least one successful malpractice case in which the physician did not, at the request of the parents, tell his adolescent patient that he had HIV. The patient’s girlfriend caught it and sued the physician [7]. I feel sure there are many more cases like this that have been quietly settled and no one will ever hear about.Usually, questions about adolescents giving consent to treatments that their parents don’t know about involve outpatient treatment. In the first place, hospital administrators, who are much more interested in getting paid than they are in advancing the rights of autonomous adolescents, are not going to admit for a non-emergency problem a minor whose parent has not made some sort of financial arrangement to pay for it. Secondly, in most households, if Little Herman doesn’t show up for supper or throughout the evening, someone notices and a few telephone calls later discovers that Little Herman is in the hospital.     

THE MISTREATED CHILD

“The battered child” has recently attracted the attention of physicians and social workers, but despite the fact that inflicted trauma produces characteristic x-ray changes, physicians are often reluctant to admit this cause. The neglected child may be more difficult to diagnose and is probably more common. The most typical example is the infant who is admitted to the hospital for “failure to thrive,” yet gains weight rapidly while away from his parents.The parents of both types of children are likely to be immature and inadequate, but much more study is required before the factors common to these parents are known, to say nothing of the means required for prevention and treatment.When the physician suspects that the parent is causing the difficulties manifested by the child, he should seek the help of a social worker in clarifying the situation and in contacting the appropriate social or legal agency. A greater awareness of the problems of these children should result in more rapid recognition of the condition, the establishment of well-defined methods of handling such cases, and ultimately better legislation to safeguard the child''s rights to a safe and healthy childhood.     

IS IT NEUROSIS?

So-called “minor psychiatry,” the treatment of neurosis in persons who are not psychotic, may well be undertaken by the general practitioner.The first duty of the physician in dealing with a neurotic person is to determine whether psychosis may develop. He must be patient and thorough in hearing the history of the case and should have full information on the patient''s life and family.A recent classification of the neuroses is given and the more generally recognized symptoms of these conditions are described.     

The Medical Investigation of Alleged Rape

The web of human entanglement resulting from the cry “rape” may twist and disrupt the lives of the persons involved. The physician who is prepared and able to deal with the forensic medical aspects of the problem can play a vital role in the determination of innocence or guilt. And, if he is prepared to recognize and deal with the psychologic problems, the emotional distress and the anxiety, the physician can provide invaluable help.     

Analysis of Your Professional Liability Insurance Policy

The most important lessons for the physician to learn in regard to his professional liability insurance coverage are the following:1. The physician should carefully read his professional liability policy and should secure the educated aid of his attorney and his insurance broker, if they are conversant with this field.2. He should particularly read the definition of coverage and carefully survey the exclusion clauses which may deny him coverage under certain circumstances.3. If the physician is in partnership or in a group, he should be certain that he has contingent partnership coverage.4. The physician should accept coverage only from an insurance carrier of sufficient size and stability that he can be sure his coverage will be guaranteed for “latent liability” claims as the years go along—certainly for his lifetime.5. The insurance carrier offering the professional liability policy should be prepared to offer coverages up to at least $100,000/$300,000.6. The physician should be assured that the insurance carrier has claims-handling personnel and legal counsel who are experienced and expert in the professional liability field and who are locally available for service.7. The physician is best protected by a local or state group program, next best by a national group program, and last, by individual coverage.8. The physician should look with suspicion on a cancellation clause in which his policy may be summarily cancelled on brief notice.9. The physician should not buy professional liability insurance on the basis of price alone; adequacy of coverage and service and a good insurance company for his protection should be the deciding factors.     

THE THORNY CHILD

Too many physicians—and parents—hide behind the overworked excuse that “Johnny is just going through a stage.” If the remark is inaccurate a great disservice can be done to both mother and child, and ultimately to society. The well oriented physician would no more permit a young mother to unwittingly feel “guilty” because her two-year-old “little stinker” behaves like a two-year-old little stinker than he would casually reassure when a ten-year-old behaves as though he were two.Actually much of the unpleasant behavior of children is quite normal. If physicians would help all young mothers to recognize this without dismissing abnormal behavior, it would do much to avert the overwhelming sense of inadequacy that so many modern young mothers feel—especially with their first baby. If they can be made comfortable with their first the others usually come easily. Many physicians who care for children are not trained in the rudiments of developmental behavior. By means of a simple outline and drawing of “the thorny child” even the least of the experts can better understand some of the chronologic variations in developmental behavior.     

BEYOND THE SURGEON'S SKILL

The scientific attainments of medical science have advanced greatly in this generation. The art of the practice of medicine has not kept pace. The kindly spirit, unselfish service, and spiritual uplift which were characteristic of most physicians in the “horse-and-buggy days” are needed more today than they were a generation ago. A combination of medical science and spiritual counseling will do much to relieve the sufferings of mind and body. The personal physician-patient relationship and the building up of the patient''s confidence in his physician are a most important aspect of the physician''s duty. A belief in God and a knowledge of the availability of help from above is of great benefit to both physician and patient.     

The Troubled Adolescent Patient—How the General Practitioner May Be Helpful

The disturbed adolescent is psychologically isolated from the worlds of childhood and adulthood. His sense of alienation results from both the upsurge of instinctual drives and his uneasy attempts to master changing physical attributes and new freedoms and responsibilities. The former result in conformity and in concerns about “normality.” The latter lead to confusion and to alternating rebellion and over-dependence.The general practitioner may be the first person consulted by the troubled adolescent or his parents. The physician''s sensitivity can be crucial in helping the family work together toward a solution. Persistent anxiety in either parent or child is in itself a problem. An understanding of those factors inherent in the adolescent experience may provide the physician with a recognition of disturbance denied by the adolescent with a facade of bravado or indifference.The physician must be prepared to help the adolescent accept a protracted period of stress, usually with only partial resolution of distressing problems.     

THE IMPORTANCE OF POTASSIUM AFTER OPERATION

A deficiency of potassium in a patient after operation is manifest clinically by anorexia, malaise, apathy, weakness, abdominal distention and hypochloremia.Many patients who have had a prolonged disturbance in nutrition may have a “subclinical” hypopotassemia.Prophylaxis by means of replacement of the potassium excreted daily in the urine is the ideal treatment.When the clinical picture of potassium deficit develops, the amount of the potassium ion needed for replacement should be calculated on the basis of the total amount of water in the body of the patient.     

Decision-Making in Multiple Sclerosis Consultations in Italy: Third Observer and Patient Assessments

Objective

To assess decision-making in multiple sclerosis (MS) from third observer and patient perspectives.

Method

Audio recordings of first-ever consultations with a participating physician (88 outpatients, 10 physicians) at four tertiary MS care clinics in Italy, were rated by a third observer using the Observing Patient Involvement in Shared Decision Making (OPTION) and by patients using the Perceived Involvement in Care Scale (PICS).

Results

Mean patient age was 37.5, 66% were women, 72% had MS, and 28% had possible MS or other disease. Mean PICS subscale scores (range 0 poor, 100 best possible) were 71.9 (SD 24.3) for "physician facilitation" (PICS-F); 74.6 (SD 22.9) for "patient information exchange" (PICS-I); and only 22.5 (SD 16.2) for "patient decision making" (PICS-DM). Mean OPTION total score (0 poor, 100 best possible) was 29.6 (SD 10.3). Poorest OPTION scores were found for items assessing “preferred patient approach to receiving information” and “preferred patient level of involvement.” Highest scores were for “clinician drawing attention to identified problem”, “indicating need for decision making,” and “need to review the decision.” Consultation time, woman physician, patient-physician gender concordance and PICS-F were associated with higher OPTION total score; older physician and second opinion consultation were associated with lower OPTION score.

Conclusions

In line with findings in other settings, our third observer findings indicated limited patient involvement abilities of MS physicians during first consultations. Patient perceptions of physician skills were better than third observers’, although they correlated. Consultations with women physicians, and younger physicians, were associated with higher third observer and patient-based scores. Our findings reveal a need to empower Italian MS physicians with better communication and shared decision-making skills, and show in particular that attention to MS patient preferences for reception of information and involvement in health decisions, need to be improved.     

THE PSYCHOTHERAPEUTIC APPROACH TO EMOTIONAL PROBLEMS

Physicians are confronted with more and more psychological problems in their daily practice. Not only must a physician be able to recognize the problems, he must also be prepared to treat a certain number of them. Some of the patients will improve just because of a good relationship with the physician. Others will require more definitive, yet comparatively simple, psychotherapy. On the other hand, some patients with clear-cut emotional problems are best treated by the physician''s traditional medical approach rather than by some type of “formal” psychotherapy. In some circumstances psychotherapeutic efforts may be damaging.     

WORK INJURY—A Second Look at the Doctor's First Report

Injured employees require medical care and, if disabled, compensation payments for subsistence. The law requires that the employer or insurance carrier supply these benefits promptly. In the absence of prompt and adequate information from the attending physician, these benefits are withheld. The necessary information required to process employee''s claim is that called for on the standard accident report form, commonly called the “pink slip.” Not to supply this minimum information may constitute a hardship on the employee. By supplying more elaborate information than that called for, the physician may be increasing his load of “paper work” immeasurably.     

Resuscitation of the terminally ill

The CMA believes that there are conditions of ill health and inevitable death for which a “no resuscitation” order, signed by the attending physician, is appropriate and ethically acceptable. The association encourages physicians who are faced with the decision of writing a “no resuscitation” or “do not resuscitate” order to consider the clinical criteria and procedural guidelines in the Joint Statement on Terminal Illness. This protocol is intended as a basic, national guideline for those involved in the care of the terminally ill. Individual institutions may wish to develop their own directives as an adjunct to the national statement.     

ANALYSIS OF ABSENTEEISM IN INDUSTRY

There are many nonmedical factors that contribute to employee absenteeism in industry. An employee''s total life situation or total environment may be a causative factor in excessive “sick absenteeism.” In many instances the cure for “abnormal” sickness absenteeism is within the province of supervisory personnel, who should look upon abuse of sick leave benefits among employees as morale problems and as evidence of possible maladjustment to the demands of the job or the industry. There are, however, many problems in mental and physical health affecting absence rates in which preventive psychiatry and medicine can make greater contributions. Even truancy and malingering may sometimes be conditions requiring professional medical care.The role of a private physician in determining and certifying the true state of a patient''s health is a most important one economically to industry and the community. The total problem of absenteeism for sickness, as it exists in industry today, points up the need for the most effective cooperation and communication possible between industrial and private physicians. Since no more than 25 per cent of the total work force is employed in industries having in-plant medical programs, the burden of responsibility for the control of absenteeism for sickness rests mainly with private practitioners.     

THE CHALLENGE OF THE “WELL CHILD”

Upon general practitioners and pediatricians falls the responsibility of recognizing and treating most emotional problems in young children. This may be best carried out by the anticipation of expected problems, and the advance guidance or counseling of parents. That such problems are of high incidence was indicated in experience at a pediatric clinic where approximately 40 per cent of 7,000 children observed had psychosomatic symptoms.In order to utilize effectively the limited time available in office practice for Well Child care, a physician must have at hand certain basic information on personality development. Many of the normal behavior patterns in children which frequently are misinterpreted as “behavior problems” by parents are presented herein in chart form, divided into critical age periods, to help physicians quickly recognize what is normal and what abnormal in various periods of maximal crisis. Most of the problems of conflict within a child and of conflict between parents and child, it is felt, could be and should be handled at the pediatric level. Some seriously disturbed children need to be referred for psychiatric care. When this is necessary, skillful preparation of the parent and the child by the family physician for referral is most important to successful psychotherapy.     

THE ANESTHETIST IN THE PRACTICE OF MEDICINE

In this age of specialization it is often difficult for the patient to determine who “his doctor” is. In the circumstances of anesthesia and surgery, the professional services of both physicians, the anesthetist and the surgeon, are highly integrated and the lines of responsibility must be clearly established. In the particularly close associations between anesthetist, surgeon and patient there is an urgent need for the application of scientific method in order to facilitate communication, improve the approach to the solution of problems, and enhance the welfare of the patient.     

THE INTERSEXED PATIENT

There are at present two opposing points of view on problems of dealing with the intersexed patient (not the typical homosexual or transvestite) who has clearcut anatomical or biochemical qualities of the opposite sex. The first is that in the growing child or adult coming for treatment, the sex the patient should adopt is the summation of somatic sex. The other is that the sex role should be assigned according to the predominant psychological identification already present.A case history of a middle-aged pseudohermaphrodite, castrated in youth but raised from birth as a female and living thus in “homosexual” relations with women until examined and interviewed at UCLA Medical Center is presented to illustrate the psychological problems in sexual identity with which the patient had to cope.Psychiatric investigation revealed how confused the patient''s sex identity was until treatment by a team consisting of psychiatrist, psychologist and endocrinologist permitted the patient, even at so late a date, finally to establish what his gender is. The patient was able, despite early rearing as a female and a castrating operation, to swing to a more masculine identification. This was possible because of some uncertainty of sexual role from an early age.