The state hospital offers a logical solution to the training problem. Most state hospitals have an ongoing staff development program that can easily include mdividuals from the community. Their staffs have a high level of expertise in the treatment of chronic and geriatnc patients, and because they are becoming more and more proficient in the prevention and reversal of deinstitutionalization, they can help to prevent communitybased institutionalization. In addition, state hospitals often have the physical resources, such as classrooms, audiovisual equipment, parking areas, and food service facilities, that are needed for training programs. The hospital can serve as the meeting place for a multicounty region, and the hospital staff can conduct training programs in the various counties served by the hospital. They can also serve as the coordinator for consultants from other agencies, especially academic institutions. Over the past two years, the Riverside Cente a community-oriented regional psychiatric center in lonia, Michigan (recently relocated in Dimondale), has conducted training and educational programs and workshops for community-based personnel. In 1973 the center was awarded a federal hospital staff development grant of $25,000 a year for three years to help promote its transition from a forensic, maximum-security institution (Ionia State Hospital). For the most part, the grant funds have been expended on services of consultants. A conscious effort has been made to ensure that both the Riverside Center staff and consultants have been available to community-based personnel. The hospital has been quite successful in developing working relationships with staff and faculty of a number of other agencies, especially academic institutions. Faculty members from the department of psychiatry at Michigan State University are heavily represented on the consulting staff. Other schools that are represented are Montcalm Community College in Sidney, Central Michigan University in Mount Pleasant, Case Western Reserve University in Cleveland, Ohio, and even the University of Dacca in Bangladesh. In addition, professionals in private practice or associated with other agencies have also served as consultants and have been recruited from as near as Grand Rapids and as far as Phoenix. The training effort has taken two approaches: cornmunity personnel have been invited into the hospital for a variety of programs, and hospital staff and consultants have conducted programs in the community. The in-hospital programs have included clinical and treatment programs, such as workshops in psychodrama, sociodrama, and role playing; lectures on such diverse topics as nutrition for the elderly, psychopharmacology, and the identification of illegal drugs; reports of proceedings from national professional meetings; and discussions of brief psychotherapy techniques, family therapy, small group approaches to treatment, community placement, and geographic decentralization of psychiatric hospitals. Other in-hospital programs have dealt with legal and administrative issues. They have
736
HOSPITAL
&
COMMUNITY
PSYCHIATRY
included a conference on Michigan’s mental health code, discussions on giving expert testimony and on confidentiality, training programs for supervisory personnel, and a course in effective writing. The first training program in the community was held in June 1975 at the request of the Cedar Rest Care Facility, a nearby 50-bed foster-care home. The six-day program was designed and presented by staff and consultants from the Riverside Center and the Montcalm County Mental Health Center. Conducted at Cedar Rest, the program included sessions on the effects of institutionalization on behavior, techniques in working with the anxious and aggressive patient, chemotherapy, and activities and treatment programs for chronic and disoriented patients. More than 30 trainees participated, including Cedar Rest employees, high school students enrolled in a health careers class, and area foster-care-home operators. Since then, a number of programs on treatment of elderly, withdrawn residents have been conducted by hospital staff both at Grand Rapids Junior College and Montcalm Community College as part of the training programs for foster-care-home operators. Similar classes were also conducted at the Cherry Creek Nursing Home in Lowell. Recently Montcalm Community College held a training program for Ionia area foster-carehome operators at the Riverside Center, with hospital personnel and consultants making up most of the resource staff. The hospital serves as a resource to the community in still another way. Community agencies are able to borrow from its rather substantial library of books and audioand videotapes covering a wide range of psychiatric and medical topics. Future plans include exploring the possibility of the hospital’s serving as the focal point and coordinating agency for staff development programs for community agencies in a 14-county area. It is hoped that the agencies involved might pool their training and travel budgets to carry out the program, and that such an areawide program would qualify for federal support.
A MODEL FOR PHYSICIANS TO WITH DIFFICULT Melvin Richard
TRAINING DEAL PATIENTS
S. Gale, M.D. Levy, M.D.,
MPH.
relationship between doctors and undergone significant changes in recent become briefer and less intimate, making cult to manage. In the past a long-standing
patients has years. It has it more diffirelationship
uThe
Dr.
Gale
is director
professor
in
director
of the
of
emergency
231 Bethesda
the
of the
psychiatric
department division medicine,
Avenue,
of
of emergency University Cincinnati,
emergency psychiatry services of
service and and
Cincinnati
Dr.
and Levy
assistant
assistant is
acting
professor
Medical
Center,
Ohio 45267.
(Continued
on page
738)
(Continued from page 736) between doctor and patient was the ruk, not the exception. The trust that developed made the patient more forgiving of errors made by the doctor. At the University of Cincinnati Medical Center we have developed a method for teaching the management of the new genre of doctor-patient relationships. Our target group includes interns, medical, surgical, and emergency medicine residents, and senior medical students, all of whom are rotating through the emergency department for one to three months. Each day they must grapple with the vicissitudes of patients’ personalities and problems. The emergency department represents one end of the spectrum of relationships between doctor and patient. Typical doctor-patient encounters are almost always limited to one visit; the doctor pays little attention to his relationship with the patient and regards it as rather businesslike. However, occasionally the doctor’s idea that the relationship is not of great significance is challenged by a patient who complains, who is unhappy with his recommendations, who becomes angry and shouts, or who questions his competence. Some patients may also become problems because they arouse strong feelings in the doctor. It is to such difficult interactions that we address ourselves in our teaching sessions. The goal of the sessions is to help physicians think through the management of brief doctor-patient interactions commonly encountered in emergency departments. We feel the lecture format is inadequate for that purpose and instead have devised a teaching method using real-life examples that demand a response from doctors and stimulate them to think about a solution. The basic concepts that are developed can be applied to many other situations. The teaching is done by two members of the emergency services staff (the authors) in a weekly session devoted to psychological awareness issues. One presents provocative patient vignettes; the other serves as moderator for the session. We think it is important that both presenter and moderator be perceived by the participants as knowing what it is really like to work in the emergency department. The series takes place in the department, and the housestaff are expected to attend regularly. A typical vignette is as follows: a 38-year-old man comes to the emergency department after hurting his leg in a fall. He is examined by a resident and a tentative diagnosis of hernatoma is made. The resident explains that to be sure the leg isn’t broken, he will get an x-ray. The x-ray is done quickly, and the resident feels it is normal. He tells the patient, “Just as I thought, you don’t have anything as serious as a fracture. There are four things I want you to do to get better: stay off the leg, keeping it elevated as much as possible; apply an ice pack for the next 24 hours as much as possible; take two aspirins every four hours for pain; and return to the orthopedic clinic in three or four days if the leg isn’t better.”
738
HOSPITAL
& COMMUNITY
PSYCHIATRY
The patient looks up with an expression of distrust and says, Doc, I felt my leg break. Are you sure you read that x-ray right? Besides, how am I going to work when I can’t even stand? Another thing, Doc, who are you kidding? Aspirin isn’t strong medicine arid I’m hurting.” At that point the presentation is stopped, and participants are asked how they would respond to the patient. They are encouraged to express what they would be tempted to say to the patient as well as responses they consider appropriate, since those who are aware of what they might like to say or do are usually better prepared to choose the most desirable response. In the vignette presented, the physician responding inappropriately might: . Insist that the diagnosis is correct, and tell the patient that if he wants a second opinion there are many other emergency departments in the city. . Ask who the doctor is, himself or the patient. Explain how many years It takes to become a physician. . Tell the patient he learned t be an expert on the use of nonnarcotic analgesics in his pharmacology course, so he is absolutely certain that aspirin is all the medicine the patient needs. . Tell the patient he’s very busy and that the patient can take or leave his advice. The physician responding appropriately would: . Admit that he cannot be absolutely certain, but that all evidence indicates he is correct in his evaluation. . If a radiologist is not present, assure the patient that he personally will call him if the radiologist later reads the films differently than he has. . Discuss the practical issues of the treatment plan and ask if the patient will be able to follow his advice. Give thought to the injury and how it affects the patient’s work. Some flexibility about time off work may be needed. . Ask the patient if he wishes to have another doctor look at his leg and give a second opinion. I If, in the physician’s estimation, the patient is not a drug abuser, ask him what usually helps when he has a similar amount of pain. The physician may be able to give the patient what he wants, even though it’s not what he thought of first. . Within reason, take extra time with a difficult patient to explain the injury in greater detail. Interpersonal relations between doctor and patient need not be vague and unclear. Concrete guidelines can be developed, and potential responses can be sorted through ahead of time, thereby permitting an intelligent response when difficult situations occur. There are important differences between merely being courteous to the patient and communicating necessary information to him appropriately. The kind of learning experience described enables the physician to recognize and refrain from responses that may impair the doctorpatient relationship.i ‘ ‘
736
HOSPITAL
&
COMMUNITY
PSYCHIATRY
included a conference on Michigan’s mental health code, discussions on giving expert testimony and on confidentiality, training programs for supervisory personnel, and a course in effective writing. The first training program in the community was held in June 1975 at the request of the Cedar Rest Care Facility, a nearby 50-bed foster-care home. The six-day program was designed and presented by staff and consultants from the Riverside Center and the Montcalm County Mental Health Center. Conducted at Cedar Rest, the program included sessions on the effects of institutionalization on behavior, techniques in working with the anxious and aggressive patient, chemotherapy, and activities and treatment programs for chronic and disoriented patients. More than 30 trainees participated, including Cedar Rest employees, high school students enrolled in a health careers class, and area foster-care-home operators. Since then, a number of programs on treatment of elderly, withdrawn residents have been conducted by hospital staff both at Grand Rapids Junior College and Montcalm Community College as part of the training programs for foster-care-home operators. Similar classes were also conducted at the Cherry Creek Nursing Home in Lowell. Recently Montcalm Community College held a training program for Ionia area foster-carehome operators at the Riverside Center, with hospital personnel and consultants making up most of the resource staff. The hospital serves as a resource to the community in still another way. Community agencies are able to borrow from its rather substantial library of books and audioand videotapes covering a wide range of psychiatric and medical topics. Future plans include exploring the possibility of the hospital’s serving as the focal point and coordinating agency for staff development programs for community agencies in a 14-county area. It is hoped that the agencies involved might pool their training and travel budgets to carry out the program, and that such an areawide program would qualify for federal support.
A MODEL FOR PHYSICIANS TO WITH DIFFICULT Melvin Richard
TRAINING DEAL PATIENTS
S. Gale, M.D. Levy, M.D.,
MPH.
relationship between doctors and undergone significant changes in recent become briefer and less intimate, making cult to manage. In the past a long-standing
patients has years. It has it more diffirelationship
uThe
Dr.
Gale
is director
professor
in
director
of the
of
emergency
231 Bethesda
the
of the
psychiatric
department division medicine,
Avenue,
of
of emergency University Cincinnati,
emergency psychiatry services of
service and and
Cincinnati
Dr.
and Levy
assistant
assistant is
acting
professor
Medical
Center,
Ohio 45267.
(Continued
on page
738)
(Continued from page 736) between doctor and patient was the ruk, not the exception. The trust that developed made the patient more forgiving of errors made by the doctor. At the University of Cincinnati Medical Center we have developed a method for teaching the management of the new genre of doctor-patient relationships. Our target group includes interns, medical, surgical, and emergency medicine residents, and senior medical students, all of whom are rotating through the emergency department for one to three months. Each day they must grapple with the vicissitudes of patients’ personalities and problems. The emergency department represents one end of the spectrum of relationships between doctor and patient. Typical doctor-patient encounters are almost always limited to one visit; the doctor pays little attention to his relationship with the patient and regards it as rather businesslike. However, occasionally the doctor’s idea that the relationship is not of great significance is challenged by a patient who complains, who is unhappy with his recommendations, who becomes angry and shouts, or who questions his competence. Some patients may also become problems because they arouse strong feelings in the doctor. It is to such difficult interactions that we address ourselves in our teaching sessions. The goal of the sessions is to help physicians think through the management of brief doctor-patient interactions commonly encountered in emergency departments. We feel the lecture format is inadequate for that purpose and instead have devised a teaching method using real-life examples that demand a response from doctors and stimulate them to think about a solution. The basic concepts that are developed can be applied to many other situations. The teaching is done by two members of the emergency services staff (the authors) in a weekly session devoted to psychological awareness issues. One presents provocative patient vignettes; the other serves as moderator for the session. We think it is important that both presenter and moderator be perceived by the participants as knowing what it is really like to work in the emergency department. The series takes place in the department, and the housestaff are expected to attend regularly. A typical vignette is as follows: a 38-year-old man comes to the emergency department after hurting his leg in a fall. He is examined by a resident and a tentative diagnosis of hernatoma is made. The resident explains that to be sure the leg isn’t broken, he will get an x-ray. The x-ray is done quickly, and the resident feels it is normal. He tells the patient, “Just as I thought, you don’t have anything as serious as a fracture. There are four things I want you to do to get better: stay off the leg, keeping it elevated as much as possible; apply an ice pack for the next 24 hours as much as possible; take two aspirins every four hours for pain; and return to the orthopedic clinic in three or four days if the leg isn’t better.”
738
HOSPITAL
& COMMUNITY
PSYCHIATRY
The patient looks up with an expression of distrust and says, Doc, I felt my leg break. Are you sure you read that x-ray right? Besides, how am I going to work when I can’t even stand? Another thing, Doc, who are you kidding? Aspirin isn’t strong medicine arid I’m hurting.” At that point the presentation is stopped, and participants are asked how they would respond to the patient. They are encouraged to express what they would be tempted to say to the patient as well as responses they consider appropriate, since those who are aware of what they might like to say or do are usually better prepared to choose the most desirable response. In the vignette presented, the physician responding inappropriately might: . Insist that the diagnosis is correct, and tell the patient that if he wants a second opinion there are many other emergency departments in the city. . Ask who the doctor is, himself or the patient. Explain how many years It takes to become a physician. . Tell the patient he learned t be an expert on the use of nonnarcotic analgesics in his pharmacology course, so he is absolutely certain that aspirin is all the medicine the patient needs. . Tell the patient he’s very busy and that the patient can take or leave his advice. The physician responding appropriately would: . Admit that he cannot be absolutely certain, but that all evidence indicates he is correct in his evaluation. . If a radiologist is not present, assure the patient that he personally will call him if the radiologist later reads the films differently than he has. . Discuss the practical issues of the treatment plan and ask if the patient will be able to follow his advice. Give thought to the injury and how it affects the patient’s work. Some flexibility about time off work may be needed. . Ask the patient if he wishes to have another doctor look at his leg and give a second opinion. I If, in the physician’s estimation, the patient is not a drug abuser, ask him what usually helps when he has a similar amount of pain. The physician may be able to give the patient what he wants, even though it’s not what he thought of first. . Within reason, take extra time with a difficult patient to explain the injury in greater detail. Interpersonal relations between doctor and patient need not be vague and unclear. Concrete guidelines can be developed, and potential responses can be sorted through ahead of time, thereby permitting an intelligent response when difficult situations occur. There are important differences between merely being courteous to the patient and communicating necessary information to him appropriately. The kind of learning experience described enables the physician to recognize and refrain from responses that may impair the doctorpatient relationship.i ‘ ‘
