Families, Systems, & Health 2014, Vol. 32, No. 1, 130 –132
© 2014 American Psychological Association 1091-7527/14/$12.00 DOI: 10.1037/fsh0000025
PRESIDENT’S COLUMN: COLLABORATIVE FAMILY HEALTHCARE ASSOCIATION
Getting Beyond “Pandora-Phobia” Robert A. Cushman, MD This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Connecticut School of Medicine and Saint Francis Hospital and Medical Center, Hartford, Connecticut
It has been my impression that clinicians, regardless of discipline, tend to prefer those areas of their practice in which they feel a sense of mastery, a confidence in their ability to manage the conditions being presented to them by their patients. In contrast, in clinical scenarios when the history and/or physical exam findings consist of vague and difficultto-interpret elements, the resulting discordance may challenge some clinicians’ sense of mastery. This lack of fitting into a clinician’s diagnostic explanatory models can be disquieting for some, creating a creeping sense of frustration. Common clinician responses to patients presenting with diagnostic dilemmas may include: (a) ordering more tests in hopes of finding some biomedical abnormality which may serve as a clue to an obscure condition, (b) referring the patient to a consultant for additional evaluation, (c) experiencing frustration and at times dislike for the patient who is being “difficult” by not fitting neatly into a diagnostic box, or (d) some combination of (a), (b), and/or (c). This common primary care scenario, the presentation of symptoms for which no “organic,” pathologic, physical diagnosis can be discerned, has come to be referred to as Medically Unexplained Symptoms (MUS). A comprehensive, 25-year review of the English language literature on MUS (Edwards, Stern, Clarke, Ivbijaro, & Kasney, 2010), identified MUS as the most common category of complaints in primary care, accounting for between 14% and 50% of patient visits in various studies. Despite this high prevalence, the
Correspondence concerning this article should be addressed to Robert A. Cushman, MD, 99 Woodland Street, Harford, CT 06105. E-mail: [email protected]
authors note that primary care physicians frequently “experience MUS as difficult and frustrating,” with their frustration “tied to a range of negative emotions, including feelings of inadequacy, resentment, and a fear of patients who may manipulate the course of treatment” (Edwards et al., 2010, p. 211). These same patients, if they first present to behavioral health clinicians, can be perceived as medically alarming. Symptoms like chest pain, headache, shortness of breath, and abdominal pain cause behavioral health clinicians to refer urgently to medical colleagues to “rule out” life-threatening physical illness. In both contexts, clinicians experience these patients as challenging because instead of fitting neatly into either a straightforward, “organic,” biomedical rubric, or a strictly psychological rubric, their presentation spans the biopsychosocial spectrum that whole persons inhabit outside the textbooks. Thus, the approach to these patients necessitates avoiding choosing between the false dichotomy of addressing the “either/or” and instead embracing the “both/and” (Edwards et al., 2010). Clinical trainees experience “complicated” patients as particularly challenging. My 25⫹ year experience as faculty working with medical students and family medicine residents has taught me to pay close attention to these scenarios, for the sake of both the patients and the trainees. Student and resident trainees’ learning tasks are to grow both their “book” and practical knowledge; they must learn to assemble patients’ presenting concerns together with the initial history and physical findings, and fit these into their existing cognitive frameworks. When they encounter a less-than-good fit, they may (a) jump tentatively and prematurely to a diagnosis, usually by disregarding one or more pieces of infor-
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This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
GETTING BEYOND “PANDORA-PHOBIA”
mation that contribute to the poor fit; or (b) “blame the patient” for being a “poor historian.” Both responses emanate from trainees’ desire to feel competent, and to demonstrate their growing strengths to their colleagues and supervisors. When premature closure, or just plain uncertainty, is the response, this may be inadvertent and passive, due to a shortfall in knowledge. Alternatively, premature closure may result from a subconscious avoidance of (a) sensitive topics that the history is pointing toward, or (b) cues from the patient about psychosocial concerns and a desire for emotional support. When I ask residents about why they have not collected pertinent, albeit sensitive, psychosocial information, they typically respond, “I forgot to ask;” “I didn’t feel comfortable going there;” or “I didn’t want to open Pandora’s box!” This hesitancy to ask about the patients’ thoughts and feelings results from a fear of getting entangled in a conversation from which the trainee cannot easily escape. I now refer to this avoidance as “Pandora-phobia.” Every faculty colleague who has heard the term has immediately recognized the phenomenon! (No one has misinterpreted it to be a fear of either Internet-based radio, or of charm bracelets!) The reference is to Pandora, the first human woman in Greek mythology, who was given a large jar (later mistranslated as “box”) and instructed by the gods not to open it under any circumstance. When her simple curiosity prompted her to open the vessel, a multitude of evils and diseases rapidly escaped and spread across the world; thus, today the phrase “to open Pandora’s box” has come to mean a minor action which results in severe and far-reaching consequences (Wikipedia, 2013). For trainees or seasoned clinicians “not opening the box” may be a protective attempt to stay in control by avoiding the chaos and “time-sink” of the furies. Our task in the training environment is to help young clinicians (of all types) gain experience in “lifting the lid” of Pandora’s box. This is ideally achieved by trainees observing the role-modeling of accomplished mentors, and their working with capable, multidisciplinary teammates. This is the beauty of the collaborative, integrated care delivery team; there is a balanced set of skills and expertise
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brought by an expanded number of caring persons (beyond the solo clinician) supporting those patients whose conditions most need a combination of biomedical and psychosocial expertise. When clinicians-intraining experience a safety net of expertise around them, they can learn the patience to listen, and begin to acquire a sense of how the different chaotic furies swirl, how to buffer them, and how to allow the pent-up energies to seep, rather than burst, out of the box. Trainees can learn to become more comfortable facing complexity and uncertainty, and learn to see a situation from multiple perspectives. After all the evil spirits had escaped from Pandora’s opened vessel, the only thing that remained inside once she managed to close the lid was the spirit of hope (Wikipedia, 2013). This has an interesting parallel to the therapeutic process. We often need to facilitate the release of a multitude of pent up, chaotic, and frequently destructive thoughts, feelings, and behavior patterns that burden our patients who struggle with MUS and more complicated mental illnesses. It frequently requires the release of these “furies” for such patients to experience a moment of space and perspective, a quieter, deep-seated sense of hope, and a potential to return toward health. As clinicians, we can only get to that point with our patients by overcoming our own fear of asking the important questions. It is our responsibility to “lift the lid.” I alluded above to “the beauty of the collaborative, integrated care delivery team.” This care delivery model has no stronger proponent than the Collaborative Family Healthcare Association (CFHA), an amazing organization of professional colleagues spanning diverse disciplines. CFHA is a collaborative “metateam,” an extended learning community for those of us involved in teaching and research in this vibrant and evolving model of care, keeping us focused on the goal of “developing the knowledge base of collaborative family health care” and promoting “opportunities that enable students, providers, [and] educators . . . to acquire knowledge, skills, relational competencies, and experiences applying collaborative family health care.” Through CFHA, and this, its affiliated journal, Families, Systems, and Health (FSH), we are reminded, encouraged, and reenergized to
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continue to attend to the important, sensitive, and difficult questions in the lives of our patients and their families. We are reminded of our calling to “lift the lid,” and to help our trainees learn to embrace that responsibility. I have found CFHA and FSH to be potent, systemic antidotes to “Pandora-phobia.”
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Edwards, T. M., Stern, A., Clarke, D. D., Ivbijaro, G., & Kasney, L. M. (2010). The treatment of patients
with medically unexplained symptoms in primary care: A review of the literature. Mental Health in Family Medicine, 7, 209 –221. Wikipedia, The Free Encyclopedia. (2013). Pandora’s box. Retrieved from http://en.wikipedia.org/wiki/ Pandora
Received November 26, 2013 Revision received January 7, 2014 Accepted January 7, 2014 䡲
© 2014 American Psychological Association 1091-7527/14/$12.00 DOI: 10.1037/fsh0000025
PRESIDENT’S COLUMN: COLLABORATIVE FAMILY HEALTHCARE ASSOCIATION
Getting Beyond “Pandora-Phobia” Robert A. Cushman, MD This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Connecticut School of Medicine and Saint Francis Hospital and Medical Center, Hartford, Connecticut
It has been my impression that clinicians, regardless of discipline, tend to prefer those areas of their practice in which they feel a sense of mastery, a confidence in their ability to manage the conditions being presented to them by their patients. In contrast, in clinical scenarios when the history and/or physical exam findings consist of vague and difficultto-interpret elements, the resulting discordance may challenge some clinicians’ sense of mastery. This lack of fitting into a clinician’s diagnostic explanatory models can be disquieting for some, creating a creeping sense of frustration. Common clinician responses to patients presenting with diagnostic dilemmas may include: (a) ordering more tests in hopes of finding some biomedical abnormality which may serve as a clue to an obscure condition, (b) referring the patient to a consultant for additional evaluation, (c) experiencing frustration and at times dislike for the patient who is being “difficult” by not fitting neatly into a diagnostic box, or (d) some combination of (a), (b), and/or (c). This common primary care scenario, the presentation of symptoms for which no “organic,” pathologic, physical diagnosis can be discerned, has come to be referred to as Medically Unexplained Symptoms (MUS). A comprehensive, 25-year review of the English language literature on MUS (Edwards, Stern, Clarke, Ivbijaro, & Kasney, 2010), identified MUS as the most common category of complaints in primary care, accounting for between 14% and 50% of patient visits in various studies. Despite this high prevalence, the
Correspondence concerning this article should be addressed to Robert A. Cushman, MD, 99 Woodland Street, Harford, CT 06105. E-mail: [email protected]
authors note that primary care physicians frequently “experience MUS as difficult and frustrating,” with their frustration “tied to a range of negative emotions, including feelings of inadequacy, resentment, and a fear of patients who may manipulate the course of treatment” (Edwards et al., 2010, p. 211). These same patients, if they first present to behavioral health clinicians, can be perceived as medically alarming. Symptoms like chest pain, headache, shortness of breath, and abdominal pain cause behavioral health clinicians to refer urgently to medical colleagues to “rule out” life-threatening physical illness. In both contexts, clinicians experience these patients as challenging because instead of fitting neatly into either a straightforward, “organic,” biomedical rubric, or a strictly psychological rubric, their presentation spans the biopsychosocial spectrum that whole persons inhabit outside the textbooks. Thus, the approach to these patients necessitates avoiding choosing between the false dichotomy of addressing the “either/or” and instead embracing the “both/and” (Edwards et al., 2010). Clinical trainees experience “complicated” patients as particularly challenging. My 25⫹ year experience as faculty working with medical students and family medicine residents has taught me to pay close attention to these scenarios, for the sake of both the patients and the trainees. Student and resident trainees’ learning tasks are to grow both their “book” and practical knowledge; they must learn to assemble patients’ presenting concerns together with the initial history and physical findings, and fit these into their existing cognitive frameworks. When they encounter a less-than-good fit, they may (a) jump tentatively and prematurely to a diagnosis, usually by disregarding one or more pieces of infor-
130
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
GETTING BEYOND “PANDORA-PHOBIA”
mation that contribute to the poor fit; or (b) “blame the patient” for being a “poor historian.” Both responses emanate from trainees’ desire to feel competent, and to demonstrate their growing strengths to their colleagues and supervisors. When premature closure, or just plain uncertainty, is the response, this may be inadvertent and passive, due to a shortfall in knowledge. Alternatively, premature closure may result from a subconscious avoidance of (a) sensitive topics that the history is pointing toward, or (b) cues from the patient about psychosocial concerns and a desire for emotional support. When I ask residents about why they have not collected pertinent, albeit sensitive, psychosocial information, they typically respond, “I forgot to ask;” “I didn’t feel comfortable going there;” or “I didn’t want to open Pandora’s box!” This hesitancy to ask about the patients’ thoughts and feelings results from a fear of getting entangled in a conversation from which the trainee cannot easily escape. I now refer to this avoidance as “Pandora-phobia.” Every faculty colleague who has heard the term has immediately recognized the phenomenon! (No one has misinterpreted it to be a fear of either Internet-based radio, or of charm bracelets!) The reference is to Pandora, the first human woman in Greek mythology, who was given a large jar (later mistranslated as “box”) and instructed by the gods not to open it under any circumstance. When her simple curiosity prompted her to open the vessel, a multitude of evils and diseases rapidly escaped and spread across the world; thus, today the phrase “to open Pandora’s box” has come to mean a minor action which results in severe and far-reaching consequences (Wikipedia, 2013). For trainees or seasoned clinicians “not opening the box” may be a protective attempt to stay in control by avoiding the chaos and “time-sink” of the furies. Our task in the training environment is to help young clinicians (of all types) gain experience in “lifting the lid” of Pandora’s box. This is ideally achieved by trainees observing the role-modeling of accomplished mentors, and their working with capable, multidisciplinary teammates. This is the beauty of the collaborative, integrated care delivery team; there is a balanced set of skills and expertise
131
brought by an expanded number of caring persons (beyond the solo clinician) supporting those patients whose conditions most need a combination of biomedical and psychosocial expertise. When clinicians-intraining experience a safety net of expertise around them, they can learn the patience to listen, and begin to acquire a sense of how the different chaotic furies swirl, how to buffer them, and how to allow the pent-up energies to seep, rather than burst, out of the box. Trainees can learn to become more comfortable facing complexity and uncertainty, and learn to see a situation from multiple perspectives. After all the evil spirits had escaped from Pandora’s opened vessel, the only thing that remained inside once she managed to close the lid was the spirit of hope (Wikipedia, 2013). This has an interesting parallel to the therapeutic process. We often need to facilitate the release of a multitude of pent up, chaotic, and frequently destructive thoughts, feelings, and behavior patterns that burden our patients who struggle with MUS and more complicated mental illnesses. It frequently requires the release of these “furies” for such patients to experience a moment of space and perspective, a quieter, deep-seated sense of hope, and a potential to return toward health. As clinicians, we can only get to that point with our patients by overcoming our own fear of asking the important questions. It is our responsibility to “lift the lid.” I alluded above to “the beauty of the collaborative, integrated care delivery team.” This care delivery model has no stronger proponent than the Collaborative Family Healthcare Association (CFHA), an amazing organization of professional colleagues spanning diverse disciplines. CFHA is a collaborative “metateam,” an extended learning community for those of us involved in teaching and research in this vibrant and evolving model of care, keeping us focused on the goal of “developing the knowledge base of collaborative family health care” and promoting “opportunities that enable students, providers, [and] educators . . . to acquire knowledge, skills, relational competencies, and experiences applying collaborative family health care.” Through CFHA, and this, its affiliated journal, Families, Systems, and Health (FSH), we are reminded, encouraged, and reenergized to
132
CUSHMAN
continue to attend to the important, sensitive, and difficult questions in the lives of our patients and their families. We are reminded of our calling to “lift the lid,” and to help our trainees learn to embrace that responsibility. I have found CFHA and FSH to be potent, systemic antidotes to “Pandora-phobia.”
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Edwards, T. M., Stern, A., Clarke, D. D., Ivbijaro, G., & Kasney, L. M. (2010). The treatment of patients
with medically unexplained symptoms in primary care: A review of the literature. Mental Health in Family Medicine, 7, 209 –221. Wikipedia, The Free Encyclopedia. (2013). Pandora’s box. Retrieved from http://en.wikipedia.org/wiki/ Pandora
Received November 26, 2013 Revision received January 7, 2014 Accepted January 7, 2014 䡲
