Is Your Psychiatrist Paying Attention?

In my post of 2/24/2010, Counting Symptoms that Don't Count, I discussed how many psychiatrists these days are taking huge shortcuts in order to squeeze as many patients into an hour as they possibly can. I described how they are focusing just on symptom counts without trying making the slightest effort to ascertain whether or not the symptoms in question are clinically significant for a particular diagnosis, or whether they might require psychotherapy rather than drug treatment.

As I have pointed out many times in this blog, in order to make such a determination, the doctor has to take into account the timing, pervasiveness, persistance, and subjective quality of a symptom. The psychiatrist has to know what other symptoms are present at the same time and at different times. Most importantly, the doctor has to know something about the psychosocial context of a symptom.

One of my partners reported a particular glaring example of what can happen when this is not done: A patient with no previous psychiatric history became depressed right after finding her husband in bed with another woman.  Her "depression" was characterized, not surprisingly, mostly by anger and preoccupation with the discovered affair.  Nevertheless, when she came to the attention of a psychiatrist, he diagnosed her with "major depressive disorder."  Really?  I mean, really???

Another time saving "convenience" is for the doctor to write down the information that the patient is relaying during an interview on the patient's chart, using either pen and paper or a computer, as the patients speaks. This not only saves time, but solves a second problem: Some insurance companies do not want to pay for a doctor's time unless it is spent face to face with the patient. Even time spend reviewing the patient's record and writing down all the information that insurance companies demand in order to pay the doctor is supposed to be donated, I guess. So instead of writing a progress note after the patient leaves, it is written with the patient still in the room!

So, aside from wasting the patient's time while the doctor does that, what's wrong with that?

Well, I'll tell you.  When a doctor is writing or typing away on a computer, his or her attention is split between doing that and observing the patient. Often a patient's body language or facial expression can give a doctor a clue that what the patient is saying may not be completely accurate or may not be the whole story, so that the doctor then needs to ask for clarification with follow-up questions. When the doctor is staring at a chart instead of the patient, that is probably just not going to happen.

Even more important, patients will often mutter vitally important information quickly and in passing, or even under their breath. This is particularly likely to happen if the information patients are relaying is troublesome to them in one way or another, such as reporting things they are ashamed of. If the doctor is not paying close attention, he or she will literally not hear it!

In my book, How Dysfunctional Families Spur Mental Disorders, I describe in detail a videotape of a psychiatry trainee doing a diagnostic interview in front of two senior faculty members in order to practice for her upcoming oral boards. In the videotape, a real patient was used. During the interview, the patient stated in passing that she had been repeatedly molested by a close relative. In fact, the matter even ended up in court. After the interview, the examiners both said that they "suspected" that a trauma history was "likely" in the patient.

There were three doctors in the room, all of them preoccupied with the trainee's performance.  All three of them either missed or forgot that abuse was not only likely, but had actually been mentioned!