Am
J Psychiatry
135:9,
September
1978
BRIEF
1971
9. Curry A: Myth, transference, and the black psychotherapist. Psychoanal Rev 51:7-14, 1964 10. Altman L: The Dream in Psychoanalysis. New York, Inter-
Psychiatric
Training
Gynecologist
for
the
national Universities Press, 1969, p 54 11. Oremland JD: A specific dream during the termination successful psychoanalyses. I Am Psychoanal Assoc 302,
Primary
phase of 21:285-
1973
Care
Obstetrician-
Resident
BY PRISCILLA
DAY
BOEKELHEIDE,
M.D.
The author describes a modelfor the psychiatric training ofobstetrics-gynecology house staff members who serve as primary care physiciansfor women. By integrating psychiatric skills with specialty training, the psychiatrist can enhance continuity ofpatient care for the resident during his transition to the role of primary care obstetrician-gynecologist.
house three
staff included residents, two
students. tnibuted cology shaped
a teaching-attending interns, and one
WELL BEFORE THE 1975 position statement by the American College of Obstetricians and Gynecologists and the American Board of Obstetrics and Gynecology on the role of the obstetrician-gynecologist in the primany care ofwomen (1), I was invited to share a woman’s point of view with the obstetrics and gynecology house staff of a large inner city nonprofit hospital who viewed themselves as total physicians offering comprehensive continuity ofcare to women. The house officers already recognized that they were often the first medical contact for their patients, that their responsibility should not be limited to acute illness, and that normative life crises required diverse skills such as marital, pregnancy, and sexual counseling, menoparsal care, and supportive therapy for the cancer patier1t. The keys to their development as primary cane physicians were their eagerness to learn and to accept the role and the use of a peer collaborative psychiatric consultant on their team. In addition to the senior psychiatric consultant, the
is Assistant Professor of Psychiatry, University of School ofMedicine, Chapel Hill, NC. 27514. At the was done, she was a psychiatric resident, Mt. Zion Francisco, Calif.
The author gratefully acknowledges the supervision of Drs. Haskell Bazell and Thomas Stein, Department of Psychiatry, and Dr. Fred Berman, Department pital, San Francisco,
of Obstetrics Calif.
and
Gynecology,
0002-953X/78/0009-I087$0.35
Mt.
Zion
Hos-
physician, on two medical
No grant or special external incentive conto the program, and most obstetrics and gyneteaching situations could rather easily be toward the same goals. My acceptance into the
program
was
a fellow
resident
probably
enhanced
but
also
College of Obstetricians The mutual academic
Dr. Boekelheide North Carolina time this work Hospital, San
COMMUNICATIONS
by my being
a Fellow
of the
and Gynecologists. goal was training
not only American
for better
pa-
tient care by increasing understanding and skills; the focus was often broadened to include the patient’s panents, her husband or boyfriend, her children, and even grandparents and neighbors if necessary.
METHOD
The tools were the staff’s medical background, their empathy, and their eagerness. Through weekly informal discussion and demonstration we studied the following areas over a period of 20 months: I) interview techniques, 2) selection and use ofpsychotropic drugs, 3) personality diagnosis, 4) psychosocial aspects of the patients’ everyday lives, and 5) health care rather than
medical
illness.
This
focus
obstetrician-gynecologist
practice
preventive
consideration and on the
Balint
offered as
mental
a unique
view
a specialist
health
who
care
(2). The
was on the doctor-patient chief drug, tincture of doctor,
of the should
overall
relationship described
by
(3).
The psychiatric consultant guided the sessions in an air of mutual inquiry. As early as feasible the psychiatnist helped to sort out the majority of patients whom
the staff advised stances
could handle as necessary. there
was
themselves In most
joint
and supervised of the remaining
observation
and
few
patients
were
referred
for further
tion.
When
staff
anxiety
was
© 1978 American
Psychiatric
Association
high
and in-
discussion.
direct or
when
A
consultaspecial 1087
BRIEF
Am
COMMUNICATIONS
knowledge such rect consultation
as legal involvement was required, diwith the patient was available. Occa-
sionally there were conflicting traditional medical/surgical about a hysterectomy.
CLINICAL
opinions, e.g., and psychiatric
between opinions
VIGNETTES
primary
throughout
and
his newborn
for a circum-
check. His anxiety offered the intern to discuss his feelings as a new father
an opporand as a
recently
neglected (as he saw it) sexual partner. A mother brought her 10-year-old pubescent daughter to check her vaginal discharge, asking covertly for sex education help. 2.
3.
A grandmother
married
accompanied
adolescent
a hysterectomy,
her
granddaughter.
abortion, placement, 4. A young, single,
the
what
.
cision tunity
care
and illegitimacy nulliparous,
challenging
pregnant,
Social
the
were feminist
house
un-
issues
of
discussed. insisted
officers’
135:9,
September
1978
3. Interdepartmental practices were examined for therapeutic interaction. 4. “Nuisance” calls from patients declined dramatically as the house officers learned to meet dependency needs more directly in the clinics. 5. More appropriate referrals for psychiatric consultation were made, reflecting a focus on prophylaxis and preventive care.
6. Stafftime Some examples that typify the life cycle follow: I A young father brought
J Psychiatry
house
with
patients
officers
Burnham
became
became
(4)
calls
more
conditioned
“practice
productive gradually
to
i.e.,
the
shock,”
pleasure oftreating all types ofpatients instead of only the unusual, esoteric, or very difficult. 7. The usual clinic diagnostic categories such as toxemia, unwanted pregnancy, and imperforate hymen were redefined to include such concepts as anxiety, dependency, ambivalence, and nonconsummation of marriage. 8. Problem orientation broadened to include the patient’s family, body image, and sexual identity.
on
value
DISCUSSION
systems.
In addition, the overburdened the frankly psychotic pregnant cation of learned medical skills sultant’s specialized psychosocial-medical personal physician
couraging
him/her
diagnostic, supportive Seman’s
RESU
viewpoint needs. involved
to participate
and treatment psychotherapy, techniques, etc.
abusing mother and woman required applias well as the peer conto meet the patients’ The aim was to keep the as much as possible, en-
by using
interviewing,
skills as needed for Masters and Johnson’s
brief or
Sound psychiatric interventions, terfere with the busy clinician’s
LTS
As tients, having
the house staff reported progress with their pathey were encouraged to be more flexible in patients return according to psychological needs; e.g. the postpartum patient who was depressed was seen briefly but frequently rather than for the usu,
al one quickly
visit at four to six weeks. The staff learned to focus on the emotional problem, not neces-
sarily the presenting obstetrics or gynecology problem. As a result, some important changes occurred: 1. Labeling of patients changed from “that hysteric” to “Mrs. A,” and family dynamics were exam-
ined.
1088
service
and
hence
in training
of its staff.
once thought schedule, can
tegrated into the usual 10- to 20-minute This addition makes clinical orientation vant experience for both patient
Through
teaching
and
years the psychiatrist stetnician-gynecologist
example can aid this to primary
during
to inbe in-
patient visit. a more neleand physician.
the
residency
transition from cane physician.
ob-
REFERENCES 1 . Position
Newsletter 2.
2. In selected instances various social services, the pediatrics department, or the occupational therapy section helped in the functioning of the obstetrics-gy-
necology
Many demands are placed on the obstetrician-gynecologist when he/she changes from the omniscient and omnipotent authoritarian figure and becomes a true participant in primary health care delivery and service for a large segment of the population. As the primary care physician for women he/she must be prepared to offer periodic comprehensive evaluation oftheir health status, which includes health education, preventive care, health maintenance, referral to and integration of other health services, and traditional therapeutic services throughout the life cycle of his/her female patients.
statement
for
AMA
workshop
on primary
care.
ACOG
19:4, 1975
Caplan G: Practical steps for the family physician in the prevention of emotional disorder. JAMA 170:1497-1506, 1959 3. Balint M: The Doctor, His Patient and the Illness. New York, International Universities Press. 1957, pp 11, 18 4. Burnham iF: Primary care within the academic tradition. JAMA 233:974-975, 1975
J Psychiatry
135:9,
September
1978
BRIEF
1971
9. Curry A: Myth, transference, and the black psychotherapist. Psychoanal Rev 51:7-14, 1964 10. Altman L: The Dream in Psychoanalysis. New York, Inter-
Psychiatric
Training
Gynecologist
for
the
national Universities Press, 1969, p 54 11. Oremland JD: A specific dream during the termination successful psychoanalyses. I Am Psychoanal Assoc 302,
Primary
phase of 21:285-
1973
Care
Obstetrician-
Resident
BY PRISCILLA
DAY
BOEKELHEIDE,
M.D.
The author describes a modelfor the psychiatric training ofobstetrics-gynecology house staff members who serve as primary care physiciansfor women. By integrating psychiatric skills with specialty training, the psychiatrist can enhance continuity ofpatient care for the resident during his transition to the role of primary care obstetrician-gynecologist.
house three
staff included residents, two
students. tnibuted cology shaped
a teaching-attending interns, and one
WELL BEFORE THE 1975 position statement by the American College of Obstetricians and Gynecologists and the American Board of Obstetrics and Gynecology on the role of the obstetrician-gynecologist in the primany care ofwomen (1), I was invited to share a woman’s point of view with the obstetrics and gynecology house staff of a large inner city nonprofit hospital who viewed themselves as total physicians offering comprehensive continuity ofcare to women. The house officers already recognized that they were often the first medical contact for their patients, that their responsibility should not be limited to acute illness, and that normative life crises required diverse skills such as marital, pregnancy, and sexual counseling, menoparsal care, and supportive therapy for the cancer patier1t. The keys to their development as primary cane physicians were their eagerness to learn and to accept the role and the use of a peer collaborative psychiatric consultant on their team. In addition to the senior psychiatric consultant, the
is Assistant Professor of Psychiatry, University of School ofMedicine, Chapel Hill, NC. 27514. At the was done, she was a psychiatric resident, Mt. Zion Francisco, Calif.
The author gratefully acknowledges the supervision of Drs. Haskell Bazell and Thomas Stein, Department of Psychiatry, and Dr. Fred Berman, Department pital, San Francisco,
of Obstetrics Calif.
and
Gynecology,
0002-953X/78/0009-I087$0.35
Mt.
Zion
Hos-
physician, on two medical
No grant or special external incentive conto the program, and most obstetrics and gyneteaching situations could rather easily be toward the same goals. My acceptance into the
program
was
a fellow
resident
probably
enhanced
but
also
College of Obstetricians The mutual academic
Dr. Boekelheide North Carolina time this work Hospital, San
COMMUNICATIONS
by my being
a Fellow
of the
and Gynecologists. goal was training
not only American
for better
pa-
tient care by increasing understanding and skills; the focus was often broadened to include the patient’s panents, her husband or boyfriend, her children, and even grandparents and neighbors if necessary.
METHOD
The tools were the staff’s medical background, their empathy, and their eagerness. Through weekly informal discussion and demonstration we studied the following areas over a period of 20 months: I) interview techniques, 2) selection and use ofpsychotropic drugs, 3) personality diagnosis, 4) psychosocial aspects of the patients’ everyday lives, and 5) health care rather than
medical
illness.
This
focus
obstetrician-gynecologist
practice
preventive
consideration and on the
Balint
offered as
mental
a unique
view
a specialist
health
who
care
(2). The
was on the doctor-patient chief drug, tincture of doctor,
of the should
overall
relationship described
by
(3).
The psychiatric consultant guided the sessions in an air of mutual inquiry. As early as feasible the psychiatnist helped to sort out the majority of patients whom
the staff advised stances
could handle as necessary. there
was
themselves In most
joint
and supervised of the remaining
observation
and
few
patients
were
referred
for further
tion.
When
staff
anxiety
was
© 1978 American
Psychiatric
Association
high
and in-
discussion.
direct or
when
A
consultaspecial 1087
BRIEF
Am
COMMUNICATIONS
knowledge such rect consultation
as legal involvement was required, diwith the patient was available. Occa-
sionally there were conflicting traditional medical/surgical about a hysterectomy.
CLINICAL
opinions, e.g., and psychiatric
between opinions
VIGNETTES
primary
throughout
and
his newborn
for a circum-
check. His anxiety offered the intern to discuss his feelings as a new father
an opporand as a
recently
neglected (as he saw it) sexual partner. A mother brought her 10-year-old pubescent daughter to check her vaginal discharge, asking covertly for sex education help. 2.
3.
A grandmother
married
accompanied
adolescent
a hysterectomy,
her
granddaughter.
abortion, placement, 4. A young, single,
the
what
.
cision tunity
care
and illegitimacy nulliparous,
challenging
pregnant,
Social
the
were feminist
house
un-
issues
of
discussed. insisted
officers’
135:9,
September
1978
3. Interdepartmental practices were examined for therapeutic interaction. 4. “Nuisance” calls from patients declined dramatically as the house officers learned to meet dependency needs more directly in the clinics. 5. More appropriate referrals for psychiatric consultation were made, reflecting a focus on prophylaxis and preventive care.
6. Stafftime Some examples that typify the life cycle follow: I A young father brought
J Psychiatry
house
with
patients
officers
Burnham
became
became
(4)
calls
more
conditioned
“practice
productive gradually
to
i.e.,
the
shock,”
pleasure oftreating all types ofpatients instead of only the unusual, esoteric, or very difficult. 7. The usual clinic diagnostic categories such as toxemia, unwanted pregnancy, and imperforate hymen were redefined to include such concepts as anxiety, dependency, ambivalence, and nonconsummation of marriage. 8. Problem orientation broadened to include the patient’s family, body image, and sexual identity.
on
value
DISCUSSION
systems.
In addition, the overburdened the frankly psychotic pregnant cation of learned medical skills sultant’s specialized psychosocial-medical personal physician
couraging
him/her
diagnostic, supportive Seman’s
RESU
viewpoint needs. involved
to participate
and treatment psychotherapy, techniques, etc.
abusing mother and woman required applias well as the peer conto meet the patients’ The aim was to keep the as much as possible, en-
by using
interviewing,
skills as needed for Masters and Johnson’s
brief or
Sound psychiatric interventions, terfere with the busy clinician’s
LTS
As tients, having
the house staff reported progress with their pathey were encouraged to be more flexible in patients return according to psychological needs; e.g. the postpartum patient who was depressed was seen briefly but frequently rather than for the usu,
al one quickly
visit at four to six weeks. The staff learned to focus on the emotional problem, not neces-
sarily the presenting obstetrics or gynecology problem. As a result, some important changes occurred: 1. Labeling of patients changed from “that hysteric” to “Mrs. A,” and family dynamics were exam-
ined.
1088
service
and
hence
in training
of its staff.
once thought schedule, can
tegrated into the usual 10- to 20-minute This addition makes clinical orientation vant experience for both patient
Through
teaching
and
years the psychiatrist stetnician-gynecologist
example can aid this to primary
during
to inbe in-
patient visit. a more neleand physician.
the
residency
transition from cane physician.
ob-
REFERENCES 1 . Position
Newsletter 2.
2. In selected instances various social services, the pediatrics department, or the occupational therapy section helped in the functioning of the obstetrics-gy-
necology
Many demands are placed on the obstetrician-gynecologist when he/she changes from the omniscient and omnipotent authoritarian figure and becomes a true participant in primary health care delivery and service for a large segment of the population. As the primary care physician for women he/she must be prepared to offer periodic comprehensive evaluation oftheir health status, which includes health education, preventive care, health maintenance, referral to and integration of other health services, and traditional therapeutic services throughout the life cycle of his/her female patients.
statement
for
AMA
workshop
on primary
care.
ACOG
19:4, 1975
Caplan G: Practical steps for the family physician in the prevention of emotional disorder. JAMA 170:1497-1506, 1959 3. Balint M: The Doctor, His Patient and the Illness. New York, International Universities Press. 1957, pp 11, 18 4. Burnham iF: Primary care within the academic tradition. JAMA 233:974-975, 1975
