The Gap Between Psychiatric Practice and the Medical M ode1 Rita R. Rogers and Beatrice Rasof
T
HE AUTHORS HAVE attempted to pinpoint causes for the disparity between the information psychiatrists say they give to referring physicians and patients and the information the referring physicians and patients say they receive. Using questionnaires and open-ended interviews, this study has shown there was a highly significant discrepancy between the information patients said they received and what psychiatrists said they gave with respect to the rationale of treatment prognoses with or without treatment. This gap could be attributed to various factors, among them the unavailability of psychiatrists or lack of outcome studies. Moreover, this study tends to point out the sequential difference in the treatment of psychiatric outpatients, e.g. the patient is helped by his doctor through treatment to diagnose himself and that adherence to this psychiatric style of interviewing could be utilized by the primary physician to improve his rapport with patients and, perhaps, increase their knowledge and understanding of their own disease. As previously reported, residents in child psychiatry, working under the supervision of the senior author, were reluctant to commit themselves to a diagnostic framework and completely avoided formulating prognoses, even though they were accomplished in understanding and conveying clinical data. The primary aim of our work was to attempt to link our trainees psychiatric and medical identities, which appeared to be totally divergent. In all of the cases covered by our study the trainees failed to provide diagnoses to referring physicians 48% of the time and to patients 45% of the time.’ Prognoses were never offered. We have attempted to elicit reasons for this divergence from standard medical practice. STUDY ORGANIZATION Basically five separate control groups were used. Trainees in child psychiatry who had participated in the original study, designated Group I, were asked why they avoided giving diagnoses and prognoses to referring physicians and patients. Psychiatrists on the staff at Harbor General Department of Psychiatry, designated Group II, were asked whether they gave diagnostic and prognostic feedback to referring physicians and what they thought their reasons were for not adhering strictly to standards of medical practice. Psychiatrists involved in practice in the South Bay Area, designated as Group III, were asked essentially
From the Medical School, University of California at Los Angeles, and Harbor General Hospital, Torrance, California. Rita R. Rogers, M.D.: Clinical Professor of Psychiatry. UCLA Medical School, and Chief, Child Psychiatry Division, Harbor General Hospital: Beatrice Rasof, Ph.D.: Assistant Clinical Professor, Child Psychology Division, UCLA Medical School, and Clinical Psychologist. Harbor General Hospital, Torrance, Calif: Reprint requests should be addressed to Rita R. Rogers, M.D.. Harbor General Hospital, 1000 West Carson St., Torrance, Calt$ 90509. o 1977 by Grune & Stratton, Inc. ISSN 0010~44OX. Comprehensive Psychiatry, Vol. 18. No. 5 (September/October),
1977
459
460
ROGERS AND
RASOF
the same questions as staff psychiatrists in Group II above, while nonpsychiatric physicians from the South Bay Area, selected consecutively from the telephone directory and designated Group IV, were asked whether they received diagnostic and prognostic feedback from psychiatrists to whom they referred patients, what kinds of information they would most appreciate receiving and what areas of nonpsychiatric study they believed the trainees in psychiatry should receive in order to improve communication between the primary physician and psychiatrist. Patients designated as Group V were selected from private practice and Harbor General Hospital and asked about their experience receiving information concerning their illnesses, their prognoses with and without treatment, prescribed treatment and whether they welcomed information about their illnesses and treatment. In all groups, the subjects were obtained without the use of formal selection procedures, and open-ended interviews were conducted with eight subjects from each of the five groups. Analyzing a comparison of questions asked of the subjects in Groups I through III, i.e., the giving of diagnoses and prognoses with and without treatment to either the referring physician or the patient, there appeared to be no significant differences between the groups; however, psychiatrists in private practice. Group III, are inclined more often than not to give diagnoses to their patients than are either of the other two groups. There was a significant relationship between what the subjects in Groups I through III told the referring physician and what they told their patients. The trend was for more information to be given to the referring physician than to the patient. Groups I through III did not vary significantly in offering prognoses based on whether treatment was given or not, nor did the same groups differ significantly in conveying the rationale of the treatment they offer. Interestingly, Group I subjects differed from those subjects in either of the other two groups in the difficulty they said they experienced adhering to standard medical practice communicating with both referring physicians and patients. By comparing the responses to our questionnaires by subjects in Groups III and IV, we were able to evaluate the degree to which the referring physicians received information the psychiatrists said they gave. It was evident that the greatest discrepancy between psychiatric and standard medical practice appeared in the area of prognosis. A significant discrepancy was found between the information patients said they received and what psychiatrists reported they gave with respect to rationale of treatment and prognosis without treatment. Psychiatrists reported disclosing this information to a greater degree than patients reported they received it. The question of prognosis without treatment was the area of greatest discrepancy. Judging from their explicit answers to the open-ended questions presented about the kinds of information they would appreciate or expect to receive from their psychiatrist, the observed discrepancy does not appear to be a major problem for most patients.* *Copies
of the questionnaires
used may be obtained
from the authors
by request.
461
GAP FROM PRACTICE TO MODEL
DISCUSSION
The questionnaires and open-ended interviews showed a wide gap between psychiatric practices and the practice of primary physicians. (The study reflects attitudes and styles of practicing dynamically oriented psychiatry in the South Bay Area of Los Angeles. The samples of psychiatrists and nonpsychiatric physicians were independently selected of each other and may not be overlapping. This study cannot claim universality nor does it encompass the multitude of psychiatric models or the many “Psychotherapies.“) In this sample the psychiatrists have gone through the same rigorous training as other physicians, including lengthy specialization and board certification; there were some specific differences in the way in which psychiatrists practice medicine that sets them somewhat apart as a group. Similar findings are reported by Morse.2 Many of these differences are related to external factors, but most of the basic differences are due to the intrinsic aspects of the specialty.
External Factors The primary physicians in Group IV reported finding that psychiatrists tended not to be available, either to them or to their patients. They did not usually have secretaries, answered their phones only at certain times, if at all, did not check with their message services, could not be found in the staff lounges or dining rooms of hospitals, and were rarely members of their AMA district branches. They were said to treat only the less sick and were very rarely available for consultation about the patient with a severe medical disorder that is complicated by an emotional problem. Most consistently, the primary physicians expressed a wish for better communication with psychiatrists. The psychiatrists interviewed, on the other hand, did not express a wish for better communication with the primary physician. This might be due to the fact that nonpsychiatric physicians deal with emotional problems and might therefore desire consultation, and that psychiatrists rarely deal with the medical problems of their patients. Also, psychiatrists have had a general medical education while some primary physicians have not had much psychiatric training. The primary physicians stated that what they wanted mostly from the psychiatrist to whom they had referred a patient was routine feedback: an acknowledgement that the patient had indeed made contact, a working diagnosis, dynamic formulation, prognosis, treatment recommendation, and follow-up. They reported feeling that psychiatrists failed to check back because they had unlearned medical etiquette. Many felt that the psychiatrists, through a lack of exposure to the flavor of standard medical practice, did not know about the kind of relationship the nonpsychiatric physicians had with their patients and were contemptuous of them. One physician said, “They (the psychiatrists) think we don’t understand their fancy dynamics because we have not had training in that.” Among the South Bay practicing psychiatrists interviewed, one heard statements like, “We can’t give the primary physician a diagnosis because he would not understand and cannot be trusted with it.” One primary physician put it this way: “What we want from psychiatrists are more civilized manners, professional courtesy, follow-up reports
462
ROGERS AND
RASOF
with suggestions to the referring physician on how to improve his therapy and understanding of the psychodynamics of each case.” The psychiatrists interviewed gave reasons for not giving their patients a diagnosis. The reasons were varied: uncertainty as to the correct diagnosis, discomfort with labeling people, the diagnosis being perhaps something pejorative, and the unsuitability of diagnosis. The reason for not giving prognoses was the paucity of statistical data on outcome and the dependence of recovery on many variables in the patient’s milieu. Intrinsic Factors The specialty of psychodynamically oriented psychiatry is distinguished by the fact that the tool most often used is the psychiatrist himself. This fact, plus the unique methods of psychiatric treatment, make the specialty appear nonmedical in its orientation. Treatment frequently focuses on conflict, interaction, and behavior, thus emphasizing the descriptive aspects of evaluation. Labels and diagnostic categories often cannot take this fact into account. Moreover, thr lack o/’ outcome studies hinders both diagnosis and prognosis. Hence, the psychiatrist frequently encounters difficulties in describing his method of treatment to the referring physician and to patients. Indeed, the open-ended nature of psychiatric technique is antithetical to the hard-and-fast practice of forming diagnoses. A diagnosis can be looked at as a projection upon the patient and one that could harm him, if, in telling the patient what is wrong with him, the psychiatrist assumes a role previously assumed by parents and other authority figures. The psychiatrist, by predilection, temperament, and long years of training, acquires the attitude of the listener, rather than of the talker. He asks questions and does not give firm answers. The longer he treats a patient, the more aware he becomes of how much he does not know about the patient. Because the psychiatrist helps his patients search for answers in the privacy of his office, remote from the hospital and away from settings in which the practice of medicine is undertaken, and because he has had no exposure to medical procedures beyond his year of internship, he becomes estranged from his medical colleagues, becomes unaware of their relationships with their patients and their basic desire for him to communicate to them in a way that helps them understand their patients. Moreover, he deprives his colleagues of exposure to his style of treatment and his way of giving open-ended interviews. It would seem likely, for instance, that in ophthalmology, surgery, obstetrics/gynecology, and other medical specialties, the opportunity for patients to express themselves as they do in psychiatric treatment might speed their recovery. An example will illustrate how this is so: One of our subjects, a psychiatric resident in child psychiatry, reported that a little girl whose brother had died of cancer on her birthday asked him what caused cancer. He replied that he did not know, but was sure that it was not anger. Much guilt could be alleviated if a pediatric surgeon could express himself in this way when he is asked to explain what causes cancer or why legs have to be amputated. In psychodynamically oriented psychotherapy there is a difference in style and sequence of diagnosis and treatment. The therapist’s attempts at developing a
GAP FROM PRACTICE TO MODEL
463
relationship with the patient facilitate the patient’s gradual awareness of his difficulties and of himself. The therapist becomes the catalyst for the patient’s diagnosing himself. Example: As one of the interviewed participants of the teaching drill put it; in general medicine the physician is the captain and the patient the passenger; in dynamic psychotherapy the doctor is the navigator. The interaction between the psychiatrist and his patient is frequently intense and psychiatrists seem better able (in the course of treatment) to communicate to their patients the subtle aspects of their specialty than to their medical colleagues. Nevertheless, as evidenced from our questionnaires, ps_~chiatrists think the-v explain the treatment they give to their patients much better than patients say they do. It is because of the difficulty in defining what psychodynamically oriented therapy is that the apparent contradiction exists (a discrepancy between what patients understand and what psychiatrists say they explain). On the other hand the difficulty in defining what psychodynamically oriented psychiatric treatment is might be contributing (along with other causes) to the flourishing of so many different kinds of therapies some of which, considered rigorously, are not therapies at all. The collaboration between psychiatrists and their medical colleagues would be enhanced if psychiatrists adhered more stringently to practices of standard professional etiquette that facilitate communication, and if nonpsychiatric physicians became more familiar with the process of “working-through,” which is the hallmark of psychiatric practice, and the open-ended style of interviewing which helps the patient participate in his diagnosis and treatment. Both psychiatrists and primary physicians should familiarize themselves with the special relationships that the other forms with his patients. They would then seek to form therapeutic alliances with one another. The tools of psychiatry should be taught explicitly to medical students as a means by which the doctor helps his patient gain emotional awareness of himself and his needs. The medical student should learn both the open-ended style of interviewing and the process of patient participation in a therapeutic procedure in which diagnostic formulation is continuous and within which the patient’s relationship with the therapist helps him assimilate diagnosis and treatment. REFERENCES I. Rogers
RR, Rasof B: Teaching drill in child psychiatry. Am J Psychiatry 132:1%163, 1975 2. Morse T: A serious and little-recognized
deficit in postwar psychiatric Am J Psychiatry 115:899-904,
residency 1959
training.
T
HE AUTHORS HAVE attempted to pinpoint causes for the disparity between the information psychiatrists say they give to referring physicians and patients and the information the referring physicians and patients say they receive. Using questionnaires and open-ended interviews, this study has shown there was a highly significant discrepancy between the information patients said they received and what psychiatrists said they gave with respect to the rationale of treatment prognoses with or without treatment. This gap could be attributed to various factors, among them the unavailability of psychiatrists or lack of outcome studies. Moreover, this study tends to point out the sequential difference in the treatment of psychiatric outpatients, e.g. the patient is helped by his doctor through treatment to diagnose himself and that adherence to this psychiatric style of interviewing could be utilized by the primary physician to improve his rapport with patients and, perhaps, increase their knowledge and understanding of their own disease. As previously reported, residents in child psychiatry, working under the supervision of the senior author, were reluctant to commit themselves to a diagnostic framework and completely avoided formulating prognoses, even though they were accomplished in understanding and conveying clinical data. The primary aim of our work was to attempt to link our trainees psychiatric and medical identities, which appeared to be totally divergent. In all of the cases covered by our study the trainees failed to provide diagnoses to referring physicians 48% of the time and to patients 45% of the time.’ Prognoses were never offered. We have attempted to elicit reasons for this divergence from standard medical practice. STUDY ORGANIZATION Basically five separate control groups were used. Trainees in child psychiatry who had participated in the original study, designated Group I, were asked why they avoided giving diagnoses and prognoses to referring physicians and patients. Psychiatrists on the staff at Harbor General Department of Psychiatry, designated Group II, were asked whether they gave diagnostic and prognostic feedback to referring physicians and what they thought their reasons were for not adhering strictly to standards of medical practice. Psychiatrists involved in practice in the South Bay Area, designated as Group III, were asked essentially
From the Medical School, University of California at Los Angeles, and Harbor General Hospital, Torrance, California. Rita R. Rogers, M.D.: Clinical Professor of Psychiatry. UCLA Medical School, and Chief, Child Psychiatry Division, Harbor General Hospital: Beatrice Rasof, Ph.D.: Assistant Clinical Professor, Child Psychology Division, UCLA Medical School, and Clinical Psychologist. Harbor General Hospital, Torrance, Calif: Reprint requests should be addressed to Rita R. Rogers, M.D.. Harbor General Hospital, 1000 West Carson St., Torrance, Calt$ 90509. o 1977 by Grune & Stratton, Inc. ISSN 0010~44OX. Comprehensive Psychiatry, Vol. 18. No. 5 (September/October),
1977
459
460
ROGERS AND
RASOF
the same questions as staff psychiatrists in Group II above, while nonpsychiatric physicians from the South Bay Area, selected consecutively from the telephone directory and designated Group IV, were asked whether they received diagnostic and prognostic feedback from psychiatrists to whom they referred patients, what kinds of information they would most appreciate receiving and what areas of nonpsychiatric study they believed the trainees in psychiatry should receive in order to improve communication between the primary physician and psychiatrist. Patients designated as Group V were selected from private practice and Harbor General Hospital and asked about their experience receiving information concerning their illnesses, their prognoses with and without treatment, prescribed treatment and whether they welcomed information about their illnesses and treatment. In all groups, the subjects were obtained without the use of formal selection procedures, and open-ended interviews were conducted with eight subjects from each of the five groups. Analyzing a comparison of questions asked of the subjects in Groups I through III, i.e., the giving of diagnoses and prognoses with and without treatment to either the referring physician or the patient, there appeared to be no significant differences between the groups; however, psychiatrists in private practice. Group III, are inclined more often than not to give diagnoses to their patients than are either of the other two groups. There was a significant relationship between what the subjects in Groups I through III told the referring physician and what they told their patients. The trend was for more information to be given to the referring physician than to the patient. Groups I through III did not vary significantly in offering prognoses based on whether treatment was given or not, nor did the same groups differ significantly in conveying the rationale of the treatment they offer. Interestingly, Group I subjects differed from those subjects in either of the other two groups in the difficulty they said they experienced adhering to standard medical practice communicating with both referring physicians and patients. By comparing the responses to our questionnaires by subjects in Groups III and IV, we were able to evaluate the degree to which the referring physicians received information the psychiatrists said they gave. It was evident that the greatest discrepancy between psychiatric and standard medical practice appeared in the area of prognosis. A significant discrepancy was found between the information patients said they received and what psychiatrists reported they gave with respect to rationale of treatment and prognosis without treatment. Psychiatrists reported disclosing this information to a greater degree than patients reported they received it. The question of prognosis without treatment was the area of greatest discrepancy. Judging from their explicit answers to the open-ended questions presented about the kinds of information they would appreciate or expect to receive from their psychiatrist, the observed discrepancy does not appear to be a major problem for most patients.* *Copies
of the questionnaires
used may be obtained
from the authors
by request.
461
GAP FROM PRACTICE TO MODEL
DISCUSSION
The questionnaires and open-ended interviews showed a wide gap between psychiatric practices and the practice of primary physicians. (The study reflects attitudes and styles of practicing dynamically oriented psychiatry in the South Bay Area of Los Angeles. The samples of psychiatrists and nonpsychiatric physicians were independently selected of each other and may not be overlapping. This study cannot claim universality nor does it encompass the multitude of psychiatric models or the many “Psychotherapies.“) In this sample the psychiatrists have gone through the same rigorous training as other physicians, including lengthy specialization and board certification; there were some specific differences in the way in which psychiatrists practice medicine that sets them somewhat apart as a group. Similar findings are reported by Morse.2 Many of these differences are related to external factors, but most of the basic differences are due to the intrinsic aspects of the specialty.
External Factors The primary physicians in Group IV reported finding that psychiatrists tended not to be available, either to them or to their patients. They did not usually have secretaries, answered their phones only at certain times, if at all, did not check with their message services, could not be found in the staff lounges or dining rooms of hospitals, and were rarely members of their AMA district branches. They were said to treat only the less sick and were very rarely available for consultation about the patient with a severe medical disorder that is complicated by an emotional problem. Most consistently, the primary physicians expressed a wish for better communication with psychiatrists. The psychiatrists interviewed, on the other hand, did not express a wish for better communication with the primary physician. This might be due to the fact that nonpsychiatric physicians deal with emotional problems and might therefore desire consultation, and that psychiatrists rarely deal with the medical problems of their patients. Also, psychiatrists have had a general medical education while some primary physicians have not had much psychiatric training. The primary physicians stated that what they wanted mostly from the psychiatrist to whom they had referred a patient was routine feedback: an acknowledgement that the patient had indeed made contact, a working diagnosis, dynamic formulation, prognosis, treatment recommendation, and follow-up. They reported feeling that psychiatrists failed to check back because they had unlearned medical etiquette. Many felt that the psychiatrists, through a lack of exposure to the flavor of standard medical practice, did not know about the kind of relationship the nonpsychiatric physicians had with their patients and were contemptuous of them. One physician said, “They (the psychiatrists) think we don’t understand their fancy dynamics because we have not had training in that.” Among the South Bay practicing psychiatrists interviewed, one heard statements like, “We can’t give the primary physician a diagnosis because he would not understand and cannot be trusted with it.” One primary physician put it this way: “What we want from psychiatrists are more civilized manners, professional courtesy, follow-up reports
462
ROGERS AND
RASOF
with suggestions to the referring physician on how to improve his therapy and understanding of the psychodynamics of each case.” The psychiatrists interviewed gave reasons for not giving their patients a diagnosis. The reasons were varied: uncertainty as to the correct diagnosis, discomfort with labeling people, the diagnosis being perhaps something pejorative, and the unsuitability of diagnosis. The reason for not giving prognoses was the paucity of statistical data on outcome and the dependence of recovery on many variables in the patient’s milieu. Intrinsic Factors The specialty of psychodynamically oriented psychiatry is distinguished by the fact that the tool most often used is the psychiatrist himself. This fact, plus the unique methods of psychiatric treatment, make the specialty appear nonmedical in its orientation. Treatment frequently focuses on conflict, interaction, and behavior, thus emphasizing the descriptive aspects of evaluation. Labels and diagnostic categories often cannot take this fact into account. Moreover, thr lack o/’ outcome studies hinders both diagnosis and prognosis. Hence, the psychiatrist frequently encounters difficulties in describing his method of treatment to the referring physician and to patients. Indeed, the open-ended nature of psychiatric technique is antithetical to the hard-and-fast practice of forming diagnoses. A diagnosis can be looked at as a projection upon the patient and one that could harm him, if, in telling the patient what is wrong with him, the psychiatrist assumes a role previously assumed by parents and other authority figures. The psychiatrist, by predilection, temperament, and long years of training, acquires the attitude of the listener, rather than of the talker. He asks questions and does not give firm answers. The longer he treats a patient, the more aware he becomes of how much he does not know about the patient. Because the psychiatrist helps his patients search for answers in the privacy of his office, remote from the hospital and away from settings in which the practice of medicine is undertaken, and because he has had no exposure to medical procedures beyond his year of internship, he becomes estranged from his medical colleagues, becomes unaware of their relationships with their patients and their basic desire for him to communicate to them in a way that helps them understand their patients. Moreover, he deprives his colleagues of exposure to his style of treatment and his way of giving open-ended interviews. It would seem likely, for instance, that in ophthalmology, surgery, obstetrics/gynecology, and other medical specialties, the opportunity for patients to express themselves as they do in psychiatric treatment might speed their recovery. An example will illustrate how this is so: One of our subjects, a psychiatric resident in child psychiatry, reported that a little girl whose brother had died of cancer on her birthday asked him what caused cancer. He replied that he did not know, but was sure that it was not anger. Much guilt could be alleviated if a pediatric surgeon could express himself in this way when he is asked to explain what causes cancer or why legs have to be amputated. In psychodynamically oriented psychotherapy there is a difference in style and sequence of diagnosis and treatment. The therapist’s attempts at developing a
GAP FROM PRACTICE TO MODEL
463
relationship with the patient facilitate the patient’s gradual awareness of his difficulties and of himself. The therapist becomes the catalyst for the patient’s diagnosing himself. Example: As one of the interviewed participants of the teaching drill put it; in general medicine the physician is the captain and the patient the passenger; in dynamic psychotherapy the doctor is the navigator. The interaction between the psychiatrist and his patient is frequently intense and psychiatrists seem better able (in the course of treatment) to communicate to their patients the subtle aspects of their specialty than to their medical colleagues. Nevertheless, as evidenced from our questionnaires, ps_~chiatrists think the-v explain the treatment they give to their patients much better than patients say they do. It is because of the difficulty in defining what psychodynamically oriented therapy is that the apparent contradiction exists (a discrepancy between what patients understand and what psychiatrists say they explain). On the other hand the difficulty in defining what psychodynamically oriented psychiatric treatment is might be contributing (along with other causes) to the flourishing of so many different kinds of therapies some of which, considered rigorously, are not therapies at all. The collaboration between psychiatrists and their medical colleagues would be enhanced if psychiatrists adhered more stringently to practices of standard professional etiquette that facilitate communication, and if nonpsychiatric physicians became more familiar with the process of “working-through,” which is the hallmark of psychiatric practice, and the open-ended style of interviewing which helps the patient participate in his diagnosis and treatment. Both psychiatrists and primary physicians should familiarize themselves with the special relationships that the other forms with his patients. They would then seek to form therapeutic alliances with one another. The tools of psychiatry should be taught explicitly to medical students as a means by which the doctor helps his patient gain emotional awareness of himself and his needs. The medical student should learn both the open-ended style of interviewing and the process of patient participation in a therapeutic procedure in which diagnostic formulation is continuous and within which the patient’s relationship with the therapist helps him assimilate diagnosis and treatment. REFERENCES I. Rogers
RR, Rasof B: Teaching drill in child psychiatry. Am J Psychiatry 132:1%163, 1975 2. Morse T: A serious and little-recognized
deficit in postwar psychiatric Am J Psychiatry 115:899-904,
residency 1959
training.
