IMPATIENT ATTENDING
A few years into my first faculty job as an attending psychiatrist, where I saw patients and taught trainees, I was asked to direct the unit. I agreed, and the hospital printed a batch of business cards. They listed my name and my new title: “Director of Impatient Psychiatry.” I passed them out for a couple years until a friend pointed out the typo. We agreed that it was fitting. Like most physicians, I like telling people what to do instead of asking if and how I can help them. Exercise more. Stop smoking. Drink less. Don’t be depressed. It is a finger-wagging form of magical thinking: physician speaks, patient changes. It is never that simple, but I behave as though it is when I meet patients like Veronica.
Veronica, a twenty-nine-year-old woman who could not stop retching, came into the Emergency Department with her arms clenched over her stomach. When the urge to vomit overcame her, she released her hands so she could tightly grip the sides of a waste bin, as though she were holding on to the rails of a rolling ship. The pills she vomited into the waste bin and onto her hospital gown and the floor smelled of the antifreeze she had used to wash them down.
Once admitted to the hospital, a patient like Veronica will come my way sooner or later. No one drinks antifreeze for its health benefits. So unless you can convince the emergency physicians that it was a remarkable accident, you will be admitted to the psych service either immediately or after the internists have cleaned you out with intravenous fluids and serial blood draws. The internists declined to admit her, so Veronica was routed directly to psychiatry.
When she arrived on the unit, she told us, “I can go home. It was a mistake.” I asked if she knew that this mistake could have killed her. She looked away and softly said, “I hoped so.” We sat in silence. After a minute, she said, “I wanted to die.”
“No. Maybe. I don’t know. Yes.”
She told us that the previous night she had drunk eight beers, ingested some of the pills in her cousin’s medicine cabinet, and fallen asleep hoping for death. When she awoke the next morning, disappointed by her failure even to kill herself, she smoked a bowl of cannabis sativa and drank the Prestone she found in her cousin’s garage. Two separate attempts at suicide in twelve hours indicates a determined decision, not a sour moment.
Veronica admitted that she had been feeling depressed for three weeks. During that time, she ate less than usual, had trouble getting to sleep, felt tired most days, and lost interest in her favorite television shows. Veronica, in the technical phrase favored by gymnastic judges and contemporary psychiatrists, “met criteria” for major depressive disorder.
The evidence-based treatment algorithms for depression call for talk therapy and the judicious use of antidepressants. Both are beneficial, but they work best if their recipient is interested in changing. So when I talk with somebody about being depressed, I like to start by asking the person what changes he or she can make. When I asked Veronica, she said, “I don’t know,” while avoiding my gaze.
This inability to identify potential changes is a common response, even for a person who has been hospitalized for drinking antifreeze. As I was thinking about how to convince her that she had other options, the psychiatric intern broke in.
“You need to drink less, stop smoking pot, get a job, and exercise. You could run a marathon. I run marathons, and it will really help your mood to run a marathon.”
Veronica stared at the intern as if she were a visitor from outer space, or at least another zip code, a more prosperous place where those choices were sanctioned and even expected. I asked, “Does that sound a little overwhelming?”
“Uh, yes.”
“Can we try again?”
“Sure.”
So we tried again, this time asking Veronica about her life. Whom do you live with? How do you spend your days? What do you like and dislike about yourself? As she started talking, her mood brightened, and she had ideas. She told us she wanted to move out of the house she shared with her husband because when he drank, he hit her. She thought she might take her son with her and stay at her father’s house. When I asked, “When was the last time you felt hopeful about the future?” she told me it had been years.
We meet people like Veronica all the time. Discouraged, demoralized, and often depressed. They know their life is a mess. They seek help. A physician gives them a pill or tells them to run a marathon. They nod, and they return to their usual patterns or, even more unfortunately, they follow the advice and it makes things worse.
The latter was true for Veronica. Six months before we met, she visited an Emergency Department complaining of headaches. The emergency physician examined her, ordered a head CT, read the results, and sent her home with Vicodin. She took the Vicodin for a couple of weeks but hated that it made her feel foggy and bloated. A friend recommended that she ditch the pills for a natural treatment. Veronica visited her friend’s marijuana physician—her friend received a free eighth of an ounce for the referral—and told the physician she had pain. Physicians in Colorado can recommend marijuana for just about anything, but most of the time they recommend it for the nonspecific diagnosis of “severe pain.”1 Veronica said the marijuana physician never asked where she experienced pain or why. He never examined her, just pulled out two forms, a permission slip to join our state’s medical marijuana registry and a preprinted bill for services rendered.
While the marijuana physician filled out the forms, he asked Veronica if she had tried marijuana before. She nodded. He signed the forms and suggested she purchase an eighth of sativa next door.
When we met Veronica, we could see from her chart that she had tried marijuana before, but we needed details. She told us she first smoked at age eighteen. By the time she was twenty-three, she was smoking two or three joints a day. After about six months of this, she became despondent. While high one night, she attempted suicide by swallowing a bottle of acetaminophen. When she woke up, a plastic tube filled her trachea, an intravenous line coursed into her antecubital fossa, and a forest of IV poles and monitors surrounded her hospital bed. Over the next week, the forest thinned out, and Veronica stabilized. She was sent home at the end of the week with a referral to the local mental health center and a stack of bills she could not pay. The emergency physician had not been an employee of the hospital but a contractor who did not accept her insurance. She had bills from him, from the hospital, and from several physicians who consulted on her care while she lay unconscious. Unpaid bills were her souvenirs of these medical encounters. With more bills to pay, she had more worries, so she smoked more joints because “marijuana still relaxed me and made me less worried.” It worked for a bit, but when she found work as a massage therapist, the marijuana made her too lethargic to work. She gradually stopped using it during the work week. She felt more energetic, and she eventually stopped using all together. She told us, “I kind of grew out of it.”
When headaches brought her to the marijuana physician, she had not been using any marijuana at all, but at his advice she started smoking daily. The physician had, after all, recommended it. By the time we met, she had been smoking twice daily for three weeks but was still feeling some pain.
Neither the Emergency Department physician nor the marijuana physician had bothered to figure out why Veronica’s head hurt in the first place. We asked. She said it had been hurting ever since her husband hit her. She told us that when she thought of him, “I carry this copper taste of fear in my mouth that he will hit me again.”
There were a number of reasons for Veronica to be depressed. She told us what they were when we asked in the right way.
. . .
I sometimes ask medical students and residents to imagine walking into a bar. They see an attractive stranger and want to make the person’s acquaintance. I ask how they would approach the stranger. Someone volunteers that one might use a pickup line. So I ask what pickup lines they know. They offer a few, all of which sound ridiculous while we sit, sober, in a conference room.
Then we consider a more direct approach, such as simply asking the stranger for an embrace. They all agree that unless you are a famed actor, that approach is more likely to result in a deserved dismissal than an amorous encounter.
So I ask why most physicians use one of these two approaches (or a mash-up of both) when they meet strangers as patients. We step behind curtains in the emergency department, open the door into a clinic room, or stride into an operating room and begin a barrage of scripted questions.
I call this the psychiatric robot interview. You walk into the room and immediately ask, “How is your mood? Are you having thoughts of suicide or homicide? Are you seeing or hearing things?” As an introduction to a stranger, these questions give the impression that between patient interviews, your joints will be oiled, your batteries replaced, and your operating system updated.
I spend a lot of time teaching students and residents how to talk with people, rather than to them, because it was something I had to learn for myself. I hate to wait my turn in a conversation, and I like to take shortcuts when I think I know where the conversation is headed. As my business cards once advertised, I am impatient and do not like to ask in the right way. I, like my resident, would prefer to direct the patient, “Do this. Don’t do that. Listen to me, and you will be better.” But when I think about it, I realize that such commands do not make me change my own habits, and they do not work for anybody else either. “Listen to me” never works as well as “Can I show you?” We do not receive new habits; we acquire them.
I acquired my habits reluctantly, preferring to take every available shortcut, until I realized that the shortcuts left me lost.
As a medical student, I was once interviewing a young woman who was brought to the Emergency Room with chest pain. We determined that her chest pain was caused by her cocaine use, which was sufficiently extensive that she was prostituting herself to support the habit. Because she used cocaine, I assumed that she probably used other mind-altering substances as well. Instead of asking whether she did, I took the direct route, asking, “How much alcohol do you drink in a week?” She blushed and said, “Oh no, sir, I am a Baptist. I never drink alcohol.”
I made embarrassing missteps like this, whether an assumption that annoyed the patient or simply an interruption to the conversation, with every patient, and rarely was the result humorous. Usually, the patient ended up withholding information that was critical to his or her care. I would misunderstand the patient’s story because, as Dr. Rogers had warned years before, one my own character stains—impatience—caused me to miss seeing the person before me. The secret of the wise attending physicians was that they put a patient at ease first, so that he or she would open up to them. Not I. I was always in a hurry, eager to obtain the data I needed from the patient so I could fill out the forms I needed to complete every day.
In residency, I learned to slow down only when I trained in psychotherapy. Time is measured differently in psychotherapy, and it is recorded differently as well. In psychotherapy you maintain an alternate chart, the supervision notebook, which you keep as an aid to memory instead of documentation to support a bill. The notebook itself is not a part of the medical record, that overgrowth of transcribed dictations, scrawled notes, and billing slips. Instead, the supervision notebook is where a psychiatrist in training writes down what goes on in the therapy room. The notebook is the record of a privileged conversation, like the notes a reporter takes in a postgame locker room, but also an emotional account of how it feels to be in that room, like the diary an adolescent keeps under the bed. The notebook is the record of two people alone in a room—one person doing most of the talking, and the other doing the listening and writing.
Once a week, I left the hospital and took the notebook to my supervisor—just as I had brought my schoolwork to my parents as a child. Supervision is the peculiar psychiatric practice that developed over the past century to answer the question of how, exactly, to train someone to perform psychotherapy. Unlike surgery, which is conducted under the bright lights of an operating suite—with many assistants, students, and trainees from several disciplines gowned and scrubbed—psychotherapy, an even more invasive procedure, is conducted alone in a closed room.
The first time I closed the door to the therapy room, all I shared with my patient was fear. I wondered whether the patient would see me for the fraud I was. What I could possibly have to offer another person? Should I behave like one of the cinematic shrinks, either coolly distant or warmly overinvolved?
I tried to remember what my teachers had advised, to ask a question and then listen, listen, listen. The resulting silence lasted for less time than I imagined, because all I could think about was failure. I wanted to speak, to retreat to the familiar ground of offering advice, but we journeyed on in the silence. When the patient spoke a word or two, it was as welcome as the first sight of land. I wrote the words down in my supervision notebook. We had a destination. Then I waited again for further direction, for more words.
The words came, week after week, session after session. I started to wonder what to do with them, how to make sense of the hesitating pauses, the false starts, the frightening statements. In the meantime, I kept writing them all down.
The supervisors were practitioners who had been performing psychotherapy for decades in the community. In medical school, I did not know that these supervisors existed. They were not the teachers who earned admirers in the lecture hall or the clinicians who wowed adherents on the wards or the researchers whose peers celebrated their publications. And yet as a resident, I learned the most from David Moore, a supervisor with whom I spent an hour each week. Moore, an Episcopal priest who had left the vestry to become a psychologist, had eyebrows that drew up into points like the crown of an evergreen and white hair that fell across his forehead to form the soft, swooping part favored by southern white men of his generation. We would meet at his home, surrounded on all sides by long-leaf pines, and sit in his office, surrounded by his books, where two chairs faced each other in a clearing.
He would ask about my cases, and I would read to him from my supervision notebooks. He would listen and then ask how it felt when a particular comment was made. I learned things from him that I could never have learned on my own. As I began to understand how to make sense of what I had recorded, I also learned how to listen and what to listen for. Finally, in his company, the advice I had received all my life—be patient, wait your turn—settled within me. My anxiety and worry decreased as I felt less pressured to get all my questions answered. I trusted that a patient would provide the necessary guidance in time.
David Moore conducted his practice very differently from the way I conducted mine at the hospital. The clinic rooms at the hospital were impersonal, decorated with indestructible furniture and whatever magazines had migrated from the waiting room. His therapy room was adorned with books and images of his choosing. I entered each hospital room with a preprinted billing sheet, to aid me in translating a person’s experiences into an ICD-9 code and our time together into a CPT code. David entered the therapy room with empty hands.
As a volunteer member of the faculty, David gave his time freely to me, seeing me weekly in exchange for little more than an annual thank-you note from the department.
Eventually, I realized that I looked forward to our conversations because while we discussed the patients I was seeing in therapy, I was learning about my own limits, about the many things I did not do well, about how I could and could not help a person. I experienced a measure of the vulnerability my patients felt with me. I started to realize that in psychiatry, you are your own instrument; you are the tool that you employ to coax a person back to health, and to successfully wield that tool, you have to learn different ways of being with a patient.
David Moore favored an attachment-based psychoanalytic theory built around mentalization, the ability of a patient to understand his or her own mental state and the mental states of other people. Other supervisors favored cognitive behavioral therapy, intensive short-term dynamic therapy, group therapy, dialectical-behavioral therapy, or some other variant. Psychiatry has an abundance of therapeutic techniques, and many of the supervisors were adherents of a particular one. They would press photocopied articles and highlighted books into my hands, encouraging me to consider the particular technique of their favorite therapist. I went home from these sessions with texts by Habib Davanaloo, John Gunderson, Marsha Linehan, and Irvin Yalom. I sat at home trying to make sense of how their various therapies worked, then tried out the different techniques with patients. If you visited me on any given week in residency, I was equally likely to be speaking in a ginned-up therapy voice, walking about in a tweed jacket, or shopping online for a psychotherapy couch. There is a company that specializes in making them.
I was confused.
When I moved to Denver a couple of years later, Joel Yager, a senior member of the Colorado faculty, directed me to a book, Persuasion and Healing, which dispelled my confusion. The author, the psychiatrist Jerome Frank, had spent his career studying the efficacy of different psychotherapy techniques. He found that psychotherapeutic techniques that developed from opposed accounts of why people become ill—say biomedicine, psychoanalysis, and shamanism—could achieve similar treatment outcomes. We often attribute such findings to placebo responses, but Frank instead identified common processes for a healing relationship. Frank found that all effective healing relationships were composed of three elements: a socially sanctioned healer, a demoralized sufferer who seeks relief from the healer, and a circumscribed relationship in which they meet. Within the relationship, a healer can aid a sufferer simply by identifying a particular theory and exhibiting confidence in that theory.2 Frank found that a therapist could discuss impaired attachments, misfiring NMDA receptors, or conflicts with dead ancestors and achieve health so long as the processes he identified were present.
Frank found inspiration for his theory in the aphorism of the Stoic philosopher Epictetus—“Men are not moved by things but by the views which they take of them.”3 Most people, Frank observed, are reluctant to change. They have fallen and can no longer imagine standing up. They have experienced an event or feeling and endowed it with a pathologic meaning. When an employer did not hire you, you were unemployable. When a girl did not return your call, you were unlovable. The truth might have been that neither the job nor the girlfriend was a good fit, but once you settled on the pathologic meanings, other possible interpretations would seem impossible. These pathologic assumptions, Frank wrote, lead to demoralization, a sense of powerlessness and passivity. The only way out of this emotional slumber is to be awakened and forced to reevaluate the meaning of the event or feeling. By turning down a date with an attractive girl or declining to hire a qualified applicant, you might come to realize that the rejections you experienced when you were younger do not always reflect upon the rejected.
If you cannot come to such a realization on your own, a healer can help. A shaman might use drums and sleep deprivation to give a new meaning to the death of your infant. Twelve-step programs might use group meetings and reflective talk to help you see why you drank so much vodka that the police had to carry you away from your mother’s funeral. The cognitive-behavioral therapist might use anxiety inventories and thought records to help you understand why every time you think about your ex and his new partner, you have a panic attack that streaks your shirt with sweat. Frank concluded that in each of these kinds of encounters, a healer aroused sufficient emotion in a sufferer that the patient prepared to transform the meaning of an event. Each of these therapies, despite their manifest differences, defeated demoralization by renewing a patient’s hope, increasing a patient’s sense of self-mastery, and reintegrating a patient into his or her community.
Reading Persuasion and Healing, I wondered whether, instead of measuring physicians on the basis of their ability to generate revenue or follow standardized procedures, we could measure them by their ability to help patients make changes they could not achieve on their own. Sometimes when a patient enters a hospital, physicians might need to follow an evidence-based script, and in other cases, when perhaps the patient’s problem was not a medical issue at all, physicians might need to act like a gardener and get out of the way of the body’s ability to renew itself. But when a patient needs to learn a new habit, he or she may need a different kind of physician. I thought about how a physician could be more like a teacher who helps a child sounding out vowels and consonants to read sentences, paragraphs, chapters, and books. The word doctor, in fact, comes from the Latin docere, “to teach.”
. . .
As I finished residency, it was my experience with teachers like David Moore that made me want to teach medical students and residents. The trouble was that, apart from decades of schoolwork, my only training as a teacher came from fitfully climbing Osler’s ladder, where the phrase “See One, Do One, Teach One,” was still celebrated. Teaching was a variation of clinical practice, not a skill of its own. I taught that way for a few years, but when the University of Colorado announced a new program to train faculty physicians as educators, I enrolled.
The program included faculty from all over the medical center. After years of training only alongside other shrinks, I found it refreshing to learn alongside pediatric anesthesiologists, interventional radiologists, and research pharmacologists. For a year, we spent Tuesday afternoons discussing different techniques for learning and teaching. The techniques had unexpectedly humorous names that would have worked as album titles for math-rock (Maastricht History-Taking and Advice-Scoring List) or doom metal (Death Telling Evaluation) bands. The technique that caught my ear, though, was the One-Minute Preceptor Method. In the method, the teacher follows five steps: getting a student to commit to an aspect of a patient’s care, asking for evidence to support the student’s commitment, teaching the student general rules, reinforcing what the student did right, and finally, correcting any mistakes the student made. The teaching model, like most of the models we learned, had been evaluated using the techniques of evidence-based medicine, in clinical trials. This was evidence-based teaching.4
To learn the One-Minute Preceptor, I started writing out the five steps on the bottom of the list of patients I was assigned to see each day in the hospital. I wrote the list out so I could remember to use the technique with my students and residents. Each morning, I set it down like an earnest prayer that I become the kind of teacher my students deserved. After a medical student interviewed a new patient, I would look at the list and then quiz the student. What is the patient’s diagnosis? What evidence supports that diagnosis? What are the general rules for that diagnosis? What did you get right in making the diagnosis? What did you get wrong in making the diagnosis? The steps were simple, but as I went over them again and again, they improved my teaching. It became a habit to engage students on what they believed and why they believed it and then to reinforce or correct their beliefs as necessary. My teaching became more efficient and effective, but also more particular to each student. I developed a better sense of where they were and where they needed to be.
Then one morning, while listening to Veronica talk about how her husband had struck her until her head throbbed and how doctors had recommended opiates and marijuana, I grew frustrated by the ways medicine often becomes a word-association game. A patient says “depression,” and we give a pill. A patient says “pain,” and we dispense another pill. It makes me feel like a drug dealer, selling my wares without considering whether my customer needs them. I was frustrated that we physicians had missed the cause of Veronica’s pain and subsequent self-violence, frustrated enough that, as Jerome Frank would have it, I was emotionally awakened from my usual practices. My angry eyes alighted on the five questions handwritten on my census sheet. It occurred to me that most of the time we physicians tell people what to do but do not teach them how to do it. So I wondered whether the techniques I was learning as a teacher of physicians could be of use with my patients as well.
Instead of using direct approaches and canned pickup lines—the rhetorical approaches we typically use as physicians—I started speaking with Veronica in ways that encouraged her own abilities. As I did, I felt less like a dealer and more like a teacher. Now I was helping Veronica achieve changes she could attribute to her own efforts. Instead of being in charge of “fixing” the broken parts of Veronica, my responsibility shifted to helping her renew her hope in her ability to effect change, develop mastery over her health, and reinterpret her personal experiences.
A couple of years ago, students of Jerome Frank revisited Persuasion and Healing. They reviewed his conclusions and updated them with additional findings. They observed that when a patient like Veronica makes a change that she can claim as her own, it is more enduring than when she attributes it to an external source, like a medication. Frank’s students found that self-efficacy, the belief that we can accomplish a given task, is a critical predictor of health. In multiple placebo-controlled psychotherapy trials (the kind Cochrane liked), Frank’s students found that patients who believed in their own efficacy had better outcomes, whether they received active psychotherapy or a placebo. Behavioral changes that a patient claimed for himself or herself were more enduring than those they attributed to a physician, a medication, or a surgery.5
If Frank and his students are right, the first step any physician can take in helping a patient toward health is to form a therapeutic alliance with that patient. Instead of trying out the pickup line, approach the stranger at the bar with openness, and try to get to know who he or she is. A therapeutic alliance, the metaphorical dance between a patient and physician, is a relationship in which patient and physician mutually commit to the patient’s well-being. This alliance is established when a patient identifies treatment goals and the physician allies with the patient in pursuit of those goals. In shrink talk, you form an alliance between yourself and your patient to mobilize healing forces within your patient by psychological means. Your ability to form these alliances profoundly influences the efficacy of your work for the patient. It also improves your satisfaction with being a physician.
Frontline physicians are increasingly exhibiting signs of burnout. In large surveys, physicians typically exhibit more signs of burnout and depression than other professionals.6 Physicians are more likely to commit suicide than other professionals, or than the general population.7 This might be in part because physicians feel fully responsible for too much. We feel that we have to fix what is broken, even when it cannot be fixed, even if it is not ours to fix. What if physicians were not held responsible for broken parts, but charged with renewing patients’ hopes in their ability to effect change, develop mastery over their health, and reinterpret their personal experiences?
While I admire the analogy of the physician as gardener, I worry that it still assumes our control of the natural world and therefore a physician’s control of the body. When I think of the physician as a teacher, I feel less dominion over the bodies of the people I meet as patients.
One morning, I found that I no longer needed to write out the steps of the One-Minute Preceptor. I had internalized them. It had become a habit to engage students and patients on what they believed and why they believed it, and then to reinforce or correct their own habits as necessary. I stopped writing out the list.
One way to renew medicine is for physicians to consider seriously how people learn and make changes in their life. If we do so, physicians like me will have to give up our roles as directors of impatience and become teachers.