Take the time to address patient's psychosocial needs during exam
Family physicians have all the skills and abilities they need to efficiently and effectively deal with their patients' psychosocial needs. The only challenge is to make time for counseling and psychotherapy during a typical 15-minute (or less) patient visit.
Ways to meet that challenge were outlined during a three-hour course on "The 15-Minute Hour: Effectively Incorporating Counseling and Psychotherapy Into the Every Day Management of Patients" during the 1997 Scientific Assembly in Chicago.
"In today's health care environment, behavioral health services tend to be overlooked," said Joseph A. Lieberman III, MD, MPH, who is chairman of the department of family and community medicine at the Medical Center of Delaware. "But these services are so integral to what we do, we need to do them better and not leave them out," he said.
Dr. Lieberman presented the course along with Marion R. Stuart, PhD, clinical professor at the Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School.
Physicians tend to focus their attention on diseases and conditions, such as coronary heart disease, cancer, or AIDS, and fail to recognize mood disorders and other psychiatric problems, Dr. Lieberman said. Yet psychiatric disorders are more easily and effectively treated than most medical disorders.
"The traditional medical model of illness is disease oriented," he said. "Diseases are independent, they can be categorized, and each disease has a cause. We operate in an acute care system and tend to separate the mind from the body."
FPs must address their patients' mental problems because quite often, psychological health improves physical health, he said. "The problem is that we are not oriented to approach these issues with our patients in the office setting."
"In today's health care environment, it is important that primary care physicians do what they do better," Dr. Lieberman said. "Addressing psychological problems is something we can do better."
Dr. Stuart continued the presentation by noting that family physicians often deal with crisis intervention.
"When a patient is experiencing a crisis, it is a time of greatest potential change," she said. "You need to be able to help your patients take advantage of this opportunity for change."
She noted that stress is a syndrome that results from having to adapt to demands from internal and external environments. Everyone copes differently with stress, she added, and overwhelmed people tend to regress functionally.
"Poor adaptation to stress causes ill health," Dr. Stuart said. "Stress itself doesn't make us sick; it's how we adapt to the stress that makes us sick."
As stress levels rise, she noted, we tend to feel a loss of control. Yet with increased social support, the perceived level of subjective stress tends to decrease.
"When your patients feel supported, their stress levels go down," she said. "As a family physician, you are in an important position to give your patients meaningful support."
During a 15-minute office visit, Dr. Stuart said, it is possible to recognize psychological problems.
The goals of this 15-minute therapy are to prevent dire consequences of the patient's condition, to re-establish the patient's premorbid level of functioning, to help expand the patient's behavioral repertoire, and to enhance the patient's self esteem.
She presented the BATHE technique as a way to ascertain and treat the psychosocial context of every patient visit:
- Background -- "What is going on in your life?"
- Affect -- "How do you feel about that?"
- Trouble -- "What about that troubles you most?"
- Handling -- "How are you handling that?"
- Empathy -- "That must be very difficult."
Dr. Stuart said that psychotherapy begins with listening to your patient's story.
"We constantly tell ourselves, as well as others, stories," she said. "These stories create our reality and affect our experience."
Psychotherapy means editing the story, she continued.
"As a family physician, you must first hear your patient's story, then reflect it back with empathy," she said. "Then you need to challenge the patient's limits."
These limits are often identified by key words such as always, never, everyone, no one, can't, must, should, and impossible.
"Replace those with the word 'yet'," she suggested. "Yet implies possibility and impending change. Yet empowers people to contemplate changes."
When the patient begins to use the word yet, she noted, behavioral change will follow.
Drs. Lieberman and Stuart recommended that family physicians start with the BATHE technique and let the patient tell his or her story.
"You are in the best position to help your patients recognize and deal with their problems before they become more difficult to manage," Dr. Lieberman said. "If you don't do this, then there is a good chance that no one will and your patients will continue to suffer."
- FP Report is published by the AAFP News Department.