Managing Difficult Patients: Roles of Psychologists in the Age of Interdisciplinary Care

Integrated Case Presentation Seminar: Bridging Parallel Fields to Improve Psychiatry and Psychology Learner Experience

Daily clinical practice of mental health professionals often requires interaction between providers from diverse training and professional backgrounds. Efforts to engage mental health trainees across disciplines are necessary and have had varied outcomes. The current study reviews the development and implementation of a monthly one-hour integrated case presentation seminar (ICPS) as part of independent psychology and psychiatry two-year fellowships at a Midwestern teaching hospital. The training integrated a semi-structured seminar to facilitate case presentation within a group setting. The focus of the seminar was to allow for exposure to conceptualization, diagnostic, and treatment strategies and skills, as well as science-based practice techniques for trainees. Learner survey results and the sustained offering of the seminar suggest the format and goals of the seminar are feasible and acceptable. Based on the current preliminary findings, similar training programs may find benefit in strategies to enhance integrated training opportunities for psychiatry and psychology trainees.

Understanding College Students' Healthcare Avoidance: From Early Maladaptive Schemas, through Healthcare Institutional Betrayal and Betrayal Trauma Appraisal of Worst Healthcare Experiences

Understanding healthcare avoidance among college students is critical. In this study, we consider two broad cognitive contributors to greater healthcare avoidance: specific early maladaptive schema and negative appraisals of students' prior worst healthcare experiences. From schema theory, we proposed college students holding greater levels of two early maladaptive schema (disconnection/rejection and impaired autonomy/performance EMS) would be more likely to appraise their problematic healthcare experience as both containing healthcare institutional betrayal (HIB) behaviors and as traumatic and betrayal-inducing; both EMS and these appraisals would predict healthcare avoidance. Using a cross-sectional survey in a large, diverse college student sample (n = 1383, 61.1% female, 18.9% African American, 7.2% Asian, 6.4% Hispanic/Latino), as predicted, both EMS were significantly related to healthcare avoidance. Furthermore, a sequential mediation model was supported, indicating students holding greater EMS of disconnection/rejection or impaired autonomy/rejection reported more HIB in their worst healthcare experience, and appraised that experience as more betraying. Taken altogether, this model accounted for 23% of the variance in students' reports of healthcare avoidance. Core beliefs formed early in life may be a foundational lens through which potentially traumatic healthcare experiences are processed in ways that can impact emerging adults' future healthcare engagement. Findings also support the importance of addressing HIB actions and repairing trauma appraisals accrued during problematic healthcare experiences to prevent healthcare avoidance by emerging adults.

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit?

Objective

To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit.

Methods

A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales.

Results

Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration.

Conclusion

Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration.

Innovation

Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness.

Level of evidence

N/a.

Is there a role for ethics in addressing healthcare incivility?

In a healthcare setting, a multitude of ethical and moral challenges are often present when patients and families direct uncivil behavior toward clinicians and staff. These negative interactions may elicit strong social and emotional reactions among staff, other patients, and visitors; and they may impede the normal functioning of an institution. Ethics Committees and Clinical Ethics Consultation Services (CECSs) can meaningfully contribute to organizational efforts to effectively manage incivility through two distinct, yet inter-related channels. First, given their responsibility to promote a humane, respectful, and professional climate, many CECSs and Ethics Committees may assist institutional leadership in evaluating and monitoring incivility policies and procedures. Second, when confronted with individual incidents of patient/family incivility, Ethics Consultants can and often do work with all stakeholders to address and mitigate potentially deleterious impacts. This manuscript presents an overview of the multifaceted ethical implications of incivility in the healthcare environment, discusses the inherent qualifications of Ethics Consultants for assisting in the management of incivility, and proposes specific mitigating actions within the purview of CECSs and Ethics Committees. We also invite healthcare organizations to harness the skills and reputation of their CECSs and Ethics Committees in confronting incivility through comprehensive policies, procedures, and training.

Multidisciplinary Care for Adults With Chronic Pancreatitis: Incorporating Psychological Therapies to Optimize Outcomes

ABSTRACT

Chronic pancreatitis (CP) is associated with a high disease burden, extensive negative impact on quality of life, increased rates of depression and anxiety, and significant health care utilization and expenditures. Pain is a hallmark feature of CP, present in up to 90% of patients with this condition, and can lead to high rates of disability, hospitalization, and opioid medication use. Current perspectives on the management of CP have evolved to advocate a multidisciplinary approach which offers new pathways for helping patients manage symptoms. Psychologists play an important role in a multidisciplinary team effort by applying scientifically based psychological principles and techniques to improve pain and adaptation to chronic illness. This review will detail the fundamentals of delivering psychological interventions for adults with CP managed in an outpatient setting. Recommendations for integrating psychological care in multidisciplinary management of CP will be offered. Future directions for psychological care in CP multidisciplinary teams are also discussed.

Bitten by the System that Cared for them: Towards a Trauma-Informed Understanding of Patients' Healthcare Engagement

The BITTEN theoretical framework of trauma-informed healthcare proposes that each patient presents to a healthcare encounter with a baseline level of historical institutional Betrayal and trauma exposure that interacts with their Indicator for healthcare engagement to potentially Trigger trauma symptoms, impacting patients' Trust in healthcare providers and shaping their current and future Expectations of and Needs for healthcare. The current study sought to test and extend components of the BITTEN theoretical framework to better understand the link between trauma exposure (childhood trauma and institutional betrayal) and healthcare engagement. Results largely supported the propositions of the BITTEN theoretical framework: childhood trauma was directly related to healthcare avoidance behaviors. The relation between childhood trauma and healthcare avoidance was partially mediated by patients' reduced trust in healthcare providers. Further, the relation between childhood trauma and reduced trust in healthcare providers was potentiated by experiences of institutional betrayal. Interpreting patients' interactions with healthcare providers and the healthcare system as a whole in light of their interpersonal and institutional trauma histories is needed to more fully embody trauma-informed healthcare. The BITTEN theoretical framework of trauma-informed healthcare appears to be a viable foundation for developing a trauma-informed understanding of patients' healthcare engagement.

Ethical Duties of Nephrologists: When Patients Are Nonadherent to Treatment

When providing care, nephrologists are subject to various ethical duties. Beyond the Hippocratic notion of doing no harm, nephrologists also have duties to respect their patients' autonomy and dignity, to meet their patients' care goals in the least invasive way, to act impartially, and, ultimately, to do what is (clinically) beneficial for their patients. Juggling these often-conflicting duties can be challenging at the best of times, but can prove especially difficult when patients are not fully adherent to treatment. When a patient's nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing hemodialysis, including episodic extreme agitation, poor renal diet, missed hemodialysis sessions, and emergency presentations brought on by nonadherence. Furthermore, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the coronavirus disease 2019 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritizing a patient-narrative approach that is attentive to patients' values and preferences, multidisciplinarity, and the use of behavioral contracts and/or technology where appropriate.

Medical students as the volunteer workforce during the COVID-19 pandemic: Polish experience

In response to the COVID-19 pandemic medical students in different countries were mobilized to support healthcare systems during the emergency. This study presents the experience of 580 students of a single medical university in Poland who served as volunteers at different healthcare units during the first six months of the first case being recorded in the country (March-September 2020). The mean ± SD hours and days spent on volunteering in the studied group were 52 ± 36 h and 144 ± 126 d, respectively, the collective number of worked hours amounted to 83,460 h. Compared to other fields of study students of medicine engaged in volunteering for more hours and for more days. The main tasks performed by the surveyed group included triage, servicing call-centers for patients and working at the admission ward, hospital clinics, emergency departments and diagnostic labs. The level of fear at the beginning of volunteering was relatively low in the studied group and did not increase over the course. The majority of students received positive feedback from families, friends, patients and healthcare workers, revealed a high level of satisfaction from volunteering (also when experiencing COVID-19-related prejudice), while gaining professional experience and a sense of giving real aid were among the most frequently indicated benefits. The results of the present study demonstrate that although medical students are not essential workers in response to the COVID-19 pandemic, they can be of real assistance to healthcare systems during times of emergency, and should be considered as such in the future in case such a need arises again.

They've been BITTEN: reports of institutional and provider betrayal and links with Ehlers-Danlos Syndrome patients' current symptoms, unmet needs and healthcare expectations

Introduction

Patients with rare and/or care-intensive conditions, such as Ehlers-Danlos Syndrome (EDS), can pose challenges to their healthcare providers (HCPs). The current study used the BITTEN framework1 to code EDS patients' open-ended written responses to a needs survey to determine their self-reported prevalence of healthcare institutional betrayal and its link with their expressed symptoms, provider perceptions, unmet needs, and on-going healthcare-related expectations.

Methods

Patients with EDS (n = 234) were recruited via a rare disease electronic mailing list and snowball sampling. A total of one-hundred and six respondents (45.3%) endorsed having unmet healthcare-related needs; of these, 104 (99%) completed an open-ended prompt about these needs. Responses were coded for components of BITTEN, a framework designed to link patients' past, current, and future healthcare-related experiences in a trauma informed manner.

Results

Many respondents with ongoing needs endorsed experiencing past institutional and provider betrayal (43%; n = 45), current mental health symptoms (91.4%; n = 95), negative expectations for future healthcare (40.4%; n = 62), and a lack of trust in their healthcare provider (22.1%; n = 23). There were no significant differences in post-traumatic stress disorder (PTSD)/anxiety, depression/sadness, or isolative symptoms between respondents coded for institutional betrayal (n = 45) compared with those not (n = 59). However, EDS respondents reporting institutional betrayal were significantly more likely to self-report anger and irritability symptoms, a lack of trust in their HCPs, and more negative expectations for future healthcare than those not reporting institutional betrayal.

Discussion/conclusions

The frequent spontaneous reporting of past healthcare betrayals among patients with EDS implies the need for trauma-informed care and provider education. Given that experiences of institutional betrayal are associated with increased anger and irritability, as well as with negative expectations for future healthcare interactions, efforts to repair healthcare provider and system-wide relationship ruptures might have positive healthcare consequences.

Plain language summary

Reports of Institutional and Provider Betrayal and Links with Ehlers-Danlos Syndrome Patients' Current Symptoms, Unmet Needs and Future Healthcare Expectations What is EDS? Ehlers-Danlos Syndrome (EDS) refers to a group of rare genetic connective tissue disorders that are primarily characterized by skin hyperelasticity, joint hypermobility, and tissue fragility. Connective tissue is largely responsible for the structural integrity of our bodies, and there are several EDS subtypes which each describe a specific connective tissue problem. In addition, there is significant overlap between EDS types and other kinds of connective tissue disorders. As a result, recognizing, diagnosing, and treating EDS is often challenging. What is Institutional betrayal? Institutional Betrayal here refers to a harmful action (i.e. commission) or lack of action (i.e. omission) on the part of a healthcare institution, individual provider/healthcare team, or insurance company. When a patient trusts that the healthcare system will act in their best interest, and trust is violated, institutional betrayal occurs. What is BITTEN? BITTEN is an acronym for Betrayal, Indicator, Trauma symptoms, Trust, Expectations, and Needs. It is a framework meant to capture previous problematic healthcare-related experiences in EDS patients, then to consider how those experiences influence a patient's current symptoms, provider trust, future expectations in healthcare encounters, and on-going needs. Why was this done? EDS, like many rare diseases, is hard to recognize and manage. We aim to:Give voice to EDS patients and their common unmet needs and healthcare-related expectations.Highlight how healthcare providers can apply BITTEN to improve care practices in rare disease patient encounters. What did we do? Using a newly articulated applied model of healthcare, BITTEN, we analyzed the open-ended responses of EDS patients describing their unmet emotional and mental health needs. What did we find? Nearly half of EDS patients who indicated they had unmet needs reported experiencing institutional betrayal.EDS patients who reported institutional betrayal also expressed anger, a lack of trust in healthcare providers, negative expectations for future healthcare, and more unmet needs more frequently than EDS patients who did not report institutional betrayal. What does this mean? The EDS patients in this sample were not directly asked if they had experienced institutional betrayal, so the exact prevalence is not known. Furthermore, responses were obtained voluntarily via the internet, so caution should be taken when generalizing these findings.However, results indicate that too many patients with EDS have experienced healthcare betrayals; these experiences are associated with current anger and negative expectations for future healthcare interactions.The prevalence of past negative healthcare experiences, along with current unmet needs and future negative healthcare expectations in EDS patients who have experienced institutional betrayal, highlights the need for healthcare providers to tend to these experiences, mend patient-provider barriers, and provide higher quality healthcare.

Nurses' experiences of communicating respect to patients: Influences and challenges

BACKGROUND

Respectful care is central to ethical codes of practice and optimal patient care, but little is known about the influences on and challenges in communicating respect.

RESEARCH QUESTION

What are the intra- and inter-personal influences on nurses' communication of respect?

RESEARCH DESIGN AND PARTICIPANTS

Semi-structured interviews with 12 hospital-based UK registered nurses were analysed using interpretative phenomenological analysis to explore their experiences of communicating respect to patients and associated influences.

ETHICAL CONSIDERATIONS

The study was approved by the Institutional ethics board and National Health Service Trust.

FINDINGS

Three interconnected superordinate themes were identified: 'private self: personal attitudes', 'outward self: showing respect' and 'reputational self: being perceived as respectful'. Respectful communication involved a complex set of influences, including attitudes of respect towards patients, needs and goals, beliefs around the nature of respectful communication, skills and influencing sociocultural factors. A tension between the outward self as intended and perceived presented challenges for nurses' reputational self as respectful, with negative implications for patient care.

DISCUSSION

The study offers an in-depth understanding of intra- and inter-personal influences on communicating respect, and sheds light on challenges involved, helping provide practical insights to support respectful care.

CONCLUSION

Findings stress the need for improved conceptualisations of respect in healthcare settings to formally recognise the complex attitudinal and socially constructed nature of respect and for appropriate professional training to improve its communication.