Dear Therapist: I Google-Stalked My Therapist

Lori Gottlieb
The Atlantic
Originally published March 21, 2108

Here is an excerpt:

Most of us wonder who our therapists are outside of the therapy room, usually because we like them so much. Sometimes, of course, people Google their therapists if something feels off—to see if their credentials check out, or if other patients have posted similar concerns. More often, though, our curiosity is a reflection of how important our therapist has become to us, and in some cases, it’s a way to feel connected to the therapist between sessions. The problem is, of course, that we want therapy to be a space where we feel free to talk about absolutely anything. And no matter what we discover—a bombshell like yours, or something more mundane—the fallout of a Google binge becomes a secret that takes that freedom away.

Carl Jung called secrets “psychic poison” for good reason. When I finally confessed my Google-stalking to my therapist, all the air returned to the room. My verbal shackles were removed, and we talked about what was behind my desire to type his name into my search engine. But more important, the way I handled the situation before fessing up taught me something interesting about how I handle discomfort—something far more interesting than anything I learned about my therapist online.

And I think the same might prove true for you.

What people do in therapy is pretty much what they do in their outside lives. In other words, if a patient tends to feel dissatisfied with people in her life, it’s likely that she’ll eventually feel dissatisfied with me. If she tries to please people, she’ll probably try to please me too. And if she avoids people when she feels hurt by them, I’ll be on the lookout for signs that I’ve said something that may have hurt her, too (she cancels her next session, or clams up, or comes late).

The information is here.

Overcoming patient reluctance to be involved in medical decision making

J.S. Blumenthal-Barby
Patient Education and Counseling
January 2017, Volume 100, Issue 1, Pages 14–17

Abstract

Objective

To review the barriers to patient engagement and techniques to increase patients’ engagement in their medical decision-making and care.

Discussion

Barriers exist to patient involvement in their decision-making and care. Individual barriers include education, language, and culture/attitudes (e.g., deference to physicians). Contextual barriers include time (lack of) and timing (e.g., lag between test results being available and patient encounter). Clinicians should gauge patients’ interest in being involved and their level of current knowledge about their condition and options. Framing information in multiple ways and modalities can enhance understanding, which can empower patients to become more engaged. Tools such as decision aids or audio recording of conversations can help patients remember important information, a requirement for meaningful engagement. Clinicians and researchers should work to create social norms and prompts around patients asking questions and expressing their values. Telehealth and electronic platforms are promising modalities for allowing patients to ask questions on in a non-intimidating atmosphere.

Conclusion

Researchers and clinicians should be motivated to find ways to engage patients on the ethical imperative that many patients prefer to be more engaged in some way, shape, or form; patients have better experiences when they are engaged, and engagement improves health outcomes.

The article is here.

Florida Doctors May Discuss Guns With Patients, Court Rules

 Lizette Alvarez
The New York Times
Originally posted February

Here is an excerpt:

A federal appeals court cleared the way on Thursday for Florida doctors to talk to their patients about gun safety, overturning a 2011 law that pitted medical providers against the state's powerful gun lobby.

In its 10-to-1 ruling, the full panel of the United States Circuit Court of Appeals for the 11th Circuit concluded that doctors could not be threatened with losing their license for asking patients if they owned guns and for discussing gun safety because to do so would violate their free speech.

"Florida does not have carte blanche to restrict the speech of doctors and medical professionals on a certain subject without satisfying the demands of heightened scrutiny," the majority wrote in its decision. In its lawsuit, the medical community argued that questions about gun storage were crucial to public health because of the relationship between firearms and both the suicide rate and the gun-related deaths of children.

A number of doctors and medical organizations sued Florida in a case that came to be known as Docs v. Glocks, after the popular handgun.

The article is here.

Empathy is an overrated skill when dispensing medical care

Karin Jongsma

Aeon Magazine

Originally published December 15, 2016

Here is an excerpt:

In fact, this final requirement is most closely related not to empathy but to compassion – defined among emotion researchers as the feeling that arises when you are confronted with another’s suffering, including the desire to help. This non-empathetic compassion – a more distanced love and kindness and concern for others – might act as a bridge between recognising the other’s feelings and providing care without the detriments of empathy. Since compassion does not require identification with the patient, it can help in performing good care as a professional duty, building trust, and treating someone according to his or her needs, while avoiding cognitive biases and empathetic distress.

Empathy still matters in healthcare settings that don’t require action: self-help forums and family-support coordinators can be guided by empathy. And precisely because empathy is biased, physicians should be trained to critically reflect upon their empathy gaps rather than be told to fake it.

The article is here.

Scale of medical decisions shifts to offer varied balances of power

By Karen Ravn
The Los Angeles Times
Originally published June 6, 2014

Patients never used to worry about making healthcare decisions. They didn't have to. Their doctors made just about all of their decisions for them. Everyone simply assumed that doctors knew what was best.

But that paternalistic view of doctors as know-it-alls has gone by the board, says Dr. Clarence Braddock, vice dean for education at the David Geffen School of Medicine at UCLA. "Now doctors are seen as the experts on medical information and choices," he explains, "but patients are seen as the experts on what those choices mean in their own lives."

The upshot? Doctors still make decisions sometimes, but sometimes patients make them, and sometimes doctors and patients make them together.

The entire article is here.

Doctors Are Talking: EHRs Destroy the Patient Encounter

By Neil Chesanow
MedScape
Originally published May 22, 2014

There's no doubt that electronic health records (EHRs) spark strong emotions in doctors -- and many of those emotions are negative.

The gripes cover three main areas: One, EHRs have made the patient encounter far more annoying and complex than it ever was before.

Two, many physicians feel that EHRs take doctors who were trained to be independent thinkers and constrain their ability to make independent decisions, causing them to feel like data entry clerks, with a computer telling them how to practice medicine.

Last but not least, a large number of physicians feel that EHRs erode the doctor-patient relationship by creating a barrier between the two.

This article, and several others, about EHRS are here.

15-Minute Visits Take A Toll On The Doctor-Patient Relationship

By Roni Caryn Rabin
Kaiser Health News
Originally published April 21, 2014

Here is an excerpt:

“Doctors have one eye on the patient and one eye on the clock,” said David J. Rothman, who studies the history of medicine at Columbia University’s College of Physicians and Surgeons.

By all accounts, short visits take a toll on the doctor-patient relationship, which is considered a key ingredient of good care, and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave the office frustrated.

The entire story is here.

Is the Doctor-Patient Relationship Turning Into a Business Partnership?

Reports say patients are increasingly asking doctors for drugs by name, and docs are complying. If they don’t write the script, they risk a low rating on one of many doc-ranking sites.

By Russell Saunders
The Daily Beast
Originally posted April 11, 2014

“The customer is always right.” We all know the saying. It’s a truism in business. Businesses need happy customers. Happy customers keep coming back and they tell their friends. Keeping the customer happy is a businessperson’s number one priority.

Except when the business is a medical practice, and the customer is a patient.

That ever-blurring line between patient and customer is one of the most difficult things to walk in medical practice. On the one hand, people need to keep coming through the door in order to keep it open in the first place, and making sure people have a good experience when they come to you for care is important.

The entire article is here.

Loyola Bioethics Study: Med Students Reflections on Caring for Dying Patients

Loyola Bioethics Online
Originally posted January 14, 2014

The imminent death of a patient is riddled with emotions for a patient and family as well as the medical team. A study based on the reflections of third-year Loyola University Chicago Stritch School of Medicine students is shedding light on the struggle physicians in training often face when trying to control their own emotions while not becoming desensitized to the needs of the dying patient and his or her family.

“Medical students are very aware they are undergoing a socialization process by which they become desensitized to the difficult things they see every day in the hospital. They realize this is necessary to control their emotions and focus on caring for the patients. On the other hand, they are very concerned about becoming insensitive to the spiritual, emotional and personal needs of the patient,” said Mark Kuczewski, PhD, leader author and director of the Loyola University Chicago Stritch School of Medicine Neiswanger Institute for Bioethics.

The entire article is here.

An interview with Mark Kuczewski, PhD by Randi Belisomo

Doctors shame women more than men about their bodies and behavior

By Rachel Feltman
Quartz
Originally published January 16, 2014

Here is an excerpt:

Both studies found that women were significantly more likely to experience these incidents than men were: In the first cohort, which was made up of university students, 26% of women reported being “shamed” by a physician, while only 15% of the men surveyed said the same. The most common topics of this shaming were sex, dental hygiene, and weight. The second study, which included a much broader age and demographic range, showed similar results: While only 38% of men reported feeling guilt or shame because of something their physician said, 53% of women could recall such behavior.

The entire article is here.

What Is Wrong With Discharges Against Medical Advice (And How to Fix It)

By David Alfrandre and John Henning Schumann
JAMA
First published November 11, 2013

Here is an excerpt:

It is time to rethink the approach to this issue. For a profession accountable to the public and committed to patient-centered care, continued use of the discharged against medical advice designation is clinically and ethically problematic. Designating a discharge as against medical advice is a clinical practice without standards, legal requirements, or demonstrated benefits to patients, and there is evidence of its harm. The more relevant and pressing question should be, “Why would you discharge a patient against medical advice?” Without a compelling answer to that question, continued use of the practice does not seem justified. Taking leadership on this problem through enhanced research, teaching, and quality patient care ensures that the profession will honor its commitment to providing patient-centered care and improving clinical outcomes.

The entire article is here.

Thanks to Gary Schoener for this information.

When the Patient Is Racist

By PAULINE W. CHEN
The New York Times - Doctor and Patient
Originally published July 25, 2013

Here is an excerpt:

The patient had suffered only broken bones, so after my evaluation I was happy to leave him to the orthopedic surgeons. When I expressed my relief to a colleague, he smiled. “I’m sure it freaked him out to have an Asian woman taking charge of his care,” he said after I had described the patient’s menacing tattoo and threatening reaction to me.

But then my colleague paused. “What you need to do is turn this into a ‘teaching moment,’” he finally said without the slightest hint of irony. “Sit down with the patient and educate him about racism.”

I remembered this colleague’s naïve remark, and the burly patient with the swastika tattoo, when I read an essay by Dr. Sachin H. Jain in a recent issue of The Annals of Internal Medicine on the medical profession’s attitude toward patients who discriminate against doctors.

Since Hippocrates, physicians have embraced the ideal of caring for all patients, regardless of who they might be. While the father of medicine struggled to be open-minded when it came to caring for slaves, doctors more recently have wrestled with caring for patients’ of different races, gender and sexual orientation. In 2000, the American Medical Association codified its opinion on the issue, issuing in its code of ethics a mandate that doctors could not refuse to care for patients based on any “invidious” discriminatory criteria like race or ethnicity.

The entire story is here.

It turns out empathy can be taught

By Craig Dowden
Special to Financial Post
Originally published July 7, 2013

There has been increased emphasis on empathy in the field of medicine in recent years. Empathy, it turns out, is directly related to key outcomes of interest to medical observers, including improved patient satisfaction, better patient adherence to proposed treatments, and increased well-being in doctors (including lower burnout). It has also been linked to a reduction in errors by doctors and fewer malpractice claims. As a consequence, the desire to enhance empathy in doctors is not only a noble and laudable goal, but also a valuable one from a bottom-line perspective.

Seeing the profound significance of empathy in medical settings, Dr. Helen Riess, an Associate Clinical Professor of Psychiatry at Harvard Medical School and Director of the Empathy and Relational Science Program at Massachusetts General Hospital, set out to explore whether it was possible to bring about observable improvements in physician empathy. Drawing on Daniel Goleman’s work in the area of emotional intelligence, as well as elements of the neuroscience of empathy, Dr. Riess designed and implemented an empathy training program for physicians.

The entire story is here.

Blurring the lines of ethics when doctors use social media

By Wes Fisher
Dr.KevinMD Blog
Originally posted on May 28, 2013

The position paper from the American College of Physicians and the Federation of State Medical Boards, is a humbling reminder of the challenges that today’s physicians face when entering the online space.

Their recommendations for online medical professionalism, written by ethics committees for the two organizations, “provides recommendations about the influence of social media on the patient–physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician–physician communication that preserve confidentiality while best using these technologies” — no small amount of territory to summarize.

But given the tenure of their document, I should probably hang up this blog right now.  After all, why risk being vulnerable in the online world?  While well-meaning on one hand, we should appreciate that physicians have officially been put on notice on how to behave online.

To be fair, I agree with most of what they say.   All the things about patient confidentiality are appropriate.  All the things about respect for persons, better still.

But to me, the part of the document that wanders off into the “influence of social media on the patient-physician relationship” and the influence of social media on the “public perception of physician behaviors,” is more difficult to gauge in its benefit or detriment to the public discourse.

The entire article is here.

Physician Study Finds Similar Outcomes From In-Person, Telehealth Consultations

By Jonathan Field
Managing Editor - The Institute for HealthCare Consumerism

Thanks to health care reform and technological innovations in the private sector, the telehealth market is booming. And it is having a direct impact on the physician-patient relationship and on the health costs associated with an employer-sponsored health plan.

The industry predicts continued, strong growth. According to a recent market analysis by IMS Research, the telehealth market will grow by 55 percent in 2013 after growing only 5 percent from 2010 to 2011 and 18 percent from 2011 to 2012. And a 2012 report by BCC Research, the Wellesley, Mass.-based market research firm, predicted that the global telehealth market was expected to double from $11.6 billion in 2011 to over $27 billion in 2016.

InMedica, leading independent provider of market research and consultancy to the global medical electronics industry, predicts that in by 2017 the telehealth market will reach 1.8 million patients -- up from 300,000 in last year. The research firm attributes growth to four sectors of demand: federal, provider, payer and patient. For more details on the projected growth of telehealth market, view InMedica's new report The World Market for Telehealth – An Analysis of Demand Dynamics – 2012.

The entire article is here.

Letting Patients Read the Doctor’s Notes

By PAULINE W. CHEN, M.D.
The New York Times
Originally published on October 4, 2012

Here are some excerpts:


This patient’s experience, like those of so many others who have tried to obtain their medical records, came to mind this week when I read about the long-awaited results of a study in which patients were given complete access to their doctors’ notes. The findings, published in the Annals of Internal Medicine, do more than shed light on what patients want. They make our current ideas about transparency in the patient-doctor relationship a quaint artifact of the past.

Since 1996, when Congress passed the Health Insurance Portability and Accountability Act, or HIPAA, patients have had the right to read and even amend their own records.

In fact, few patients have ever consulted their own records. Most do not fully grasp the extent of their legal rights; and the few who have attempted to exercise them have often found themselves mired in a parallel universe filled with administrative regulations, small-print permission forms, added costs and repeated delays.


(cut)


For one year, the study, aptly called OpenNotes, allowed over 13,000 patients from three medical centers — the Beth Israel Deaconess Medical Center in Boston, the Geisinger Health System in Danville, Pa., and the Harborview Medical Center in Seattle — to have complete access to one part of their medical records, the notes that doctors wrote about them. Within days of seeing their doctors, patients received an e-mail inviting them to read the doctor’s signed note on a secure patient Web site. Two weeks before their return visit, patients received a second e-mail inviting them again to review their doctor’s note from the previous encounter.

After a year, almost all the patients were enthusiastic about the OpenNotes initiative.

Surprisingly, so were the majority of doctors.

The entire article is here.

The research from the Annals of Internal Medicine is here.

Prof whom Holmes allegedly threatened appears to be his psychiatrist Read more: Prof whom Holmes allegedly threatened appears to be his psychiatrist

By John Ingold and Jeremy P. Meyer
The Denver Post
Originally published September 29, 2012


The University of Colorado professor whom Aurora theater shooting suspect James Holmes allegedly threatened appears to be Holmes' psychiatrist, according to a court filing made public Friday.

In the filing, prosecutors assert that Holmes and Dr. Lynne Fenton ended their doctor-patient relationship after Holmes made threats to someone, who reported those threats to the CU police. Later in the filing, prosecutors appear to indicate that the person who contacted police was Fenton. In both cases, though, the name of the person contacting police is redacted.

"The relationship was terminated after the defendant made threats directed towards (redacted), who reported the matter to" the police, the filing states. Later on, prosecutors write: "[T]he defendant's professional relationship with (redacted) had been terminated after she reported threats to the CU police."

The entire article is here.

Can Doctors Learn Empathy?

By Pauline W. Chen, MD
The New York Times - Well
Originally published June 21, 2012

Empathy has always been considered an essential component of compassionate care, and recent research has shown that its benefits go far beyond the exam room. Greater physician empathy has been associated with fewer medical errors, better patient outcomes and more satisfied patients. It also results in fewer malpractice claims and happier doctors.

A growing number of professional accrediting and licensing agencies have taken these findings to heart, developing requirements that make empathy a core value and an absolute “learning objective” for all doctors. But even for the most enthusiastic supporters of such initiatives, the vexing question remains: Can people learn to be empathetic?

A new study reveals that they can.

The entire story is here.

Plastic surgeon suing 10 patients for posting anonymous complaints online

The Palm Beach News

WFTV.com
Originally published May 23, 2012

An Orlando plastic surgeon has posted his explanation on the Internet as to why he's suing several of his patients.

WFTV learned Dr. Armando Soto is suing 10 patients who he said anonymously posted comments online about their bad experiences inside his office in the Dr. Phillip’s neighborhood.

The entire story is here.

Thanks to Ken Pope for the above link.

Dr. Soto's blog is here.

Here is a portion of his blog post.

"In sum, a previously unhappy patient is now on the road to a better outcome, with restoration of a healthier doctor/patient relationship. To us, that’s a great outcome."

Q&A about Patient Abandonment or Wrongful Termination

The following exchange is taken from a national ethics listserv discussion.  We acquired permission from both parties to post this dialogue.

Jeff Younggren asks:

As many of you may know, I have been quite absorbed in the past year or so in the topic of abandonment/wrongful termination.  While I believe that we do owe our clients/patients pre-termination counseling when appropriate and possible, I also believe there conditions that make this unnecessary.

For example, I would argue that when a patient stops paying you, or threatens you or some other situation that compromises therapy or the therapeutic relationship; your obligations to provide pre-termination guidance or counseling are reduced and/or eliminated.  I contend that, emergencies aside, we have no obligation to see people for free if we do not want to (but you can if you want to).  I am puzzled as to how the profession can require someone to work for free when the patient/client violates the professional relationship by acting out, not paying a bill or threatening the professional in some way. 

What would you say about the rights of a licensing board, for example, to punish a psychologist for not providing free, non-emergent services to clients?

Gary Schoener replies:

These issues come up all the time because some clients threaten clinicians with a charge of abandoning them.  I have been involved in a number of cases where this has been litigated.

First of all, I agree that our field has no tradition of treating people without fee as an expectation. Medicine actually did have such a belief.  In fact, I began my career at a neuropsychology clinic and doctors and their families were treated for free by the psychiatrists and neurologists.

They expected us psychologists to do the same as a "courtesy" but we pointed out that:

(a) We did not get free care from any of our physicians; so this was not, with us, a collegial exchange of courtesies;

(b) While we might choose to treat someone for free, when we do it is usually for someone who does not have financial resources (not typical of doctors and their families); and,

(c) People often do not value free services; so this was questionable on that basis too.

BENEFICENCE:  In terms of professional issues, it is our duty to determine who we are capable of treating, to monitor progress and be willing to re-examine our presumption if they are not responding, and to cease treatment that is not working. 

NONMALEFICENCE:  Since all of our treatment techniques can be harmful, and because it is likely harmful in a general sense to provide 'treatment" which is not working, we are again obligated to discontinue treatment that is not working.

AUTONOMY:  The client can choose to leave therapy at any time, but autonomy does not include any "right to treatment." There is no such right.  If a client comes in and asks for  a lobotomy, a psychiatrist would not be expected to do it.  Autonomy in the current world means the right to have information and make informed choices, but it does not bind the practitioner to those choices.

FIDELITY:  The main issue here is that the client knows, going into treatment, that you will be both monitoring progress and that sometimes therapy does not work or does not help, and in that instance a referral should be considered.  In your initial discussion, you should outline your policies on payment for service.

JUSTICE:  Although not critical much of the time, if treatment of the client is harming other clients (e.g. disruption in the waiting room, disruption in group therapy), you can terminate the client.  Resources (e.g. you) are limited and our job is to use them where they can do the most good.  The clients are not "ours" and we are not "theirs" -- nobody has ownership.

Obviously, as a practical reality, practice standard, and consistent with the last revision of our APA code of ethics, we are not bound to provide free service, to continue with people who violate their agreements with us, or to continue in the face of threats by the client or anyone connected with them.

I believe our duty is to provide referrals and be willing to provide information to the new service provider.  It is not our job to find then another service provider -- just to make reasonable suggestions.  If they go into crisis, normally a referral to the local hospital or crisis service discharges ones duty.

In case law, there is that one exceptional case where a psychiatrist about to retire gave all his patients referrals.  However, one patient was very introverted and the psychiatrist himself admitted that a referral alone was probably not enough.  The man was on medications and the psychiatrist never got a records request.  The jury felt, based on the facts including the psychiatrist's own admissions, that he failed in his duty by not working to help this very vulnerable man (who had seen him for many years) make an adequate transition to another practitioner. This was not, of course, an abandonment case -- it was a duty to do more at the end.  I know of no other case, but this has been in the journals so often that it causes people to think that abandonment was the issue.

Jeff Younggren:

What is of great concern to me is that we have clinicians staying in nonproductive and adversarial treatment alliances out of their fear that they will be charged with abandonment if they stop seeing the client.  They fail to see that you can stop seeing anyone, it is how you do it that is key.  In some cases, you have no obligation to do anything other than stop seeing the client, like when your safety is threatened or a patient sues you and in others, like long-term treatment cases, you have a much more extensive obligation that likely includes termination sessions and referral.  We need to make sure that psychologists in practice understand this dynamic.

Gary Schoener:

I agree Jeff.  In addition, as is true for so many things like this, litigiphobia and anxiety are enemies of good decision-making.

Jeff Younggren:

Great point!  

Litigiphobia?  That is a new one for me.