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      Psychiatry, subjectivity and emotion - deepening the medical model

      editorial

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          Abstract

          Morale among psychiatrists continues to be seriously challenged in the face of recruitment difficulties, unfilled posts, diagnostic controversies, service reconfigurations and public criticism of psychiatric care, in addition to other difficulties. In this article, we argue that the positivist paradigm that continues to dominate British psychiatry has led to an undervaluing of subjectivity and of the role of emotions within psychiatric training and practice. Reintegrating the subjective perspective and promoting emotional awareness and reflection may go some way towards restoring faith in the psychiatric specialty.

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          Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities.

          André Jacques, Ilona Bartman, Roxane du Berger … (2007)
          Poor patient-physician communication increases the risk of patient complaints and malpractice claims. To address this problem, licensure assessment has been reformed in Canada and the United States, including a national standardized assessment of patient-physician communication and clinical history taking and examination skills. To assess whether patient-physician communication examination scores in the clinical skills examination predicted future complaints in medical practice. Cohort study of all 3424 physicians taking the Medical Council of Canada clinical skills examination between 1993 and 1996 who were licensed to practice in Ontario and/or Quebec. Participants were followed up until 2005, including the first 2 to 12 years of practice. Patient complaints against study physicians that were filed with medical regulatory authorities in Ontario or Quebec and retained after investigation. Multivariate Poisson regression was used to estimate the relationship between complaint rate and scores on the clinical skills examination and traditional written examination. Scores are based on a standardized mean (SD) of 500 (100). Overall, 1116 complaints were filed for 3424 physicians, and 696 complaints were retained after investigation. Of the physicians, 17.1% had at least 1 retained complaint, of which 81.9% were for communication or quality-of-care problems. Patient-physician communication scores for study physicians ranged from 31 to 723 (mean [SD], 510.9 [91.1]). A 2-SD decrease in communication score was associated with 1.17 more retained complaints per 100 physicians per year (relative risk [RR], 1.38; 95% confidence interval [CI], 1.18-1.61) and 1.20 more communication complaints per 100 practice-years (RR, 1.43; 95% CI, 1.15-1.77). After adjusting for the predictive ability of the clinical decision-making score in the traditional written examination, the patient-physician communication score in the clinical skills examination remained significantly predictive of retained complaints (likelihood ratio test, P < .001), with scores in the bottom quartile explaining an additional 9.2% (95% CI, 4.7%-13.1%) of complaints. Scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities.
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            Clinicians’ gut feeling about serious infections in children: observational study

            Ann Van den Bruel, Matthew Thompson, Frank Buntinx … (2012)
            Objective To investigate the basis and added value of clinicians’ “gut feeling” that infections in children are more serious than suggested by clinical assessment. Design Observational study. Setting Primary care setting, Flanders, Belgium. Participants Consecutive series of 3890 children and young people aged 0-16 years presenting in primary care. Main outcome measures Presenting features, clinical assessment, doctors’ intuitive response at first contact with children in primary care, and any subsequent diagnosis of serious infection determined from hospital records. Results Of the 3369 children and young people assessed clinically as having a non-severe illness, six (0.2%) were subsequently admitted to hospital with a serious infection. Intuition that something was wrong despite the clinical assessment of non-severe illness substantially increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and acting on this gut feeling had the potential to prevent two of the six cases being missed (33%, 95% confidence interval 4.0% to 100%) at a cost of 44 false alarms (1.3%, 95% confidence interval 0.95% to 1.75%). The clinical features most strongly associated with gut feeling were the children’s overall response (drowsiness, no laughing), abnormal breathing, weight loss, and convulsions. The strongest contextual factor was the parents’ concern that the illness was different from their previous experience (odds ratio 36.3, 95% confidence interval 12.3 to 107). Conclusions A gut feeling about the seriousness of illness in children is an instinctive response by clinicians to the concerns of the parents and the appearance of the children. It should trigger action such as seeking a second opinion or further investigations. The observed association between intuition and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills.
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              Perspective: Does medical education promote professional alexithymia? A call for attending to the emotions of patients and self in medical training.

              Johanna Shapiro (2011)
              Emotions--one's own and others'--play a large role in the lives of medical students. Students must deal with their emotional reactions to intellectual and physical stress, the demanding clinical situations to which they are witness, as well as patients' and patients' family members' often intense feelings. Yet, currently few components in formal medical training--in either direct curricular instruction or physician role modeling--focus on the emotional lives of students. In this article, the author examines patients', medical students', and physician role models' emotions in the clinical context, highlighting challenges in all three of these arenas. Next, the author asserts that the preponderance of medical education continues to address the emotional realm through ignoring, detaching from, and distancing from emotions. Finally, she presents not only possible theoretical and conceptual models for developing ways of understanding, attending to, and ultimately "working with" emotions in medical education but also examples of innovative curricular efforts to incorporate emotional awareness into medical student training. The author concludes with the hope that medical educators will consider making a concerted effort to acknowledge emotions and their importance in medicine and medical training.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Psychiatr Bull (2014)
                Journal ID (iso-abbrev): Psychiatr Bull (2014)
                Journal ID (hwp): pbrcpsych
                Title: The Psychiatric Bulletin
                Publisher: Royal College of Psychiatrists
                ISSN (Print): 2053-4868
                ISSN (Electronic): 2053-4876
                Publication date (Print): June 2014
                Volume: 38
                Issue: 3
                Pages: 97-101
                Affiliations
                [1 ] Tavistock and Portman NHS Foundation Trust
                [2 ] Leeds and York Partnership NHS Foundation Trust
                [3 ] West London Mental Health NHS Trust
                [4 ] Camden and Islington NHS Foundation Trust
                Author notes
                Correspondence to Jessica Yakeley ( jyakeley@ 123456tavi-port.nhs.uk )

                Jessica Yakeley is a consultant psychiatrist in forensic psychotherapy at the Portman Clinic, and Director of Medical Education and Associate Medical Director, Tavistock and Portman NHS Foundation Trust. Rob Hale is a retired consultant psychiatrist in psychotherapy and formerly Director of the Portman Clinic, Tavistock and Portman NHS Foundation Trust. James Johnston is a consultant psychiatrist in psychotherapy, Leeds and York Partnership NHS Foundation Trust, and Chair of the Medical Psychotherapy Faculty Education and Curriculum Committee, Royal College of Psychiatrists. Gabriel Kirtchuk is a consultant psychiatrist in forensic psychotherapy, West London Mental Health NHS Trust. Peter Shoenberg is an honorary consultant psychiatrist in psychotherapy, Camden and Islington NHS Foundation Trust, and former lead consultant psychiatrist in psychotherapy, Camden and Islington NHS Foundation Trust.

                Article
                DOI: 10.1192/pb.bp.113.045260
                PMC ID: 4115376
                PubMed ID: 25237517
                SO-VID: 5f43c210-10a3-4769-922d-0c8e8afe78d2
                Copyright © © 2014 The Royal College of Psychiatrists
                License:

                This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 21 August 2013
                Date revision received : 17 October 2013
                Date accepted : 4 November 2013
                Categories
                Subject: Editorial

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