“I Fired My Last Doctor for Not Taking Me Seriously”: Collaborating With a Difficult Medical Patient in a Multidisciplinary Primary Care Facility

We present the case of a multidisciplinary primary care assessment of a 32-year-old woman with multiple medical and psychological complaints. Following the collaborative care model, this assessment was conducted by a team consisting of a clinical health psychologist, Dr. J. L. Skillings, and a family physician, Dr. W. J. Murdoch. We describe the primary care environment in which this referral was made including the methods that were utilized to insure a successful professional collaboration. We report the results and recommendations from a comprehensive biopsychosocial assessment; we place emphasis on the psychological diagnosis and pain symptoms. We also describe the feedback session in which the assessment results were provided to the patient and her spouse by both physician and psychologist. Multiperspective commentary about the assessment is offered by the patient and her husband as well as the physician and psychologist assessors.     

"I fired my last doctor for not taking me seriously": collaborating with a difficult medical patient in a multidisciplinary primary care facility

We present the case of a multidisciplinary primary care assessment of a 32-year-old woman with multiple medical and psychological complaints. Following the collaborative care model, this assessment was conducted by a team consisting of a clinical health psychologist, Dr. J. L. Skillings, and a family physician, Dr. W. J. Murdoch. We describe the primary care environment in which this referral was made including the methods that were utilized to insure a successful professional collaboration. We report the results and recommendations from a comprehensive biopsychosocial assessment; we place emphasis on the psychological diagnosis and pain symptoms. We also describe the feedback session in which the assessment results were provided to the patient and her spouse by both physician and psychologist. Multiperspective commentary about the assessment is offered by the patient and her husband as well as the physician and psychologist assessors.     

Medication Administration By Family Members of Dependent Elders In Shared Care Arrangements

Twenty-three long-term care family caregivers whose care-recipients were enrolled in adult day care programs participated in face-to-face, semistructured interviews designed to learn more about their medication administration experiences. Two distinct styles of decision making were identified: self-directed and physician-directed. To help them with their medication administration responsibility, both groups used primary (physicians, pharmacists, or both) and secondary sources of information (the internet, information hotlines, nurses, more experienced caregivers, and family members with health backgrounds). Self-directed caregivers, who were significantly younger than the physician-directed caregivers, were twice as likely to report use of secondary sources of information to manage their medication administration tasks. Secondary sources of information appear to be important for the development of a caregiver's maturation and critical thinking skills over the long term and need more attention from formal providers in shared care relationships with family caregivers.     

The significance of reflective supervision for infant mental health work

Parent–infant work is inherently relational and occurs in the intersubjective space between parent, infant, and worker. This space can be charged with primitive, unmet needs of both parent and infant, and this in turn can trigger these same states in the worker. The challenge for workers is to remain open to being affected by and responsive to these feeling states when their own early and possibly preconscious responses and coping strategies are being stirred. If these remain out of awareness, they can manifest as avoidance and denial, and this can be reflected in the system and result in limited service delivery. This article emphasizes the significance of reflective supervision for parent–infant work and suggests that it needs to be an integral part of the system of service delivery. I am grateful to the infant mental health workers who allowed me to use examples of their work in this article, and thank Dr Jon Jureidini for his encouragement and support.     

Sensorimotor skills and language comprehension in autistic children

The objectives of this study were to examine the level of sensorimotor concepts of young autistic children and to relate these concepts to language comprehension. A sample of 16 autistic children with a mean mental age of 24.8 months was administered a standardized scale of sensorimotor intelligence and of receptive language. The autistic children demonstrated surprisingly sophisticated sensorimotor skills, particularly object permanence. While their initial performance was inferior to that of normal controls matched on mental age, particularly in their use of objects in combination, the difference between groups diminished on the second test administration. On the receptive language measure, the autistic children were less able to identify words correctly. The sensorimotor behavior of autistic children who demonstrated language comprehension did not differ from those who showed no language comprehension, except that the former group tended to use an object as an instrument somewhat more frequently. The fact that the autistic children were so impaired in language even with fairly good sensorimotor skills suggests that these skills, particularly object permanence, play a minor role in their language acquisition.Support for this research was provided by Biobehavioral Research Support Grant 516, Grant 12–41 from the March of Dimes, NIMH Postdoctoral Fellowship No. 1 F32 MH07550-01 (Ungerer), and NIMH Grant MH 33815-01. Subjects were recruited from the UCLA Research Center for the Study of Childhood Psychosis, funded by NIMH Grant MH 30897. We would like to thank members of the CRC, particularly Dr. Peter Tanguay, Dr. Barbara Fish, and Dr. B. J. Freeman, for their support of our research efforts.     

A family of differentiation indices

A general class of differentiation indices is introduced for profiles of scores. Their ordinal properties and an application to Holland's classification system are examined. Comparison with other suggested indices is performed both theoretically and empirically.We are grateful to Professors J. Rayman and J. L. Holland for an interesting discussion. We would also like to thank Vera lachan for suggesting the problem.     

Ethical Issues in Family-Centered Primary Care

In 1969 a new primary care medical specialty, family practice, was formally created. One element in the development of this specialty from the roots of general practice was an understanding of the importance of family process in health and health care. Family physicians are now trained to work with families in the provision of primary medical care, and many provide some formal family counseling and therapy. The family physician who works with families faces many of the same ethical conflicts with which family therapists are confronted. The primary relationship of the family physician to his or her patients, however, as the provider of continuing health care, modifies these conflicts and creates new and vexing problems.     

Talking to primary care patients about weight: a study of GPs and practice nurses in the UK

Evidence-based guidance recommends that primary care health practitioners should deliver brief interventions to their patients to change behaviours to reduce overweight and obesity. This cross-sectional study investigates UK general practitioners' (GPs) and practice nurses' communication about overweight with their overweight and obese patients. Forty general practitioners and 47 practice nurses in two inner-London primary care organizations completed a questionnaire about past practice and concerns. When there was no identified medical problem, 38% of GPs and 14% of practice nurses reported raising the issue on less than 50% of occasions. Practice nurses were more likely than GPs to raise the issue of weight, both when there was no medical problem and when there was a medical problem. When they did raise the issue of overweight, only 9% did so in the context of presenting possible solutions to weight loss or in discussions about health promotion. Fifty two per cent of GPs and 28% of practice nurses had concerns about raising the issue of overweight; the most common being that patients would react emotionally to the message. These results suggest that there is considerable room for improvement in the frequency with which primary care practitioners address the questions of weight in their overweight patients, especially amongst doctors. Training to increase skills and confidence in communicating about weight is recommended.     

Counselling psychology in primary health care: A review

This paper reviews the development of counselling psychology within the field of primary health care. Issues discussed include liaison between counselling psychologists and other professionals, evaluation of treatment in primary care, family therapy in general practice and general practitioners’ skills in counselling. The need for training and evaluation of counselling are discussed and suggestions are made for further research.     

Research as a family therapy intervention technique

The utilization of the research process as an intervention has recently been described in the family therapy literature. However, it is important to draw a distinction between research as intervention and research as a unique family therapy intervention technique. From a family systems perspective, research as an intervention technique may make therapy more palatable for some families. A case study is presented in which this technique created the context for change for a family involved in a chronic illness research project.The author would like to thank Dr. Wendy L. Watson for her participation as a member of the clinical team and Drs. Fabie Duhamel and Wendy L. Watson for their helpful critiques on earlier drafts of this paper.Supported by a grant from the Albert Foundation for Nursing Research.     

An Overview of Primary Care Family Psychology

This paper describes the application of family psychology to the primary care setting—in service, education and training, and scholarship. Primary care family psychology integrates family systems with biopsychosocial theory, yielding an approach that is uniquely suited to the generalist demands of primary care. This approach attends especially to the effects of relationships on health and healthcare, using the family as a potential resource to the patient just as the healthcare team is a resource to the clinician. Training opportunities in primary care family psychology are growing. The University of Rochester School of Medicine and Dentistry fellowship is described as an example, with core primary care family psychology training in four different clinical sites: Family Medicine, Internal Medicine, Pediatrics, and Obstetrics/Gynecology. Susan H. McDaniel is Professor of Psychiatry & Family Medicine, Director of Family Programs & the Wynne Center for Family Research in Psychiatry, and Associate Chair of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York. Dr McDaniel also directs the Primary Care Family Psychology Fellowship. Picter LeRoux is Associate Professor of Psychiatry & Pediatrics, and Director of the Family Therapy Training Program in Psychiatry, University of Rochester School Medicine and Dentistry, Rochester, New York. Dr. LeRoux also heads the Pediatric Track of the Primary Care Family Psychology Fellowship.     

Quantum logics and Lindenbaum property

This paper will take into account the Lindenbaum property in Orthomodular Quantum Logic (OQL) and Partial Classical Logic (PCL). The Lindenbaum property has an interest both from a logical and a physical point of view since it has to do with the problem of the completeness of quantum theory and with the possibility of extending any semantically non-contradictory set of formulas to a semantically non-contradictory complete set of formulas. The main purpose of this paper is to show that both OQL and PCL cannot satisfy the Lindenbaum property.I would like to thank Dr. P. L. Minari and Dr. G. Corsi for many enlightening and encouraging conversations. I am especially grateful to Prof. M. L. Dalla Chiara who sparked my interest in Quantum Logic and Philosophy of Physics.     

Profession Differences in Family Focused Practice in the Adult Mental Health System

There is a large gulf between what psychiatric services should (or could) provide and what they do in practice. This article sought to determine practice differences between the differing professions working in adult mental health services in terms of their family focused work. Three hundred and seven adult mental health professionals completed a cross‐sectional survey of family focused practices in adult mental health services. Findings highlight that social workers engaged in more family focused practice compared to psychiatric nurses, who performed consistently the lowest on direct family care, compared to both social workers and psychologists. Clear skill, knowledge, and confidence differences are indicated between the professions. The article concludes by offering direction for future profession education and training in family focused practices.     

Ministers' attitudes toward delinquency

Conclusion An effective ministry to youth offenders depends greatly on our attitudes toward them. Working with them on any personal basis requires attitudes that help prepare us to be accepting, understanding, friendly, and firm.Indispensable also is a community-mindedness that frees us to be ecumenical rather than parochial in our concern and outreach. And this community-mindedness also leads us to utilize the agencies and programs that seek to help young people and prevent delinquency.The author expresses grateful acknowledgment to Dr. Paul E. Johnson, Dr. Daniel J. Levinson, and Dr. Donald T. Devine who contributed to the study on which this article is based.     

Case vignette: the vicissitudes of managed care

Lee Wilson, age 26, was referred to Dr. Jackson for psychotherapy 5 weeks ago by a friend. Lee has been feeling increasingly depressed about longstanding family issues and the recent breakup of a 2-year relationship with a live-in companion. Over the course of the once-per-week sessions, Dr. Jackson notes persistent suicidal ideation, with vague plans to act if, as Lee puts it, "things get any worse." Just before the sixth session, Dr. Jackson is contacted by a reviewer for the managed care health insurance program covering Lee's therapy. The reviewer informs Dr. Jackson that the company will not authorize payment for further psychotherapeutic care. Dr. Jackson knows that Lee is in need of continued treatment and fears that terminating therapy at this time could result in increased suicide risk. Lee's income could cover only a small portion of Dr. Jackson's usual fee. Dr. Jackson does not wish to abandon Lee, but he already provides a significant amount of reduced-fee service to other clients. Is the health insurance carrier's stance ethical? Should Dr. Jackson be expected to treat Lee for the foreseeable future at a greatly reduced fee? How should Dr. Jackson handle this situation?     

Sexual counseling and therapy

Abstract

This article is an edited version of four interviews conducted with Dr. Ivan Boszormenyi-Nagy in the Spring of 1980. The interviews ranged in content from Dr. Nagy's early training and influences to the theoretical and clinical foundations of contextual family therapy. This article focuses on the major constructs of contextual family therapy. Since this approach is often viewed as highly theoretical and conceptual in nature, it may be helpful to the practitioner to see how Dr. Nagy uses these constructs in a clinical situation. As a practitioner, I have found his theory extremely useful in conceptualizing the family system, and also in developing a treatment strategy. Hopefully, the questions asked of Dr. Nagy in these interviews will be of interest to other family therapists who are concerned with the clinical aspects of family therapy theories.     

Parenting stress among families of children with attention deficit hyperactivity disorder

Prior research has shown that parenting stress levels can be quite high among families of children with attention deficit hyperactivity disorder (ADHD). This study investigated the degree to which such stress was related not only to the child's ADHD, but also to various other child, parent, and family-environment circumstances. Multimethod assessments were conducted on 104 clinic-referred children with ADHD. Data collected from these subjects were entered into hierarchical multiple-regression analyses, utilizing the Parenting Stress Index as the criterion. The results showed that child and parent characteristics accounted for a substantial portion of the variance in overall parenting stress. The child's oppositional-defiant behavior and maternal psychopathology were especially potent predictors. The severity of the child's ADHD, the child's health status, and maternal health status also emerged as significant predictors. These findings are discussed in terms of their impact upon the clinical management of children with ADHD.The authors are grateful to Mary Maher and Paula Nevins for their assistance in collecting and coding the data. The authors would also like to thank Dr. Kenneth Fletcher for his helpful comments regarding the statistical analyses.     

The physician and social renewal: Julius B. Richmond as role model

We live in an age of “high tech” medicine which affects both health care recipients and physicians who are taught its many wonders and uses. It is easy in this atmosphere of specialization for clinicians, professors and medical students to become isolated and to ignore social issues which affect health care in its broadest sense. Individuals who are committed to the “common good” are the ones historically who have been effective change agents. It would be tragic simply to stand back and allow the cynical and greedy to dominate any profession which deals with the poor, the uninsured and the homeless. It is imperative for physicians to take a broad view of today's problems in health care delivery systems, for they can have an enormous impact on the kind of world our children will inherit. It is essential for physicians to become involved in social concerns, and in improving health care delivery, at all levels in their practice. Given their power and prestige, it is crucial for physicians and aspiring physicians to have positive role models. Dr. Julius B. Richmond provides an admirable example of a physician who cares about his profession, his patients and his nation. Through his research, his public service and his teaching, Dr. Richmond has demonstrated the difference a single individual can make in improving the quality of life for all Americans.