When I was in PA school, one of my favorite classes was Clinical Assessment.
What made this class so great? First, I was lucky enough to have a couple of amazing teachers. One was the kind of teacher who rolled into a 5pm class with a giant Dunkin Donuts coffee – full of jokes and ready to impart whatever real-world, inspired-by-real patients knowledge he had on us. The second reason I loved this class was because it was where we learned to perform a patient history and physical exam.
This professor used to say that patients know what’s wrong with them, and it’s the PA’s job to ask the right questions to sniff it out. I loved how he framed this because it made history-taking feel more like being an investigative journalist and less like running through a random checklist of symptoms and questions. The longer that I’ve practiced medicine, the more pride I feel in the expertise it takes to connect patient-reported symptoms from a checklist to creating a fully-formed list of differential diagnoses.
In psychiatry, though, this expertise can be a trap.
Miller & Rollnick discuss how assessment – even the process of client intake – can create a power hierarchy and places clients in a passive role. The implicit assumption of asking the right questions to make the right diagnosis so that I’ll be able to tell the client what to do only offers superficial solutions. When people come to us in emotional pain and confusion, the diagnosis matters much less than helping the client understand s/he is the expert in themselves and their feelings and is the source of their own solution. Providers who use question after question may be doing so as a coping mechanism to quell anxiety – either their own, or the clients’ – by retreating to this predictable power structure. Firing off questions to a patient can suggest “I’m the expert and the one who’s in charge here”, and it also indicates that if enough of the right questions are asked, then the expert will generate the correct cure. As Miller & Rollnick write, “this might work for a sore throat … but part of good motivational interviewing is knowing that you don’t have the answers for clients without their collaboration and expertise.” (p. 42).1
I recently received a referral for a patient who presented about 6 weeks postpartum. She had not slept well in over a week, was tearful and anxious, and was on the verge of a self-described “mental breakdown” due to the stress of mothering a new baby, postpartum depression/anxiety, and sleep deprivation. In the same breath, she also voiced her complete opposition to taking any and all medications. This includes zoloft, which is a first line treatment for postpartum depression and anxiety. The physician assistant in me wants to be the expert: I want to diagnose the patient and provide treatment. I want to fix it. Anyone who’s wanted to vent to a significant other about a stress or anxiety in their life knows how ineffective this approach is: we don’t want a practical solution or fix, we want to be heard. The desire is one for emotional support.2
As a physician in a dual role - as clinician and counselor - my duty is to support this patient’s desire for change.
There are many ways to support change in others, but one of my favorite techniques is simply to ask “What now?” or “What else?”. This is a form of replanning.3 Most goal-oriented tasks consist of small steps that build upon one another in a specific direction. When there are setbacks or unexpected obstacles, approaching the dilemma with an attitude of curiosity can open just enough space for the patient to explore, create their own solutions, and safely experiment with different scenarios. In the case of the patient with postpartum anxiety, she was able to come up with a list of possibilities that didn’t include medication – such as using meditation apps, asking for more help from friends and family, creating a sleep ritual – that allowed her to move forward.
I’m proud of my training in the medical model, but effective psychotherapy requires a less algorithmic and more organic approach. One of the things I love about how I’m able to practice is that I have the time to create space and set aside the checklists. Patients do know what’s wrong with them; turns out, they know the cure, too. What an honor to help facilitate their discovery of it.
REFERENCES
- Mollnick, W., & Rollnick, S. 2013. Motivational Interviewing: Helping People Change. 3rd ed. Guilford Press, p.40-44.
- https://www.psychologytoday.com/us/blog/skills-healthy-relationships/201606/stop-trying-fix-things-just-listen
- Gutierrez, D; Fox, J; Jones, K; and Fallon, E., The Treatment Planning of Experienced Counselors: A Qualitative Examination (2018). Journal of Counseling & Development, 96(1), 86-96. https://doi.org/10.1002/jcad.12180
