The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
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In this section, we will highlight some of the essential basic principles of examining a patient with mental health problems. Each encounter with the patient is an opportunity for the treating physician to establish a rapport as well as further cement the therapeutic alliance, a kind of working relationship, with the patient as well as the main caregiver and/or the next of kin chosen by the patient.
Each medical student, newly graduated doctor and other health professional will develop their own personal methods of communication with their patients, which work for them in all aspects of their clinical work. The basic principles of respect, privacy and dignity for your patient must be maintained at all times. The patient must develop that “belief” in you that you care for him/her; that you will go an extra mile to help and support him/her and more significantly, you are honest and caring and accessible to them, especially when they really need you. At the same time, you must maintain respectable distance and boundaries for yourself as well as dignified space and boundaries for your patient. Yes, you are available for your patient, and your are a hard working honest person and your main concern as a doctor is your patient’s welfare, but you must never compromise with your own professional etiquettes and respect and dignity for yourself.
From here on, what follows is the method and approach that has worked well for the author in the last four decades in taking history and mental examination from a patient with mental health disorder, which you may modify to suit your own style and your clinical practice.
Your first concern should be where you should see your patient. Finding a suitable area/room is very difficult in our NHS facilities. It is more difficult if you have been asked to see a patient as an emergency in Accident & Emergency or a surgical ward. Most recently, I had to visit a patient in a local police cell, where the patient was strapped by two hefty leather belts and held down by two strong police officers on the floor. Here, I could only ask the officers to loosen the belts, ask the patient to sit up and offered him a glass of water before I could begin to talk to him. Hence, the first principle is, interview the patient when and wherever he/she could be made most comfortable in a given situation. It is always easy if you have been asked to visit a patient at home, usually an older person who cannot travel to your consulting rooms. There, it is the patient who decides in which room you can interview him/her. But in a hospital setting, it is your responsibility to find a suitable room, which will always be difficult. However, we all have to learn to live with our limited resources. Fortunately, in some clinical settings, there are clearly specified rooms available for medical consultations, so please book them in advance otherwise, at the last minute, you will find that the room is occupied by someone else.
There is nothing more upsetting for a patient than to wait for the doctor to be called in for the consultation. If you are running late for any reason, it is courteous to let the patient know how long it would be before you can see him. A wait becomes more tolerable if the patient knows how long he/she has to wait. A comfortable waiting room with some privacy always helps but this is not a norm within the NHS. Facilities for bathrooms, hot & cold drinks will help but not always available.
If you have found a room to interview your patient and you are on time, you are doing well. The next step is to fetch your patient from the waiting area. It is always courteous and pays in establishing the essential rapport with your patient, if you yourself fetch the patient to the interview room rather than asking a secretary or nurse to send them in. It may not always be practical in General Practice setting, but if one is able to follow this principle, then they will realise that it has its benefits for both the doctor and the patient. For the doctor to be on his feet between patients for his personal health reasons and for the patient and his caregiver to see the doctor in a more informal manner. Take this opportunity to ask the patient if he would like his accompanying relative to join him in the consulting room or should they be invited in towards the end of the interview for the final briefing about he patient’s diagnosis and management plan. The involvement of the family members and others (only with the patient’s consent) is very important in all branches of medicine and especially in psychiatry, where the relatives would like to know the outcome of the proposed treatment and whether there are any risks to the personal safety of the patient or to others and whom they can contact if all does not go as planned and hoped for.
The patient is seated first, then any other person who has been invited in by the patient to accompany him and finally the doctor takes his seat. Both the patient and the accompanying person are seated on the right side of the doctor without a desk separating the doctor and patient. After the initial greetings, check the patient’s personal details such as name, date of birth, address and GP details. Then introduce yourself and clearly state the purpose of the interview, who referred the patient, and approximately how long the interview is likely to last. At this point, I often mention that if we were unable to complete the assessment today in the allocated time, then how soon I would be able to see them again (usually within 2-3 days) to complete the assessment, and also gather all other data that I may need from other health professionals, medical notes, etc. Once again, patient’s consent is taken to contact others regarding his/her health issues. The next step, which I often practice, is to offer tea, coffee or a glass of water and be prepared to get it yourself, if needed. Within the NHS out-patient clinics, the receptionist or the clinic nurse is not expected to make drinks for the patients. I, as a routine, would make my own tea or coffee at the beginning of the clinic, but would not drink it as a rule, if the patient does not have a drink.
To relax the patient and also yourself, you ask some open-ended questions such as:
All the above are asked only if appropriate.
The next step is to talk about his/her emotional health issues. Follow the standard schema as outlined in History Taking in Psychiatry – 2 section. However, your role is to ask the right questions to elicit the history; listen; facilitate and respond appropriately to the verbal and non-verbal expressed emotions and answers of the patient; react empathically without making a judgement as to how the patient is feeling; aim to understand the patient’s feelings and suggest “how difficult it has or must have been for them,” etc. Never try to rush a patient to talk about their current problems in detail if they are not willing or ready to do so.
Take a hint from your patient and move on to the next part of the history, which is less traumatic and can be described with ease. Say something to shift to another topic, such as “I know it is difficult for you to talk about it now,” or “Let us leave it for the time being and we will come back to it later,” etc.
This is the opportunity to take a family and personal history. While discussing the personal history, be mindful of the others’ presence in the room and this may be the opportune time to ask the patient once again whether they would prefer to talk to you by themselves or happy for the accompanying person/s to stay in the room. Often the relatives themselves would suggest to the patient to talk freely and openly to the doctor and offer to leave the room for the duration. Always take the hint from the patient as to what they would prefer. Often, after the first consultation (or first few), the patient himself would request to see the treating doctor on a one-to-one basis. This happens when the patient trusts the doctor. The treating doctor must not unnecessarily create a wall of “confidentiality” for a patient from his/her loved ones if the patient has no problem by being accompanied by them. Sometimes the patient’s relatives would request to see the doctor privately away from the patient, and here one should take each case on its own merit. For example, a case of Paranoid Schizophrenia may never allow his family members to see his doctor, but it is important to obtain an independent account of the patient’s illness and behaviour outside the consulting room. It is appropriate to discuss the patient’s illness in private to gain further understanding in patient’s presenting problems and behaviour, as long as you do not breach the patient’s confidence in you and disclose anything to the patient’s family/next of kin until you have the formal consent from the patient to do so.
As the interview progresses, take a brief moment to summarise all the relevant information out aloud simply to check that you have understood correctly the patient’s description of his/her problems. It is also useful to understand clearly the patient’s wishes and his expectations from the doctor and how he/she would like to be helped.
Remember, sometimes the patient may not wish you to communicate even with his referring doctor or the family members who accompanied him to the consulting room, and you should respect that.
As stated earlier, you have to float backwards and forwards when asking the relevant question in order to elicit the key signs and symptoms of presenting problems, gather all the relevant information and also complete the Mental State Examination in your first meeting with the patient. The first interview would at least provide you with the primary/principal working diagnosis and that would follow you management plan. Sometimes, you do not have every bit of the information needed for various reasons. Sometimes the patient is uncooperative while on other occasions, you failed to ask the right questions and also you ran out of time due to various unavoidable reasons and most commonly, that you are faced with a difficult and uncontrollable patient who preferred to talk only about his “psychic powers” and condemning all members of the family and health professionals that they have met and seen in the past. Cases like these need direction and transition statements. It is very difficult to acquire this particular skill of keeping the patient on track and focussed on the key issues of your examination. Do not despair. You will learn as you progress in your career.
I have sat with medical students in their first clinical examination in psychiatry and neurology and felt sorry for them that they are given only six minutes to take history, carry out mental state examination, formulate their case and thoughts and do it all in front of the examiner, and furthermore, it is not only the examiner who marks you but also the patient. It is not fair but we have all gone through the same journey. It is the attitude and skills that we, as examiners are interested in and also the knowledge (clinical observation) that helps you to ask the right questions and finally, and most significantly, how you empathise with your patient. A firm and final clinical diagnosis is often made much later, after you have all the relevant history and investigations results.
For me, this part of the interview is as important as the beginning of the interview. In fact, in my practice, it is more important. Some basic principles must always be followed for a satisfactory closure of your first and subsequent consultations with your patient. Once again your communication skills are being tested here and if your prefer, you should have some standard written information for the patient and their families to take away so that they may read it in their own time.
Before we get on to the specific principles of finishing the interview, please always follow the basic principles of all meetings and consultations and that is keeping to your time. If the agreed time at the start of the interview is up, then you have to stop the consultation in a polite manner. Overrunning the time with one patient will delay every other patient in the clinic and it does not serve any useful purpose in the long run. As a student of medicine, you have to practice being always on time for all your assignments as well as for your patients and learn to finish the interview a few minutes prior to the earlier agreed time.
The last few minutes must be spent in discussing the following:
Please make sure that the patient is aware of all the telephone numbers during and out of office hours, so that they can contact someone in case of emergency.
The success or failure of your treatment outcome often depends upon your follow up arrangement and how accessible you are in case of emergency.
The next section deals with the Mental State Examination in Psychiatry
Author:
Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent