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Author Information and CME Disclosure
Dorothy E. Stubbe, M.D., Associate Professor and Program Director, Yale University School of Medicine; Child Study Center, New Haven CT.
Dr. Stubbe reports no competing interests.
Address correspondence to Dorothy Stubbe, M.D., Associate Professor and Program Director, Yale University School of Medicine Child Study Center, New Haven, CT
“A good laugh and a long sleep are the best cures in the doctor’s book.”
Psychiatrists are experts in psychosocial interventions as well as psychopharmacology. Patients may be referred from primary care physicians or they may self-refer when their symptoms are more complex, more intractable, and/or more severe, as in the case, for example, of sleep disorders. Patients that have received a full medical workup for insomnia or other chronic sleep issues with no physical cause elucidated may be referred to a psychiatrist to help understand and treat this disorder. Patients often present to the psychiatrist expecting medication for the disorder or may already be taking medications prescribed by another physician that are not effective (1).
Sleep disorders are common. It is estimated that chronic sleep difficulties accompanied by daytime impairment range from 8%−12% of the adult population and the rate rises in prevalence across the lifespan and with co-occurring medical disorders. Sleep disorders may cause severe functional impairment in and of themselves, or may complicate the treatment of other disorders (2). The assessment and treatment includes close collaboration and effective communication among multiple providers to diagnose the often-complex interactions between medical and psychiatric predisposing, precipitating, and perpetuating factors underlying the sleep difficulties (3).
Hypnotic drugs are effective medications in the treatment of insomnia, but are often associated with tolerance, residual morning sedation, cognitive impairment or disorientation, and the potential for dependence and addiction. Their effectiveness wanes after several weeks of continuous use. Thus, psychosocial treatments are key to the chronic management of sleep disturbance. Effective interventions that are supported by evidence include sleep hygiene, restriction of sleep to nighttime, cognitive therapy to control presleep thoughts, and relaxation (1). These treatments require active therapeutic engagement of the doctor and patient in both the conceptualization of the problem and the treatment solution. For patients coming to the psychiatrist expecting only medication, and for those for whom compliance with regular daily routines and skill practice is more difficult, effective communication, psychoeducation, and skilled engagement are particularly crucial.
“Look,” Mr. Smith began before he made it fully into the office. “I’m all for sleep hygiene and all of that, but I still can’t sleep! We’ve got to go back to Valium. It’s the only thing that really works.”
Dr. Fernandez paused, thought for a moment as they both sat down, and then asked, “Well then, tell me what happened.”
“Well, for one thing, the sleep hygiene thing didn’t work. And second, the sleep hygiene thing didn’t work. What is it that you want to know?” Mr. Smith asked sarcastically. Dr. Fernandez knew that Mr. Smith could be difficult. His internist had referred Mr. Smith to Dr. Fernandez after completing a full medical workup. He told Dr. Fernandez that “You are good with this kind of patient. But, you should know that he ‘doctor-shops’ to find someone that will prescribe benzodiazepines.” Still, Dr. Fernandez believed Mr. Smith’s sleep problems were real—putting him at risk of losing his job if he continued to arrive late or fall asleep at his desk.
Dr. Fernandez started again, this time with a playful demeanor, “I think I am getting your gist. You seem to be telling me that the sleep hygiene techniques didn’t work for you. Yes?”
“Yes, you’re catching on pretty quick,” quipped Mr. Smith.
“Ok. So, let’s go through the whole story to pick it apart together. Spare none of the gory details,” replied Dr. Fernandez with a smile.
Mr. Smith related his experience with stopping caffeine by noon, not having his usual “nightcap” drink before bed, and using the relaxation breathing technique he had been taught. It was clear that Mr. Smith was having a difficult time adhering to all of the suggestions, and he quickly gave up when they didn’t work immediately. None of the suggestions had been adhered to as recommended. “And the melatonin didn’t work either,” Mr. Smith finished.
When Mr. Smith had finished recounting his negative experiences using nonpharmacological treatment of his insomnia Dr. Fernandez said, “You thought that stopping caffeine by noon and reading a book rather than watching TV may have been just a little helpful. Right?”
“Only a tiny bit,” replied Mr. Smith quickly.
“But you think that Valium is most helpful, but it stops working after a while.”
“Yes, but it’s the only thing that does work,” remarked Mr. Smith.
“How about if we try three things for several weeks, and see if that will help?”
“Which things?” Mr. Smith queried dubiously.
Dr. Fernandez wrote out the suggestions: (1) no caffeine after noon; (2) read until you feel sleepy and then go to your bed; and (3) I’d like you to try a different medication similar to Valium but faster acting. Zolpidem 5 mg––take it when you’re in bed because it acts rapidly. “Just check these off if you do them every day. Be honest, we want to really know what works and what doesn’t. What do you think of this plan?”
“I’ll give it a try. But, will you consider Valium if this doesn’t work? ”
“First lets evaluate how this whole plan works using all of these tools together. I think if we work together with all of the tools that are known to help insomnia, that we can help you sleep better every night.”
Mr. Smith smiled, and in an almost apologetic tone replied, “Ok, doc. Maybe you’re not as clueless as I thought. See you next week?”
Adherence rates to primary care physicians’ recommendations for all treatments average about 75%. For individuals suffering from chronic health conditions, adherence rates dip to 30%−60%. Chronic pulmonary disease, diabetes, and sleep disorders are examples of chronic health conditions for which adherence rates are low (4). Adherence rates drop even further with treatments that require a change in lifestyle and active practicing. Lack of adherence frequently lowers health outcomes, and may lead to more chronic or severe disorders over time. Common components of models of care designed to improve adherence rates involve interventions around health professional-patient communication, patients’ beliefs, and patients’ resources (5).
Barry and colleagues (6) described the importance of the matching of communication style between doctor and patient—specifically, matching the voice of medicine (the language and understanding of the physical medical problem) and the voice of the lifeworld (the multifaceted, contextualized, and meaningful patient narrative, which includes hopes and fears). They researched the communication styles of doctors and patients via patient interviews, doctor interviews, and transcribed consultations across 35 general practice case studies. Their results suggest that for simple medical problems (e.g., an ear infection) the doctor and patient may communicate effectively when they both use the voice of medicine exclusively (strictly medicine). When both doctor and patient engaged with the lifeworld, more of the patient’s personal agenda and concerns were voiced (mutual lifeworld) and patients felt recognized as unique individuals (psychological plus physical problems). This mutual communication pattern was less common than communication in which the doctor used the voice of medicine, but adherence rates were noted to significantly improve with mutual lifeworld conversations. However, patients were noted to be reluctant to voice their personal agenda and true concerns unless specifically asked, frequently placing the onus on the physician for beginning the mutual lifeworld discussion. The poorest outcomes occurred when patients used the voice of the lifeworld but were ignored (lifeworld ignored) or blocked (lifeworld blocked) by the doctors’ use of the voice of medicine. This happened most commonly for patients with chronic and/or nonspecific physical complaints. The analysis supported the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings (6).
A further component of compliance relates to the doctors’ ability to listen attentively, to demonstrate interpersonal fairness (7), and to accurately “read” their patients’ nonverbal behavior (8). Social and cultural variables may also play a role. Patients whose doctors are more sensitive to their nonverbal communication are more satisfied and have better health outcomes (8). A study by DiMatteo and colleagues found that the doctor’s nonverbal sensitivity was correlated with the patient’s sense that the doctor understood and cared about them (9). The patient whose doctor demonstrated high nonverbal sensitivity tended to like the doctor more and described the doctor as compassionate (10). In addition to enhanced patient satisfaction, doctors who were more skilled in interpreting patients’ nonverbal behavior tended to have fewer appointment cancellations, better overall patient understanding of the treatment plan, and greater adherence to treatment recommendations (9, 11). Evidence has accrued that physicians generally, but especially those that are of White ethnicity, have a more difficult time accurately interpreting the nonverbal communication of non-White patients. Missing or misinterpreting these nonverbal cues presents a barrier to full and accurate communication. This may negatively impact patient engagement and treatment adherence, and inadvertently contribute to racial disparities in patients’ satisfaction and health outcomes (8, 12).
The electronic medical record (EMR) has complicated doctor-patient communication. The need to enter the information obtained into the record may interfere with doctor-patient communication by decreasing the time of directly looking at the patient and reading of nonverbal cues (13). However, a study by Silverman and Kinnersley (14) suggested that physicians may learn methods to overcome the interpersonal distancing, both verbally and nonverbally, with which computer use is associated. For example, first talking to the patient without looking at the computer is suggested. Collaborative reading of the EMR, and completing the encounter notes jointly with the patient to ensure understanding and accuracy may actually contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care.
Although some physicians may come to the profession with attuned listening skills and a refined ability to read nonverbal cues, some do not, and probably all will benefit from practice. Physicians who are effective communicators have a 19% higher rate of patient adherence to recommendations than those who are less-skilled communicators (11). However, as DiMatteo and colleagues have described (4), physicians may significantly improve their communication skills through training. In fact, some medical schools have adopted a curriculum to help students “unlearn” automatic biases (15), practice cross-cultural understanding of facial expressions (16), and train in microexpression recognition of their patients’ nonverbal cues. These curricula have demonstrated positive effects in terms of medical students’ comfort levels with individuals of other racial backgrounds and appear to enhance cultural competence and the ability to connect with patients of all socio-cultural backgrounds (17). Psychiatric training emphasizes empathic engagement, and psychiatrists have been shown to exhibit better listening skills than nonpsychiatric physicians overall (18). However, skilled communication requires ongoing practice, with attention to ethnic and cultural, socio-economic, transference, countertransference, and projective identification factors as they relate to the therapeutic engagement of each unique patient. This engagement engenders authentic communication that may lead to improved adherence and more permanent positive behavioral change (18,19).
Explore and agree upon shared goals for treatment.
Articulate and agree upon the treatment plan/methods that will be used to meet the goals of treatment. Review and update this plan regularly.
Use a shared language—match the patient’s lifeworld (life narrative, hopes, and fears) or medical (biological explanation) speak.
Ask about lifeworld issues—expectations of treatment, hopes, fears, and attributions.
Listen carefully to verbal and nonverbal communication.
Practice reading nonverbal communication—particularly with patients of backgrounds other than one’s own. Ask the patient if these cues have been read correctly. Help the patient educate you about the meaning of his/her nonverbal communication.
When using an electronic medical record, look at the patient and ensure full engagement before turning to the computer.
Try jointly looking at the EMR and reviewing what you are typing into it to increase patient engagement, provide patient education, and ensure accuracy of information.
Address issues of patient adherence directly and in a nonjudgmental manner. Ask the patient to help you understand the barriers to adherence.
Pay attention to issues of transference, countertransference, and projective identification in the treatment relationship. Use this to understand “drug-seeking” behavior, nonadherence, and acting out.
Monitor your practice for patients that are nonadherent. Follow trends, diagnoses, and other patient similarities of those that are poorly adherent, and use this information to make practice changes to more effectively address adherence issues of these patients.
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