Wednesday, July 20, 2011

Clinical Encounters: The Psychiatrist as Patient to the Patient

I've been thinking we should start a Clinical Encounters series where psychiatrists can write in with cases and other psychiatrists could give opinions-- all anonymous, of course.  Clink and Roy aren't so sure this is a good idea (or they are sure it's a bad idea!) but I thought I would try a preview with my own confabulated encounter and ask for your insights---this one is open to everyone.  It's an altered version of something that happened to a shrink friend of mine many years ago, so while the details are disguised, the uneasiness of the situation is not.  

Dr. Mind is a psychiatrist in private practice who is having an embarrassing little problem and he goes to see a urologist.  He needs a procedure, something quick that can be done in the office on an outpatient basis.  In comes the nurse to assist Dr. Phallus, the urologist, and the nurse greets Dr. Mind with a smile.  Ah, she is a former patient of Dr. Mind-- the now very vulnerable patient who does not want this nurse/ex-patient of his in the room to have any part of his procedure or rather sensitive body parts.  He's in quite the pickle here: He's the patient and he has his feelings to consider, but he can't exactly divulge to Dr. Phallus, "Your nurse was my patient and I don't want her here"-- complete with any incriminating things he might know: she's got a drug problem, she told me stories about her treatment of patients that made me cringe...or she's a wonderful person but he just doesn't want her here.  

Your thoughts on how Dr. Mind should handle this?


aek said...

Straightforwardly. Ask to speak with the physician alone for a moment. Simply state "I know X from another setting and I prefer that she not attend my case."

rob lindeman said...

Seriously, this is a dilemma? What aek said.

wv = ononfun. What Onan had. With himself, of course. (Gen. 38:8-10)

Dinah said...

Perhaps it's a dilemma because of the setting: the psychiatrist doesn't have time to think and he's there in a vulnerable, compromised setting. He risks have the urologist say "I can't pull another nurse out of thin air and I need her to's a medical procedure and she's a professional." Or, "well how do you know her?" Sure, it's not relevant, but the urologist might ask it, and then what does the psychiatrist say? Or reveal by what he doesn't say.

Oh, there is no correct answer. Aek's is good. But seriously, this is a dilemma. And I thought perhaps it would be nice to have a conversation....

The Alienist said...

I like the question. I have often been uncomfortable when seeing patients outside my office. It's not that I am embarrassed to be their psychiatrist or that I think they should be embarrassed to be my patient. I simply do not know how comfortable they would be with some of my actions or questions. My first instinct and general rule is, "Treat them as you would treat anyone else you know." This works well under most situations. If more needs to be done, I like what aek said.

Still, many years ago I went to a packed cafeteria for Sunday lunch with my family. A patient of mine worked as a server in the cafeteria. I saw him and acknowledged him while we were still 15 - 20 feet apart and was prepared to let it go at that. Suddenly, I heard a shout from down the line, "Hey! It's my psychiatrist! I see him for my psychiatry appointments!" Sometimes, the patient's solve the problems for us. (We did have a talk about how he thought he handled the situation at his next appointment. He was fine with it.)

Sarebear said...

Since he may need to go to a urologist again in the future, he maybe could say that he needs to find another urologist; I'm not sure how he'd say it in a way that wouldn't offend this doc, or not give up info on the nurse, but he needs a different doc. Of course, if he really needs what he came in for to be done right then, postponing it won't work. I mean if you're a female in for a UTI, you're in so much discomfort and even pain that putting it off isn't an option; you need them to deal with it NOW.

Anonymous said...

This story frightened my poor penis.

Sunny CA said...

If I were Dr. Mind I would say, "I really feel awkward making a fuss about this, but Nurse Phallus is someone I know socially, so I would be uncomfortable being treated by Nurse Phallus." I would say "socially" because I would want to maintain Nurse Phallus's right to keep her psychiatric history a secret from her employer. I would not for that reason tell the urologist she/he was a patient of mine since that would violate psychiatrist-patient confidentiality. If the urologist insisted we use Nurse Phallus, then I would refuse to go forward with the treatment, but in no case would I show my private body parts to my former patient. There is always the possibility it would be upsetting to the former patient despite his/her professionalism on the job. Also, to show the private body part would make it virtually impossible for the ex-patient to choose to return to treatment in the future.

As a patient, I know that I would not want to be in Nurse Phallus's position and be forced to look at my former psychiatrist's "privates". Somehow it would seem like a violation of boundaries even in the setting you describe. I disagree with Rob Lindeman on this one. If I were your friend, the psychiatrist, such a situation would be terribly awkward.

aek said...

Thanks, Dinah, for the feedback and further questions. One thing I note is that you refer to him as the psychiatrist. Actually, in this scenario, he's not - he's the patient. In that role, he controls what and how much he shares with the urologist. There are several possibilities: the procedure is rescheduled to accommodate a different assistant; the patient chooses to see another urologist; the patient allows the former patient/nurse to assist; the urologist substitutes another staffer to assist or performs it without assistance.

As to the larger issue of acknowledging patients/treaters outside the clinical setting:

Treaters have the luxury of considering how they would lke to approach this and should devise a general policy about it and share with their patients at initial or early encounters. It seems to me on the face of it that it is an area ripe for negotiation and flexibility.

Patients who have questions about this should feel comfortable in discussing their questions and preferences with the treaters.

One clinical researcher I know would share the policy and real life "how this works" with study participants at the outset, giving control to participants to acknowledge/contact researchers and treaters outside the clinical setting, but explaining that the researchers and treaters would never initiate contact or acknowledgement.

They report great satisfaction and little confusion. What says the group here?

aek said...


I don't believe you mentioned it, but the patient might also have concerns about what clinical information his former patient/now nurse would have access to, so the notion of considering switching docs might not be too far-fetched if treatment urgency and other clinician availability aren't primary issues.

Angela said...

I love this idea. I hope you keep doing it.

Sunny CA said...

My psychiatrist did discuss the issue of accidentally running into each other outside the office with me early in our sessions. Once we knew we'd be at the same jazz concert with a relatively small audience. My date already knew I saw a psychiatrist and I forewarned him that my doc would be there. After the concert I introduced my date to my psychiatrist and my doc introduced his companion to me and the four of us chatted briefly. As the Alienist did, my psychiatrist asked me at the next session if I was OK with the interaction. I was and he was.

I had a therapist once who did not discuss the possibility of encountering each other and I ran into her twice. She pretended I was a wall; not even there. The first time was at a Greyhound Bus Depot as I was traveling home to visit my parents from college. I warmly said "Hi!" and she coldly turned away from me as though she had not seen me even though we both appeared to be alone. I felt insulted.

I am glad my current psychiatrist is willing to be cordial. Still, I would not want to be his nurse in a urology office, handling his private parts.

Anonymous said...

I think the psychiatrist/patient should just wear it. Use the experience to remember what being a vulnerable patient is all about.
As a doctor, I would happily treat my psychiatrist for medical problems.

Anonymous said...

I believe the professional onus is on the former patient, the nurse, in this scenario, to tell urologist that she partners with that she cannot treat him because she knows him in another context and that she would be violating his confidentiality to treat him at all--given the nature of urology. Or she could have the urologist approach the patient and ask him if he is comfortable having Jane Doe, RN treat him as she has disclosed that she knows Dr. Patient Mind from another context. This should preferably be done in advance by phone. (I am sure a prior auth had to be gotten for a procedure from the insurance company.) If Dr. Patient doesn't remember her name and doesn't look up her name in his records and consents only to be shocked when procedure day comes he see her then remembers her he will have had his own teaching moment. If the urologist asks how Dr. Mind knows Jane RN he is violating HIPPA (and, inadvertently-?- employment laws about medical treatment privacy)and should be reminded of this by Dr. Mind before he transfer his care.

Anonymous said...

This is very interesting in its own right, but also because the choices opne to Dr. Mind would not be available if he were to lose it (his mind, not his phallus) one day and ended up in a psychatric ward for an involuntary, up to 72 hour stay. Dr. Mind could be locked up with a nurse who may have been a fomer patient or even a current one. The nurse could/should ask that another nurse take over but would still know all about Dr. Mind's stay in the way that everything is open on a psych ward or in an ER setting. I wonder which Dr. Mind would choose, having the former patient as a nurse in a urology setting or in a psychiatric setting.

Dinah said...

I think you all are generous in believing the urologist would be sensitive to the patient's wishes, or that there might be another nurse available to take over, or that the urologist might have provisions in place for patient discomfort with his staff. I don't.
I think the urologist might be sensitive to "this is my psychiatric patient and she's told me stories of being vindictive and she's on lots of medicines, and I don't want her seeing my genitals or being involved in my care." I don't imagine he'd care that there was a social connection (docs treat friends all the time, it's a medical procedure not a romance) and I think he'd be angry that a procedure was being disrupted for this---unless there was another nurse who could step in or there was a way for him to easily do the procedure alone--otherwise I think this shrink has to find a new urologist. Is there a uro-blogger we could ask?
Re: shrink should eat it and see how it feels....I think if the assistant were a man, or if it were a very-ex patient with no bad karma, that may well happen.
Re: What if it were a psych unit: boy do I have stories.

Maybe my next post.

Anonymous said...

I guess the fact that Nurse Phallus is an ex-patient and not a current patient makes it less awkward for everybody. I think the psychiatrist needs to speak up (without revealing too much) or put up with it and allow the former patient to be in on his procedure.

My own shrink doesn't seem to want me to have any outside viewing of him. Once a cop came into the office because a silent burglar alarm code had gone off that morning when the shrink opened up and the cop demanded my shrink's date of birth so that he could report the incident as ppproperty owner's slowness to enter code. The shrink insisted that the cop follow him around a corner and out of my earshot before he'd give out the info. But another time, my shrink just happened to telephone my place of work to ask for a colleague (on a matter relating to a client) and I disguised my voice rather than say, "That's my shrink on the line! How are ya, Doc?"

Anonymous said...

This happens to people more often than one might imagine. Psych unit question aside, would Dr Mind, have a problem with his next door neighbor as the nurse, or his child's teacher or his ex girlfriend and so on? Probably. Is the real issue that this nurse is a former patient? What if Dr. Mind were Dr. Ear Nose and Throat? Could he tolerate exposing himself to a former patient?
If Dr. Mind has not peed in 2 days, guaranteed that he will let the former patient nurse assist. It is kind of like a woman in labor. If he can hold out, he will go see another urologist. Funny that the urologist is Dr. Phallus since women see them too. Could be penis envy, could be kidney stones or cancer, but they do.

Sarebear said...

This isn't like the situation describedf, as I'm not a doctor and the nurse treating me obviously wasn't a patient or former patient.

BUT. (lol) I think it is similar enough in some issues, to relate.

When I was in the hospital for one of my knee replacements, one night a male nurse comes in as I'd rung for a nurse to help me get out of bed and get to the bathroom. It was late in the day of surgery, so of course I needed assistance.

The male nurse who came in came in and then stopped suddenly, at the foot of the bed, and greeted me as if I should know him. He looked familiar, but I couldn't place him. He said, "I'm _*****, your husband's cousin." I then realized who he was, and which Aunt he belonged to, and I said so.

He then came over to the side of the bed where I get out and he started helping me, all the while chatting in a friendly way, more familiar than a nurse who is a stranger to me.

As he approached me, I froze; I thought, "He's going to see my BUTT! OHMYGOSh what do I do? My husband's cousin, MALE cousin, is going to see my behind!"

As thoughts raced through my mind in the very short time it took him to get to me at the side of the bed, I realized that, well, he sees butts all day, and in the end (no pun intended) what's another rear to him anyway? I also saw that he was very kind and taking his job seriously and professionally (although since he knew me, he was using a manner more familiar than would be done with other patients, but I could still see him doing his job) and so I figured since he wasn't making a big deal of it, I wouldn't either.

Then of course he was helping me, both there and back, and we talked a little more (nurses are busy, so it wasn't long).

Aboutt 15 minutes later, another male nurse came in and, it seemed, had been told by the cousin that he was related to me and how. This male nurse that came in asked if I'd like the cousin to be removed from responsibilities of caring for me on his shift, since of course it could be awkward, and I said no, since the horse had already left the barn.

I did though have a feeling of, "I wish they'd thought of that 15 minutes ago!" but, in the moment when it first happens, I think my cousin was taken with surprise it was me, and concern for me since of course I was in pain and such, and he was filled with the urge to help me, to be of assistance, ESPECIALLY because we were related, and that it would take a bit for other ramifications to sink in for him. I do not think he was being insensitive at all.

Anyway, like I say, I believe there's some similarities to th e situation in this post, and then of course there's obvious differences.

I just thought it might highlight some similar issues.

jesse said...

Sarebear, hindsight is always 20/20, and your cousin-by-marriage later thought if he should have asked you if you were comfortable with him proceeding (at the least his cohort thought that, so they likely had discussed it).

Your relative was caught in the dilemma between being strictly professional, which allows the patient to more comfortably reveal otherwise consealed anatomy, and being warmer and more overtly welcoming, which was more appropriate socially. The anxiety you felt is very understandable.

The nurses were very professional and kind, but you can imagine how difficult it might be at the next family gathering if the situation were psychiatric.

Sarebear said...

Yes, I can imagine that. Actually, since I haven't seen him since, it might be awkward. I ended up deciding, well I'm sure he doesn't go home and regale his wife with stories of everyone's anatomy; I'm sure he'd treat me with respect that way, as well as regarding the personal medical info in my chart and in the computer. I figured he could get in trouble if he didn't treat that with privacy, not that I thought he'd violate that particular boundary.

Still, I imagine feeling something wierd the next time I see him, lol. Psych would have made it much worse (although thinking about it now, I don't know if he found out my psych diagnoses and meds and stuff from my chart; I keep everyone not immediate family in the dark about that stuff . . . hmmm.)

jesse said...

yes, Sarebear, again that is the reason for the concern about the electronic medical records and what they contain or don't. I suspect that psychiatric records will continue to be bowdlerized further from where they already are as psychiatrists learn to write down only the most descriptive and least "personal" personal information, but it is still a major concern.

Anonymous said...

I've run into my therapist (a SW) on the way to sessions, etc. She knows me so we say hi and it's no big deal. Once I saw a fellow patient, however, at a professional exam prep class and she came up to me and asked me not to share that I knew her through the therapist's office. I didn't know her that well and I wouldn't do that anyway but I was pissed at her assumption that i would. I saw a recent shrink outside the office and said hi. She gave me a cold 'hello' back, although she was speaking w/ someone else so it may be that. I just Deal if it occurs. Shrinks put their pants on the same way I do.