Background (100-030-001-0) Avital and Tami
The patient, Mrs.Katz, age 65, was recently widowed when her husband with chronic kidney failure died unexpectedly.
Mrs Katz has a lifelong burden of loss, being the daughter of holocaust survivors and the sister of a fallen soldier. Her two children are not very close to her geographically or emotionally.
Despite that background she has always functioned well and was known in the local medical clinic for her general cheerfulness and her regular holiday gifts to the staff. However, she is now overwhelmed by her husband’s death and can’t see how she’ll manage without him- including how she will run their small business on her own.
At her daughter’s suggestion she approaches her family doctor for a prescription for 20 sleeping pills.
The action
The doctor is empathetic and conveys sincere caring for the patient’s pain and difficult adjustment ahead.
The doctor shows awareness of the need of the patient for psychological support; and when it appears that the family can’t provide it she wisely recommends a referral to a psychologist.
The doctor argues that just ventilating has a cathartic and therapeutic benefit. However, in the end, the doctor fails to get her to agree on a psych referral.
The doctor acquiesces to the request for sleeping pills as a good idea with no discussion or warnings.
Educational opportunities
- The importance of Milestone #2 : arriving at a shared agenda Why the patient didn’t agree to the psych referral is mainly because there was no joining of doc-patient on the definition of the problem and the goals of the treatment. (Milestone #2) One problem was depression, and one was an adjustment problem related to her helpless without her husband at work (eg her repeated “I’m alone”, “ I don’t know how I’ll manage”, etc.). Had these problems been made explicit it would have found it easier to recruit the patient for a program that included a referral to a psychologist to solve each of them.
- Discuss “empathy”: In what way was the doctor empathetic? [body language, encouragement etc.] and in what ways could she have been more empathic? [Reflecting and relating to the patients emotions explicitly, Exploring her clear cues about her loneliness and helplessness, etc.]
- Discuss the issue of the sleeping pills: This can be discussed under the heading of “handing –over”: What are the essential elements in any handing over of a diagnosis and treatment plan? What do the terms “safety-net “ and “patient contract” have to contribute to this discussion? In what ways did this doctor’s handing over fulfill these elements and not? It can also be discussed from the point of view of expectations and of setting-limits according to the formula R3 NO2 Ad2.
- Clear example of Miller’s Rule: if a patient repeats himself a third time check out what you haven’t heard the other two times”
