Humor as Used in the Doctor-Patient Relationship: Constructive and Destructive(2)

I wondered whether humor in psychiatric practice was a useful tool in the psychiatrist-patient relationship or whether there were special concerns with its use as compared with the use in general medical practice.

Psychiatrist Shrinkette covers this issue on her blog and has responses from some visitors on how they look at humor in psychiatric consultations. In addition, Shrinkette wrote me e-mail stating, in part, her view:

"...what's different about psychiatry is that the relationship between psychiatrist and patient becomes fodder for understanding the patient's life and symptoms. People respond to us as they've responded to other important figures in their past (it's called transference). So humor becomes one more variable to interpret.

Another difference is that sometimes patient's symptoms can include
extreme humor (manic patients, for example). We're supposed to model
appropriate behavior, and that means not cracking up at their stream of
manic jokes (if the whole session consists of the patient joking and me
laughing, that's not therapy!) But sometimes we can soften an
important message to a patient with a little joking (at least we hope
so)."

Thanks Shrinkette. ..Maurice.

Parental Medical Decision Making: In Whose Best Interest?

I indicated in my last post that the in evaluating the ethics of the parental medical decision-making scenarios I presented, the goal would be in terms of the best interest with regard to the child patient. However, this goal may not be the most realistic and most just in this situation.

A 1985 article in the Journal of Medical Philosophy (vol. 10, nr 1, pages 45-61 ) titled ”Parental discretion and children's rights: background and implications for medical decision-making.” by F. Schoeman raises the issue of in whose best interest should parental decision making for their children be considered appropriate by law and society—only that of the child involved or of the child, parents and the family as a whole. The abstract of the paper is as follows:

”This paper argues that liberal tenets that justify intervention to promote the welfare of an incompetent do not suffice as a basis for analyzing parent-child relationships, and that this inadequacy is the basis for many of the problems that arise when thinking about the state's role in resolving family conflicts, particularly when monitoring parental discretion in medical decision-making on behalf of a child. The state may be limited by the best interest criterion when dealing with children, but parents are not. The state's relation with the child is formal while the parental relation is intimate, having its own goals and purposes. While the liberal canons insist on the incompetent one's best interest, parents are permitted to compromise the child's interest for ends related to these familial goals and purposes. Parents decisions should be supervened, in general, only if it can be shown that no responsible mode of thinking warrants such treatment of a child.”

Do you agree that parents who make medical decisions for their child also have the responsibility to consider the decision in terms of their entire family and not solely in what is in their sick child's best interest? How should possible conflicts of interest in this situation be evaluated and handled? ..Maurice.

Now Its Time to Take Ethics Quiz I

From Associated Press today: “CORPUS CHRISTI, Texas -- Child welfare officials seized a 12-year-old cancer patient from her parents, saying they were blocking radiation treatment that doctors say she needs.” With this story in the background to show how society can affect parental medical decision-making, let’s all take an ethics quiz using 3 variations of a different scenario.

Scenario 1- Both parents of a 12 year old son, who has already received two courses of very symptomatic chemotherapy treatments for a fatal cancer condition without improvement, are informed by the boy’s physicians that another treatment is “medically indicated” but the chance of response and improvement is only one in ten and may be much less. The physicians insist on attempting one more course, however both parents feel the toxicity to their child will be too profound and refuse to approve the therapy. The physicians want the court to take custody of the child if the parents refuse.

Scenario 2- Same as Scenario 1 but the son when informed by the physicians that he may die without another course of chemotherapy does not give assent to the treatment.
He explains that he doesn't want to experience the terrible symptoms he had with the previous treatments.

Scenario 3- Same as Scenario 1 but there is parental disagreement: mother approves another course and the father refuses. The son when informed that he might die without another course of chemotherapy does not give assent for the same reason as in Scenario 2.

Write me your comments about what you think is the most ethical resolution of each of the three scenarios if the goal of the decision-making is to provide care in the best interest of the 12 year old patient. ..Maurice.

Humor as Used in the Doctor-Patient Relationship: Constructive and Destructive

As a followup on my previous post presenting doctor jokes and their meanings, I would like to extend the thread to an excellent paper titled “Humor in the Physician-Patient Encounter” by Jeffrey T. Berger, MD; Jack Coulehan, MD, MPH; Catherine Belling, PhD published in the Archives of Internal Medicine 164: 825-830:April 26,2004. The therapeutic but also the possible negative effects of humor in doctor-patient relationships is discussed. Empathetic humor is advised: “Humor in medicine, however, may also be grounded on a recognition of the human condition that is shared by patient and provider. Such humor relies on empathy and compassion rather than on irony and avoidance. It embraces rather than excludes.” Examples of constructive but also destructive humor to the relationship by both the physician but also by the patient is presented. An excerpt of a concluding guideline to humor in clinical practice follows:

Useful parameters for humor in the therapeutic relationship include the following:

• The physician should be assiduously
conservative in selecting the
content and manner of humor, because
patients are often intrinsically
power disadvantaged and may feel too
inhibited to express their disapproval.
Encounters based on empathy,
respect, and authenticity diminish
the perception of power imbalance
and facilitate a deliberative model of
the physician-patient relationship.
While humor may assist in this process,
poorly selected quips or comments
may also distance the physician
and serve as a barrier.
• Gently self-deprecating humoror
externally focused humor(eg,
weather or parking) carries the least
risk, in terms of miscommunication,
especially when the physician’s
relationship with the patient is
not well developed. In such situations,
a joking comment humanizes
the physician and is unlikely to offend
the patient.
• To minimize the impression
of flippancy, the physician should not
rely exclusively on humor as a mode
of communication during a physician-
patient encounter.
• Physician-generated humor
should be grounded in empathy; ie,
the physician should have a relatively
accurate understanding of the
patient’s values, limits, predispositions,
and receptivity.
• The physician should be
receptive and respond in kind to
the patient’s attempts at constructive
humor.
• To clarify the patient’s
meaning and to help resolve anger,
confusion, or other barriers to trust
and continued communication, the
physician should directly confront
inappropriate or destructive
patient-generated humor.

I hope you all have a chance to read the entire article. I can tell you that I am going to make this article reading and discussion fodder for my first and second year medical students as they learn how to relate to patients. Where I teach, humor, as an element of patient interaction, has not been a point of discussion for these student groups in the past. Do any of the physician visitors to my blog recall this topic in early medical school teaching? Also how do you use humor in your practice? ..Maurice.

Note: Thanks to primary author Jeffrey Berger, M.D. for making me aware of the article and permitting this posting.

Doctor Jokes and Their Meaning

Many doctor jokes have a meaning or reality as their basis. That is why they are worth reading and chuckling over since that reality is what makes them funny and something we can learn from them.

Here are a few and you can read a whole lot more if you go to globalfamilydoctor.com Each joke is followed by my own "thoughtful" comment. By the way, if you think of a better astute comment than I posted, let me know. I hope you find the jokes as funny as I did. ..Maurice.
***

A young GP notices that all the doctors in the surgery are relatively bright first thing in the morning, but all, except one, look frazzled by evening. The one exception is an older GP who always appears fresh and happy. The younger doctor is keen to know if it is his attitude, life outside medicine, certain skills in handling people, a different range of patients and problems, would it be worthwhile sitting in with him during consultations etc. During these thoughts, he notices the other doctor in the car park and decides to seek advice.
"I get worn out from listening to people's worries and concerns and sad stories all day. What is your secret for remaining so fresh?"
The older GP smiles and says: "I never listen!"
(My comment: The difference between a technician and a physician.)
***

Margie received a bill from the hospital for her recent surgery, and was astonished to see a $900 fee for the anaesthetist. She called his office to demand an explanation.
"Is this some kind of mistake?" Margie asked when she got the doctor on the phone.
"No, not at all," the doctor said calmly.
"Well," said Margie, "that's awfully costly for knocking someone out."
"Not at all," replied the doctor. "I knock you out for free. The 900 dollars is for bringing you back around."
(My comment: Patient’s aren’t always aware of what physicians do.)
***

Waiter to GP at a modern pharmaceutical company sponsored educational meeting: "How did you find your steak, Sir?"
GP: "I looked under a mushroom …. and there it was."
(My comment: The companies are learning.. but wasn’t that mushroom a black truffle?)
***

Three GPs were on their way to a convention when their car got a flat. They got out and examined the tyre.
The fist doctor said, "I think it's flat."
The second doctor examined it closely and agreed. "It sure looks flat."
The third doctor felt the tire. "Mmm, yes. It feels like it's flat."
All three nodded their heads in agreement. "We'd better run some tests."
(My comment: In medicine uncertainty trumps observation.)
***

George went to his doctor complaining that he was no longer able to do all the things around the house that he used to do.

His doctor took more history, performed a thorough examination and ran a gamut of tests. When he returned for follow-up, George said, "Now, Doc, give it to me straight. I can take it. Just tell me, in plain English, what is wrong with me."

"Well, in plain English," his doctor replied, "you're just plain lazy."

George paused. "Okay," he said, "Now give me the medical term so I can tell my wife."
(My comment: Sometimes plain English is better understood.)
***

A college professor was explaining a particularly complicated concept to his class when a pre-med student interrupted him.

"Why do we have to learn this stuff?" the frustrated student blurted out.

"To save lives," the professor responded before continuing the lecture.

A few minutes later the student spoke up again. "So how does physics save lives?"

The professor stared at the student without saying a word. "Physics saves lives," he continued, "because it keeps the idiots out of medical school."
(My comment: Maybe there is a better way.)
***

The psychiatrist said to his nurse: "Just say we're very busy. Don't keep saying 'It's a madhouse.'"
(My comment: All those in healthcare have to think before they speak.)
***

The GP met Fred back in the consulting room following further history, review of investigations and specialists letters and further examination and said, "Fred, I have some good news and some bad news."
"Oh, no. Give me the good news first, I guess," Fred replied.
"I'm going to name a disease after you."
(My comment: ..and the bad news is more importantly “there is no treatment”.)
***

GP interviewing potential new associate: "For a doctor with little experience in general practice, you are certainly asking for a high salary."
Applicant: "Well, the work is much harder when you don't know what you're doing!"
(My comment: Honesty is the best policy.)
***

A GP asked a medical student, as they discussed a patient's management:
"What would you do if you were in my shoes?"
"Polish them!"
(My comment: Patients pay attention to the whole doctor.)

Ready for more? Just go to the link above.

Need to Determine Medical Decision-Making Capacity: Surrogates as well as Patients

There is more work for the physician to do when attempting to establish a medical decision for a patient who is incapacitated to make decisions but who has a surrogate, designated or not. The physician must now determine whether the surrogate has the capacity to make a medical decision for the patient. Specifically this means whether the surrogate is cognitively, medically and emotionally able to make a decision as honest substituted judgment or in the true best interest of the patient, free of self-interest or other various conflicts of interest. [A substituted judgment is the act of making a decision based on knowledge of the values and preferences of the patient and not what the surrogate would have wanted if they were in the patient’s position. If these are not known, then the surrogate must make a decision in the patient’s best interests, that is, a decision that would most likely contribute maximally to the patient’s benefit or what an average, reasonable person might decide.]


K.A. Bramstedt writing an article in Internal Medicine Journal 2003; 33: 257–259 titled “Questioning the decision-making capacity of surrogates” gives an example of her own experience and discusses the approaches to deal with this responsibility. Interestingly, she points out, in the following excerpt, the weakness of substituted judgment by the surrogate. (Her resource references are deleted in this excerpt. Read the original article for details.)

“Research has shown that the presence of documented patient health-care preferences such as an AdvanceDirective, or even prior verbal discussions between the surrogate and patient do not automatically facilitate substituted judgment by an appointed surrogate. Frequently, surrogates project their own values and health-care preferences into their decision-making for the patients for whom they are decisionally responsible. Friends and family functioning as surrogates tend to overestimate, while physicians tend to underestimate, the amount of medical intervention the patient would want. However, studies have also shown that patients believe that their appointed surrogates will
indeed act according to their written or spoken wishes. Whether patient, physician or surrogate, people tend to believe that others are likely to behave as they do; thus their decisions for others are frequently projections of their own values and preferences Substituted judgment is thus difficult for surrogates to perform and therefore unlikely to be realized, despite the wishes of patients.

However, in her conclusion, she does not feel that substituted judgement is “fatally flawed” but is useful and “might be aided by descriptively written advance care plans, and by research generating methods to better convey the descriptive information to surrogates for their substituted judgment activities.”

In previous postings, I have mentioned this responsibility of the physician to evaluate the surrogate as part of considering the surrogate’s request. The physician, of course, has neither the time nor resources to turn into a private detective with regard to the surrogate’s motives for the decision. However, taking a little time to communicate with the surrogate and evaluate the surrogate’s responses to questions dealing with the basis or rationale for the decision or request may be sufficient for either physician confidence or concern about the surrogate. If there is concern about the capacity of the surrogate, the physician has the duty to take this into consideration before writing orders. It may require the physician to look to another surrogate, have the assistance of an ethics committee or even involve the courts. Any questions? ..Maurice.

An Ethical Response by Physicians?: “When Patients Refuse Assessment of Decision-Making Capacity”

Most times the patient is quite willing and even eager to listen to the physician who is attempting to get informed consent for a procedure or treatment that the physician advises and will make their own decision known followed with an explanation.. The informed consent process is not a one-way communication with the doctor talking to the patient. It requires that the patient communicate his or her understanding of the information to the doctor so that the consent or dissent is validated. But what if the patient wants to be left alone or refuses to communicate and the procedure or treatment is beneficial for the patient’s health? If the patient refuses to explain this behavior or request in spite of the apparent benefit offered, how can the physician evaluate the patient with regard to capacity to make personal medical decisions? What should be the response of the physician? What should happen next? Should the physician assume that the capacity is absent and simply go ahead with the procedure or treatment?

This dilemma of clinical medicine is discussed in an interesting article titled “When Patients Refuse Assessment of Decision-Making Capacity: How Should Clinicians Respond?” by Samia A. Hurst, M.D. in the Archives of Internal Medicine 2004;164:1757-1760. The author concludes the paper with:

“Patients who refuse to explain the reasons for their choice make assessment of their decision-making capacity impossible. I have argued that if a patient who refuses beneficial treatment also refuses to explain why, clinicians should first do their best to engage in a dialogue with the patient, and to try to find others with whom the patient would agree to discuss the reasons. If this is unsuccessful, clinicians should assess the risk to the patient if the patient's wishes are followed. If this risk is significant, they should choose a course of action as if the patient were incompetent. The reasons for choosing this course of action should be explained to the patient as if the patient were competent. This approach neither sacrifices respect for the patient's choices nor care for the patient's best interest. It permits satisfactory resolution of difficult situations with the least possible harm. By outlining a framework for decision making in defined situations, this approach could help prevent decision making from being frozen by the impossibility to assess capacity. More important, it gives clinicians who face such situations the possibility of persisting in their efforts to establish a conversation with their patients.”

You must read the entire article to fully understand the rationale for the conclusion. However, do you think that this approach to the dilemma is ethical, not paternalistic and if not representing patient autonomy it does represent beneficence towards the patient? ..Maurice.