Formulation #1

A diagnosis highlights commonality between patients, while a formulation is about finding the unique story for this patient.

It begins with a good summary statement about the patient. We want to answer the question,
"Why did this patient present, with this problem, in this particular way, at this time?"

The skill to practice is including all relevant and important information, while culling extraneous information.

For example...

Grant* is a 33 year old man, never married, who lives with his parents and younger sister in Granville*, Sydney. He has presented with police, to Emergency, after an argument with his mother where he pushed her. He has not left the house for two years, because of fears about what people will say about him and because he has rituals that prolong showering to the point where he has not been able to do it for four weeks.

to be continued...

* Indicates identifiers that I have invented/changed.

Skills in Psychiatry - Formulation

I am going on a journey. I'm on my way to the place where good formulations get made. I've started reading about formulation as a skill and I'm going to get practicing. I'm just realising that there's a hole in my exam armour, that needs repairing...

I'll be writing some postcards on the way.

PS. This is what I just posted a couple of weeks ago...

Skills in Psychiatry #2

Asking difficult questions - being tactfully direct.

A conversation that may include questions about hearing voices, thoughts of killing yourself, childhood abuse and sexual dysfunction can get uncomfortable. And at the end of the uncomfortable conversation, there needs to be enough rapport to engage someone into a treatment plan. This can be a delicate juggle.

I find it helpful to...

• Normalise - "Some people with the symptoms you describe, also get ... . Has that happened to you?"

• Ask open, general questions first - "Have you had any strange or confusing experiences?" can yield all sorts of answers.

• Acknowledge the intrusive nature of questions - "I know this can be embarrassing/difficult to talk about, but the answers can give us information that really helps."

• Ask an important question in a couple of different ways.

• Listen carefully, and use it to direct further questions - "You mentioned ... earlier, I'm wondering how often that's been happening recently?"

• Say clearly what you mean. Try not to use euphemisms. - "How often do you drink alcohol?", is preferable to "Are you a drinker?". Even better is "People who are having trouble sleeping sometimes find alcohol can help get them to sleep. Is that something you have done?"

Having said all this, sometimes words just come out clumsily. I have asked a 15 year old boy if he was "still having thoughts of killing people?" Unfortunately, he'd never had such thoughts and from that point he wanted to escape from the room as quickly as possible. I never saw him again.

Trouble with rapport due to uncomfortable questions can be repaired with patience and listening well. Just be willing to laugh and acknowledge your mix-up or faux pas. Most people cannot resist humility and someone who can laugh at themselves.

Skills in Psychiatry #1

Negotiation - learn how to do it or get a very sore head.

Whether it's getting a mentally ill patient to participate in treatment, or juggling demands on your time from other staff, making deals is bread and butter psychiatry.

These are general tips for dealing with competing demands on your time or management plans.

• Know what is important, so you know what you can afford to yield. Agreeing to take a smaller dose of medicine, might be a better outcome than an adamant 'no' to the reccommended dose.

• Don't argue with someone who is acutely psychotic. They will not suddenly say "OK, your flawless logic has convinced me. I think I will have that medication I've steadfastly refused for the last 6 minutes/days/months. Thanks." Do what you need to do and talk again when they are more settled.

• Tell people clearly what you are planning to do. Let them know what to expect. Then let them ask   questions if they need to.

• Don't talk down to people. They will not appreciate or respect it. And they just might ignore what you say.

• Listen to what the patient/family/case worker is saying. Don't dismiss it. You might disagree, but listen first.

• Answer your pager when it goes off. I am allergic to my pager. But when I answer reliably, people get much less frustrated with me and complain to their supervisors less about me. They even start to cut me some slack.