Primary care physicians treat the majority of patients in this country who have mental health disorders. But how well prepared are we for these patients when they present to our offices?
WHAT MAY UNDERLIE PHYSICAL SYMPTOMS
Robert Lowes wrote that the medical education system has taught physicians to view patients as "disease puzzles to solve rather than as people to listen to."1 And that is the problem. We deal very well with the biological component of a patient's presentation but not quite so well with the psychosocial component.
Thus, we may fail to recognize underlying psychiatric disorders when patients present with vague somatic complaints, such as headache or abdominal discomfort. This was most eloquently expressed by Henry Maudsley, MD (1835-1918), who observed that "the sorrow that has no vent in tears may make other organs weep." We frequently see patients with physical symptoms that are actually manifestations of psychiatric conditions, such as a depressive disorder. Kurt Kroenke, MD, has identified a wide variety of patients over the years who present with organic symptoms that have no organic cause.;2
HOW TO UNMASK THE HIDDEN COMPLAINT
Back in the 1980s, Marian Stuart, PhD, and I began to look at this problem to better understand how patients' presenting symptoms relate to the problems they actually have. We devised the BATHE technique-Background, Affect, Trouble, Handling, and Empathy for the Patient-described in our book The Fifteen Minute Hour: Therapeutic Talk in Primary Care.3 The BATHE technique is an extension of the problem-oriented medical record SOAP (Subject, Objective, Assessment, and Plan) format. Because the SOAP approach fails to capture the psychosocial dimensions of each patient's visit, we teach our medical students and residents to start with SOAP and then use BATHE.
Using BATHE, physicians do not simply ask the patient, "How are you doing?" because the response is likely to be "OK." Instead, the physician asks, "What is going on in your life?"
Physicians must be careful when they ask patients about what is going on in their lives because patients will tell them-and possibly in great detail. At this point, I remind our students and residents that at some point the patient must stop talking and take a breath. Once the physician has sufficient information to understand what may be underlying a patient's symptoms, he or she can interject, "I understand there's a lot going on in your life, but how does it make you feel?" Getting to the patient's feelings (affect) is the goal.
The next question is, "What is troubling you the most?" followed by, "How are you handling that?" The answer to the latter question can provide insight into the patient's coping skills.
Finally, if it is appropriate to give the patient an empathic response, the physician can validate the patient's feelings and provide support.
A number of other concepts and tools can be used to facilitate discussion with patients. These are detailed in part 1 of a series of 4 podcasts I recorded, which are posted on the ConsultantLive Web site. Part 2 is a discussion of difficult patients- chronic complainers, substance abusers, and hypochondriacs; part 3 covers major depression, anxiety, and bipolar disorder and simple tools to help diagnose a disorder; and part 4 provides a list of questions that clinicians can use to start a discussion with their patients as well as pointers on how physicians can take care of themselves.
My goal in this podcast series is to show that not only is it possible for us to deliver quality mental health care in the primary care setting, it is essential that we do so.
Lowes R. Patient-centered care for better patient adherence. Fam Pract Manag. 1998;5:46-47, 51-54, 57.
Jackson JL, Kroenke K. Prevalence, impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med. 2008;70: 430-434.
Stuart MR, Lieberman JA. The Fifteen Minute Hour: Therapeutic Talk in Primary Care. 4th ed. Abingdon, UK: Radcliffe Publishing; 2008.