Lorna A. Rhodes

Reasons for repeated medical visits among patients with chronic back pain

OBJECTIVE: This study identifies the key motivations of patients repeatedly seeking medical care for chronic back problems.DESIGN: We conduced one-on-one, in-depth interviews with patients to discuss their experiences with low back pain and its care. To validate our interpretation of the qualitative data, participants were mailed questionnaires listing the themes identified in the interviews and asked to rate the importance to them of each of the themes.SETTING: Managed health care plans in Atlanta, Dallas, and Seattle.PARTICIPANTS: Fifty-four patients (37% male, 63% female) who were 25 to 65 years of age and had three or more medically attended episodes of low back pain during the 3 years preceding the study.MAIN RESULTS: In describing their motivations for seeking medical care for back pain, nearly all participants cited difficulty in performing normal activities and the desire to discover the cause of the pain. Other motivations for seeking medical care for back pain included increased pain and the desire for a diagnostic test or a new treatment. Many of the verbalized reasons for repeated medical visits among patients with chronic back pain are probably best understood as seeking validation of their suffering.CONCLUSIONS: Patients with chronic back pain report many unmet needs and expectations. Overall satisfaction might be improved if clinicians elicit patients’ views of underlying causes and their expectations from office visits.

Bridging cultural differences in medical practice. The case of discussing negative information with Navajo patients.

AbstractBACKGROUND: Cultural differences between doctors and their patients are common and may have important implications for the clinical encounter. For example, some Navajo patients may regard advance care planning discussions to be a violation of their traditional values. OBJECTIVE: To learn from Navajo informants a culturally competent approach for discussing negative information. DESIGN: Focused ethnography. SETTING: Navajo Indian reservation, northeast Arizona. PARTICIPANTS: Thirty-four Navajo informants, including patients, traditional healers, and biomedical health care providers. MEASUREMENT: In-depth interviews. MAIN RESULTS: Strategies for discussing negative information were identified and organized into four stages. Assessment of patients is important because some Navajo patients may be troubled by discussing negative information, and others may be unwilling to have such discussions at all. Preparation entails cultivating a trusting relationship with patients, involving family members, warning patients about the nature of the discussion as well as communicating that no harm is intended, and facilitating the involvement of traditional healers. Communication should proceed in a caring, kind, and respectful manner, consistent with the Navajo concept k’é. Reference to a third party is suggested when discussing negative information, as is respecting the power of language in Navajo culture by framing discussions in a positive way. Follow-through involves continuing to care for patients and fostering hope. CONCLUSIONS: In-depth interviews identified many strategies for discussing negative information with Navajo patients. Future research could evaluate these recommendations. The approach described could be used to facilitate the bridging of cultural differences in other settings.

Hospice patients' attitudes regarding spiritual discussions with their doctors.

The purpose of this study was to assess hospice patients’ attitudes regarding the discussion of spiritual issues with their physicians. We conducted in-depth interviews using open-ended questions on living with illness, spirituality and religion, and physician-patient relationships. The interviews were audiotaped, transcribed, and analyzed for dominant themes. The following dominant themes were identified: (1) treating the whole person, (2) treating with sensitivity, (3) favorable attitudes toward religious or spiritual discussions with doctors, and (4) no “preaching.” Our findings suggest that patients do not expect physicians to be their primary spiritual advisors; however, physicians should be aware of and comfortable communicating with patients about religious or spiritual issues. More training in this topic may enhance the care physicians provide to patients near the end of life.

“This will clear your mind”: The use of metaphors for medication in psychiatric settings

Psychiatric medications are an important part of the interaction between patients and clinicians in psychiatric settings. This article examines metaphors used by patients and clinicians to talk about the effects of antipsychotic medication. Metaphors provide a way to communicate about issues of identity and change involved in giving and taking medication. Although metaphorical language can contribute to misunderstandings between patients and clinicians, metaphor is also a major way in which clinical experiences are given shared meanings.Psychiatric medications are an important part of the interaction between patients and clinicians in psychiatric settings. This article examines metaphors used by patients and clinicians to talk about the effects of antipsychotic medication. Metaphors provide a way to communicate about issues of identity and change involved in giving and taking medication. Although metaphorical language can contribute to misunderstandings between patients and clinicians, metaphor is also a major way in which clinical experiences are given shared meanings.

Assessment of Psychosocial Impairment in a Supermaximum Security Unit Sample

This article concerns a study of Washington State supermaximum security unit (SMU) residents conducted to generate systematic, empirical data for this population and to investigate behavioral, institutional, and policy issues that affect their treatment. The Brief Psychiatric Rating Scale (BPRS) is used to standardize interview-based assessments of participants’ psychosocial functioning, in conjunction with other operational, situation-specific measures. Results indicate that the BPRS is a reliable and effective measure of psychosocial impairment in SMU residents. Comparison of factor-based BPRS scores in this sample with scores and factor analysis solutions achieved in other populations points to considerations specific to this population that require further study. Finally, assessment of SMU residents using the BPRS and convergent measures of impairment indicates that a significant number demonstrate psychosocial impairment and/or meet criteria for serious mental illness.

Psychiatry with Teeth: Notes on Coercion and Control in France and the United States

‘‘Psychiatry with teeth’’: with just three words, a head psychiatrist in Lyon, France, captures the confined spaces and internal discipline of a new type of intensive treatment center for ‘‘difficult patients’’ (Velpry and Eyraud 2014). His pithy phrase provides a vivid yet disconcerting image for the ‘rough edge’ of psychiatry where, as the editors of this issue of Culture, Medicine, and Psychiatry devoted to emergent forms of care and control remind us, constraint and coercion signal a fundamental division between patients and clinicians (Velpry and Brodwin 2014). At the level of institutions and the state, it is through constraint that the larger social ‘‘will’’ (to power, to social order) shows its teeth. We can understand ‘‘teeth’’ at the material level as the community supervision, restraints, locked units, quiet rooms, involuntary hospitalizations, and (in some cases) medications through which the will of clinicians and the power of institutions are enacted upon the bodies of psychiatrically defined individuals. Each of these papers offers a close reading of some aspect of this enactment at the local level. In the relationships constitutive of psychiatric practice, constraint and coercion mark the sites of greatest conflict between patient, clinician, and institution—the places where teeth are most likely to be bared in disputes over the moral status of the patient and the legitimacy of the institution. ‘Teething pains’ afflict those involved in this dynamic, pains of growth as individual clinicians learn to accept constraint as a necessary aspect of their work.

Imagining the injured child: Engaging the social at a therapeutic community prison in Britain

Drawing on a comparison with the supermax (solitary confinement) prison in the United States, this article explores the meaning and social circulation of narratives of childhood trauma at HMP Grendon, a therapeutic community prison in Britain. Grendon prisoners incorporate the haunting effects of abuse and neglect into practices of group therapy and communal solidarity, in contrast to the persecution and repression characteristic of interactions in supermax. These differences are discussed in relation to historical changes in the framing of incarcerated personhood and the ‘death of the rehabilitative ideal’ in the United States.

Physician Attitudes About Breastfeeding

Despite mounting evidence of the health importance of breastfeeding, physicians demonstrate persistent, suboptimal knowledge about and support for breastfeeding.1 Educational interventions can increase physician breastfeeding knowledge, and yet not necessarily improve behavior.2 This suggests the need for a richer understanding of physician attitudes towards breastfeeding, including how those attitudes relate to utilization of data and clinical practice.