Malkah T. Notman

Boundaries in the doctor-patient relationship.

Boundaries in the doctor–patient relationshipis an important concept to help healthprofessionals navigate the complex andsometimes difficult experience between patientand doctor where intimacy and power must bebalanced in the direction of benefitingpatients. This paper reviews the concept ofboundary violations and boundary crossings inthe doctor–patient relationship, cautions aboutcertain kinds of boundary dilemmas involvingdual relationships, gift giving practices,physical contact with patients, andself-disclosure. The paper closes with somerecommendations for preventing boundaryviolations.

Sexual knowledge and attitudes of adolescents: relationship to contraceptive use.

Despite the decline in the total birth rate in the United States, there has been an increase in adolescent pregnancies, most of which are unplanned. This report discusses the medical and psychologic complications of teenage pregnancy and presents data from a study of 296 adolescents. The study includes pregnant adolescents who planned to continue their pregnancy and those who requested abortion, and compared these groups with non- pregnant high school students. The areas of inquiry included sexual information, contraceptive practice, relation of sex education course to use of contraceptives, methods of coping, and family relations. No significant difference was found between the groups in source of information—in all groups peers were the usual source. Those in the abortion and nonpregnant sample were more likely to use contraceptives. Of those who failed to use contraceptives in all groups, the most frequent response reflected a failure to acknowledge consciously the consequences of sexual activity. Adolescents in maternity homes showed less emphasis on independent decision making. They also revealed less conflict at home. The authors suggest that expectations for consistent, responsible contraceptive planning may be at variance with the developmental stage of many sexually active adolescents. Furthermore, they suggest that conscious and unconscious motivation to become pregnant may be important factors. This, added to the problem of obtaining adequate contraception or of finding creative alternatives to establishing adulthood, may play a role in the high incidence of adolescent pregnancy.

Stress and adaptation in medical students: who is most vulnerable?

Abstract There is concensus that medical school years are stressful but there has been little systematic investigation of the relationship between these stresses and manifestations of distress in the students. This paper reports results from the first wave of data in a longitudinal study of the physical and psychological health concomitants of the stresses of medical school. Two entering classes were surveyed by questionnaire in the fall of 1980. The number of recent life changes, degree of perceived stress, habits of nervous tension, depression, anxiety, and number of physical symptoms were among the variables measured. There were no significant sex or minority status differences in number or amount of perceived stresses. Moderate positive correlations were observed between level of stress and both psychological and physical distress. Few sex or minority status differences appeared. This diverse population of medical students showed a marked similarity in levels of stresses brought to the training period although there was some variation in the source of the stresses.

Midlife Concerns of Women: Implications of the Menopause

Midlife has received recent attention but is still difficult to define. Womens developmental phases are most appropriately understood as different from mens, with a complex integration of biological context, family development and roles, and individual development. Menopause has been considered a determining event, and a variety of symptoms have been attributed to menopausal changes. Emerging data indicate that menopause does not appear to be responsible for most of the symptoms. Midlife stresses are the result of a combination of personal, family, social, and biological variables, with postmenopausal development an important phase.

Psychosomatic aspects of obstetrics and gynecology.

Abstract This paper reviews some of the psychosomatic aspects of obstetrics and gynecology in the light of current data and in the context of changing views of femininity. Several conditions for which earlier concepts have changed are considered in more detail. These are premenstrual and menstrual responses, pregnancy and childbirth, nurturing behavior, postpartum reactions, menopause, pelvic pain, and hysterectomy. Biologic and psychiatric factors and reciprocal psychobiologic interactions are described, where possible.

Coping resources and health responses among men and women medical students

The structures and pressures of medical education raise particular concerns about how coping resources vary among students as they enter training. Most past studies have focussed on male students. Our data considers the coping and health-related responses of men and women students during the initial phase of their socialization into medicine. Subjects were 179 men and 80 women in entering classes of two medical schools who completed a variety of self-report measures. A multivariate analysis of these data revealed profile differences between men and women on measures of coping and health-related responses. Univariate tests demonstrated sex differences in mastery, number of health symptoms and reliance on alcohol. Men and women, however, showed similarly high esteem and use of social networks. The variation observed between men and women medical students as they begin their training suggests different potential sources of vulnerability. The importance of these findings is to provide a context of initial coping repertoires of men and women medical students for future evaluation of the effects of socialization.

The hormone replacement therapy controversy

SummaryThe issue of hormone replacement treatment for menopausal symptoms, osteoporosis, various cardiac problems, and other disorders has received a great deal of attention. Recent data concerning the benefits and risks have changed ideas about indications and contra-indications. In this paper we will consider the multiple factors that determine an individual womans decision about taking or continuing to take hormone replacement therapy, not only the medical indications. We will discuss the established benefits of replacement therapy, conditions for which the benefits are not established, areas of controversy, risks of treatment, and factors underlying the decisions about undergoing the treatment.

Medical Student Stress, Adaptation, and Mental Health

With the growth of interest in the problem of the impaired physician and concerns about the origins and possible preventive approaches, attention has been focused on the mental health of medical students, and more specifically on their psychological vulnerabilities. Medical training shares many characteristics with other graduate and professional programs. There are, however, some specific and unique features: the length, rigidity, and intensity of the training period from the beginning of medical school through residency is unequalled in other professional or graduate programs. Although other educational programs may span the same number of years, they do not involve the same total and inflexible commitment during those years.1,2,3

Aggression in Women: Conceptual Issues and Clinical Implications

In this chapter, we discuss some aspects of aggression in women, the interrelationship between self-esteem and aggression, and particularly the negative effect that women’s recognition of their own aggression has on their self-esteem. We clarify these concepts in the light of the recent increased understanding of early childhood development and the impact of parental and societal attitudes, expectations, and definitions on psychological functioning.

Psychotherapy and Psychoanalysts in Psychiatric Residency Training

There is a renewed interest in teaching psychotherapy in psychiatry training programs in the context of the current accreditation standards for developing competency in psychotherapy. However, meeting the standards requires adequate faculty, expertise, motivation, and patient population to support a substantive didactic and experiential base for residents to develop phase-appropriate competence. Psychoanalysts are in a position to provide capable instruction and supervision in psychodynamic as well as supportive psychotherapy, but they are not evenly distributed in the United States. The psychoanalyst authors investigated the experience of psychiatry residency training programs in eastern Massachusetts and northeast Ohio with regard to their current practice in psychotherapy training in general and psychodynamic psychotherapy in particular. They asked about the time given to formal teaching, therapy experience and supervision, the composition of the faculty, and the presence of psychoanalysts as teachers or supervisors. Personal interviews to clarify aims, attitudes, and needs supplemented responses to the questionnaire. This article describes these findings and the opportunities and challenges that are evident in the current environment of psychiatric training. We found that most programs made substantial efforts to teach psychodynamic and cognitive-behavioral therapies, but that supportive therapy received less focused attention. The involvement of psychoanalysts in teaching was generally welcomed in this sample, but was dependent on their availability in the community. (Journal of Psychiatric Practice 2012;18:438–443)