Michael W. Kahn

Etiquette-Based Medicine

Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved? Michael Kahn believes that medical education and postgraduate training should place more emphasis on “etiquette-based medicine.”

Let's Show Patients Their Mental Health Records

Should we health professionals encourage patients with mental illness to read their medical record notes? As electronic medical records and secure online portals proliferate, patients are gaining ready access not only to laboratory findings but also to clinicians’ notes.1 Primary care patients report that reading their doctors’ notes brings many benefits including greater control over their health care, and their doctors experience surprisingly few changes in workflow. 2 While patients worry about electronic records and potential loss of privacy, they vote resoundingly for making their records more available to them and often to their families.

What would Osler do? Learning from "difficult" patients.

Dr. Michael Kahn started giving lessons to third-year medical students on working with “difficult” patients. Kahn writes that the exercises can demonstrate the immediate payoff of knowing even a little bit about a patients life.

Needing Treatment, Wanting Nothing: Ethical Dilemmas in the Treatment of the Homeless Mentally III

&NA; One of the most uncomfortable dilemmas faced by contemporary clinicians is that of balancing a sense of responsibility for a patient with a desire to respect the patients autonomy. A patient may “need” treatment but, unless incompetent or dangerous, freely decline it. The clinician may thus feel forced to sit by and watch the patient make seemingly ill‐advised choices.

Roles, Quandaries, and Remedies: Teaching Professional Boundaries to Medical Students

&NA; This article conceptualizes a predictable set of tensions that medical students experience in their new roles with patients on clinical clerkships: empathy versus overidentification, objectivity versus avoidance, collaboration versus coercion, and self‐confidence versus “specialness.” These tensions are framed in a developmental context for students and are used to highlight potential boundary difficulties. The role of supervision in teaching students and other beginning trainees about possible boundary issues is discussed.

On Taking Notice — Learning Mindfulness from (Boston) Brahmins

Although the great physicians of past centuries might have called it something else, proficiency at promoting mindfulness has always been and should remain part of a doctors clinical toolkit.

Transparency in the Delivery of Mental Health Care—Reply

We also agree with Lannin that there are limitations to the currently available tools for predicting breast cancer risk for individual women. Tools more recent than the Gail model—for example, ones that include breast density—may offer additional utility to patients and clinicians in assessing risk.3 Further research is needed to improve these tools, clarify the effect of screening mammography for women at high risk, and develop decision support tools to help women at average risk and those at higher risk make informed mammography screening decisions.

Does this mean I'm crazy? Hidden worries of treatment-naive patients.

Medications for depression and anxiety have never been so widely used or so easily prescribed—but have they become easier for patients to take? Certainly the side effects of the newer agents are more tolerable than those of the older ones, and the stigma associated with taking medication has diminished as pharmacotherapy has become commonplace. Yet for many patients who are considering taking medication for the first time, the prospect of doing so raises a host of significant worries. In this paper I will identify seven predictable worries that some patients may not raise spontaneously, due to fear, shame, or embarrassment. Left unexamined, such worries may undermine treatment through their negative effects on medication compliance. Unless clinicians proactively acknowledge these concerns as normal and understandable, patients may never volunteer their ambivalence about following through with a proposed treatment. Acknowledging these worries requires paying attention to the meaning that a medication has for the person taking it.1,2 This task need not be complicated or esoteric, and can be done by primary care clinicians, who treat a large proportion of depressed and anxious patients.3,4 Clinicians are already familiar with introducing potential somatic side effects by saying something like, “Here are some of the unpleasant things that this medicine may do to your body.” I am suggesting that they can add, “Here are some of the concerns that people may have when they consider taking this medicine.” When discussion is encouraged, patients typically feel more comfortable sharing their worries and can then participate more actively in treatment planning. Other authors5−8 have addressed compliance issues from the patient’s perspective. I focus here exclusively on the pharmacological treatment

Psychosis, delirium, or both?

Mr. L., a 37-year-old, never-married white man with a 16-year history of a chronic psychotic illness variously diagnosed as schizophrenia or schizoaffective disorder, was transferred from a private hospital to a state-funded inpatient psychiatric unit after a month-long hospitalization when his third-party coverage was discontinued on the grounds that he was no longer an “acute” patient. The clinicians at the receiving facility had to piece together his history from several sources because Mr. L. was psychotic and an unreliable historian, the information accompanying him on his transfer was scanty, and his outpatient treater was difficult to contact. The chief message from the transferring hospital was that Mr. L. “may have an organic brain syndrome of undetermined etiology.” Mr. L. had lived alone stably in an apartment building with an attentive landlord who kept a fairly close eye on him. He was described by the landlord as “odd, but pleasant; socially related; a jokester.” He received medication from the local community mental health center: 24 mgtday of perphenazine, 900 mgJday of lithium, 1 mg of benztropine twice daily, and 0.5 mg of lorazepam three times daily. For several months before his admission, he had been on increasing doses (up to a maximum of 80 rndday) of fluoxetine for depression. He was known to be compliant with his medication. His medical history was unremarkable,

Psychocatalytic Benefits of the Unexpected

Few doctors would say they deliberately try to catch their patients off guard, but doing so under the right circumstances can have what might be called “psychocatalytic” effects, triggering or crystallizing a change in perspective.