Michael Weissberg

Patients who leave without being seen

We conducted this study because very little is known about patients who leave without being seen. A total of 4,868 patients were registered in an emergency department during a six-week study period. Sixty-eight (1.4%) left before treatment was completed; 97% (66 patients) left before ever being seen by a physician. Thirty of the 68 patients were interviewed later in followup A comparison group of 23 patients who did not leave prematurely was also selected and matched for age, sex, urgency of chief complaint, and time of presentation. Fourteen of these patients were interviewed later. Patients who left without being seen (LWBS) and nonLWBS patients did not differ in waiting time in the ED. The two groups also did not differ in the spectrum of chief complaints. Twenty-two of 30 LWBS patients were suffering from acute psychological distress at the time of their visit, however, compared to only one of the comparison group (P = .0005). The walkouts reported recent deaths of relatives or friends, recent bouts of alcoholism, acute financial problems, suicidal thoughts and behavior, court appearances, pregnancies and miscarriages, new people in the home, acute illnesses in relatives, and other psychological and social crises.

The meagerness of physicians' training in emergency psychiatric intervention.

This study was undertaken to determine how much training physicians receive in emergency psychiatric intervention (EPI) during their residency programs. In 1988 the author mailed a questionnaire to 256 program directors of residencies in the major nonpsychiatry specialties. A total of 236 (92%) responded. Their responses indicate that emergency medicine and family practice residency programs provide the most training in EPI, followed by pediatrics, internal medicine, obstetrics-gynecology, and surgery. But overall, EPI training was meager. The findings indicate that 75% of the programs never assigned EPI-oriented readings to the residents and 70% of the programs never gave lectures or seminars on that subject. The author concludes that EPI skills are frequently absent in current medical practice because physicians have not been taught these skills; he recommends that more training is essential and indicates what it might consist of.

Multiple Personality Disorder and Iatrogenesis: The Cautionary Tale of Anna O

An examination of Breuers treatment of Anna O. illustrates some of the controversies surrounding the recent rise of case reports of multiple personality disorder. Anna O., the first patient of the cathartic method, psychoanalysis, and dynamic psychiatry, fits current criteria for multiple personality disorder. Breuers treatment, however, may have contributed to her states of absence; the timing, type, and intensity of Breuers interventions make it possible that he unwittingly encouraged and amplified Annas dissociations, reified her ego fragments, and then explained Annas symptoms with the pseudomemories and confabulations recovered from Anna while she was hypnotized. A review of Breuers treatment highlights some of the controversial aspects of multiple personality disorder, specifically its possible vulnerability to iatrogenesis via suggestion and unconscious collusion and other factors. The current stance of some multiple personality disorder enthusiasts, opaque to their participation in interactions that may lead to certain patient productions, resembles the older psychoanalytic stance exemplified by the early Breuer and Freud. The dialectic of the therapist as a neutral observer versus as an influential participant continues to be a focus of controversy, both within psychoanalysis and psychotherapy and in the understandings of the etiology and treatment of multiple personality disorder.

Unsigned: why anonymous evaluations in clinical settings are counterproductive.

The benefits of anonymous evaluation do not necessarily apply to clinical medical education, regardless of whether the evaluator or recipient is a student, resident or faculty member. This is not to say that anonymous evaluations are without benefit because anonymity can remove potential sources of bias. Depending on the educational setting, anonymity may be given to the evaluator, the recipient, or both. The question to be asked is: what is the cost to our educational enterprise?

Medical student attitudes to risk taking and self‐perceived influence on medical practice

Context  Little has been published on medical student risk‐taking attitudes and behaviours and whether students think these attributes will affect how they treat patients.

The crash of continental 1713: The impact on hospital-based personnel

Psychological morbidity is a common finding in rescue personnel following a disaster. However, no serious attention has been given to the possibility that hospital-based personnel are also at risk. Therefore, 12 to 16 months after the crash of Continental 1713, 15 subjects who had worked with crash victims and their families only while in the hospital, were given a structured interview. Eight of 15 said they developed at least one symptom in each domain of Post Traumatic Stress Disorder within 2 weeks of the crash; of the remaining 7 subjects, all endorsed at least one re-experiencing symptom. Half also reported serious disruptions at home and in their work with other patients. Thirteen subjects also experienced significant worries about flying and 4 actually changed travel plans. Subjects were still symptomatic at 12 to 18 months, though to a lesser degree. We conclude that the emotional effects of disasters on hospital-based personnel are not trivial.

Less is more : The case for basic psychiatry and the Colorado Medical Student Log

Because of the rapid growth of our field, psychiatric educators are faced with two related questions. Are we teaching our students about too many things thereby making it difficult for them to discern our essential message(s)? And, two, have we really decided on what our essential message(s) actually is? The answer is “yes” to the former and “no” to the latter. The problem is deceptively simple: as distinct fromwhat we teach, as a profession we have not yet parsed out theminimum we expect our students toreally know—andreally know how to do—by the time they graduate from our schools. We, therefore, developed the menu and method of the Colorado Medical Student Log which articulates the minimal educational goals for our students: ten core clinical experiences and ten core psychiatric screens. The log also provides an easy method by which we can be satisfied that our minimal goals are being met.

Weaknesses in Emergency Psychiatric Education: A Solution

Emergency psychiatry training is beset by various problems although it is recognized as essential for psychiatrists. Trainees often function under such adverse circumstances that constructive learning is impossible. An important case of these problems is the lack of integration of emergency room training with other departmental activities. In an attempt to address this difficulty an off-hours volunteer teaching program was developed. The author describes this aspect of a large training program in emergency psychiatry which has had numerous benefits, including the integration of the emergency service with the rest of the department, the education of the faculty about emergency psychiatry and the promotion of the feeling in trainees that their work is appreciated and important. Under such positive circumstances, effective learning can and does take place.