The Neurology and Psychiatry Work-Up (Patient Encounters)
NEARLY 1 of 6 outpatient visits is considered difficult by clinicians, 1 , 2 who have labeled the patients seen in such encounters as "heartsink" 3 - 5 or "black holes" 6 in the United Kingdom, and as "difficult," 1 , 7 - 15 "problem," 16 , 17 "disliked," 18 "frustrating," 19 "troublesome," 20 or even "hateful" 21 in the United States. Most previous studies of such encounters have been anecdotal, 7 - 10 , 12 - 15 , 21 focused on highly selected patient groups, 17 - 19 or used unproved methods for assessing difficulty.
In a prospective study of patients presenting to a general medicine walk-in clinic with physical symptoms, we sought to determine what patient or physician characteristics predict difficult physician-patient interactions and how these interactions related to outcomes. Adults presenting to the general medicine walk-in clinic at Walter Reed Army Medical Center, Washington, DC, with a chief complaint of a physical symptom were eligible. Exclusion criteria included an upper respiratory tract infection as the primary symptom or dementia. There were also questions on the 5 most common symptom-related expectations 24 causal explanation, expected duration, prescription, diagnostic test, referral, other.
The PRIME-MD is a validated instrument, with 2 parts, a patient questionnaire followed by a semistructured interview among patients endorsing certain questions. Immediately after the visit, patients completed the RAND 9-item satisfaction survey 28 and a questionnaire that asked about postvisit serious illness worry and the presence of any unmet expectations.
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Two weeks and 3 months after the visit, patients were mailed a questionnaire on symptom outcome, residual serious illness worry, unmet expectations, functional status, and satisfaction with the index encounter. Telephone contact of nonrespondents was attempted. All eligible patients presenting to the clinic on selected half-days were invited to participate. While selected half-days were selected for convenience, the specific half-day sampled was rotated to ensure balanced sampling among all possible clinic half-days during the study period October to December This clinic primarily provides continuity-of-care appointments, but has walk-in appointments available for patients desiring to be seen that day.
Such walk-in patients are assigned to physicians on a queue system: first come, first assigned to the next available clinician.
The clinician is assigned from a roster of available appointments, with clinicians listed alphabetically within each time slot. Nearly all study patients were seen by physicians seeing them for the first time.
Fellowship in Consultation-Liaison Psychiatry
The demographics and case mix of patients seen in a military outpatient clinic are comparable to civilian settings. Informed consent was obtained prior to the visit by 1 of 2 clinical researchers. Prior to study participation, physicians completed the Physician's Belief Scale, a item questionnaire that measures attitudes regarding psychosocial aspects of patient care. Scores range from 32 to , with higher scores reflecting poorer psychosocial attitudes. This instrument has been found to be a reliable and valid brief measure of physicians' psychosocial beliefs.
After each patient visit, physicians completed the item Difficult Doctor-Patient Relationship Questionnaire DDPRQ 2 , 31 to assess clinician-perceived difficulty of the encounter, and indicated whether a subspecialty referral was provided. From the clinical database, prescription and diagnostic test orders were obtained for each patient.
These were tabulated using Health Care Financing Administration relative value units and converted to dollars using the Medicare schedule. Prescription costs were based on either Health Care Financing Administration rates or generics when available. Predictors of difficulty were evaluated using logistic regression. In addition, potential confounding or interactive effects of other variables were explored. For example, functional status was adjusted for well-described confounders such as mental disorders and age.
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Because of the clustered sampling technique, the Huber formula was used to produce robust confidence intervals. Difficulty was analyzed as a dichotomous variable using a score of 30 or greater as indicative of difficulty. Data exploration using various cut points for difficulty confirmed the previously held cut point of 30 as functionally identifying a unique subgroup of patients.
An attempt to use DDPRQ scores to categorize patients into 3 groups, "difficult," "average," and "satisfying," after the suggested hierarchy of Lin et al 19 was not successful. A cut point of 70 on a scale of was used as indicative of "poor" physician psychosocial attitude score for several reasons.
First, dichotomization was necessary because the Physician's Belief Scale score was not linear over the logit function. Second, preliminary evidence suggests that a cut point of 70 may discriminate among physician specialties that differ in the degree of their biopsychosocial orientation. These data were collected as part of a clinical trial of providing previsit information to clinicians on patient symptom-related expectations and mental disorders. Since one outcome of the intervention 36 was a reduction in the frequency that patient encounters were labeled as difficult, adjustment for study group was made in all analyses.
Five hundred twenty-eight adults were invited to participate. The participants were similar to nonparticipants in terms of age, race, sex, and type of symptom. Study patients were seen by 38 physicians with no physician contributing more than 34 patients. Patients had a mean age of A depressive or anxiety disorder was present in Major depression was present in 8.
Among 38 participating physicians, 35 were general internists and 3 were family practitioners. Sixteen were faculty members and 22 were house staff. The mean age of participating clinicians was Encounter difficulty was not associated with patient sex, age, ethnicity, educational level, or marital status Table 1. Previsit expectations of care, including desiring an explanation of the symptom's cause, a prescription, an estimate of likely symptom duration, and subspecialty referral, did not differ between difficult and not-difficult patient encounters.
There was no relationship between the duration of the presenting symptom or patient report of recent stress and difficulty. Patients in difficult encounters were more likely to have an underlying mood or anxiety disorder, were worried that their symptom might represent a serious illness, reported greater symptom severity, and had higher rates of somatization Table 1. Patients from difficult encounters had lower functioning on all domains of function assessed overall health, physical, pain, role, social, and emotion , although the difference in emotional functioning was eliminated after adjusting for age and the presence of mood or anxiety disorders Figure 1.
There was no relationship between the type or number of mental disorders and physician-perceived difficulty. No specific type of presenting physical symptom was associated with difficulty. Physician age, sex, ethnicity, house staff vs staff status, and the number of years of practice were not associated with the likelihood of rating patient encounters as difficult. There was no interaction between patient or physician age, sex, or ethnicity with regard to difficulty ratings.
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Individual questions from the DDPRQ were also analyzed, using responses of 4 to 6 as indicative of difficulty. Follow-up data were available on all patients immediately after the visit, on There were no differences between respondents and nonrespondents at any time, including the proportion of encounters considered difficult. There were no differences in visit costs or in the likelihood that a patient would receive a specific intervention from the physician, including a diagnostic test, prescription, or subspecialty referral.
Patients from difficult encounters had no increase in the number of previsit expectations for care and were neither more nor less likely to receive desired interventions. Despite this, patients from difficult encounters were more likely to have unmet expectations for care both immediately after the visit and at 2 weeks.
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Patients from difficult encounters were less likely to be satisfied overall with the care they had received immediately after the visit and at 2 weeks, and were more critical of all aspects of the physician-patient encounter measured. Patients also experienced significantly improved functioning in all 6 domains by 2 weeks after which functional status did not change appreciably over the ensuing several months.
Initial functional status differences between difficult and not-difficult groups Figure 1 were no longer present at either 2-week or 3-month follow-up. Also, the greater dissatisfaction with the index visit that the difficult group expressed immediately after the index visit and persisting out to 2 weeks was no longer apparent at 3 months.
Fifteen percent of encounters involving walk-in patients presenting with physical symptoms to a walk-in clinic were experienced as difficult by the clinician. Patient characteristics associated with difficult encounters included the presence of depressive or anxiety disorders, more somatic symptoms, and greater symptom severity.
Poor physician psychosocial attitude was strongly predictive of experiencing more encounters as difficult. Adverse outcomes associated with difficult encounters included more unmet expectations, higher utilization rates, and greater dissatisfaction with the overall care received as well as with all aspects of the physician-patient relationship. Several of our findings are similar to those seen previously. A relationship between difficult encounters and the presence of mental disorders, 1 , 2 , 16 - 19 , 37 greater somatization, 2 , 19 , 37 and higher health care utilization 2 , 10 , 19 have been reported.
What is a Neurologist?
Similar to previous reports, the relationship between patient functional status and difficulty disappeared when adjusted for the other patient characteristics. We are also the first to report on the lack of impact of "difficulty" on symptom or functional status improvement or on visit-specific costs. For example, Lin et al 19 used a single question asking physicians to rate their experience with high users of ambulatory services as "satisfying," "average," or "frustrating.
Walker et al 37 used the DDPRQ as a continuous variable in asking rheumatologists to rate the difficulty of 68 patient encounters with fibromyalgia or rheumatoid arthritis. Hahn et al 2 used the DDPRQ as both a continuous and categorical measure in a study of patients presenting for primary care. All 3 studies corroborated our own findings of more psychopathology among patient encounters rated as difficult or frustrating.
We found no interaction between physician and patient sex, age, or ethnicity and the likelihood difficult ratings, similar to a previous report. Their finding was limited by clinician interest measurement based on responses to a single, nonvalidated question. Physicians with an interest in managing patients with psychosocial disorders tend to accumulate such patients in their practice. A higher interest in psychosocial disorders may result in a clinic population with a higher proportion of patients with such disorders. In our study of physicians seeing new, arbitrarily assigned walk-in patients, a item validated measure of psychosocial interest found that clinicians with better psychosocial attitudes experienced significantly fewer patient encounters as difficult.
The Physician's Belief Scale used in our study has been found by other investigators to correlate with better physician communication skills and with a higher proportion of time spent discussing psychosocial issues. It is possible that difficulty could be reduced by recognizing and treating mental disorders and by improving physician skills or attitudes toward addressing psychosocial problems or patient's serious illness concerns.
Specific training in caring for "difficult" patients has also been found to help trainees gain understanding and empathy for such patients, rendering them less difficult. Most reports suggesting approaches to managing difficult patients have focused on patient-physician communication. By 3 months, the relationship between encounter difficulty and patient dissatisfaction had faded. However, after 3 months, the intensity of patient dissatisfaction is likely to shift to more recent clinical encounters.
Most patients had at least 1 interim follow-up visit, usually with a different clinician than seen in the index visit, and patients from difficult encounters averaged more than 7 follow-up visits. The patient's recall for the index encounter may be limited.
Does this sound like you? Take our free career test to find out if neurologist is one of your top career matches. Neurologists work mostly in hospitals or other multi-specialty clinical settings. Depending on the country, a neurologist may have a private medical office, but this is less frequently encountered due to the nature of the work.
Neurologists usually don't work in primary care units or in emergency healthcare settings, but they may be called in certain situations to assess the status of a patient in such units.
The most concise distinction between neurologists and neuroscientists is this: Neurologists are physicians. Neuroscientists are researchers. As practising physicians, neurologists are specialists who diagnose and treat conditions and diseases of the central, peripheral, and autonomic nervous systems. Neuroscientists study the mechanics of the central nervous system. They conduct research on patients and laboratory animals to learn about its structure, function, genetics, and physiology.
Their objectives are to identify the underlying cause of neurological disorders and to understand how their findings can help neurologists treat diseases of the nervous system. Another significant distinction between neurology and neuroscience is the level of specialization that typically occurs in each discipline. Such targeted specialization is not the norm in neuroscience. However, some neuroscientists may focus their research on a particular disease or on a particular area such as neuro-immunology the study of the interaction between the nervous system and the immune system.
Epilepsy : A neurological disorder associated with abnormal electrical activity in the brain, causing recurrent, unprovoked seizures and loss of consciousness. Stroke and other cerebrovascular diseases : A stroke occurs when a blood vessel is prevented from delivering oxygen and nutrients to the brain, due to a blood clot or rupture. Migraine and other headache disorders : A severe, reoccurring headache often paired with nausea and disturbed vision.
Multiple Sclerosis : A chronic disease involving damage to nerve cells in the brain and spinal cord characterized by numbness, speech and muscular impairment, blurred vision, and severe fatigue. Brain tumor : A mass of abnormal cells in the brain, leading to impaired cognitive function. Tourette Syndrome and other disorders of function : A neurological disorder, coupled with involuntary tics and vocalizations, as well as the compulsive exclamation of obscenities.
Neurologists may also treat people who are having problems with their sense of touch, vision, or smell, as sensory dysfunction is sometimes caused by disorders of the nervous system. It is important to note that neurologists can recommend surgical treatment, but do not perform surgery. Neurosurgeons specialize in performing surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord, peripheral nerves, and cerebrovascular system. It would be wise to find a mentor who can give advice and guide you on your path to becoming a neurologist.
A good mentor can be one of the neurology faculty members at your university. It's important to connect with your mentor on a personal level, and find someone who has an interest in you. You may be able to get a glimpse of what it's like to be in this career by shadowing a neurologist. If at all possible, consider doing research by connecting with researchers or research programs within your university.
There are also research scholarships available for medical students that you may be able to take advantage of. The following are highlights of advice for medical students studying neurology, compiled by the American Academy of Neurology. Create a solid foundation in neuroanatomy Knowing the neural and motor pathways and functions of systems will make learning neurological disorders and diseases much easier.
Keep in mind that neurology is a logical discipline that emphasizes first localizing the lesion based on the clinical history and physical exam, and then determining the most likely diagnosis. Practice makes perfect Quiz yourself on pathways until it becomes second nature. Group study is often helpful and web-based resources, such as Utah Med have great online quizzes.
Learn the Neurologic Exam Even for physicians, the neurologic exam can be intimidating. Practising neurologists invariably advise students to develop a logical and systematic approach that they can follow almost without thinking. Read clinical vignettes Seeing or hearing about patients and their cases often makes it easier to remember the pathology, diagnosis, and treatment of diseases. Neurologists have a wide availability of treatments, high-tech equipment, and diagnostic capabilities that they can offer their patients, many that weren't available ten to twenty years ago.