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1985 to the future

Posted by Margaret Donohue on May 3, 2017 at 7:45 AM

It was 1985.  I was newly licensed with specialty training in this weird not-yet-ready-for-prime-time area of psychology no one really knew anything about-Medical Psychology.  And I was working in a medical practice with a physician I knew.  I had training in both medicine and pharmacy.  So I went through paper charts of any patient that had been seen for four visits with no clear diagnosis.  While all of the patients I saw had psychiatric symptoms, 80% would be found to have a primary medical conditions that would account for those symptoms.  The patients were then scheduled.  I took vitals of height, weight, blood pressure, temperature, and reviewed all their medications and how they were taking them.  The history took from 1-3 visits to ensure I had everything correct.  I documented in the patient's chart.  I had patients document symtpoms and keep records. I made house calls.  I made recommendations for lab studies, changes in medications, and referrals for specialty care.  I explained diagnosis, lab studies, medications, and how to take them.  I set up systems for taking medications.  I explained diets.  I would even help patients shop for food.  I did psychological testing to differentiate psychological conditions.  The internet was not a standard household item.  I had AOL dialup service at home, but I had access to multiple medical libraries in Los Angeles.  When the field of medical psychology was initially conceptualized this was how it looked.  A cross between psychological history taking and testing services and physician assistant and health educator.  Ideally, in the future, we would have prescribing abilities.  The future never came.  


There are about 5 medical psychologists in the greater Los Angeles area.  We know each other.  The field merged with Health Psychology back in the late 1990's and the concept of psychologist as physician assistant was lost in the process.  It's a field that needs to return.  In force.  


It's 2017.  A patient sees their physician or physician assistant or nurse practitioner.  They download all their initial information from a patient portal and upload it back to an electronic health record (EHR).  The physician's scheding team books the first appointment and ensures the physician has access to the patient data.  In the 15 to 30 minute initial office consultation, the patient is expected to report their symptoms and get any needed testing or treatment planning for future visits.  Five minutes of that visit are spent taking vitals.  The patient may have completed a health screening questionnaire or a psychological symptoms checklist.  If they check positive on those questionnaires they may be sent to a psychologist for further treatment.  80% of them will have a primary medical condition that accounts for their psychological symptoms.  It's likely to be missed.  


There's another issue now that wasn't present back in 1985.  A patient contacted me because the labs in her patient access portal had come back positive.  Her physician will see her in two weeks.  Because the scope of practice in medical psychology is weird, (I can make suggestions to physicians that they can accept or reject) but I can't actually order things directly, I had made recommendations for the labs that had now come back abnormal.  So I now have more information than her physician does.  I can see her urgently and provide her with information (based on research) about her illness, give her information about support groups, provide her online information about clinical trials, and suggest all the next steps she'll need to discuss with a specialist she needs to have her physician refer her to.  The patient portal is new.  Physicians don't yet know how to manage that.


in the past, this process could have taken months. The diagnosis part alone could have taken that long.  Her psychological complaints don't match the medical illness, unless you listen for 40 minutes and really hear what she's saying.  You also have to look at her.  Medical things are often visible.  That part of looking at people to see medical illness is known as clinical medicine and it's a lost art and getting more lost as it's replaced by laboratory medicine.  That means that if the lab reports are all normal, some physicians will say the person is normal too.  And they are wrong.  80% of the time and more likely with women than with men patients.  Women start with psychiatric complaints and then go to physical complaints.  This gets physicians off on the wrong decision tree.  So a heart attack will present as depression, fatigue, feeling tired and not able to do housework, almost like the flu in women.  Men will complain of nausea, chest, neck, back or jaw pain with a heart attack.  So women get a prescription for Prozac and men get an ER visit.  So my patient's medical symptoms got lost in the psychiatric complaints that are part of the medical condition.  The patient portal allowed her to send me labs in seconds.  I had her diagnosis as soon as the positive labs were read.  I have her full history and I saw her and actually looked at her.  Now there is nothing psychiatric.  She'll get some specialty care to rule out complications, but she can now spend her time investigating treatment options.


In the future there should be more people like me.  We will likely have virtual practices.  I can see the patient through a video.  I can get their labs through their patient portal.  I can still take a history.  In rare cases I may need to see the person face to face.  But may cases like this can be done through telehealth.  There still needs to be the psychologist/physician that says it's not a psychological condition untill all the medical conditions are ruled out.  we still need the field of medical psychology.  Maybe it can be brought back.

Categories: Diagnosis

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