Updating Comprehensive Care

SUMMARY Rendering comprehensive care does not have to be tedious or excessively time-consuming for the primary care physician. Certain principles and concepts can be applied to every patient. Of overriding importance is the use of the biopsychosocial model in patient care, rather than a purely biomedical model. The practitioner must remember that man is a symbol maker and that physical symptoms and organic illness can have profound psychological meaning for a patient. Successful medical care involves the practitioner discovering those psychological meanings for a particular patient and using this informtion effectively in the treatment. It is also not enough to consider the patient as an isolated entity. Successful treatment must take into account the social networks surrounding the patient; the physician should inquire about the patient's interrelationships with significant others, including family, friends, and at work. The physician and the patient together form their own social system. The thoughtful physician will be an observer of that social system. Feelings or reactions that the physician has about the patient can often be diagnostically and therapeutically useful. If the physician does not attend to the interpersonal aspects of his own experience with the patient, he will miss the transference and countertransference reactions. If the physician and patient both have positive feelings for each other, this may not be of clinical concern. If feelings on either side are negative and are not dealt with, this phenomenon can be highly destructive to good patient care as well as to the morale of the physician. A consultative relationship with a psychiatrist can help the primary care physician more effectively manage the psychosocial aspects of his practice. The physician must pick the consultant with considerable care, since not all psychiatrists by temperament, knowledge, or experience are suited to this work. Such a consultant needs to be comfortable making direct and active interventions and using language which is readily understandable and not psychiatric jargon. The primary care physician may want to use a psychiatrist not just as a consultant, but also for referrals of more difficult and complicated cases. All of the criteria that apply to consultation pertain here as well; the psychiatrist must be a specialist who communicates rapidly and clearly with the primary care physician. Increasingly primary care practitioners should be more skilled in clinical interviewing, since medical schools are now improving this facet of their curriculum. Primary care practitioners can also attend continuing education courses in clinical interviewing that are held in conjunction with certain national meetings or which are offered on occasion by local departments of psychiatry. In addition, certain schools of medicine allow practitioners in the community to audit certain medical student and faculty development education programs in clinical interviewing. Better schools have faculty development programs in which teachers can assess their own interviewing skills; some of these programs offer opportunities to interview patients under supervision, and in some instances to review interviews on video tape.