The psychiatric examination in the walk-in clinic. Hypothesis generation and hypothesis testing.

Rapid assessment for decision making is a major goal of the initial psychiatric interview in walk-in clinics, emergency psychiatric services, and the ambulatory services of community mental health centers. To accomplish this task, the clinician must learn to elicit specific data to confirm or refute clinical hypotheses rather than gather a complete history. This report, in formulating a hypothesis generating and testing approach for the initial psychiatric examination, proposes 16 hypotheses that organize the clinical data necessary for most decisions. This approach is intended to help the clinician make efficient use of limited time, guard him from coming to premature closure in the collection of data, and provide a stimulus for the exploration of relevant but neglected clinical questions.

The customer approach to patienthood. Attending to patient requests in a walk-in clinic.

This report conceptualizes the initial psychiatric interview as a process of negotiation between the clinician and patient. Patients are conceived of as appearing with one or more requests, many of which represent legitimate needs. It is the clinician's task to elicit the request, collect the relevant clinical data, and enter into a "negotiation" that should foster a relationship of mutual influence between patient and clinician. We have attempted to show that this approach to patienthood not only improves patient care and patient satisfaction but also leads to improved staff morale. The "customer approach" has special relevance to those clinical settings (walk-in clinics and community mental health centers) in which clinicians see a broad range of patients with a broad definition of psychiatric problems and requests.

Are there social class differences in patients' treatment conceptions?

Traditionally, lower-class individuals who have sought psychiatric help have been hampered in their efforts by classrelated inequities in the delivery of psychiatric services. A common explanation for this phenomenon has been that the treatment conceptions of lower-class individuals are "inappropriate." This report presents theoretical and research evidence challenging this notion. A review of the literature from 1954 through 1974 yielded no good evidence that lower-class patients need, expect, or want treatments incongruent with those of upper-middle-class therapists. An experimental study of the requests for help made by 278 walk-in clinic patients confirmed this observation. Patient requests, as measured by an 84-item, self-rated questionnaire, were largely independent of social class. It was concluded that social class differences in treatment disposition and outcome cannot be attributed to social class differences in patients' treatment conceptions. The possibility that methodological and sociological factors can account for the discrepancies between the findings of this study and past studies is discussed. Strategies for minimizing treatment biases against lower-class patients and for maximizing treatment effectiveness with higher-class patients are also suggested.

"Adherence" and the negotiated approach to patienthood.

A study was conducted on adherence to treatment referrals made in the psychiatry walk-in clinic of a general hospital. One hundred thirty patients were administered the patient request form, a general information questionnaire, and a postinterview evaluation questionnaire. Information on adherence was obtained from the hospital records. Forty-one percent of the patients adhered to the treatment referral. Adherence was significantly related to negotiation, as predicted. Another significant predictor of adherence was the patient's getting the plan he wanted. Adherence was not found to be related to demographic measures or scores on the patient request form. The index of negotiation also correlated significantly with the patient's evaluation of the interview, replicating previous findings. The relationship of adherence and negotiation is discussed.

Shame and humiliation in the medical encounter.

Patients are at high risk for experiencing shame and humiliation in any medical encounter. This is because they commonly perceive diseases as defects, inadequacies, or shortcomings; while the visit to the hospital and the doctor's office requires physical and psychological exposure. Patients respond to the suffering of shame and humiliation by avoiding the physician, withholding information, complaining, and suing. Physicians may also experience shame and humiliation in medical encounters resulting in their counterhumiliation of patients and dissatisfaction with medical practice. A heightened awareness of these issues can help physicians diminish the shame experience in their patients and in themselves. Twelve clinical strategies for the management of shame and humiliation in patients are discussed.

Relations between academic departments of psychiatry and pharmaceutical companies.

The financial pressures placed on academic departments of psychiatry make the offers of assistance from pharmaceutical companies very attractive. The authors provide a sequential three-step decision-making approach to help the academic physician and the psychiatry department address the ethical issues involved in any given interaction with a pharmaceutical company. They also provide examples of the application of these guidelines.

Attitude of psychiatric residents toward patient requests.

The authors assessed residents' comfort in dealing with 14 previously identified types of patient requests in inpatient, outpatient, and acute service settings. First-year residents expressed significantly more discomfort than more experienced residents on 11 categories. They were also significantly less comfortable in the acute service than the inpatient setting. All residents expressed more comfort dealing with dynamic, psychological, and "nonsevere" requests. These findings suggest a need to teach residents specific therapeutic responses to various categories of requests and to evaluate the desirability of starting the residency experience on an acute service.

Disposition decisions in a walk-in clinic: social and psychiatric variables.

The success of a walk-in clinic in providing care without regard to social and diagnostic factors is measured in a study of 391 patients. Results indicate that acceptance or nonacceptance into the clinic system were unrelated to social class or diagnosis, although these factors did influence referrals to specific clinic resources.

Evaluation of the initial interview in a walk-in clinic. The patient's perspective on a "customer approach".

There have been different models on how to conduct the initial psychiatric interview in a walk-in clinic. A "customer approach" has been developed which stresses: a) eliciting and understanding the requests that patients have regarding how they hope to be helped; and b) negotiating a treatment plan with the patients. We evaluated this customer approach from the perspective of the patient. The first hypothesis was supported. The patient's perception of the clinician's utilization of the customer approach correlated positively and substantially with measures of outcome, especially feeling satisfied and helped. The second hypothesis was also supported. Utilization of the customer approach continued to correlate positively and substantially with outcome even when patients did not get the disposition originally wanted. We discussed the clinical significance of the customer approach especially in regard to patient objectives in the initial interview--a treatment plan vs. symptom relief.