If you’ve ever wondered how doctors are trained to diagnose and treat patients presenting with mental health concerns, keep reading below. I’ll start by introducing the general framework for how doctors are trained to talk with patients and then include more specific examples relating to mental health assessment.
How doctors are trained to talk to patients
During medical school all medical students take a course in communication whereby there are repeated opportunities to practice obtaining a focused history from standardized patients (actors who are paid to play different patient roles).
Reflecting on my experience and summarizing how it is that I had been trained to listen (and in turn think) when eliciting a history from a patient, I would describe it as follows:
Step 1: Greetings
Any clinical interview starts with an exchange of basic social pleasantries and introducing yourself and your role as a physician.
Step 2: Setting the agenda
The interview begins with establishing reasons for why the patient is seeking care and what issues they are interested in exploring today and achieving mutual agreement on which issue(s) will be discussed in this visit.
Step 3: Asking questions
With taking any history from a patient, the physician will typically start with more open ended questions and then progressively shift to more close ended questions to narrow the focus of the conversation.
Step 4: Discuss Treatment
After taking a focused history from the patient, the physician will perform a focused physical exam as well if indicated. Otherwise, they will segue into a discussion reviewing the suspected diagnosis and related treatment options. They will attempt to establish a plan in conjunction with the patient moving forward.
How Doctors are Trained to Think While Listening to You
Reflecting on my own medical training, as a physician I was basically trained to listen for certain “buzzwords” that patients may use when describing their challenges which would then prompt me to consider different potential diagnoses. In order to then ask directed questions to evaluate as to whether one diagnosis or another is present, I would then search my memory for different diagnostic criteria or distinguishing symptoms that would be relevant to ask my patient as part of the clinical interview. All of this mental activity happening in real-time while talking to the patient.
Often times, what this process is reduced to when it comes to mental health assessment is recalling different mnemonics (memory recall devices to help remember diagnostic criteria for different conditions–such as a pattern of letters that when memorized, help jog your memory on some other associated ideas) which I would then sequentially ask patients questions about in order to either rule in or rule out any particular diagnostic possibility.
A typical example of a memory shorthand that commonly would come up in a mental health assessment is: MSIGECAPS. This mnemonic is a shorthand whereby each of the nine letters represent one of the 9 different diagnostic criteria for the diagnosis of “Major Depressive Disorder” as per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
|Diagnostic Criteria for “Major Depressive Disorder” from the DSM-5|
|M: Mood (decreased)|
|S: Sleep disturbance|
|I: Interest in hobbies, daily activities, etc. (decreased)|
|G: Guilt or feelings of worthlessness|
|E: Energy (decreased)|
|C: Concentration (impaired)|
|A: Appetite (increased or decreased)|
|P: Psychomotor symptoms (feeling that their limbs are heavy, or feeling restless)|
|S: Suicidal ideation or Self-harm|
Anyone who has presented to a physician for a mental health assessment will almost certainly be familiar with the above criteria as in the process of taking a mental health history, as soon as a physician hears a patient say, “I feel depressed,” “I feel burnt out,” “I feel tired all the time,” “I’m having difficulty concentrating,” etc. they will likely feel prompted to pull out the MSIGECAPS mnemonic from their memory in order to assess for a diagnosis of depression among their different diagnostic possibilities (differential diagnosis). There exist a host of other mnemonics for various mental health diagnostic labels found in the DSM: BESKIM for “Generalized Anxiety Disorder,” DIGFAST for “Bipolar Disorder,” or TRAUMA for “Post-Traumatic Stress Disorder.”.
What works for general medicine isn’t helpful in mental health
In my experience as a family physician by training who upon transitioning into independent practice now only practices psychotherapy, I found that the way that I was trained to listen to patients and take a history to be entirely inadequate. While this approach may be helpful in general medicine where you need to be more “hands-on” in directing the conversation to evaluate for the likelihood of different diagnostic possibilities, which in turn directs your physical exam maneuvers you perform and as a result, which diagnostic tests you order, this approach could not be more off-the-mark when it comes to mental health.
My critique of this approach
Essentially, as a physician I was trained to listen for various “buzzwords” that a patient would use and then redirect the conversation irrespective of what the patient is talking about and ignore their personal narrative in the process, simply in order to satisfy my own false sense of confidence as a physician, that if I just ask these questions (whether MSIGECAPS, DIGFAST, BESKIM, or others), that I will be able to confidently evaluate this person’s mental health concerns and provide them with a diagnosis on the spot as well as the corresponding treatment options. This style of performing a mental health assessment does not serve the patient AT ALL. Somehow this has become the standard of care.
The treatment option discussion I was trained to provide was also very much a “cookie-cutter” schpiel as well unfortunately. I was trained to generally encourage patients to consider making improvements to their sleep hygiene, to exercise, to mind their nutrition, would make a fleeting recommendation that they seek therapy if they are open to it, and otherwise maintain some sort of social contact as their circumstances allow. Ultimately however, as a physician, it really boiled down to whether the patient wanted me to write them a prescription or not and based solely on my medical training, that was all that I was in a position to offer, as medical education regarding addiction and mental health is nearly non-existent. I had about a 3 week course on mental health during medical school and all of two lectures on “opioid use disorder” and “alcohol use disorder” neither of which were particularly informative. In my experience, the curriculum during residency similarly left much to be desired.
What actually works
Once I had completed my medical training and was no longer beholden to whatever unique practice preferences the various supervising physicians I was working under possessed, I realised that I had to question everything that I had been taught around performing mental health assessments and instead elected to take a more patient-centred approach.
When performing a mental health assessment, I do not listen for buzzwords or try to constantly redirect the conversation so that I can ask the rote questions I have memorized for the various diagnostic criteria from the DSM.
Instead I simply listen intently while holding the time and space for the patient in front of me to gradually unfold their own personal narrative and maintain a warm curiosity to allow them to gently explore their own thoughts, feelings, and beliefs in a non-judgmental environment. I do not have an agenda for discussing “X, Y, or Z” during any of my hour long appointments as therapy is process oriented and organic.
Rather than try to fit patients into different diagnostic boxes as per my training, I allow them to share and explore their own understanding of their issues and I reflect what I am hearing back to them, help them interpret what they are experiencing, re-frame certain thoughts, humanize their experience, and invite parts of themselves into their awareness that they may not yet be cognizant of. This all occurs within the context of a relational-based approach to therapy, with an emphasis on attunement to their emotional states.
At this time, if I had to summarize my experience as a physician-psychotherapist, I would describe psychotherapy as follows:
- 90% listening carefully and holding space while the patient explores their internal world
- 10% what I reflect back to the patient and how I help them interpret things
- Overall, it is a very organic and spontaneous process, that is very permissive and entirely patient-driven
I am merely there to facilitate my patient’s own process and I have no control over their progress. This is very much in opposition to my training as a physician whereby we are trained to see ourselves as “fixers” or “problem solvers” or “solution finders” where we buy into this delusion that as a physician I somehow possess the power to “fix” my patient through some means, irrespective of the multitude of factors that have contributed to them being in the circumstances that they currently are in, and that I am somehow going to effect change within the patient rather than it coming from within them.
Becoming an effective physician and psychotherapist requires open-mindedness, the willingness to challenge what I have been taught, the courage to unlearn what isn’t helpful, the curiosity to expand my knowledge and grow both personally and professionally, as well as compassion for myself and others.
Most of all, it requires acknowledging my own limitations and remaining connected to a sense of humility.
These are all skills that medical school and residency do not teach you.