Psychotherapy, Atypicals—and Physical Contact?

By Dr Geppert is chief of consultation psychiatry and ethics at the New Mexico VA Health Care Center in Albuquerque. She is also associate professor of psychiatry and director of ethics education at the University of New Mexico. | January 15, 2010

I’m a psychiatrist in private practice and do not have a secretary or nurse. One of my patients who has bipolar II depression is undergoing psychotherapy. I have prescribed an atypical antipsychotic for this patient. The drug’s manufacturer recommends periodic checks for metabolic syndrome—which means (among other things) checking the patient’s blood pressure, weight, and BMI via measurements of his waist circumference.

I am willing to weigh patients undergoing psychotherapy and check their lab test results and blood pressure, but I am uncomfortable making physical contact to check waist circumference. Instead, I discuss with patients how to take care of themselves, and refer them to a primary care physician.

Is it appropriate to touch such patients for clinical purposes? If not, could I be blamed if a patient has an MI secondary to high blood cholesterol levels if I haven’t been monitoring these parameters?

Does touching a patient in this setting constitute a boundary violation?

We invite you listen to this podcast, in which ethicist and psychiatrist Cynthia Geppert, MD, PhD, tackles the ethical considerations. Dr Geppert is chief of consultation psychiatry and ethics at the New Mexico VA Health Care Center in Albuquerque. She is also associate professor of psychiatry and director of ethics education at the University of New Mexico.

Our thanks to Virginia Buki, MD, a psychiatrist in Aventura, Florida, who sent this case to Dr Geppert. If you are faced with an ethical dilemma, we invite you to submit the details to editor@psychiatrictimes.com.

Psychotherapy, atypicals — and physical contact?
Psychotherapy, atypicals — and physical contact?
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by Yvonne Barash | July 30, 2010 3:18 AM EDT

Regarding the questioner's concern about BMI measurement, is it really necesssary to take a waist measurement? Can't you just divide the patient's weight by his/her height?

by Thomas Patitucci | July 29, 2010 11:25 AM EDT

Thomas Patitucci

Clearly, a bio-psychosocial treatment approach requires a variety of tests to monitor the physical conditions of patients being treated with psychotropic medications and for co-occuring medical conditions. Failure to perform the required tests is not only unethical by poor medical care and actionable in court.

As I see it the prohibition against touching a person one treats is fine if a person is psychotic. Attempts to offer consolation by touching is poor practice in these instances and dangerous to everone. This is akin to a 3_D movie scene where a giant hand comes out of the scene at you if you are the person who is psychotic you can become extremely upset.

Beyond these instances normal human interactions like handshaking, a pat on the shoulder etc perferates no particular professional boundaries.

If a professional is unwilling to perform the required monitoring for what ever reason, then they would need to either hire a nurse/ CNA to perfrom the tests or refer the person to have the tests completed and monitor the results.

Finally, you can simple ask the person to place a tape measure around there own waste and observe the results.

by Berry Edwards | July 29, 2010 10:35 AM EDT

That one should even ask this question is another sad legacy of psychiatry's unfortunate association with psychoanalytic theory. Psychiatrists have no more obligation to understand the unconscious (if it even exists) implications of physical examination than do primary care physicians. Ironically psycho-analytically oriented psychiatrists are the first to complain that the "psycho"has been lost from the biopsychosocial model. Yet by abstaining from doing physicals we abandon the "bio."

by Keir Todd | July 03, 2010 8:17 PM EDT

I am a Physician Assistant in full time psychiatry. Most of my job is working up internal medicine/primary care issues that are frequently part & parcel of psychiatry. Each patient is informed apriori about the various maneuvers that may be a required during the exam including, auscultation, palpation, imaging, venipuncture, etc. I spend a fair amount of time with each patient discussing potential adverse effects of drugs and the need to keep on top of each problem. I have never had a patient refuse. This all takes place the same day as the psychiatric interview. My supervisor and I go over each case. Our system works well. We've never had a problem with insurance reimbursement or payments.
Kindest regards,
I Keir-Todd, PA-C, M.Ed.

by Nsn Jones | June 17, 2010 6:05 PM EDT

This is an argument that rages on on the medscape physician connect foum. While I think it is essential to use your medical skills as part of being a psychiatrist, I DISAGREE that the "evidence"would support the physical exam as the best way to use our limited time. If I am not mistaken, even primary care doctors debate the value of a physical exam, especially as compared to the value of a good history. My favorite examples are of a time I picked up diabetes in a patient when her PCP didn't. I was exploring what she meant by trouble sleeping, and got that she was using the bathroom A LOT at night. I also noticed that she had lost a lot of weight in a short period of time. Both things came to me because I knew this patient well, and spent a lot more time with her than did her PCP. Labs where remarkable for a very elevated blood sugar. And look! No hands!

There are times when certain symptoms could represent thyroid disease, but I have NO confidence that I would get enough experience palpating a thyroid to rely on that over labs.

So MAYBE in an ideal world, there would be enough psychiatrists working in offices with examining rooms and chaperones, and enough insurance companies to pay for that time spent AND the things that ONLY we can do...and primary care docs would also do a really good mental status exam ( what I consider my "specialty" physical , and the answer to many delirium vs "functional" differentials. ). In this less than ideal world, I think history is as good as or better than a physical for most of what gets referred to psychiatrists, and does not require as much of a paradigm shift.

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Psychotherapy, Atypicals—and Physical Contact?

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