Bariatric Times - August 2008 - (Page 17) Bariatric Times • August 2008 Consultant’s Corner 17 affect other patients. She empathizes with the patient, but also sets limits by telling Annette she does not want to be sworn at or yelled at, and maintains the adult: adult relationship. The receptionist offers the patient someone else who might relate differently to her. The receptionist disapproved of Annette’s behavior but still respected her. Assertive communication respects one’s self and the other. When it becomes clear to this receptionist that nothing she will say or do will work with Annette, she still does not take it personally. Her offer to allow Annette an opportunity to discover her primary concern in the privacy of the office manager’s office displays interest in helping her, even if Annette is difficult. This powerful message can have unlimited positive impact on Annette and any other patients observing what took place. The receptionist focused on serving without losing her own self respect. A policy in writing to guide the receptionist, or all staff members for that matter, on handling angry patients in a consistent, respectful manner is a good risk management strategy. A couple of years following surgery, we have seen that some of our patients become depressed. Why is this? You would think they would be ecstatic about their weight loss and physical appearance, but surprisingly, not all are. Our male population in particular has been having more problems than we anticipated. Should we make special concessions for this patient population? Experts: There has been increasing interest in literature pertaining to male depression—not just in the weight loss surgery patient—but men in general. Certainly weight loss surgery has an extremely positive impact on the individual’s overall health and quality of life; however, the many changes that accompany massive weight loss can be stressful in a way the patient could not have anticipated. Roles, relationships, opportunities, and the mandate to make choices all work together to create varying levels of stress. As part of preoperative clearance, a behavioral healthcare provider is asked to evaluate the surgical candidate. The ASMBS has published suggestions to guide providers in understanding the purpose of preoperative psychological screening. As valuable as the assessment is, it is not a substitute for long-term follow-up and continued assessment and intervention as needed, which leads to a more comprehensive discussion of long-term follow-up. One of the reasons long-term follow-up is important is not only to capture physical progress and assessment, but also threats to emotional and mental health. Patients evolve through the life cycle and can develop depression regardless of the positive changes and attained weight loss goals. Each year, depression affects about six million American men and 12 million American women. These numbers may not tell the whole story, especially among the male population because men may be reluctant to discuss depression. This is probably why experts believe many men with depression are undiagnosed, and consequently are untreated. When men return for their annual follow-up visits, they are more likely to focus on physical complaints—headaches, digestive problems, or chronic pain— rather than on emotional issues. In both men and women, common signs and symptoms of depression include sleeping poorly, sadness, guilt, lack of energy or joy, and a feeling of worthlessness. In some cases, men are unaware that physical symptoms, such as headaches, digestive disorders, chronic pain, or fatigue, could be symptoms of male depression. As the specialty of weight loss surgery evolves, so do the many nuances of managing the needs of complex individuals who become our patients. Behaviors such as depression, anger, and anxiety may simply become more apparent as the many changes that emerge from weight loss surgery unfold. Long-term follow-up along with understanding and recognizing these challenges are part of the exciting and emerging role of those interested in improving care for those on their weight loss journey. It is also not only the patient that may experience emotional responses to weight loss surgery. We have seen spouses and significant others who are unable to cope with their partner’s weight loss and new attitude. This is why education of the impact of weight loss surgery is essential for both the patient and family. TABLE 1. Rules for engaging the angry patient 1. Engage but do not do emotional work for the patient. 2. Maintain adult-adult communication rather than fostering the patient’s dependency. 3. Avoid personalizing the patient’s anger. 4. Adopt a patient-centered worldview by ascertaining his or her values, priorities, hopes. 5. Normalize anger so that the patient can move through this stage. TABLE 2. BATHE Model for handling an angry patient3 Background: Use active listening to truly hear the patient’s situation. Affect: Validate the patient’s emotion by naming it: “My understanding is that you feel angry right now.” Avoid either ignoring or reacting to the patient’s feelings. Trouble: Determine the primary emotion. Explore what scares or troubles the patient most about his or her present and future. Just asking the question, “Tell me what concerns or frightens you” will help the patient focus on circumstances he or she may not have considered. Handling: Knowledge and positive action can help mitigate fears and reduce anger. How are they handling life changes, such as finances, family, or relationships? Empathy: By displaying empathy and concern, you can help the patient feel understood and less abandoned and alone. Avoid statements such as: “I know what you’re going through.” Paraphrasing the patient’s comments is an effective way to convey that you heard and are seeking to understand. “So you feel it’s unfair your wife continues to undermine your weight and health goals.” SUGGESTED READING 1. Saxton JW. The Satisfied Patient: A Guide to Preventing Malpractice Claims by Providing Excellent Customer Service. Marblehead MA: HCPro, Inc.;2003. 2. Stewart MR, Lieberman J. The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician, 2nd Edition. Westport, Connecticut: Pager Publishing;1993. 3. Boyle D, Dingell B, Platt F. Invite, listen, and summarize: A patient-centered communication technique. Academic Med. 2005;80(1):29–32. 4. Reich, WR. What care can mean for pharmaceutical ethics. J Pharr Teaching. 1996;5:1–17. 5. Suggestions for the pre-surgical psychological assessment of bariatric candidates. Accessed at: www.asbs.org/html/pdf/PsychPreSurgicalAssessment .pdf. 6. Male depression: Don’t ignore the symptoms. Accessed at: www.mayoclinic.com/health/maledepression. Column supported by an educational grant from http://www.asbs.org/html/pdf/PsychPreSurgicalAssessment.pdf http://www.asbs.org/html/pdf/PsychPreSurgicalAssessment.pdf http://www.mayoclinic.com/health/male-depression http://www.mayoclinic.com/health/male-depression http://www.novusrrg.com http://www.novusrrg.com http://www.novusrrg.com
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