Heart Of The Matter: Treating The Disease Instead Of The Person
by Leana Wen, MD
June 25, 2014
… As soon as they get home, they file a complaint with hospital about their terrible experience.
All told, it took only 22 minutes from the time the man entered the hospital for the cardiology team to clear the blockage. The cardiology team is proud that they beat the national average for what they call door-to-balloon time by 42 minutes. The faster a blockage can be cleared, the better the odds are for a full recovery.
The patient gets well without complications. Two weeks later, he’s back at work and exercising again. The ER and cardiology teams consider the man’s case a resounding success.
Why then are there such different views of the same ER visit? Who’s right?
The doctors who believe they delivered exemplary care, or the patient and his wife who feel he was treated badly?
The two viewpoints of this ER visit end with one thing in common.
Just as the providers were surprised by the patient’s complaint, the patient and his wife were taken aback when the team that I was part of presented them with their doctors’ point of view.
“We had no idea they were trying so hard,” the man said. “It’s too bad we didn’t know that at the time.”
Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University.
She is the author of “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Care,” and founder of Who’s My Doctor, a project to encourage transparency in medicine.
A model for streamlining psychotherapy in the RDoC era: the example of ‘Engage’
Molecular Psychiatry (2014) 19, 14–19
G S Alexopoulos and P Arean
A critical task for psychotherapy research is to create treatments that can be used by community clinicians. Streamlining of psychotherapies is a necessary first step for this purpose. We suggest that neurobiological knowledge has reached the point of providing biologically meaningful behavioral targets, thus guiding the development of effective, simplified psychotherapies. This view is supported by the Research Domain Criteria (RDoC) Project, which reflects the field’s consensus and recognizes the readiness of neurobiology to guide research in treatment development.
‘Engage’ is an example of such a streamlined therapy. It targets behavioral domains of late-life depression grounded on RDoC constructs using efficacious behavioral strategies selected for their simplicity. ‘Reward exposure’ targeting the behavioral expression of positive valence systems’ dysfunction is the principal therapeutic vehicle of ‘Engage’. Its first three sessions consist of direct ‘reward exposure’, but the therapists search for barriers in three behavioral domains, that is, ‘negativity bias’ (negative valence), ‘apathy’ (arousal) and ‘emotional dysregulation’ (cognitive control), and add strategies targeting these domains when needed. The end result is a structured, stepped approach using neurobiological constructs as targets and as a guide to personalization. We argue that the ‘reduction’ process needed in order to arrive to simplified effective therapies can be achieved in three steps: (1) identify RDoC constructs driving the syndrome’s psychopathology; (2) create a structured intervention utilizing behavioral and ecosystem modification techniques targeting behaviors related to these constructs; (3) examine whether the efficacy of the new intervention is mediated by change in behaviors related to the targeted RDoC constructs.
Keywords: engage; late-life depression; psychotherapy development; RDoC; structured personalization
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