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Psychiatry Newsletter - Safeguarding ‘the Phipps History’ Patient Examination

Hopkins BrainWise - Summer 2013

Safeguarding ‘the Phipps History’ Patient Examination

Date: July 3, 2013

Electronic records can’t undo 100 years of a psychiatric signature

Looking over Meyer's shoulder
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We’ve merged old and new to hit home longstanding themes in Johns Hopkins Psychiatry. For a century, this institution has opposed discrimination against people with psychiatric disorders. Simply setting up a psychiatric clinic in an academic medical setting, and not a freestanding asylum, emphasized these ills as disease-based rather than character flaws. And the idea of treating the whole patient, starting with Adolf Meyer’s interview that views mental illness in a larger context still serves patients well. Left to right: psychiatrists Karen Swartz, Adolf Meyer, Patrick Triplett, Paul McHugh and Ray DePaulo.

Electronic medical records. They’ve become an unexpected tie, uniting Johns Hopkins clinicians as the entire institution switches to a single, online record-keeping system. Having a patient’s whole, comprehensive chart pop up after a few keystrokes, plus the better, safer practice it should bring, are golden prizes. They help offset clinicians’ grumbles that giving birth to the new system, called Epic, comes with several years of labor pains.

Psychiatrists, though, have other concerns than a long switchover. “Epic could profoundly affect our practice,” faculty member Pat Triplett told a recent Psychiatry Grand Rounds, “partly because of the vast difference between clicking to record a patient’s strep infection and explaining why you believe someone is slipping into depression.” It’s the old body-mind dichotomy, but coming up against the technology hammers it home.

What’s particularly unsettling, Triplett says, are thoughts of compromising the “Phipps” history-taking—the  revered model of U.S. psychiatric examinations. This approach to patient assessment has been at the heart of Johns Hopkins psychiatry in some form for most of the department’s 100 years. Triplett, Psychiatry’s clinical director at The Johns Hopkins Hospital, says residents in the Emergency Department rely on a concentrated version of it for the roughly 3,000 patients that they assess each year. On inpatient floors, there’s more time to fill the framework that Adolf Meyer laid down when he came to head Psychiatry in 1909, at what would become the Henry Phipps Clinic.

What does the “Phipps” patient examination do? It documents why a patient seeks help, the patient’s personal and medical history, the family’s history, what life was like before things went awry and the subsequent psychiatric history. It also sizes up present mental status. This, of course, takes no little time and effort. 

Psychiatry’s present director, Raymond DePaulo, says, “Meyer preferred this very human formulation as a common-sense way of understanding a patient’s troubles when a pathology wasn’t evident”—as it rarely was back then. Mental disorders, Meyer believed, don’t so much strike as they emerge from fertile soil. The effect of a deep history, DePaulo says, was and still is profound. “It lets us assess patients as people, as lived lives, not just as carriers of pathologies that we need to remedy.” And quietly, almost inadvertently, treatment becomes personal.

After World War II, Meyer’s approach fell victim to this country’s tidal wave of interest in Freudian psychoanalysis. However, the Meyerian history-taking held strong in England, having been brought there by several of Meyer’s early residents. A young Paul McHugh, who would later become psychiatry director at Johns Hopkins (1975-2001), trained at London’s Institute of Psychiatry. McHugh warmed to Meyer’s method even as he realized its drawbacks. It was labor-intensive. A product of its time, it didn’t anticipate the modern biological approach to psychiatry that was emerging in the latter part of the 20th century. 

Ultimately, McHugh brought Meyer full circle, back to Baltimore. But under McHugh’s watch, Meyer’s emphasis on recording objective details of a patient’s life was transformed into a set of tools to help resolve the complex problems of those patients. McHugh’s ideas, with those of colleague Philip Slavney, took the shape of a now classic text, The Perspectives of Psychiatry, which underpins the Johns Hopkins approach to the practice and teaching of psychiatry.

The result, says former Johns Hopkins psychiatrist Francis McMahon, is that “when I sit down with patients, I’m able to understand their life stories, how illness has affected their relationships, the context of their habits and behaviors. That breaks us away from thinking of psychiatry as a checklist of symptoms. We understand how psychiatric disorders impose themselves on the whole person.”

Checklists: There’s the hitch. Existing electronic records, says Triplett, lean toward charting well-mapped bodily diseases where physicians can check off a molecule’s blood levels or upload CT scans. “In psychiatry, we rarely have that level of understanding. That makes us rely heavily on narrative.”

Fortunately, Triplett, who’s both a point person for Epic transition and loyal to the ‘Phipps’ patient examination, says things are still plastic. “We’re assured that Epic’s psychiatric notes section is a big text box where the traditional narrative will still have a home.”

Johns Hopkins isn’t alone in facing these issues—they challenge academic psychiatry nationwide. But psychiatrists know the power of resilience. “I can’t imagine,” says Triplett, “that technology will diminish the power of the “Phipps” patient examination. We need to find ways to integrate it into the electronic medical record.”