Coursebook sonopsychology ch29

Sonopsychology ….

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EFSUMB – European Course Book Editor: Christoph F. Dietrich

Sono-Psychology Lucas Greiner

Corresponding Author Lucas Greiner, MD, FRCP Professor of Internal Medicine and Gastroenterology ISCUS Director www.flyingfaculty.de

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Content Content ....................................................................................................................................... 2 Introduction ................................................................................................................................ 2 The main actors .......................................................................................................................... 2 Inner scenario ............................................................................................................................. 3 Room for magic moments .......................................................................................................... 4 Outer scenario: sonophilia, sonophobia, and others................................................................... 4 Conclusions and recommendations............................................................................................ 5

Introduction Medical doctors and psychology – a daily must, and most doctors like it: considering and reflecting their patient`s and their own behavior, reactions, emotions, interactions, and roles.

Performance capabilities in doctors usually exceeds an amateur level – or is quite different to what is considered a “professional” psychological approach, whatever this might be.

The reader is invited to share some considerations on psychological implications before, during, and after ultrasound examinations and interventions – looking at an “inner” and at an “outer” scenario.

The main actors These are the patient/the fellow citizen, the doctor, and the ultrasound machine (Tab.1). The latter has – as from a rationalistic point of view – no emotions nor affectations. However, in the perception of both the doctor and the patient, the machine maybe is gifted with sort of a personality as being the main mechanical tool in meeting and answering the questions, the main topic (Tab.1) of the examination. And these questions of health and disease, of living and maybe even dying – they might be considered as so to say the number four main actor.

Table 1

Main components of “inner” and “outer” scenario, and their ranges

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Inner scenario Motivations to be with an ultrasound examination are zero for the machine (of course), but manifold and diverse for the patient as well as for the doctor. Spending a span of time together in a darkened (!) room means for the expectations, wishes, and fears of the patient and of the doctor only in part the same (Tab. 2a,b).

Table 2

Wishes and expectations of patient/citizen, and doctor

Tab. 2a

Tab. 2b

Patient

Doctor

• •

•

•

inferior position expectation and communication o verbalized o non verbalized level of o role experience as a good patient o intellectuality o pre-information fears of o bad findings o false diagnosis o wrong diagnostic or therapeutic consequences

• •

•

•

superior position expectation and communication o verbalized o non verbalized level of o role experience as a good doctor o intellectuality o pre-information fears of o overlooking o false diagnostic or therapeutic decisions, underor overreaction

The patient – or the co-citizen and not-yet-patient in case of getting a “health check up” (sometimes a doubtful enterprise) – first and chiefly wants to get a good result: situation improving, no new/additional findings, or no abnormality detected at all, especially no signs of malignancy.

Second and well understood is that the machine and the procedure – though harmless physically - may give uncomfortable (e.g. gallstones) or even dangerous (e.g. malignancy) results.

Third, the patient knows that the examination with ultrasonography absorbs the doctor for some minutes, leaving the chance of undivided attention and allowing himself to grab hold of the examiner. In this, patients/citizens understand that the examining doctor is dedicated and not reluctant to closely get into contact, both metaphorically speaking and physically.

The doctor, interpretor of findings and diagnostician, must make best use of a limited span of time in getting an idea of the patient`s problems, history, and personality. Patients must be addressed on an appropriate level of language and intellectuality (probably the most fascinating aspect at all in working in the medical field). The doctor should meet all these requirements clearly, friendly, indefatigably, and completely – yes, and of course: including

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an ultrasonography examination high in competence and quality of performance, looking into the body without cutting it open (unlike a surgeon, and patients of course appreciate this). The doctor is to some extent the master of the sequence of actions – either by speeding up the examination (with increasing fears of overlooking an important finding), or – in the case of too much talking from the patient – giving an extra command on taking a deep breath and holding it as long as possible.

Having been in the patient`s role once himself can be a good help for the doctor to practice a more pronounced understanding of the scenario, and of the own position.

Room for magic moments Occult handlings including cold jelly on undressed skin, commands from the examiner, mysteriously moving grey and coloured pictures, and strange (doppler-) sounds in a dark room: all this is not so far away from a shamanic behavior of the examining doctor, communicating with supernatural forces via the competently ruled machine and monitor.

Moreover, the doctor being capable of his role of interpretor and “medium” is close up, touching the patient both manually and in the more figurative sense, exposing him/herself directly and without restraint or escapement – a situation completely different to what patients experience with the “secondary” imaging modalities (computed tomography (CT), magnetic resonance (MR), etc.). All this and the underlying position of the patient contribute to the power of the doctor, whether patients like it or not. Those who do not like this type of mastery will sometimes start to offer sort of a graded resistance, more or less subconsciously – a well understandable type of reaction, which the doctor must have ways for, too.

And he must always remember the fact that his non-verbal communications and especially his face are under most attentive and maybe anxious observation. So in doubt – e.g., finding a mass suspicious of malignant origin – a pokerface concentration is needed for the examiner.

For the doctor, ultrasound examination is a routine work. The patients – experiencing the examination as a special event in their life - will however repeatedly recall all its details to their memories and re-evaluations.

All this means – in an attempt to summarize the inner scenario – that ultrasound examination is - loaded with a strong magic component in the triangular relationship of patient, doctor, and machine; - psychologically standardized by the underlying questions of health, disease, and even fatality – so in its performance, ultrasound examination can be - sort of a movie equivalent, harbouring both comedy and drama options.

Outer scenario: sonophilia, sonophobia, and others These interpretations of ultrasound examinations will be understood easily by those doctors who perform it themselves, whatsoever medical subspecies they are from.

Such sonophilic colleagues, however, are usually met with scepticism by others: the sonophobics, presenting as either a tolerant or a more militant sub-subtype. The sonophobic tolerants complain about patients being too fat, too immobile, too meteoristic, and similar lame excuses for avoiding acceptance – or even self-performance – of the ultrasonography examinantion. The militants simply deny any sense in performing

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ultrasonography. Both the tolerant and the militant sonophobic feel better and relieved by ordering a CT- or MR-scan, which saves them from own responsibility, too – and filling in the template for ordering a CT-/MR examination is a matter of a minute only.

It is remarkable how widespread tolerant and militant sonophobia are. The reasons for this can be quite clear – ultrasonography means challenging work, direct exposure to a non-sedated patient, and a high degree of personal responsibility , with no personalized (e.g. financial) benefits for the examiner. And it means competition to more simple imaging modalities such as CT and MR – notwithstanding their limited additional information and limited local resolution capability. This is especially true in abdominal indications, where most (>80%) of CT- and MR-scanning is made superfluous by ultrasonography “only”. Sonophobia is even found with gastroenterologists of the merely endoscopists type – an attitude which makes these gastroenterologists less than one-eyed and more than half-blind in gastrointestinal (GI) disease. Their view is limited to the mucosa perspective of the GI tunnel, they voluntarily avoid the rich informations of abdominal and especially of intestino-sonography. The same holds true for hepatologists, only recently discovering e.g. non-alcoholic steatohepatitis by means of ultrasonography, and voluntarily avoiding further ultrasound informations about the liver (some making use of a very meager substitute in the sense of “elastography” by expensive and non-informative machines). This close-your-eyes-policy is difficult to understand; maybe some jealousy concerning the ultrasonography expert is in part a psychological explanation. The split and still highly ambivalent surgical attitude to ultrasonography will here not be stressed in more a detail.

Clinical ultrasonography is a well established high-tech tool with a marked potential for further development (e.g., by contrast enhanced ultrasonography (CEUS)) – however, as it is true for all morphological and functional imaging modalities, it is more useful for practical than for scientific reasons. Building an academic carreer on “merely” ultrasonographical scientific work is considered less trendy, acceptable, and fundable than e.g. working with nacked mice, clinical oncology experiments, or genetics.

Conclusions and recommendations The sonophilic and maybe even a bit sonomaniac reader having gone through all these considerations is met with appreciation and thankfulness, and comments and criticism are welcome as well as addenda and completion.

We know that ultrasonography is to be praised as a not yet fully detected jewel in practicing a doctor`s work, extending palpation, auscultation, and the knowledge of the patient`s history in an immediate and wholesome approach for quick further decision making.

Table 3

• • • • • • • •

Recommendations

don’t be shy, rely in your method ultrasonography is high tech ultrasonography is one of the most sophisticated clinical tools accept its limitations, including a limited value in scientific research CT and MR only when really needed perform daily case-related ultrasound meetings, e.g. combined with X-ray conference perform continuous education, training, teaching use the high “psycho- and confidentiality-index” of clinical ultrasonography

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The method is by far good enough to overcome the psychological obstacles for present users and non-users (Tab.3) - especially since it is an ideal “soft” technology bearing just the adequate dosage of medicotechnical armentarium awaited and well tolerated by our patients.

The fine art of clinical ultasonography – combining the skills of the doctor and of the machine for the patient in a very specific atmosphere – creates a good basis for a confidential cooperation between doctor and patient. The adequate use – underuse can be as much a problem as overuse -, and marketing of clinical ultrasonography is highly recommended, for the sake of our patients, and for the pleasure in work for us as medical doctors, too (and maybe – who really knows – for the machine a little bit as well).