Patient, parent, and physician perspectives on pediatric oncology rounds.

To provide data to guide physicians regarding the extent to which pediatric patients and their families should be involved in decision-making discussions by their health care teams, we compared the standard rounding procedure in a pediatric oncology unit (rounds conducted out of earshot) with bedside rounds in which management was discussed in front of patients and parents. Type of rounds was alternated in 2-week blocks for 4 months. The impact of the two types of rounds of 35 parents and children was studied. Parents preferred bedside rounds to standard rounds, and perceived increased opportunities to obtain information and ask questions. Parents and children differed in their reports of how much bedside rounds upset children. Older children, compared with younger children, more strongly disliked standard rounds; this appeared to be related to feelings of exclusion. The two types of rounds differed in their effectiveness in providing specific types of education to residents. The findings suggest that bedside rounds have a positive impact on parents' attitudes toward physicians, that they do not dilute the child's sense of relationship with the primary attending physician, and that they contribute to certain aspects of resident education.

Clinicians' fallacies in psychiatric practice.

Eleven common clinicians' fallacies have been briefly described. Based on experience, the authors of this article believe these are the most common and pernicious ones in interdisciplinary psychiatric treatment. These patterns may lead to erroneous interdisciplinary treatment decisions for many patients. In order to protect the well-being of psychiatric patients, their families, and the integrity of interdisciplinary treatment teams, it behooves each and every team member to become knowledgeable about clinicians' fallacies. Those aware of clinician's fallacies will reason more soundly basing judgments on empirical evidence, careful observation, measurement, and a determination not to be influenced by emotional appeals.

A mobile crisis unit in the psychiatric emergency room.

A mobile psychiatric crisis intervention service based in the emergency room of a county receiving hospital sends teams into the community to screen and treat patients in crisis. The teams have been able to treat 70 percent of the patients seen in the community without hospitalization. Two-thirds of those hospitalized are admitted to nonpublic community hospitals, thus relieving the load on public institutions. To augment their work with patients, the teams employ a multisystems approach to treatment that attempts to identify and resolve problems not only within the patient's family, but also with the referring therapist and agency, and even with the crisis intervention service itself. The service has ensured its survival by paying close attention to the needs of its sponsoring institutions.

A hospital team approach with parents of a Down's syndrome infant.

This article is a description of a multidisciplinary team approach with parents of a Down's syndrome infant in the obstetrical department of the Royal Victoria Hospital in Montreal. After a brief explanation on the reason why a refinement of this approach became necessary, the authors give an account of the in-service training that was implemented for professionals as well as some comments on parents' initial reactions to the birth of a Down's syndrome child and the role of professionals in these situations. Finally, a "Protocol for management of Down's syndrome infants in hospital" is included in the last part of the article.

Guidelines for developing multidisciplinary treatment plans.

The formulation of a multidisciplinary treatment plan is important not only because it is required by federal and accreditation agencies but because it increases communication, consistency, and direction among members of the treatment team. Input from all disciplines is most effectively obtained through the multidisciplinary treatment planning conference. The author provides guidelines for formulating a plan in each of four major steps: assessment, problem identification, planning (including priorities, long- and short-term goals, and interventions), and evaluation.

The crisis intervention team at Christchurch Hospital.

It is clear that the Crisis Intervention Team has a vital part to play in the provision of acute psychiatric care in Christchurch. Over the past ten years it has undergone a number of changes in response to the needs of those using the service. Although it is hard to measure its effectiveness, the figures the team has so far collected compare favourably with those of teams operating in other countries. It seems that as pressure comes to bear on the existing services, other centres are looking at the feasibility of setting up their own Crisis Intervention Teams. It may be that as a result, the Canterbury Hospital Board will soon lose the lead it has had in this area, as teams are set up in other main centres around New Zealand.

Inpatient behavior therapy: the St. Louis University model.

Many of the problems that impede the practice of behavior therapy on traditional psychiatric and medical inpatient services can be avoided by a separate behaviorally-oriented inpatient unit, but few guidelines exist for establishing such a unit. The present paper describes the inpatient Behavioral Treatment Unit developed at St. Louis University Medical Center. Critical administrative and clinical features of the Unit are discussed, including the administrative philosophy which emphasizes unit autonomy and participative management, the central role of nursing staff, the importance of the clinical team system, the development of referral sources, admission procedures and criteria, and basic approaches to assessment and treatment.

Pregnancy and diabetes. Team approach.

Each year, 10,000 babies are born to diabetic women. Gestational diabetes occurs in 2% of all pregnant women, resulting in 60,000 to 90,000 cases of gestational diabetes yearly. Prior to 1922 and the discovery of insulin, fetal mortality for the pregnant diabetic was almost 100%. Today, total fetal mortality for the pregnant and gestational diabetic is approaching that of the nondiabetic. This has been achieved by extremely tight control of blood glucose levels throughout pregnancy, with blood glucose levels averaging under 100 mg/dL/day and glycosylated hemoglobin levels in the normal range throughout pregnancy. An increased number of malformations in fetuses of pregnant diabetic women is still a problem. However, animal and human studies indicate that a normal level of glycosylated hemoglobin at conception may significantly reduce these malformations.

Home assessment and treatment in a community psychiatric service.

The work of a new community-based crisis intervention team is described. 326 psychiatric emergencies were seen over a period of 3 years. An increasing proportion of these were acutely psychotic at the time of assessment. Home treatment was effective for a significant number of patients, including those with a previous history of hospital admission. Some practical and theoretical aspects of the service are discussed.

Pattern of discussion in traditional and novel ward-round procedures.

A novel ward-round procedure was introduced on an acute psychiatric admissions ward. There was an equal balance in number of staff and patients attending the meetings simultaneously, and all team members participated in the interviewing and discussion. This was compared to the traditional type of ward-round procedure in which one patient attends at any given time, and the consultant is the exclusive interviewer and director of team discussion. The content of negotiation in the traditional ward round was compared to that in the novel style of meeting and it was found that the novel format produced a swing away from medical and diagnostic issues to domestic and social matters.

A model of intervention in child-abusing families: a wider systems view.

This paper describes the application of some principles, taken from the modern psychotherapies by a therapeutic team, to the assessment and treatment of serious child abuse. Factors and dilemmas identified from the assessment and decision-making process are outlined, with particular reference to the roles of the various statutory and community agencies involved with such families. The paper demonstrates the ways in which the range of community and professional agencies may play a pathological role, unintentionally contributing to and maintaining child-abusing dynamics in families. The significance of dangerous unintended consequences of well-meaning agency interventions and of covert interagency activities are stressed.

The shared field: a precursor stage in the development of a psychotherapeutic alliance with the hospitalized chronic schizophrenic patient.

Psychotherapeutic work with chronic schizophrenic patients is difficult for both patient and therapist. Such patients lack many of the capacities necessary to participate in psychotherapy: motivation, observing ego, the ability to communicate verbally about thoughts and feelings, the capacity to sustain a relationship. Treatment of such patients may require phases in which such capacities are nurtured until the patient is able to form a therapeutic alliance of the ordinary kind. This paper discusses the ways in which hospitalization can be helpful during pre-alliance phases of psychotherapeutic work, through the provision of a protected setting and a team approach, in conjunction with individual psychotherapy. A perspective is offered for conceptualizing the early relationship between patient and hospital staff as a stage in the development of an alliance.

A randomized trial of team care following stroke.

A randomized controlled trial was conducted to examine the effects of interdisciplinary team care on acute hospitalized stroke patients. After obtaining baseline information on 42 stroke victims receiving conventional care in a general hospital, 130 stroke patients were stratified and randomly assigned either to Traditional or Team care. Assessments by independent evaluators permitted comparisons between Team and Traditional groups with reference to patient survival, motor performance and functional abilities. Data obtained prospectively from charts and treatment logs allowed the care process across groups to be compared. Results demonstrated that Team and Traditional patients fared similarly in survival. However there was an unexpected difference in survival depending upon sex. For motor performance, male survivors performed better with Team care and female survivors with the Traditional method. In terms of functional abilities, male patients receiving Team care again performed better than their Traditional counterparts, whereas in women there was no difference between the treatment groups.

Multidisciplinary or nondisciplinary: evaluation of staff functioning in a community mental health centre.

This paper describes the staffing aspects of an experimental community mental health centre (Melville Clinic). The different components of staff roles of members of a team consisting of different health professionals, crystallised during the three-year period with a shift from a 'nondisciplinary' to a 'multidisciplinary' approach, with preservation of 'generalised' and 'specialised', 'clinical' and 'community' roles of all staff members. The decision-making in the centre oscillated between group decisions by all staff members, and the acceptance of the leading role of the psychiatrist with the active multidisciplinary teamwork in community mental health centres.

Primary care teams and the elderly in Northern Ireland.

The results of a questionnaire were used to examine how primary care workers set about the management and surveillance of their elderly patients. The majority of practices had attached visitors (76 per cent) and attached district nurses (59 per cent), while 61 per cent of general practitioners worked in health centres. Over half of the responding practices had agesex registers. Few of the practices (14 per cent) had screened their elderly patients in the last five years and maintained an ;at-risk' register. Twenty per cent of practices held a regular meeting concerning their elderly patients but only half of these reviews involved the available health visitors and district nurses.At least half of the general practitioners and district nurses plus three quarters of the health visitors felt dissatisfied with the care of the elderly.A single and systematic review of elderly patients conducted jointly by general practitioners, health visitors and district nurses would do much to improve the care of this group of patients and the morale of these workers.