When consulting on a medical or surgical ward, consider asking the patient, “How are they treating you here in the hospital?” The response to this straightforward question often clarifies the reason for the consultation and helps establish the patient’s psychiatric diagnosis.
Asking about the patient’s experience in the hospital can reveal the dynamics of his or her interpersonal relationships. In a well-functioning ward, healthy answers are, “Everybody is really nice,” or “The staff is great, but I can’t wait to go home.” Any other answer should be investigated.
Questioning reveals disorders
Patients with borderline personality disorder (BPD) will describe a hospital staff split into idealized and rejected components and try to enlist you in their fight. However, most BPD patients won’t need encouragement to discuss their conflicts with the staff.
Unhappy narcissistic patients will com-plain about assaults on their dignity—often housekeeping issues such as poor-quality food and linens, indifferent cleanliness, or delayed response when they use the call button. Happier narcissistic patients will celebrate their doctors’ outstanding credentials and clinical brilliance.
Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.
Depressed patients may guiltily apologize for wasting everybody’s time.
When patients hint that they are enjoying the hospital experience or would like to prolong their stay, inquire into their situations outside the hospital. They may be homeless, abused, or destitute. Malingerers and patients with factitious disorder typically will insist on their desire to be cured and discharged.
Proper phrasing is essential
As phrased, the question is a “counterprojective” maneuver.1 It distances you from patients’ suspicions, resentments, and presuppositions. By referring to hospital personnel as “they,” you signal that you are distinct and neutral if the patient is feuding with the staff. By comparison, asking “How are my friends on the medical staff treating you?” would invalidate this counterprojective effect, align you with the hospital staff, and subtly encourage the patient to keep his problems to himself.
If the question elicits a complaint, try to stay neutral as long as possible. Guard against perceived defensiveness and the patient’s projections by saying, “I’m sorry to hear things aren’t going well. Tell me more.” Offer to help if there is a concrete and reasonable solution.
Patients might not tell you about problems with their care in the hospital unless you ask. Some patients are too polite to say anything. Others are afraid to complain because they recognize that their comfort and perhaps even survival are in the hands of hospital staff.