The consultation psychiatrist as effective physician

1. Introduction 

The essence of effective consultation in any medical specialty lies in the expert knowledge and skill that the invited consultant brings to the bedside. If the process is to work, both the consultee and the consultant must believe this. The alternative is at best a waste of time and, at worst, a fraud perpetrated on the patient in which the best of intentions accomplish nothing. Based on this belief, the authors proffer three principles of inpatient consultation psychiatry that represent the condensed form of a year’s shared experience at a major teaching hospital and subsequent supervisory roles at four teaching hospitals. Despite their simplicity and importance, these principles are rarely clearly taught during psychiatric residents’ consultation-liaison (C-L) rotations. In setting them out here we hope to provide a means of introducing such education and discussion. Some statements are made that may seem to run counter to the “unique” educational role often ascribed to C-L psychiatry. We purposely choose to avoid the debate over this role, but instead focus on the importance of education by example of responsible, competent and confident doctoring.

2. Principle I: do not be afraid to refute notions of psychopathology 

Case: A 48-year-old man with no past psychiatric history suffers a left temporoparietal stroke with a consequent Wernicke’s aphasia. Psychiatry is consulted a week later to “evaluate and manage depression,” though the record offers no explanation of this request. Despite obvious comprehension difficulties and attendant frustration, the patient is affectively engaged with the examiner and indicates a sense of hopefulness and self-agency. He sleeps well, voraciously ate a breakfast brought by his sons that morning, and works diligently with speech pathology. The consultant diagnoses “no psychiatric disorder.”

While most nonpsychiatric disease states are identified by jargon (e.g., stroke, myocardial infarction, Pneumocystis carinii pneumonia), the names of many common psychiatric disorders are not terribly different from lay terminology for ordinary human experience (e.g., major depressive disorder, panic disorder, pain disorder). This distinction, along with psychiatry’s paucity of diagnostic tests and reputation as an intuitive field, may lead referring physicians to suspect, diagnose and medicate psychopathology based on symptoms and “common sense” rather than syndromes and clinical judgment.

C-L psychiatry may contribute to this problem through an error of omission. A small body of work illustrating the misdiagnosis of psychopathology by nonpsychiatrists garners much less attention than the large literature on the underdiagnosis of psychopathology. For example, false positive rates of nearly 30% are found in the diagnosis of major depression by primary-care physicians, [1] and preliminary diagnoses by consultees may be confirmed by psychiatric consultants only 60% of the time for depression [2] and for psychopathology in general. [3]

These are clinical realities in the consultation psychiatrist’s daily existence. When physicians request psychiatric consultation, it is usually because they recognize suffering or dysfunction in parts of the patient that form fundamental aspects of their humanity. In the subsequent evaluation of the patient, the consulting psychiatrist must attempt to separate biography from history. We define biography as that part of the patient’s story that he or she produces spontaneously or might produce for any interested party. History is that part of the patient’s story that the physician requires to formulate a diagnostic assessment and treatment plan and which may contain significant amounts of biography. For example, a patient may report or exhibit sadness and describe to their physician detailed circumstances to which their sadness might be attributed. In and of itself this is biography. When this information is joined by (and thoughtfully interrupted by) elicitation of the patient’s specific experience of the sadness, the associated symptoms, longitudinal course, and baseline, a history has been obtained.

Patients’ psychological phenomena and biographies tend to elicit more affective response from treaters than do their psychiatric diagnoses and histories. The former pair may also be seen by consultees as more germane to the practice of psychiatry than is the latter. Thus, when biography reveals distress, but history does not bear it out as reflecting the suspected psychopathology, the psychiatrist reporting this may be seen as insensitive or even incompetent by members of the treating team. Tolerating the kind of tension this can generate can be difficult, but it is essential. Such sentiments can often be preempted by writing in the note a statement such as, “This patient is certainly sad and suffering, but at this point there is no evidence for, or benefit in, pathologizing that suffering.” This sort of statement implicitly contrasts biography and history, acknowledges one’s own humanity, and affirms the validity of psychiatric diagnosis. The consultee may also be reassured by a consultant’s promise to “return for a follow-up visit to assess for consistency of presentation.”

As an expert, it is as important to accurately refute notions of psychopathology as it is to confirm them. When such refutation is absolute (i.e., “no psychiatric disorder”), billing becomes the final obstacle since current circumstances disallow reimbursement for no diagnosis. Discussion of fiscal policy is beyond the scope of this article. Suffice it to say that this “rule” merits abolition. In the meantime, the use of adjustment disorder diagnoses should not be taken lightly. The argument that they are “benign” should be weighed against the implications of assignment of a psychiatric diagnosis to a patient who is healthy and of “soft” diagnosing for the integrity of psychiatry.

3. Principle II: do not be afraid to discontinue unnecessary psychotropics 

Case: A 50-year-old man with type I diabetes mellitus and heroin dependence is admitted with a necrotic foot ulcer and undergoes right-sided below-the-knee amputation. One month later, an infectious disease note states that the patient is “feeling down,” and citalopram is started. Psychiatry is consulted four days later for assistance in managing “depression.” The patient is without significant neurovegetative symptoms, hopelessness, helplessness, or worthlessness. He reports good functioning and euthymia during past periods of sobriety. Discontinuation of citalopram is recommended, and this is done. However, on several readmissions to the acute-care hospital from the rehabilitation facility, he again is taking antidepressants even though his psychiatric presentation remains unchanged. These are repeatedly discontinued, and not restarting them is finally communicated as a discharge recommendation.

The importance of diagnostic accuracy and effective psychiatric consultation is even more evident when psychopharmacology is considered or implemented by treating physicians. The latest generation of psychotropic drugs has improved the lives of patients and physicians alike through their ease of use and minimization of certain side effects. However, these very attributes also lead to cavalier use. An example of this is the misguided invocation and treatment of an (undiagnosable) “underlying depression” in the setting of hypoactive delirium. [4] Another example is the attempt to reverse-engineer a diagnosis through a target symptom’s response to a pharmaceutical probe. The idea that certain psychotropic drugs “can’t hurt but might help” is often provided as justification in both of these situations. This notion is erroneous for several reasons.

The first reasons are patient-centered; are particularly relevant to the medically ill patient; and revolve around the fact that, while quite useful when judiciously employed, these medications are not harmless. On a physiologic level, they may interfere with the metabolism and protein-binding of other medications, cause side effects ranging from gastrointestinal distress to akathisia to the syndrome of inappropriate antidiuretic hormone secretion, or worsen mental status in cognitively compromised patients. On a psychological level, they may communicate to non-mentally ill patients that their expressions of justifiable distress are aberrant or unacceptable. Alternatively, they may provide non-mentally ill patients who are also poorly tolerant of frustration with false hope for a “simple” resolution of their distress.

The next reason is practice-centered. When consultation psychiatrists abide the use of unnecessary medications and the well-meaning arguments used to justify it, they obscure the view of psychiatry as a medical specialty. Nonpsychiatrist physicians may love us for it, but they will not respect us. In medicine, even symptomatic treatment must follow diagnosis or coherent clinical judgment. C-L psychiatrists need to demonstrate this to other physicians whose treatment of psychopathology diverges from this principle. When doing so, strong documentation and clear personal communication of one’s treatment rationale are, as in any other clinical controversy, the “gold standard” of explanation.

The final reason is society-centered and requires the least elaboration. Psychiatric medications believed to be “safe” and “easy” tend also to be expensive. With mental illness accounting for five of the top ten causes of years lived with a disability worldwide, [5] effective allocation of psychiatric resources and health-care dollars is of paramount importance. “Buckshot” use of selective serotonin reuptake inhibitors and other new psychotropics likely creates more economic problems than it solves.

4. Principle III: do not be afraid to “sign off,” when necessary 

Case: A 75-year-old man is intubated in the intensive care unit with aspiration pneumonia, wound infections and congestive heart failure. He develops fluctuation of alertness and attention and begins pulling on his iv lines and endotracheal tube. Chart notes state that he “appears alert and oriented with apparent clear cognition,” though no cognitive exam is documented. Psychiatry is consulted due to a “significant mood change this week.” On exam, the patient is obtunded and grossly disoriented during brief moments of engagement. Delirium is diagnosed and recommendation made for treatment with iv haloperidol. However, dosing recommendations are disregarded. Despite clear communication by the consultant to the contrary, progress notes continue to describe him as “depressed.” The patient’s medical condition deteriorates, as does his mental status. While a subtherapeutic dose of haloperidol is continued, citalopram is started. When the consultant explains to the team attending that he cannot help under these circumstances, no changes are made and the consultant signs off the case.

This principle is more provocative and less often necessary to implement than the prior two. Like all other consultants, consultation psychiatrists do not have final decision-making authority for the patients they see. Even in settings where consultants write their own orders, the attending physician ultimately reserves veto power. This can be extremely frustrating, perhaps particularly so for C-L psychiatrists, who may feel a duty to alter “problematic” perceptions and attitudes in their nonpsychiatric colleagues. While perhaps noble, the latter sentiment leads to trouble when untempered by a pragmatic sense of one’s usefulness, or lack thereof. If a consulting psychiatrist remains on a case despite the consultee’s repeated repudiation of well-explained and clearly communicated recommendations, it must be asked, “Whose needs are being served here?”

Those of the patient certainly are not. Recommended medications remain on the pharmacy shelf, while inappropriate ones remain on the books. It could be asserted that the consultant might still be of help psychotherapeutically in these situations. However, if the other treating physicians disagree with the psychiatric assessment, this will not be lost on the patient. Already in a compromised position, he or she will then be at risk for uncomfortable feelings of confusion, anger and/or fear. Pathos for the patient or ethical arguments against “abandonment” may seem like compelling reasons not to sign off here. The belief that one can be of help to the patient in this context is essentially grandiose. Additionally, traditional outpatient conceptions of abandonment are ill-suited to the general hospital where patients are actively under an attending physician’s care and cannot receive interventions rejected by that physician.

On the surface, it may seem that the consultee is not being served either. In a subtle way, though, this is not so. The consultee believes that the patient has a psychiatric problem. The consultant’s opinions may be rejected, but misperceptions of the problem will persist. The continued presence of a psychiatrist on such a case allows the consultee a false belief that the problem is being addressed, and an undue sense of security that help is immediately available if things get out of control. In fact, it has been advocated (G. B. Murray, personal communication, 1999) that when signing off in these situations, one ought quietly, but intentionally, to foster anxiety in the mind of the consultee with a note ending with the statement, “call back when something happens.”

As far as the consultants themselves, most psychiatrists are used to the idea of examining personal motivations in patient care, and we will not dwell on this here. The inaction of not appropriately signing off of a futile consultation may escape notice, but nevertheless warrants scrutiny. In addition, justified withdrawal from a case communicates important messages about the consultant in particular and psychiatry in general. While compromise is often necessary in medicine, acquiescence to, or passive observation of, inappropriate treatment of psychopathology is unacceptable.

5. Conclusions 

An effective psychiatric consultation answers another physician’s question with conclusions and recommendations generated by expert evaluation of a patient’s history, mental status, and objective data. It does not create new problems for the consultee. However, it also does not court the contentedness and good favor of the consultee at the patient’s expense. It is as important to define one’s limits as it is to demonstrate one’s usefulness. These three principles of consultation psychiatry address the common situations in which the goals of patient care and consultee satisfaction may find themselves in opposition to one another. In resolving such conflicts, we have found that it is ultimately better to stress what psychiatry shares with the rest of medicine than to emphasize a unique role. The principles are based on a medical approach that our colleagues in other specialties can relate to: diagnosis guides treatment, and both have prognostic implications. It is the authors’ belief that demonstration of confident use of the medical model in diagnosing and treating psychopathology bridges the gap between psychiatry and the rest of medicine.