Ownership, responsibility and hospital care: lessons for the consultation psychiatrist

OBJECTIVE: To identify scenarios in which consultation psychiatrists encounter difficulty reconciling their clinical role with consultees' expectations and to suggest concepts that help navigate these situations. METHODS: The authors' clinical experiences are used to generate and discuss three major categories of situations that require psychiatric consultants to thoughtfully adjust the breadth and depth of their obligation to patients and consultees. RESULTS: "Occam's razor 'dulled," "Conflation of the psychosocial with the psychiatric" and "Disposition preoccupation" are proposed as the major categories leading to conflicting patient management views between consultant and consultee. Each has, at its core, a compromise of patient ownership that blurs the boundaries of the consulting psychiatrist's responsibility. CONCLUSIONS: Understanding and channeling ownership back to the consultee, while appropriately gauging and embracing one's responsibility, form a two-pronged approach to clarifying one's role in consultations.     

The mental health administrator as organizational consultant

The mental health administrator is frequently in a position to serve as a consultant to other mental health organizations. This paper illustrates some of the principles of consultation, describing a year-long consultation to a department of psychiatry under new leadership. The aspects of consultation described include: (1) the consultation request; (2) the orientation of consultant and consultee; (3) the consultation contract; and (4) the consultation process.William Hausman, M.D. is Professor in the Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota 55455. Reprint requests should be addressed to him there. Harry Prosen, M.D. is Professor and Head, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba.     

Psychiatric Consultations at Medical and Surgical Wards: The Role of Psychiatric Consultant

Abstract: A one-year survey was conducted on the psychiatric consultation work at Kyushu University Hospital. It was found that an organic brain syndrome was the most frequent psychiatric diagnosis of the referred patients. The most frequent purpose of request for psychiatric consultations was for the management of the patient. The main consultant functions were diagnoses and to advise on the management of the patient. The consultant functions agreed with the purposes of request in many cases, but discrepancies between the two were found about the patient disposition. The nature of the consultant role was compared with some American studies. It was deemed necessary that consultation-liaison psychiatry based on Japan's present conditions, medical and social, should be developed.     

Referrals to psychiatric liaison nurses: Changes in characteristics over a limited time period

This article reviews the literature on the consultant/consultee relationship within psychiatric liaison nursing. Data on 284 referrals from staff nurses to psychiatric liaison nurses (PLNs) in a teaching hospital are examined to discover whether the nature of the referrals changes with the evolving consultation relationship. Referrals are found to change over time in their specificity, focus, level of sophistication, and kind of PLN involvement requested. Possible explanations for these changes are discussed.     

Psychiatric disorders and the need for mental health services among a sample of orthopedic inpatients.

This report concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed.It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.^1–6 Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19%–86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.^3,7,8 Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified.In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.^2,4,9–12 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients.     

Psychogeriatric consultation in "reception centres": a descriptive account.

"Centres d'accueil" (reception centres) for the aged will be required to become increasingly involved with seniors presenting psychological or psychiatric problems, because of both the increase in life expectancy and the philosophy of avoiding the institutionalization of such seniors in psychiatric settings. One of the activities of the consulting psychiatrist is to meet the patient to establish a diagnosis and suggest treatment; however, the support of the care-giving team is the consultant's primary concern. The psychogeriatric consultant makes a rapid, on-site decision on suitable treatment for the patient, thus avoiding a potentially upsetting transfer. In addition, the consultant encourages active involvement by staff in the management of the psychiatric problem.     

The psychiatrist as informed consent technician: a problem for the professions.

Psychiatric consultation in general medical settings is a valuable corollary to the work of other health care professionals. In various contexts, such consultation can be debased, however, to the point that the psychiatrist is serving as a technician rather than as a consultant in relation to several aspects of the informed consent process. The authors identify five inappropriate models of psychiatric consultation and review the proper approach to obtaining true informed consent.     

Difficulties in the physician-patient dyad: invoking the psychiatric consultant

Drawing upon their studies of physicians' responses to the recommendations and diagnosis of psychiatric consultants, the authors propose that the psychiatric consultant is most often invoked when the primary physician experiences an inappropriate interpersonal distance in the relationship with the patient. Sensing the threat or the reality of the patient as too close or too distant, the physician seeks the presence of the consultant. In the subsequent triadic constellation, the psychiatric consultant is suggested to function principally as buffer between the physician and the patient, restoring, or effecting a more optimal interpersonal distance in the original dyad. This construct helps to explain the consultees' "selectivity" in requesting consultation and the marked disparity between reported prevalence of psychiatric disorders in the medically ill and referral rates. It also calls attention to the role of the psychiatric consultant in assuring that the medical care of the patient with psychiatric features is not compromised or abbreviated.     

Authority,influence and control in consultation

It has long been held in the literature that in the process of consultation the recipient of consultation, or consultee, is a free agent in relation to the consultant. Yet, the concept of pure consultation as that relationship where the consultee is free to accept or reject the consultant's advice and knowledge appears to be a myth. This paper discusses authority, influence, and control as intervening factors in the consultation relationship.     

Psychiatric consultation with regard to requests for euthanasia or physician-assisted suicide

The objective of this article is to describe the practice of psychiatric consultation with regard to explicit requests for euthanasia or physician-assisted suicide in the Netherlands. Written questionnaires were sent to an unselected sample of 673 Dutch psychiatrists, about half of all such specialists in the Netherlands. The response rate was 83%. Of the respondents, 36% (199 of 549) had at least once been consulted about a patient's request for physician-assisted death. The annual number of such psychiatric consultations is estimated to be 400 (about 4% of all requests for physician-assisted death). About one in four consultations is initiated by another psychiatrist. Consultants were mainly asked to assess whether the patient had a treatable mental disorder (68%) or whether the patient's request was well considered (66%). Assessment of the influence of transference and countertransference was less frequently sought (24%). Of the 221 consultation cases described, 67 (30%) ended in euthanasia or assisted suicide, whereas another 124 (56%) did not. In most, but not all, cases where the patient's request for physician-assisted death was refused, the respondent had judged that the request was not well considered or that the patient had a treatable mental disorder, or that the decision-making was influenced by transference and countertransference. We conclude that psychiatric consultation for patients requesting physician-assisted death in the Netherlands is rare, as in other countries. The issue of psychiatric consultation with regard to requests for physician-assisted death, especially in patients with a physical disease, needs to be further addressed.     

Length of hospital stay of medical and surgical inpatients referred for psychiatric consultation: a retrospective study

Retrospective analysis of 406 consecutive psychiatric consultations with general hospital inpatients revealed that their mean length of stay (LOS) was 26.1 days, while the mean LOS of the other hospital patients was only 11.1 days. In 36.5 percent of the consultation patients the LOS in hospital was longer than that exceeded by 10 percent of the hospital patients. The factor most strongly related to a very long LOS of psychiatric consultation patients appeared to be the referring ward. Particularly on cancer wards very long LOS patients were referred to the psychiatrist. The psychiatric consultant often supported the ward staff by making recommendations for the management of such patients. Patients with a long LOS might be a suitable group for carrying out a controlled cost-effectiveness study of psychiatric consultations in a natural setting.     

Prevalence and recognition of depressive disorders in general medical inpatients

The Beck Depression Inventory (BDI) was administered to 220 of 340 patients consecutively admitted to three general medical wards of a University Hospital, whose length of hospital stay was more than five days. At least mild symptoms of depression (BDI greater than or equal to 13) were reported by 70/220 (32%) of the patients. Alternate BDI depressive patients underwent psychiatric consultation. The psychiatric consultant established a DSM-III depressive disorder in 10/33 (30%) of these patients. Only 3/10 (30%) of the DSM-III depressive patients had been referred to the consultant psychiatrist by their physician.     

A resident's rotation in consultation psychiatry : A maturational experience

The authors emphasize the importance of a consultation psychiatry experience in the maturation of the young psychiatrist by examining some of the processes operational in both community and hospital consultation work, performed by the senior author during his fourth year of residency. Such experiences can provide opportunities for developing psychiatric skills not emphasized elsewhere, including the adoption of an active therapeutic stance, the application of the psychodynamic theory to the consultation system itself, and teaching without the use of jargon. In addition the experience as consultant facilitates the transition from residency to the outside world, not only through attitudinal changes achieved by exposure to less structured settings, a change in the supervisory model, and a solidification of identity as a physician and psychiatrist, but also by providing the resident the opportunity to begin de-cathecting from the training program.     

Psychiatric aspects of organ transplantation

Technical advances in surgery and the new antirejection agents cyclosporine and muromonab-CD3 have led to improved outcome for organ transplantation. Allograft rejection and complications of immunosuppressant therapy are often associated with considerable stress, so availability of psychiatric consultation is a necessity. As a transplant team consultant, the psychiatrist treats perioperative anxiety, depression, and organic brain dysfunction and addresses medical and ethical aspects of patient selection. Studies indicate that many patients with psychopathological conditions have good postoperative results and that most living kidney donors participate spontaneously and consider donation a positive experience.     

Psychiatric consultation on an otolaryngology liaison service

Otolaryngology patients (especially those with tracheostomies) present a significant challenge to psychiatrists from both a diagnostic and therapeutic standpoint. To date, no study has been made of psychiatric disorders among this important group of patients. At the Mount Sinai Medical Center, a liaison psychiatrist has been involved with a specialized otolaryngology cluster unit since 1979. Using a 384-item computerized database protocol developed at Mount Sinai, data on 139 otolaryngology patients were recorded and compared with 1662 "Other" inpatient psychiatric consultations on the medical and surgical services during 1980-1987. The otolaryngology patients as a group were more likely to be male (p = 0.011), married (p = 0.001) and employed (p less than 0.001). Cancer was the most common medical disorder, and the average level of stress as reported on DSM-III's Axis IV (5.1, severe) was significantly greater (p less than 0.0001) than that for the "Other." The most common psychiatric response was adjustment disorder (36%). The length of stay of those ENT patients seen in psychiatric consultation was 26.4 days, in contrast to 11.1 days for all ENT patients. However, the length of stay of those patients on ENT receiving a psychiatric consultation was not different from the "Other" psychiatric consultation cohort (26.3 days). Despite the higher level of stress, the incidence of significant psychiatric morbidity was lower for the ENT cohort. The primary effect of the liaison psychiatrist was to lower the threshold for case identification that enhanced the referral rate on the ENT unit.     

Pitfalls and pratfalls in consultation-liaison psychiatry in a general hospital

As Consultation-Liaison Services continue to develop and expand in general hospitals, psychiatrists must be aware of pitfalls and pratfalls inherent in dealing with medical colleagues and other allied health professionals, as well as with the patients. Practical considerations in answering consultation requests are discussed with respect to "hidden agendas" of the consultee, role and expectations of the psychiatrist, and problem referrals. It is only through mutual respect and collaboration that Consultation-Liaison Services can truly be effective.     

Evaluation and Management in Consultation-Liaison Psychiatry

Abstract: The subjects were 95 medical and surgical inpatients referred to Kyushu University Hospital Psychiatric Consultation Service. The authors studied the mental status of each referred patient and elicited some Unclassified mental status cases. It was recommended, therefore, to bring in new concepts of normal condition and polymorphous condition in dealing with those Unclassified mental status cases which are often recognized as problematic both by the patient's primary physician and the psychiatric consultant. The ordinary style Single contact consultation was also compared with the Active follow-up consultation regarding the function of psychiatric consultations. The authors confirmed that most referring physicians who were supported by the Active follow-up consultation appreciated highly the evaluating function of a psychiatric consultant