Teaching a biopsychosocial approach on medical attending rounds

The ascent of the biotechnical, disease-oriented model of medicine threatens to relegate the integrated, patient-oriented approach to a secondary position. In response to this, a program to teach medical housestaff a biopsychosocial approach was implemented in a setting of attending rounds by having a psychiatrist participate regularly as a member of the rounding team. The effectiveness of this program's teaching effort was significantly influenced by the psychological styles and level of training of the housestaff officers. Residents were the most teachable and potentially the most effective teachers with respect to the biopsychosocial model. Interns, appearing to respond to the stresses of internship with defensive behavior, e.g., turning passive into active and isolation of affect, were less receptive. The medical attending's attitude, however, was the most important factor affecting the teaching of this approach on rounds. Three medical-attending-teaching styles were characterized, one of which appeared incompatible with teaching a biopsychosocial approach on rounds. The psychiatrist had to learn to specifically adapt his teaching efforts to each of these three attending styles, as well as to the training level related needs and the defensive styles of the housestaff.     

Effraction d’un cadre psychothérapique en milieu carcéral et décompensation psychotique

The objective of our study is to prevent pathological outcomes of the institutional abuse in a prison facility, which can trigger a psychotic breakdown of inmate patients, by enhancing a healthy communication between penitentiary staff and medical team despite the fact that they both adopt two opposite approach of inmates. In France, since 1994, public health institution took in charge medical and psychological penitentiary follow-up through Counseling and Ambulatory Care Units (UCSA). Composed of a multi-field team (psychiatrists, psychologists, medical staff), those care units have to constantly deal with security and normative issues specific to the prison facility. Usually, it is difficult to keep the psychotherapy setting safe from external “attacks” inflicted by penitentiary staff. Moreover, admitting UCSA within prison walls raises the eternal conflicting issue between two opposite logics: punishment (related to guilt) and treatment (related to illness and suffering). Whereas, UCSA staff perceives inmates as patients (to be cured), penitentiary staff perceives them as “cons” or out-laws (to be punished). The daily confrontation of such opposing logics not only affects the quality of communication between health team and penitentiary staff, but it also triggers acting-outs which put to the test the feasibility of psychotherapy in a prison setting mainly with mentally vulnerable inmate patients. Our method is based upon a case study of an inmate patient, C., who suffered a psychotic break down as a consequence to the unannounced renovation of the office dedicated to his psychotherapeutic sessions. Though, it is true that C., a former addict, had already a psychotic predisposition, his encounter with the intrusive and arbitrary authority of the penitentiary institution triggered his mental breakdown while undergoing psychotherapy. The result of our study emphasizes upon the necessity to establish a true communication between the medical team and the penitentiary staff and a mutual understanding of the value of their professional task in order to contain any conflict issues or misjudgment that may affect the progress of the most vulnerable inmate patients. Our study concludes to the importance of a complementary, cooperative, comprehensive and balanced approach of mental health problems in a prison facility through continuous training courses and discussions involving both penitentiary staff and medical teams whose roles, despite their differences, revolve around the same goal: the social and mental rehabilitation of inmates.     

Neuropsychological Consultation with School Personnel: What Clinical Neuropsychologists Need to Know

Schools request consultation from neuropsychologists employed outside the school setting to enhance assessment and intervention for children with neurological, medical, and psychological conditions. The legislative and administrative parameters governing special education services for exceptional children most pertinent to the consulting neuropsychologist are examined. The role of the school-based multidisciplinary team in determining eligibility for special education is discussed. Potential roles for the clinical neuropsychologist on the school-based team and approaches to interprofessional collaboration between clinical neuropsychologists and school psychologists are presented. Reimbursement for services and ethical considerations are also discussed.     

Psychiatric nursing in Italy: an extinguished profession or an emerging professionalism?

Ten years after the introduction of the psychiatric reform in Italy, a case study was undertaken in Santhia' (near Turin) on the experience of psychiatric nursing, to investigate nurses' perceptions of community psychiatric work as compared to their experience of the hospital setting. Members of a nursing team attached to a CMHC were interviewed, and observation of their work over a period of six months followed. Other team members--such as doctors, psychologists and social workers were also interviewed, to gather an overview, and to investigate the interaction of the specific organisational framework with nursing professional culture. The findings suggest that the move to the community has led to an emerging psychiatric nursing professional identity related to the opportunity for nurses to experience professional practices other than the medical and custodial forms, which were typical of the hospital setting.     

Active Medical Conditions Among Patients on an Assertive Community Treatment Team

The purpose of this cross-sectional study was to examine the number and type of active medical conditions among psychiatric patients treated by an assertive community treatment (ACT) team in an urban setting. Psychiatric hospitalization admission and discharge summaries of 70 patients were reviewed, and case managers on the treatment team were interviewed. Patients had a median of three active medical conditions. Osteoarthritis, hypertension, viral Hepatitis C infection, gastroesophageal reflux disease (GERD), and reactive airway disease were the most common active medical illnesses. The majority of patients were cigarette smokers and were diagnosed with alcohol or illicit substance use disorders, which were associated with viral hepatitis C infection and reactive airway disease in this patient population.John W. Ceilley, M.D., is affiliated with the Department of Behavioral Health, Denver Health, Denver, CO, USA.Mario Cruz, M.D. and Tim Denko, M.D., are affiliated with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.     

Defining discipline roles in consultation psychiatry: the multidisciplinary team approach to psychosocial oncology

Multiple mental health professions are often involved in the management of cancer patients. Psychiatry, psychology, social work, and nursing have all developed entrees to the medical setting that lead to clinical involvement of one or more of these professions at any given time. Much confusion remains about the specific contribution of these different mental health professions, and lack of role definition makes it difficult for programs to logically plan for mental health services or for services already in place to organize themselves in a collaborative manner. While these disciplines have interacted formally and informally in a number of settings for many years, there have been few published attempts to delineate the unique contributions of each and to suggest a model for their collaborative interaction. This paper attempts to define the unique contributions of each of these disciplines in relation to an oncology consultation program in a general hospital setting. The definitions are proposed as a model that can be generalized to other consultation programs.     

Effect of diagnostic labeling and causal explanations on medical students' views about treatments for psychosis and the need to share information with service users

This study examines whether medical students' views of treatments for ‘schizophrenia’ and of patients' rights to be informed about their condition and their medication were influenced by diagnostic labeling and causal explanations and whether they differed over medical training. Three hundred and eighty-one Italian students attending their first or fifth/sixth year of medical studies read a vignette portraying someone who met diagnostic criteria for ‘schizophrenia’ and completed a self-report questionnaire. The study found that labeling the case as ‘schizophrenia’ and naming heredity among its causes were associated with confidence in psychiatrists and psychiatric drugs. Naming psychological traumas among the causes was associated with confidence in psychologists and greater acknowledgment of users' right to be informed about drugs. Compared to first year students, those at their fifth/sixth-year of studies more strongly endorsed drugs, had less confidence in psychologists and family support, and were less keen to share information on drugs with patients. These findings highlight that students' beliefs vary during training and are significantly related to diagnostic labeling and belief in a biogenetic causal model. Psychiatric curricula for medical students should include greater integration of psychological and medical aspects in clinical management of ‘schizophrenia’; more information on the psychosocial causes of mental health problems.     

Influence of experience on major clinical decisions. Training implications.

We studied 779 walk-in psychiatric patients presenting to 32 first- or second-year residents and 772 patients presenting to 25 third-year residents or attending physicians as to the decision to admit to the hospital or to administer medication to those not admitted. There were no significant demographic or clinical differences between patients presenting to the two groups. The more experienced staff admitted half as many patients and treated serious depression with tricyclics twice as frequently. Inexperienced psychiatrists used hospitalization more frequently when these patients suffered from suicidal ideation, hallucinations, delusions, and inability to cope. When the training procedure was modified and second-year residents were introduced into a more structured setting, their decision-making quickly approached that of third-year residents and attending physicians. We suggest that specific training can modify decision-making, where general clinical experience may not. Implications for resident and medical student training are discussed.     

Liaison psychiatry: A model for medical care on a general hospital psychiatric unit

Liaison psychiatry is traditionally practiced on the medical and surgical floors of the general hospital. The need for liaison psychiatry on the inpatient psychiatric unit as opposed to its usual setting was realized when the medical care requirements of hospitalized psychiatric patients was assessed. In many general hospitals this medical care is provided by a psychiatrist in consultation with medical and surgical colleagues. Over a three-year period at the Medical Center Hospital of Vermont 563 medical/surgical consultations were provided to the inpatient psychiatric unit. To utilize these consultations most effectively, the role best suited for the psychiatrist was that of liaison-consultee. Case examples are used to demonstrate the effectiveness of employing liaison skills in the treatment of somatic problems on the inpatient psychiatric unit. The educational implications of learning the liaison model in this context are discussed.     

Emotional rehabilitation of the physical rehabilitation patient

Emphasis on the process and content of the emotional aspects of rehabilitation are presented as a process interwoven with a patient's physical rehabilitation. The impact of trauma and subsequent rehabilitation involves for patients the resolution of these stages: shock, denial, depressive reaction, reaction against independence, and adaptation. Factors which facilitate and impede the negotiation of these steps on both the part of the patient and attending staff are examined from the prospective of the psychiatrist as a member of the medical rehabilitation team.     

Quality of care, teaching responsibilities, and patients' preferences

A 42-year-old woman presenting to an academic medical center with low back pain radiating down her left leg was deemed to be a good candidate for a lumbar epidural steroid injection after undergoing a thorough evaluation. The procedure along with all the possible attendant side effects were thoroughly explained to the patient who readily signed the consent form. The patient was prepped and positioned, but, upon seeing that a resident rather than her attending doctor would be doing the procedure, she objected, insisting that the attending do the procedure. The attending explained that she was in a teaching hospital, where residents commonly do procedures under close supervision of attending physicians. Nevertheless, the patient still insisted on whom she wanted to do the procedure and became visibly agitated. How do you accommodate the training needs of medical students, residents, and fellows while maintaining adequate care for patients? Does the "see one, do one, teach one" principle commonly practiced in academic settings compromise the bioethical principles of nonmaleficence and beneficence? What should the attending do in this case with the patient on the table? What are the patient's rights here versus the needs of the training setting?     

Psychiatric morbidity in elderly patients admitted to non-psychiatric wards in a general/teaching hospital in Nigeria

OBJECTIVE: To determine the mental morbidity rate and types of disorders in elderly patients admitted to non-psychiatric wards of a teaching hospital in Nigeria; the ability of the non-psychiatrists to recognise the mental disorders was also assessed. METHOD: All subjects aged 60 years and above who were admitted into the medical, surgical and gynaecological wards were assessed with the Self-Reporting Questionnaire, Mini Mental State Examination and the Geriatric Mental State Schedule. Diagnoses of mental disorders were made with the ICD-10 Diagnostic Criteria for Research. The patients' case records were then examined to determine the medical and any mental disorder diagnoses made by the attending physicians. The data were analysed by the SPSS/PC(+) computer package. RESULTS: The mental morbidity rate was 45.3% with depression being the commonest disorder, followed by organic disorders (delirium and dementia), adjustment disorder and generalised anxiety disorder. There were also cases of alcohol and drug abuse. The physicians recognised only 2.8% of the mental disorders and referred one dementia patient to the mental health team. The negative predictive value for the physicians was poor. CONCLUSION: Non-psychiatrist medical practitioners in Nigeria need adequate training in mental health to enhance their ability to recognise psychiatric disorders.     

Teaching psychiatry in medical school

Considerable dissatisfaction of students and educators exists in regard to the teaching of psychiatry in medical school. This paper recommends that the liasion model of teaching directed to house and attending staffs be applied to the teaching of medical students during their clerkships throughout the general hospital, with a concomitant de-emphasis of training solely on the psychiatric service.     

Évaluation d'une action pédagogique dans le cadre de la psychiatrie de liaison

The Anglo-Saxon name of “consultation-liaison psychiatry” points to a bipolarity in the exercise of liaison psychiatry, depending on the fact that the psychiatrist works with the patient (consultation) or with the medical team (liaison). The work with the somatic care team is the specificity of this discipline. But, on the job, the psychiatrist encounters some mistrust and notes some flaws in the training in psychiatric and psychological cares. Based on this remarks, a pedagogical training has been carried out with the somatic cares teams. This pedagogical project aims at (1) improving the knowledge and skills of the trained somatic care team about psychiatrist and psychological aspects of care and (2) decreasing the mistrust triggered by the psychiatrist. According to some authors, liaison psychiatrist is basically a pedagogical procedure. For our study, one service has been chosen. The paramedical team of this service wanted to be more aware of this particular question because it frequently encountered heavy pathologies and end of lives support. Concerning training organization and content, it was composed of four sessions of 1:30 h with four or six persons. Subjects of these sessions were: medical psychiatrist/help relationship/awareness of systemic aspects/when and how work with the liaison psychiatrist? Our training aimed at bringing tools to the somatic care team, in order to take care of the patient as a whole and to improve his suffering resistance. Concerning the methodology, we have chosen a prospective approach dealing with the somatic care team, the patients and the requests for consultations sent to the psychiatrist. As far as the somatic care team is concerned, the following data have been gathered through multiple choices lists that have been proposed to everybody before and after the training: their position in the service/their involvement in the project/their feeling about the help relationship and their collaboration with the liaison psychiatrist/their anxiety level (Spielberger). Regarding the patients, the following data have been gathered through multiple choices lists that have been proposed to every in-patient between February and June 2003: age, sex, pathology/their feeling about psychological consequences of organic diseases and psychiatrist help, with QCM and QO/their anxiety level (Spielberger) and depressive symptoms (Beck). Concerning the calls for consultation sent to the psychiatrist, data collection focus on quantitative and qualitative aspects following the motive for the request. The somatic care team is composed of 25 paramedicals (13 nurses and 12 nurse's aides) and five doctors. Twenty paramedicals have taken part in the training. The somatic care team believes that they have improved their theoretical basis of the help relationship, that they face less difficulties in that relationship, that they better detect the cases where the psychiatrist has to be called for and to improve the preparation of his consultation. The mistrust towards the psychiatry has also decreased. A significant difference has been put forward regarding mistrust-state decrease (Wilcoxon's test, p = 0.004). The multiple choices lists have been proposed to all in-patients, that is to say 100 patients in February and 87 patients in June: 55% of the patients were unable to fill in the form, because of a mental or physical inability, 8% refused to take part in the study, 12% did not give the multiple choices list back because of undetermined reasons, 25%, that is 23 in February and 24 in June, have correctly filled in the form. We did not notice any influence of the training for these patients. An increase in the number of requests for consultation about mixed psychosomatic and somatic problems has been notices. It seems that it is easier to resort to the liaison psychiatrist. We have been able to detect any influence of the training through the patient's self-evaluation. Has the training missed its goal or are evaluation tools not sensitive or specific enough? In this case, let us note that we worked to fulfill the paramedical team request. However, the psychiatrist liaison is not always faced with this configuration. What can be done to make it easier for reluctant somatic care team members to accept more easily the psychiatrist help for themselves and for the patients? To our opinion, it is important to take time for each step of the procedure. Firstly, the integration of the liaison psychiatrist has to be optimized. We must answer the multiple requests and especially those of our colleagues. The target is neither to become recognized, nor to please our colleagues, but to get integrated to play his role: promote a global approach. Secondly, the somatic care team becomes aware of hidden problems. The difficulties are discussed and they must be faced with. The pedagogical action described in this article has to be thought along these lines. The trained somatic care team anxiety decrease tends to prove that they are better prepared to cope with stress. Thirdly, it is high time we started to think. According to the psychoanalytical model, when the subject is faced with a heavy somatic disease, the defense mechanisms can partially decrease the anxiety. These complex psychological processes can modify the perception of the disease and its psychological consequences. A contradiction seems to account for the gap and for the distortion of the psychological system in the situations: 89% of the patients say that they are help in the psychological difficulty by the medical team, whereas 51% say that they have not psychological difficulty. Considerable statistical problems seem to be linked to psychological processes in this kind of study. We recommend a liaison psychiatrist that strives to integrate by answering the somatic care team requests. This integration can favor pedagogical training sessions. We have tried to set up and assess these strategies; the results are globally positive. No improvement can be deduced from the patient's self-evaluation, but considerable statistical problems linked to self-evaluation tools and psychological defense mechanisms can be noticed. Even if these studies are difficult because of an important subjectivity and of a high number of variables to take into account, it is up to us to push forward the analyses and the studies to set up solid bases to deeply root our job.     

Psychothérapie institutionnelle en situation de confinement : adaptation du cadre en hôpital de jour. Vers une institution mentale virtuelle

Within the context of the SARS-Cov-2 virus epidemic, the Ambulatory Care Unit of the Toulouse University Hospital Center, offering institutional psychotherapeutic care to people with severe and/or disabling psychiatric pathologies, closed its doors to patients on the 16th of March 2020. This article aims to document the necessary adjustments to the care setting during this extraordinary period. As it was, the team had to tell patients to stay at home and to respect rules of social distancing. An inescapable paradox when our work consists precisely in de-confining, connecting, being in contact with each other. Face-to-face meetings, group workshops, the array of our mediations were suspended; the challenge for us was to bring to light what is irreducible or essential in the institutional psychotherapeutic care for psychoses, what must remain active through the confinement. These modifications of the psychotherapeutic setting will be described in terms of constructing a virtual mental institution, based on a setting twisted by the distance but not abolished, telephone consultations opening up to a speculative but not disembodied psychopathological imaginary, and finally a blog as a quasi-materialization of a virtual space. This experience led the team of the Ambulatory Care Unit to radicalize the institution to keep it in its simplest apparatus: a virtual tree structure of the mental institution. The prior interactions between caregivers and patients have been translated (and thus re-created) virtually. As to respect their singular aspects, as well as their fundamental belonging to the collective that supports our institution. This virtual mental institution can therefore maintain the framework that structures our institutional care project, and can link the before and what will be the after of the confinement. For this study, we have conducted an “on-the-spot” analysis of the concrete arrangements of our therapeutic setting from an interdisciplinary perspective: phenomenological, systemic and psychodynamic.     

Issues in the implementation of assertion training in applied settings

Based on their experiences with non-patients and psychiatric patients in a medical setting, the authors discuss issues involving the successful implementation of assertion training in an applied setting. Three key issues are: accurately assessing the target clientele and defining appropriate training goals; evolving a suitable group structure, and embedding the new program into the ongoing social system.     

A multidisciplinary approach to team nursing within a low secure service: the team leader role

PURPOSE: This article critically examines the clinical utility of redesigning a nursing practice model within the Intensive Support and Intervention Service, a new low secure mental health facility in the United Kingdom. Specifically, the “team nursing” approach to care delivery has been adapted to consist of multidisciplinary team leaders as opposed to nursing team leaders. FINDINGS: The authors describe the role, properties, and functions of the multidisciplinary team leader approach. The authors provide examples of the benefits and challenges posed to date and the ways in which potential barriers have been overcome. PRACTICE IMPLICATIONS: Nursing care leadership can be provided by multidisciplinary staff. An adapted model of team nursing can be implemented in a low secure setting.     

临床脑血管病医生对脑梗死和短暂性脑缺血发作二级预防药物干预知识的知晓程度的横断面调查

目的 调查临床脑血管病医生对脑梗死和短暂性脑缺血发作（transient ischemic attack,TIA）二级预防药物干预知识的知晓程度。 方法 在二级预防持续质量改进协作组所在的北京8家医院,进行临床脑血管病医生对脑梗死和TIA二级预防药物干预知识的知晓程度的横断面调查。 结果 总计调查140人,各职称级别人员问卷平均得分最低0分,最高56分,平均25.76分（满分100分）。其中三级医院共4家,89人,平均得分27.18分;二级医院共4家,51人,平均得分23.28分,两组差异无统计学意义（P=0.096）。住院医师平均26.27分,主治医师平均26.51分,主任医师平均23.21分,差异无统计学意义（P=0.465）。 结论 在不同级别,不同职称的临床脑血管病医生对脑梗死和TIA二级预防药物干预知识的知晓程度均差,需要采取有力措施进行相关培训。     

Managing a hospital behavior problem: Malingering

Malingering can pose a serious problem to attending medical personnel. A technique employed at the Children's Asthma Research Institute and Hospital (CARIH) in order to modify this behavioral pattern—time-out (T.O.) from positive reinforcement—is described. In addition, procedures were presented both for shaping up socially-appropriate behaviors and for insuring that gains were maintained when the subject returned home.     

Medical and surgical inpatients who referred themselves for psychiatric consultation

Medical and surgical inpatients who referred themselves for psychiatric consultation are characterized. The 25 "self-referred" compared to 787 "others" referred to the Consultation-Liaison Psychiatry Division were more likely to state depression (52%/25%) and anxiety (36%/11%) as reasons for referral. "Self-referrals" were less likely to be referred by physicians for behavior management (8%/23%), general diagnosis (4%/22%) or suicide evaluation (4%/25%). The "self-referral" represents a challenge to the current medical model referral mechanism in which the physician controls access to consultants. The data indicate that there should be a mechanism for the patient's contribution to the referral process and that increased sensitivity to psychologic difficulties in coping with medical illness would improve the use of psychiatric consultation in the medical setting.