An annotated bibliography for ethics training in consultation-liaison psychiatry.

The expanding field of bioethics has created a need in psychiatry for rapid access to the complex bioethics literature. This is especially true in consultation-liaison work. An annotated bibliography was created by a task force of the Academy of Psychosomatic Medicine charged with exploring how psychiatrists function on bioethics committees. The bibliography is organized into headings that reflect how bioethical problems came to the attention of psychiatrists. Introductory references allow the reader an overview of the history of bioethics and a selection of useful textbooks. References are provided explaining how ethical principles are used. References are also organized by areas of medical work frequently visited by consultation-liaison psychiatrists.     

Teaching and learning in the ambulatory setting

Changes in how and where health care is delivered have had an adverse effect on the traditional inpatient-based clinical education of medical students. Increasingly, medical educators are turning to ambulatory-based educational experiences as viable and useful adjuncts to the inpatient wards. However, when planning and developing an ambulatory clerkship, careful attention must be paid to the desired outcomes from the experience, the appropriate site, and instructional model to use to best meet the objectives. This report explores (1) the major differences between ambulatory and inpatient educational settings, (2) potential educational outcomes of clinical teaching in the ambulatory setting, (3) instructional models that can be used to meet educational objectives, (4) the potential barriers and critical issues that must be considered when implementing ambulatory educational experiences, and (5) evaluation strategies for measuring the educational outcome.     

Psychotherapy training in an isolated setting

This paper describes the setting up of a training programme in psychodynamic psychotherapy in Perth, 'the most isolated city in the world'. Previous attempts to do so have petered out after a short period of time. It had certainly never been possible to develop a training programme. Initially a study group of interested health professionals was formed in 1984 which met to study certain texts at fortnightly meetings and participated in workshops conducted by the supervisors who visited from Sydney, 3,400 km away. At the end of that year the study group was changed into the Association for Psychodynamic Psychotherapy of Western Australia. The foundation members were also the first training group. The training programme consisted of fortnightly meetings concerned with intragroup issues, administrative matters and with the didactic programme: this consisted of seminars being conducted as part of a training programme in Sydney which were recorded on videotape and flown to Perth. As the 3-year training progressed we also added additional topics of our own. On the alternative fortnight the members split into small groups for peer supervision of audiotape recordings of sessions with the patient being supervised. In addition there were supervision workshops conducted by the visiting supervisors from Sydney. The paper also discusses the logistical problems of conducting such a training as well as transference and countertransference issues that arose within the group of trainees as well as with the supervisors who were so far away.     

Psychotherapeutic training in an institutional setting

Many child and adolescent psychotherapists are asked to work in specialized institutions (where the children are either interns or externs), with children presenting behaviour problems, learning difficulties, mental handicap or important psychosocial problems. They learn through diverse treatment forms, or parent accompaniment during the child's treatment (bifocal or conjoint treatment more or less regular therapeutic sessions with both parents and children, etc.). The treatment of children within an institution makes the treatment modalities and technique more complicated. The psychotherapist must have a perfect knowledge of the specific environment of the child, and keep in mind the desires and requests of the direction and the people who work directly with the child (teachers, specialized teachers, etc.). How can the problems brought up by the rivalry between the institution and the psychotherapist be canalized: length of therapy, merits (how did the pedagogical intervention help, recognition of a specific action or of work done in conjunction with the educative action)? If these facts are not recognized, the treatment will often be interrupted and the psychotherapist may be excluded from the institution. This will be avoided by ensuring further training of the therapist.     

The clinical laboratory training after the graduate in local training hospital setting

As clinical training has become a compulsory element of the training of physicians, all doctors are now required to undergo training in basic abilities of diagnosis and treatment. Clinical training has become possible in local medical organizations as well as university hospitals and large hospitals. There are full-time clinical pathologists in the laboratory staff of large hospitals, but they have little time for clinical trainees in the present educational system in the field of clinical laboratory. In mid-size and small hospitals, there is no clinical pathologist at the central diagnostic and treatment division, and clinical laboratory technicians are expected to play roles of trainers. It is important for the training administrator to prepare an environment in which clinical trainees can learn the selection of examinations, execution of examinations, interpretation of results, and actual handling of patients and, particularly in the execution of examinations, to cooperate with the director of the examination division and see that trainees can learn the necessary skills that they must acquire. The training administrator must also formulate a program to help clinical trainees to develop the abilities necessary for them to function as a member of team care. Such a program must not only be effective for the training of physicians but also contribute to the development of laboratory technicians and to improvements in the quality of medical care that is provided.     

Future directions in consultation-liaison psychiatry

Consultation-liaison psychiatry in the United States has had to reassess its priorities with the change in health care economics in the 80 s. Liaison programs and educational programs for primary care staff are jeopardized. The emphasis has shifted from liaison to reimbursable consultation activities. Hospital stays are shorter with emphasis on outpatient and prepaid settings. Less expensive health care professionals are often asked to see patients previously evaluated by psychiatrists. This paper will discuss the need for focused cost-effective liaison services in this climate. Funding strategies for consultation-liaison programs, models of staffing consultation-liaison services, continuity of care from inpatient to outpatient services, integration of consultation-liaison psychiatrists in prepaid health care settings, primary-care educational programs, and psychosocial intervention programs for high-risk primary-care patients will be discussed.     

Catatonia on the consultation-liaison service.

Catatonia is a syndrome that requires both nonpsychiatric medical and psychiatric evaluation. The authors report on six patients with catatonia that were seen by a psychiatric consultation-liaison service. Five of these patients had medical conditions reported to cause catatonia. Treatment recommendations included the following: 1) subcutaneous heparin for deep venous thrombosis prophylaxis, 2) a trial of lorazepam, and 3) transfer to a medical/psychiatric unit or locked psychiatric unit. Catatonia was most parsimoniously attributed to the primary psychiatric illness in five of the patients and to corticosteroid treatment in the sixth patient. These findings suggest that clinicians should use the proposed criteria, past psychiatric history, physical exam, and laboratory and radiological studies when evaluating patients with symptoms of catatonia.     

Burnout: Stresses in consultation-liaison psychiatry

The burnout syndrome encompasses both behavioral and emotional symptoms that produce vocational difficulties. Psychiatrists involved in consultation-liaison work may be subjected to unique stresses—including role ambiguity and role con flict—in addition to the stresses that foster burnout in other health care professionals. Patients with complex medical-psychiatric problems, disinterested consultees, and specific situational constraints such as unpredictable schedules and uncomfortable work settings exert further demands. This paper examines these various areas of difficulty and proposes coping strategies. Peer-group support, effective division leadership, routine assessment of goals, and flexible approaches can help relieve the strains inherent in consultation-liaison psychiatry.     

Multidisciplinary teams in consultation-liaison psychiatry: the Yale model

The consultation-liaison service at Yale features integrated teams of psychiatrists, social workers, and clinical nurse specialists working together in both consultation and outpatient settings. The model is based on the tenets that (1) comprehensive evaluation of patients is essential for effective treatment; (2) role definition is necessary for specific disciplines, including the definition of overlapping and separate areas of expertise and practice. The multidisciplinary teams are coordinated by a psychiatric resident, who is supervised by an attending psychiatrist. The role of the resident is that of a diagnostician and coordinating physician. The social worker functions as an expert in family evaluation and treatment, and the nurse specialist functions as supportive therapist and liaison with the nursing staff. The structure of the division of consultation-liaison and ambulatory services at Yale is described and the advantages and disadvantages of the multidisciplinary team concept are discussed in comparison with other models of consultation-liaison psychiatry.     

A consultation-liaison fellowship in a community hospital

The community general hospital provides a natural setting for consultation-liaison training since the patient population offers a broad clinical experience. The stable funding for such a program enhances its value in an era of decreasing federal support for psychiatric residency stipends. This report describes the structure and content of such a program based in a community hospital affiliated with a university psychiatric residency.     

The role of psychoanalysis in consultation-liaison psychiatry

Psychoanalysis played a major role in demonstrating that psychological forces can precipitate or exacerbate physical illnesses. For a time it also played a leading part in psychosomatic medicine and in the development of consultation-liaison psychiatry. Many of the concepts and skills constituting the core of the latter derive from psychoanalysis. In recent years, individual psychoanalysts have continued to work in consultation liaison psychiatry, but most have left it. The author urges their return and describes contributions that psychoanalytic knowledge can make to consultation-liaison psychiatry.