Thursday, November 04, 2010

Surprise! I'm A Shrink and I'm Here to See You!

Lockup Doc has a post up on KevinMD.

He talks about how awkward it is to be a called to consult on a patient who is on a medical or surgical unit of a hospital when the patient hasn't been told that a psychiatric consult has been requested. The Shrink gets to announce to the surprised patient that they were called and the patient may be insulted.

What’s troubling about this all-to-common scenario is that when consultations are requested of psychiatrists, two key ingredients are often missing. First, the reason for the consultation is often unclear. Second, the consultation is often requested either without the patient’s permission or knowledge, or, the patient is informed of the consultation but an inadequate or even inaccurate, potentially insulting explanation is given.

Roy is our C-L Psychiatrist here at Shrink Rap, so I'll let him add to the comments. As an outpatient psychiatrist, I'm just never a surprise.


Anonymous said...

If a psych consult is called without the patient's knowledge or agreement, is the patient charged when the shrink shows up and the patient says I'm not interested in talking with you?

Sarebear said...

These sound like interesting situations. Awkward and difficult for most everyone except the person who called the consult and sort of dumps the two parties together . . .

Part of me has been wondering about potentially the opposite problem; what if somebody is in the psych ward, and needs some medical attention, consult, or physical therapy, or other medical, ie, physical medical as opposed to mental health medical, stuff, while they are there? I've never been hospitalized before but the possibility has never been higher. Perhaps no one had better answer that, given my situation.

Just letting you know that I've been wondering about sort of the opposite, which of course wouldn't be as awkward mentally for the patient, except for worrying about medical needs being taken care of if they'd get taken care of at all.

Anyway. Let's hope I can get through this confusing maze of distorted thoughts and feelings, alive. Uh, yeah. I'm supposed to hope that. We'll see. Boy this is getting more and more screwed up so I'd better shut up now.

But if I stopped coming here totally that'd be yet one more place I withdraw from, and that's a bad thing right now. So I'm sorry for any drama this may cause, just ignore it or something. Have patience with someone who is . . . rather about as mixed up as you can get.

Greg said...

In my experience as a psychiatrist on an inpatient psychiatric unit, I hope this helps to answer your question: If a psychiatric ward is part of a hospital, then medical consultants simply walk in from the med/surgery floors. It's usually much easier to have physical therapy and other ancillary services continue care as the psych ward is really just another floor of the hospital.

If the psych facility is free-standing, usually a internist or family physician is employed for medical consults by the hospital and is available on request. In medical emergencies, often transfer is needed to the nearest medical facility. Freestanding psych hospitals should have agreements with their nearest medical hospital to handle medical emergencies, especially since they happen all the time.

Sunny CA said...

I was inpatient, and got medical care without having to ask for it while there. In fact, I thought the medical care was better than the psych care. They monitored my blood pressure and found it high and got me on BP meds, and when they slammed my hand in a door (because I was resisting being shut into solitary confinement with no light, water, food, toilet) they ordered an x-ray. I am pretty sure the x-ray was done right on the psych ward, but don't know as I have no recollection of the x-ray being taken, though I recall being shown the x-ray. Perhaps they "drugged" me to send me out for an x-ray. Perhaps there are portable x-ray machines.

Anonymous said...

Sarebear, the answer is it depends. I was hospitalized in a free standing psych hospital and the date of my discharge the psychiatrist told me I had a UTI and to be sure and see someone for that when I got home. I guess he was completely incapable of writing a script for Levaquin. You would think that any physician could handle something as routine as a UTI, but apparently some either can't or won't.

Peter said...

I would wonder whether the medical professional / nurse / doctor who made the call to bring in a psychiatrist is always correct in their assumption that the patient needs a psych evaluation. Does it ever happen just because the patient is being difficult and the doctor doesn't want to deal with them? Interesting process...

moviedoc said...

Anonymous: Right. Next time a patient tells me they suffer from UTI I will just write a prescription for Levaquin. I'll just tell them Anonymous told me to. Or should that be "Dr. Anonymous." And of course I will document it. I never thought practicing medicine could be so easy!

Anonymous said...

Hi Dinah--"Lockup Doc" here--I'm flattered that you mentioned my post. Thank you.

It's interesting that you mentioned that you don't deal with this issue because you don't do inpatient work. Of course when a patient walks into a psychiatrist's office, it's not a "surprise" in the way that it is in the hospital, but many psychiatrists are doing outpatient consults these days, and unfortunately the same issues of poor communication with the patient and/or the psychiatrist from the referring physician occur all too often in that setting, too.

Sarebear said...

Thanks, guys, I appreciate it.

Also sorry to have somewhat hijacked the thread, but other people were on topic so that's ok. I was sort of on topic, just opposite situation.

My mind is a bit relieved, though. Not that I expected anything, but I was pleasantly surprised; thank you.

Anonymous said...

Moviedoc, if you actually read what I wrote then you would realize it was the psychiatrist who informed me I had the UTI not the other way around. I didn't diagnose myself. He told me. What hospital sends a patient home with an untreated active infection? Maybe it's common where you work?

Anonymous said...

Sarebear, if you should ever go inpatient for psych care, which I can't say I recommend, but should it happen I would opt for a psych unit within a regular hospital over a freestanding psych hospital. My experience is that in a regular hospital it's a little more professional. Also, there are people available who can treat other medical problems like UTI's, should you need it.

Roy said...

Anon #1, if I get called to see a consult and the patient says they don't want it, I document this discussion in the chart and do not bill for just asking the question. If one did get a bill for this, it should be challenged.

Sarebear, [sending you good vibes] Greg is right, we get medical consults all the time on our psych unit.

Anon just above, I agree. If you have some significant medical problems and need to be admitted psychiatrically, go to a psych unit within a general hospital. It is much easier to get specialists and tests (no ambo trip for the MRI) done in that setting.

Peter, sometimes I get consults for "difficult" patients. This usually means that the doc isn't really listening to the patient, or is not communicating effectively. We do tend to be better listeners and communicators, so I think it is entirely appropriate to bring us in if things aren't going well with the connection. In fact, by addressing these communication problems, it can head off not only a disruption in care but also lawsuits.

Anon & moviedoc, I don't see a problem with writing a prescription for an antibiotic to treat a diagnosed UTI. Most PCPs do not get culture & sensitivity for an outpatient UTI unless it fails to respond. I would go with Bactrim first, unless there's a sulfa allergy. (Seen too many hallucinations on Levaquin to make it #1, and more costly.)

tracy said...

i found, that if you are being sent to a psych ward, you don't have a go where there is a bed. Not really on topic, just saying.....

Anonymous said...

Hi Roy--I just read your open letter to physicians requesting psychiatric consultations that you wrote in 2007. Very interesting--sounds like many of us have had similar experiences.


Anonymous said...

I'm a RN. Whenever a psych consult is called, there are only a few circumstances:

1) Patient is young and has a documented psychiatric history (schizophrenia, bipolar disorder, depression) and we are evaluating the patient's stability or medication regimen.

2) Patient is elderly with post CVA or dementia and demonstrating unstable behaviors that are marked and abnormal.

I don't work a med surg unit in a hospital (I work a rehab center) so perhaps on med surg it's a little different. But in my rehab facility, I've never seen a psych consult ordered on a patient who did not have a prior psych history and psych diagnosis (schizo, bipo, depression, dementia/behavior change post cva).

Patients with a prior psych history are used to seeing psychiatrists and do not get offended. They know they have a condition and usually are glad to have the access to see a doctor.

Dementia/post CVA patients on the other hand may be confused about the type of doctor they are seeing (obviously the condition causes confusion in general) as their mental condition is new onset and so they are no used to seeing such doctors.

The utility of a psychiatrist for dementia and CVA patients is to supply PRN medications for their frequent confused/agitated episodes, their sleep disturbances, and the depression/anxiety that is often a part of having a CVA. They are very useful and I have seen patients improve with psychiatric care.

Sarebear said...

Again, thank you, anon, Roy, etc.

I really appreciate it, especially right now.

I'd do almost anything to stay out of the psych ward, partly because of my terror of the unknown, partly because I can't contemplate feeling or being trapped, and partly because I highly suspect it'll be . . . unpleasant.

A hospital is pretty much the only choice around here; I'd have to go to an ER that's not on my Medicaid plan, although at the Medicaid orientation they said if you're life is in danger, don't worry about on plan or not, just get to the nearest hospital. I'm guessing after that, if I needed to be admitted to psych that they might transfer me to an appropriate hospital, but I can't be sure. It's just one more stumbling block that makes me nervous about doing it should things come down to it, but in the end, they all say that my safety is more important so I hope I can remember that, if it comes to it.

Here's hoping not, but the fact that I've been this way, on the edge, for going on two weeks now, tells me that I'll likely end up in the hospital. It's made outpatient therapy rather . . . ineffective, he says it's like trying to treat a burst appendix at a mere clinic. And yet, there was just enough at the last appt to maybe look up a little . . . I don'tknow. He said he'dve recommended I go in that day, otherwise. Well, it was implied.

NOT having access to a psychiatrist, and not having been able to try antidepressants to find something that works these last months, well, I'm extremely frustrated with that because that's partly why I'm in this mess. Life isn't always fair, though. Anyway, Sorry to vent.

Thanks, guys.

Anonymous said...

Sarebear, having been through this I would recommend you find out exactly what is going to happen prior to going in. Ask if it is their policy to forcibly strip you. Find out if you can about the facility you will be in - any reports of patients having been assaulted by other patients or staff, etc. I had no idea about some of these issues prior to being admitted and I left significantly more depressed than I went in, not to mention the additional trauma I was left to deal with.

Find out what you will be doing while you're there. Most of the time we sat around doing nothing. I had very little contact with a psychiatrist while I was there, most of the time was spent being babysat. Ask if you will have access to fresh air and sunlight, or do you have to earn it. It's also a good idea to fill out an advance directive and keep a copy with you. If you go in as a voluntary patient find out if they are going to be difficult if you get in there and then decide it's not a good place for you.

My experience is not everyone's experience. Some feel that hospitalization was helpful, others feel like I do. It's a mixed bag, I guess.

No matter what you decide, just know that you're not alone and that there are people who do care.

tracy said...

i would truly like to know who all these people are who have a c h o i c e of what Psych facility they "get" to go to. Really. Yes, i do have insurance.

Anonymous said...

Tracy, my psychiatrist had privileges at more than one hospital, so I think the ability to choose depends on several factors: if you live in a large city and there are multiple hospitals, where the psychiatrist has privileges, if you've got insurance or not, and obviously if the admission is a "voluntary" admission. I'm sure you're correct that a lot of the time there is not much of a choice which is all the more reason why it's good to know about these issues in advance so people know what you're facing.

Anonymous said...

Wow! Where I live, it's where and IF there are any beds free.

Sarebare; I know there are many bad aspects to inpatient treatment, but sometimes it is the best thing to do. If you feel you need to, please do. Your safety is more important than short term discomfort.

I think if you or anyone does choose to go in it is important to have someone who can act as an advocate for you, family members and/or a good GP are probably the best.

Unfortunately Anon is correct, once in as a voluntary patient it seems very easy to find yourself committed, or at least "advised" not to leave and finding that being discharged is next to impossible. If you have someone who will take responsibility for you, it makes it a lot easier to leave if you want to.

Other issues are level of privacy, space, quiet, being able to go outside (fresh air and sunshine) and if you can arrange it see if you can get a friend to be able to take you for a walk outside on occasion. After all everyone says exercise and social interaction are necessary for recovery.

Sorry for butting in late, I just hate to think that anyone would read these comments and be scared off if they did need inpatient treatment.
It's not a holiday, but it can be the best thing to do.


Sarebear said...

Thanks, Bec

Anonymous said...

On topic: If I were an ER patient and someone called for a psych consult for me, but neglected to tell me beforehand, there'd be some 'splainin' to do. I would have no problem taking a doctor to task for doing that. That would shatter the trust I had in the referring physician. And I most likely would not accept the psych consult, which the referring physician would have known had he or she simply asked me. To not let me know what is going on with my own care is incredibly paternalistic and disrespectful.

Less on topic (relates to some earlier comments): I worked on a psych unit for several months on a special project. It was not my normal place of work and I was surprised by how patients were treated there. I was alarmed the first time I heard one of the nurses or aides on the overhead speaker telling patients they needed to do something (I can't remember what it was, but it wasn't something everyone necessarily wanted to do) and that if they didn't, they would not be allowed to go outside later in the day. I was incredulous. To tell adults on a voluntary unit that they were not allowed to go outside unless they did what you wanted them to do sounded completely unprofessional and certainly less than helpful. To tell people in distress that they can't go outside with the other patients just sounds like poor care. To use what sounded to me like coercive tactics does not seem like something that would be helpful for people in severe enough distress to have submitted themselves to an inpatient psych unit. I've never forgotten that - and I never will. It was my first exposure to that unit and the way it does things. Prior to that, I had a fairly pro-psychiatry view. I cannot say that is still the case.