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(Reprinted with permission from Psychosomatics 1985; 26:128—132)
Complaints abound from our fellow physicians that psychiatrists are the most difficult of all medical specialists to deal with. The most common complaints are, "Psychiatrists don't answer their telephone calls"; "They never get back to you"; "Once you make a referral to them you never see the patient again." Most psychiatrists shy away from active involvement with hospital medical staff organizations and committees. Few are active in county and state medical societies. To many of our nonpsychiatric colleagues, the image of psychiatrists is that we prefer to "hole up" in our offices, emerging after dark to slink away to some obscure private life, and seldom are seen in the light of day.
Paradoxically, this image problem persists at a time when more psychiatric patients are being hospitalized in psychiatric units in general hospitals. As consultation-liaison psychiatry becomes increasingly accepted, there is greater opportunity for psychiatric consultations to be performed on the medical and surgical wards. Considering our image problem, to some extent based on our lack of medical etiquette, it is not surprising that our medical and surgical colleagues frequently turn to psychologists and other mental health practitioners for help in diagnosing and treating their patients.
It is with this problem in mind that the following "commandments" are offered in an effort to raise our consciousness about the need for better rapport with our colleagues, and to help us improve our badly tarnished image with the rest of medicine.
Usually, the referring physician does not know precisely what is wanted from a psychiatrist. Sometimes the physician may have only a vague idea that "something is wrong"; at other times he or she may be responding to some dimly perceived negative or positive feelings about the patient or something about the patient's behavior that does not appear to be "normal." It is essential that the psychiatric consultant speak in person with the referring physician prior to the consultation, in order to discover what the referring physician really wants.
If a delay is expected in performing a consultation, medical etiquette requires discussing the delay with the referring physician to see if some other referral may be desired. In our hospital, the rule is 12 hours (at most 24 hours) for an inpatient and three working days for an outpatient. If the consultation is an emergent one, the patient should be seen at once or referred to someone else.
One major area of procrastination involves putting off reading the patient's records. Very often patients who are referred for psychiatric consultation in a large general hospital may have been seen in prior consultation by another psychiatrist. The referring physician may not be aware of this if he or she is new to the case or is covering for another physician. In my experience, when a large patient record exists, the psychiatric consultant may be one of the few physicians who reads the entire record. Reading it before seeing the patient can save a great deal of time and establishes a good base for reference. For outpatient consultations, a letter or note from the referring physician should include enough information about the patient's physicial condition and prescribed medications to permit the psychiatric consultant to make a reasonable assessment.
As with all other specialties of medicine, psychiatry has developed its own jargon. This jargon is very useful in communicating with other psychiatrists; to our medical colleagues, however, our jargon is often incomprehensible. A psychiatric consultation should be written promptly and succinctly, using the common tongue understandable to any physician. While the consultation report should be complete, "the shorter, the better" is the rule of thumb. It is not necessary to detail all of the information gleaned from the patient or the family that was used in arriving at the recommendations.
The most important part of the psychiatric consultation is the part in which recommendations are made to the referring physician for management and future disposition of the patient. Most of the time, the referring physician will skip all of the background information and go immediately to the recommendations. It is essential that these be simple and concrete, and that criteria be given for evaluating the results of any recommendations that are followed. Failure to be specific in this section complicates and worsens our image problem. If concrete recommendations are given, the referring physician will find that the psychiatric consultant is genuinely helpful to the management of the case, just as an infectious disease consultant would be helpful in managing a case of unusual or resistant infection. Fenton and Guggenheim (1) refer to this as the "marketing of psychiatric services." At the bottom line, the success or failure of our consultation efforts hinges on our ability to develop a set of useful recommendations that can be followed and evaluated.
A common failing of psychiatric consultation is the exclusive focus on the patient and the omission of recommendations about family and social networks. Often, referring physicians shy away from involvement with family because they fail to recognize that helping the family to come to terms with the patient's problems, treatment, and consequences of illness helps the patient. This is particularly true when the patient is suffering from a chronic or serious illness.
Many a good consultation has been lost in the paperwork of the patient's record or in the mail. At other times, the consulting psychiatrist is confused about issues of confidentiality and hesitates to speak with the referring physician for fear of revealing some privileged communication. Do not confuse confidentiality with mutism. Speak directly with the referring physician after the consultation. Be as discreet as appropriate, but do not hesitate to discuss your findings and recommendations with the physician in person.
The one-shot consultation rarely suffices in this day of complicated treatments and utilization review. If recommendations have been made that involve the use of medication, stick with the patient as long as the patient is in the hospital. Follow up with the patient or referring physician to confirm the effects of your recommendations. Do not hesitate to alter your recommendations if it appears that the desired effects have not been attained. For outpatients, follow up with a call to the referring physician to inquire how the patient is doing and to see if anything else is required. Such perseverance is not only good etiquette, it is good medical practice.
Surveys of physicians have revealed that what they want from psychiatrists are consultations, not preaching. Lipowski (2) has pointed to the undesirability of psychiatrists "hovering on the wards" to collar their fellow physicians and "teach" them about psychiatric problems. Do not assume that all physicians are as interested in psychodynamics as you are. Unless you are prepared for a half-hour lecture on renal transport mechanisms, do not assume that the nephrologist on the renal dialysis unit has the time or interest to learn the most recent theory of the causes of sexual dysfunction and depression in patients undergoing dialysis. On the other hand, experience has shown that hospital health care teams, including physicians and nurses, enjoy carefully prepared conferences on selected topics. Psychosocial rounds have increased nursing involvement with patients and led to improvement of morale (3).
Often one of the recommendations of a psychiatric consultation is further psychiatric treatment, either psychotherapeutic or psychopharmacologic or both. If this recommendation is made, how much treatment and with whom should be discussed with the referring physician before making a commitment or recommendation to the patient. This decision about further treatment is as much a recommendation to the referring physician as is any other recommendation. If the decision for further treatment and/or outpatient psychotherapy is agreed upon, decide with the referring physician who will be the primary physician and who will write the prescriptions for outpatient medications. In some cases, the patient's physical condition may be of secondary importance to the psychiatric need. In other cases, an ongoing relationship with the referring physician provides for continuity of care particularly if the psychiatric treatment will be of limited nature. Do not let the patient "fall between the chairs"; such a lack of courtesy alienates our medical colleagues and confuses patients.
Experience has shown that psychiatrists can play an extremely important role in medical staff organizations in their local hospitals. Often they rise to positions of leadership within the hospital and in medical societies. Of particularly increasing importance is the Impaired Physician Committee of the hospital medical staff. It is important that a psychiatrist be on that committee for reasons that are not always so obvious to our medical colleagues. Shirking the responsibility for participation is not only poor medical etiquette, but fosters the image of aloofness and distance that has plagued our specialty for such a long time. If we do not become more active, we have only ourselves to blame when our colleagues refer their patients to nonpsychiatric mental health providers.
Etiquette may be seen as a ticket or a label. For psychiatrists, etiquette is not only the form, manners, and ceremonies established by convention to build the harmonious relationship between themselves and their medical colleagues, but it may in a real sense be the "ticket" for improving the image of psychiatry and leading us in the desirable direction of enlightened and humane remedicalization.
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