Consultation-liaison fellowships: Effect on internists’ attitudes toward psychiatric consultation

I CONSULTATION-LIAISON PSYCHIATRY JULIAN T. BRANTLEY, Jr.. M.D. THOMAS N. WISE, M.D. SUSAN W AHMED. Ph.D.

Consultation-liaison fellowships: Effect on internists' attitudes toward psychiatric consultation ABSTRACT: The results of a questionnaire sent to 495 internists indicated that they would be more likely to request psychiatric consultations for their patients if they had access to psychiatrists who had completed consultation-liaison (C-L) fellowships. The attitudes of those internists initially highly reluctant to obtain psychiatric consultation were significantly more enhanced on learning about the specially trained Col psychiatrists than were the attitudes of less reluctant internists. Examination of various sources of reluctance suggests that many internists have low confidence in the value of psychiatric consultations. Only 31 % of the internists polled were aware of Col fellowships.

The growth of interest in consultation-liaison psychiatry over the past few decades has led to the establishment of postgraduate Col fellowships in many medical centers throughout the country. 1.\ Many graduates of such programs consider themselves subspecialists in Col psychiatry.· Because Col fellows are trained to improve relationships between psychiatry and

other medical specialties. many assume that physicians would be more likely to request psychiatric consultations if they were to be done by such fellowship graduates. We know of no previous attempts to examine physicians' attitudes toward Col fellowship-trained psychiatrists. In view of the underutilization of inpatient psychiatric consultation.'-" we believed that

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Dr. BrallIler is cliniCilI assistant professor of psychiatry. Dr. Wise is proj('SSOf or psrchiatrr. and Dr. Ahmed i.l· assistant professor in the division of biostatistics and epidemiolog\'. all at GeorKetown Unil'l'fsin' School of Medicine. Reprint requests to lh Bralllley. Departmelll of Psychiatry. The Fairfax Hospital. 3300 Gallows Road. Falls Church. VA 22046. 18

such an examination could have implications for future funding and other educational considerations. as well as for psychiatrists considering Col fellowship training. We conducted an attitudinal survey to answer the following questions: (I) How much would medical consultccs' attitudes toward ob-

taining inpatient and outpatient psychiatric consultations be enhanced by the knowledge that the consultants had Col fellowship training? (2) How would such attitude change vary according to the type of psychiatric disorder for which consultation is sought? (3) How would such attitude change vary according to the type of general indication for psychiatric consultation. such as diagnostic help or assistance in ward management? (4) How would attitude change be affected by the geographic region of practice, time in practice. general 1'.1' subspecialty practice. and degree of reluctance to obtain psychiatric consultations? (5) How aware are internists of the existence of psychiatric C-L fellowships? (6) What are the sources of reluctance PSYCHOSOMATICS

to obtain psychiatric consultations? Additional data collected included the average numbers of psychiatric consultations obtained per year and types of providers of psychiatric consultations. Survey procedure We sent a 33-item questionnaire to 495 members of the American College of Physicians. which is composed primarily of board-certified internists and internal medicine subspecialists. To assess for possible differences by region. 165 questionnaires were sent to mediumsized cities in the Midwest (Nebraska and Iowa) and another 165 to cities of similar size in New York state. To determine whether practitioners' responses might be influenced by the presence of Col fellowships. 165 questionnaires were sent to physicians in New York City. where a number of such programs are located. The overall response rate was 35% (39% from the Midwest. 33% from New York state. 29% from New York City). We believed that this response rate was sufficiently high to ensure that the respondents were representative of the larger group. 7 Because we were interested in the attitudes of physicians in clinical practice. respondents spending less than 50% of their professional time in clinical practice were excluded. This left us with a sample of 138 questionnaires (61 from the Midwest. 43 from New York state. and 34 from New York City). The questionnaire items covered several areas. Physicians were asked to indicate the degree to which their attitudes would be more favorable if a Col psychiatrist (referring in this paper to a psychiatrist who has completed a fellowship in Col psychiatry. defined in JANUARY 1985 • VOL 26 • NO I

the questionnaire as "that area of psychiatry that encompasses clinical activities of psychiatrists in the nonpsychiatric divisions of a general hospital") were available for consulting in regard to eight general psychiatric conditions and four general indications (see "Reason for consultation" column in Table 1). In addition. the respondents were asked to indicate the degree to which they were influenced by 12 sources of reluctance to obtain psychiatric consultations (listed in Table 2). Scores on seven of these lat-

The development ofmore favorable attitudes was significantly greater in regard to outpatient than to inpatient consultation. ter items reflect negative attitudes toward obtaining psychiatric consultations and were averaged to form a General Reluctance Factor (GRF). Respondents whose GRFs were in the lower 25% and upper 25% were designated "low-reluctance" and "high-reluctance" internists. respectively. The remaining five sources of reluctance were not thought to necessarily reflect negative attitudes toward obtaining psychiatric consultations. A loo-mm visual analogue scaleR was used to measure attitude enhancement and sources of reluctance to obtain psychiatric consultations. This instrument has been shown to be highly reliable in many trials. 9 - 11 Respondents were requested to mark the loo-mm continuum line at the point that best reflected their attitude in regard to the 12 items in Table 1 and the 12 in Table 2. The continuum did not include a negative pole. ie. the least

favorable response was 0 mm or "no enhancing effect." because the authors believed it extremely improbable that a respondent would be negatively affected by a potential consultant's extra training. This assumption proved correct in that less than 3% of the items were marked at the O-mm point. For each attitude-enhancement item listed in Table 1.0 mm indicated that availability of Col psychiatrists would have "no enhancing effect" on the respondent's attitude toward obtaining psychiatric consultations; conversely. 100 mm represented a "great enhancing effeet." When the sources of reluctance were measured (listed in Table 2). 0 mm indicated that the item was "not at all a source of reluctance." and 100 mm that the item was "to a great extent a source of reluctance." All questionnaire items were placed in random order. Analysis of variance for a repeated measures (block) design was used to test for overall mean differences in attitude enhancement among the eight specific psychiatric conditions and among the four general indications (Table 1). Where overall differences were found. the Newman-Keuls multiple comparison procedure l2 was used to determine the location of the specific differences. Two sample t tests were used to test for differences between internists with high vs low reluctance to obtain psychiatric consultation (Table 2). Chisquare tests were used for comparing two or more proportions. All statistical tests were two-tailed. Results

Attitude enhancement. Table 1 shows the total group's mean attitude enhancement scores for inpatient consultations. There were sta.9

COl fellowships tistically significant differences in attitude enhancement among the various general psychiatric conditions (P<.Ol) and among the general indications (P<.Ol). With regard to general psychiatric conditions, attitude enhancement for adverse emotional reactions to medical illness, for alcohol/drug disorders, and for psychosomatic/ psychophysiologic disorders was significantly (P<.05) greater than for psychoses, neuroses, depressive disorders, personality disorders, and marital/personal problems. For the total group, the mean "in general" attitude enhancement on the

analogue scale amounted to 37 mm for inpatient consultation and 45 mm for outpatient consultation, a significant difference (P< .05). Respondent characteristics. The respondents' attitude enhancement did not vary significantly as a function of regional location, proximity of medical centers with CoL programs, number of years in practice, or general vs subspecialty practice. When respondents located in medium-sized cities in the Midwest (mean attitude enhancement of 33 mm) were compared with those from medium-sized cities in New York state (mean enhancement of

40 mm), no significant difference was found (none of these cities were served by medical centers having psychiatric CoL departments). The responses of physicians practicing in areas (mediumsized cities in New York state) not served by medical centers having psychiatric CoL departments (mean attitude enhancement of 40 mm) did not differ significantly from those of physicians practicing in an area (New York City) with a number of psychiatric CoL programs (mean attitude enhancement of 39 mm). New York state, rather than the Midwest. was compared with (continued)

Table 1-Attitude Enhancement for Inpatient Psychiatric Consultations in Regard to Specific Conditions and Indications Total group (N=138)

High-reluctance Internists (N = 34)

Low-reluctance Internists (N = 35)

Mean·

Mean·

Mean·

mm

mm

mm

37

52

19

66

33 28 36 23 25 28 24 25 28

Reason for consultation "In general"

11

General psychiatnc conditions Adverse emotional reactions to illness Alcohol/drug problems Psychosomatic/psychophysiologic disorders Depressive disorders Marital/personal problems Personality/character disorders Psychoses Neuroses

t {53 52

f3

60 58 56 54 51 47 57

53

59 57

48

t

Mean combined score General indications Psychopharmacologic help Diagnostic help DIspOSItion problems Ward management Mean combined score

t

64

t

43 42 40 39 45

51 48 46 50

48

45 52

45 47 40 40 43

~

I

I

'Degree 10 which a consullee's altitude toward oblalnlng a psychiatric consultal/on would be enhanced by nowlng hat the consultant had compleled a psychiatric Col fellowship, as measured in mm on a visual analogue scale from 0, Indicating "no enhancemenl,'lo 100, Indlcahng 'greal enhancement" tP< 05 (Items bracketed togelher do not differ slgl1lllcantly from one another, those not bracketed togelher differ Significantly, Newman-Keuls multiple companson test)

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PSYCHOSOMATICS

C-L fellowships

New York City to minimize the p0ssible eonfounding effect of regional variability. Respondents who had been in practice for zero to ten years had a mean attitude enhancement score of 42 mm; those in practice for 11 to 20 years had a mean score of 38 mm; and those in practice for more than 20 years had a mean score of 32 mm. No significant differences in attitude enhancement were found between these three groups. When general internists (mean attitude enhancement of 38 mm) were compared with subspecialists (mean attitude enhancement of 35 mm). no significant difference was found. The average number of inpatient consultations for the total group was nine to II per year. No significant differences existed in the number of consultations obtained between the three geographic regions nor between the three different "time in practice" groups. However. there was a marginally significant difference between high-reluctance and low-reluctance internists. with the former obtaining fewer inpatient consultations per year (.05
Table 2-Sources of Reluctance Among Internists (N = 138) to Obtain Inpatient Psychiatric Consultations Source of reluctance

mm*

Lack of confidence that consultation would be helpful

42

Prior bad experiences with psychiatric consultations

30

Additional expense of psychiatric consultation

29

tFeeling that most psychiatrists are uninterested in consulting

25

Feeling that psychiatrists are not well trained to do consultations

24

Fear that psychiatric consultation may upset pallent

24

An interest in treating psychiatric disorders myself

23

Lack of psychiatric consultation resources in my area

22

tFear that psychiatric consultation might aggravate the problem

18

tFear that psychiatric consultation may Jeopardize physician! patient relationship

14

Preferring to postpone psychlatnc consultation until after discharge

13

Uncertainty about how to choose a psychiatric consultant

12

'As measured on a Visual analogue scale from O. mdicatlng "not at all a source of reluctance: to 100. indicating a "greal amount of reluctance" Faclors so mar ed were pooled and averaged 10 produce a General Reluctance Factor

ment for the four general indications for psychiatric consultation. but thc difference was not significant. In concordance with the above inpatient results. high-reluctance internists had significantly greater attitude enhancement for outpatient consultation than did low-reluctance internists (P<.05). Awareness of C-L fellowships. Only 31% of the respondents were aware of the existence of C-L fellowships. Significantly (P<.OI) fewer physicians from the Midwest (12%) were aware than were those from New York state (5I clr) and New York City (3l)%). The New York state and City groups did not differ significantly from each other in this regard. Providers of psychiatric cOl/slI/tatiol/. Psychiatrists were the most

common providers of psychiatric consultations. compared with other mental health professionals. Private psychiatrists were named by Ill) of the 130 respondents as constituting IOOIj( of their source of psychiatric consultations. Private psychologists were consulted by II respondents. but only three respondents used psychologists for more than 501j( of their consultations. Psychiatric social workers were consulted by six respondents. and psychiatric nurses by two of them. Discussion This study suggests that internists' attitudes toward psychiatric consultations would be enhanced by availability to them of psychiatrists trained on C-L fellowships. Be25

C-L fellowships

cause internists request psychiatric consultations in specific clinical contexts rather than "in general:' we believe that the mean combined scores of 45 mm and 50 mm (derived from the eight psychiatric conditions and four general indications for consultation. respectively) more accurately rellect altitude enhancement than docs the "in general" score of 37 mm. Physicians showed considerable attitude enhancement for all of the psychiatric conditions and indications for consultation. The three psychiatric conditions with the highest attitude enhancement scores (adverse emotional reactions to medical illness, alcohol/drug problems, and psychosomatic/psychophysiologic disorders) are conditions that internists may more likely consider medical than psychiatric. This finding may indicate low confidence in general psychiatrists' medical capabilities. The development of more favorable attitudes was significantly (P<.05) greater in regard to outpatient than inpatient consultation. This may reflect more general amenability toward obtaining outpatient than inpatient psychiatric consultation and may have implications for psychiatrists wishing to generate referrals from their medical colleagues. One might have expected that the internists who were most reluctant to obtain consultations would have reported little attitude change. However, we found that it was the initially highly reluctant internists who would have been most favorably influenced by knowing that their potential psychiatric consultants were CoL fellowship graduates. This held true for both inpatient and outpatient consultations. 26

Although the differences were not statistically significant. we found that those internists most recently out of medical school and residency (those with less than ten years of experience) were more reluctant to obtain psychiatric consultations than those farthest removed from medical training (more than 20 years of experience). If this finding is valid. it may be an effect of longer and more positive experience in working with psychiatric consultants. It may also reflect

The underutilization of inpatient psychiatric consultations has been weU documented. a failure on the part of psychiatric education to adequately demonstrate the value of CoL to physicians-in-training. Krakowski 13.14 concluded that negative attitudes toward psychiatric consultation may stem from "projections of the consultees' own anxieties about psychiatry and psychiatrists" and may relate to unfavorable experiences with psychiatry in medical school. This view has been supported by a recent study15 examining medical students' attitudes towards psychiatry. A major outcome of our study is that most (69%) of the internists polled were unaware of the existence of psychiatric CoL fellowships. That we must develop more effective ways of communicating with our medical colleagues is accentuated by our ascertaining that internists would be more likely to request psychiatric consultations if. in fact, they were aware of the availability to them of CoL psychiatrists.

Of the six highest-ranked sources of reluctance, five reflect negative attitudes toward inpatient psychiatric consultations. This suggests that internists have a relatively low degree of confidence in the value of inpatient psychiatric consultations. These negative attitudes are, to some degree, derived from adverse experiences ("prior bad experiences with psychiatric consultations" was second among the 12 sources of reluctance listed in Table 2) and further attest to the need for psychiatry to improve its image as a collaborative medical specialty. The sixth item, ranked third, was "additional expense." Interestingly, a recent study'6 strongly suggests that psychiatric consultations tend to reduce the length of hospital stay, thereby reducing cost. The underutilization of inpatient psychiatric consultations has been well documented. Despite psychiatric morbidity prevalence rates of 20% to 70% in general hospital inpatients, only 1% to 14% of inpatients are referred for psychiatric consultation. 17 • 19 This low referral rate might be improved if CoL psychiatrists were to take a more active stance in consulting with medical colleagues. In one study,20 C-L psychiatrists approached internists who had not sought consultation for inpatients in whom a psychiatric disorder was suspected by our staff. In 29 of 50 cases, internists who were initially resistant agreed to consultation. In 26 of the 29 cases seen, the attendings' initial reasons for not obtaining consultations were inaccurate and in 23 of those 26 cases, the consultation was judged by the authors to have been helpful. Ironically, as psychiatry is currently attempting rapprochement PSYCHOSOMATICS

with the rest of medicine, it is experiencing threats to its continued existence as a medical specialty. These threats are emanating from outside medicine, such as in the form of drastic cuts in health insurance coverage for psychiatric disorders, and from within medicine proper, such as in the increasing exclusion of psychiatrists from independent practice associations (Clinical Psychiatry News, March 1982). Many sources of estrangement exist, but we believe that a major factor is a tendency of phy-

sicians and health care administrators to view psychiatrists as less genuinely medical than other physicians. In summary, our study indicates that internists' attitudes toward obtaining psychiatric consultation would be enhanced by the availability of CoL psychiatrists. The fact that only 31 % of the respondents were aware of CoL fellowships indicates a distinct need to increase physicians' awareness of CoL psychiatry. CoL psychiatrists should adopt a more active, energetic

stance in promoting awareness of their presence in the medical community, whether it be a general community hospital or a major medical training center. The most promising area is very likely to be in medical education, where physicians-in-training can really learn to recognize the value of CoL psychiatry. This goal might be achieved most effectively by ensuring that medical students receive ample exposure to CoL during their clinical rotation through psychiatry.21.22 0

questionnaires. 1961-77. Sr Med J 18:14191421.1978 8. Aitken RC: Measurement of feelings using the visual analogue scales. Proc R Soc Med 62:989-993. 1969. 9. Luria RE: The validity and reliability of the visual analogue mood scales. J Psychiatr Res 12:51-57, 1976. 10. Folstein MF, Luria RE: Reliability. validity and clinical application of the visual analogue mood scale. Psychol Med 4:454-459. 1974. 11. Price DO. McGrath PA. Rafii A. et al: The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 17:45-56. 1983. 12. Zar JH: Siostatistical Analysis. Englewood Cliffs. NJ. Prentice Hall. 1974. pp 151-155. 13. Krakowski AJ: Liaison psychiatry: Factors influencing the consultation process. Int J Psychiatry Med 4:439-446. 1973. 14. Krakowski AJ: Psychiatric consultation in the general hospital: An exploration of resistances Dis Nerv Syst 36242-244. 1975 15. Nielsen AC. Eaton JS: Medical students' attitudes about psychiatry. Arch Gen Psychiatry 38-1144-1154. 1981. 16. Levitan SJ. Kornfeld OS: Clinical and cost

benefits of liaison psychiatry Am J Psychiatry 138:790-793. 1981. 17. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine. Psychosom Med 24:201-224. 1967 18. Lipowski ZJ: Physical illness and psychiatric disorder: A neglected relationship. Psychiatrica Fennica. 1979 Supplement. pp 32-57, 1979 19. Houpt JL. Orleans CS. Georgia LK. et al: The role of psychiatry and behavioral focus in the practice of medicine. Am J Psychiatry 137:37-47, 1980. 20. Steinberg H. Torem M. Saravary S: An analysis of physician resistance to psychiatric consultation. Arch Gen Psychiatry 37: 1007· 1012.1980 21. Weddington WW. Hine FR. Houpt JL. et al: Consultation-liaison versus other psychiatry clerkships: Comparison of learning out· comes and student reactions. Am J Psychiatry 135:1509-1512.1978 22. Schubert OSP, McKegney FP: Psychiatric consultation education-1976. Arch Gen Psychiatry 33: 1271-1273. 1976.

REFERENCES 1. Hackett TP: Beginnings: Liaison psychiatry in a general hospital. in Hackett TP. Cassem NH (eds): Handbook 01 General Hospital Psychiatry. SI. Louis. Mo. CV Mosby. 1978. pp 1-4. 2. Lipowski ZJ: Consultation-liaison psychiatry: An overview. Am J Psychiatry 131 :623630. 1974. 3. Reifler B. Eaton JS: The evaluation of teaching and learning in psychiatric consultation and liaison training programs. Psychosom Med40:99-106.1978. 4. Lipowski ZJ: Consultation and liaison psychiatry today. Read at the biennial meeting of the New York State Psychiatric Association. New York. Nov 5.1978. 5. Fauman MA: Psychiatric components of medical and surgical practice: A survey of general hospital physicians. Am J Psychiatry 138:1298-1301.1982. 6. Lipowski ZJ. Wolston EJ: Liaison psychiatry: Referral patterns and their stability over time. Am J Psychiatry 138: 1608-1611. 1981. 7. Cartwright A: Professionals as responders: Variations in and effects of response rates to

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