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The Educational Potential of the Psychiatric Consultation
VOLUME IX - NUMBER 2
MARCH-APRIL, 1968
PSYCHOSOMATICS ---------------------------------------------OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
-----------------------------------------The follOlcillg paper represellts the !inal illstallment of the serialized pl/I)licatioll of the Symposil/m "Comprehensive Medical Care and the Psychiatric Consl/ltation." The Symposium teas held durillg Nor;ember, 196.5, at the (Tllit;ersity of Califomill Medical Center in Sail Francisco, u;here physicians (/lui researchers met to examille our current assl/llIpthms ahol/t the psyr!liatric consl/ltation.
The Educational Potential of the Psychiatric Consultation ROBERT
L.
\r".LIAl\IS,
• CO:\SULT: To apply for information or illstrtlctioll. This is one definition of consult listed in \rehster's Third International LTnahridged Dictionary. Perhaps as a consequence of tIl(' passage of time and the accelerated pace of modern medical practice the expectations for instruction have hecome Illore implicit than explicit in the consultation relationship. It's important that we do not lose sight of the educational potential of a psychiatric consultation and that we J"{'cognize that the amount of education which is accomplished may have considerahle rek\'ancc to thc therapeutic results of the interaction. If education does take place in the consultation process, who gets educated? The list of lwneficiaries may he long or short depending upon the problem and the skills of the consultant and consultee. Some of the hencficiaries in the list that follows mav he mon'
Dr. Williams is Prnfl·ssor and Chairman, DeparlIlll'nt of Psychiatry. \'oll,'gl' of \ledicin('. tTniv('rsil~' of Florida, CaiJll''''ilh', Florida 32601. \larch-April. I ~ns
M.D.
ohvious than others. If we examint' the consultation process in tIl(' setting of a teaching hospital, the potential list could include a fairly large numher of people. The most ohvious are the psychiatric resident consultant and the resident physician requesting till' consultation. In order to explof(' the full range of the ('(lucational possihilitit's for tht' psychiatric consultation we must include the nursing staff and supporting nmsing pt'rsonnel. the medical student or students concerned with the patient, consultants from other nwdical specialtit's who may ht' involved with the patient's prohlem and various health related professionals whose services are necded iu the total management of the particular prohlem. Last. hut not least in the list of heneficiaries are the patient, his immediate family and at times his extended family which might include his employer, his teacher or other important people in his life. The key persons in the consultation are the resident physician who is giving the consultation and the residt'nt physician who has requested the consultation, For the purpost' of this discussion we are focusing on the
1111111111111111111111 ~II ~CHB1-CCW-XSY7
63
PSYCHOSOMATICS
psychiatric resident as the consultant, but many of the same principles could apply in other consultant-consultee relationships. The educational goal of the psychiatric resident is to learn how to utilize his special knowledge and skills in psychiatry to help solve the problem of the patient whose diagnosis or therapeutic management may extend beyond the competence of the physician requesting the consultation. It is not enough that the psychiatric resident possess special knowledge and skills, but he must also learn how to convey this information in an effective and acceptable manner to the requesting physician and to most or all of the other potential parties in the transaction mentioned above. The first task for the psychiatrist consultant often may be to set up a communication which will facilitate learning with an individual or individuals who at first (and some times at last) may resent the psychiatrist's intrusion and not reallv be interested in what he has to teach. . Frequently the psychiatrist consultant must develop a comprehensive picture of the patient, his problem and a therapeutic plan which can be c1earlv visualized and understood by all the p~rsons mentioned above. This does not mean that the primary physician shouldn't or couldn't develop such a gestalt; often, however, this becomes the task of the consultant. Frequently the primary physician has simply not taken the time. The following vignette of a case historv extracted from a recent consultation experience at the Shands Teaching Hospital of the University of Florida demonstrates how the psychiatrist consultant can serve to develop a comprehensive understanding of the patient. Case I.-eSC, a 12-year-old Negro hoy, was seen for psychiatric evaluation at the request of a resident physician on the medical service who felt that the patient was having hysterical seizures. The boy described "spells" which he had been experiencing for approximately two years. He described a stiffening of his legs, drawing of his arms and dinching of his hands, associated with mild headaches. He related that exercise frt>quently brought them on but that they did occur at other timl>s, particularly during periods of emotional stress. He denied loss of consciousness but said that he did fall to the floor or ground. Review of his past medical history revealed that he suffered from asthma for ahout sewll years and (H
had bt'en hospitalized on six occasions for asthmatic attacks and upper respiratory infections. Five years prior to the present hospitalization hI' was noted to have white blood cells in his urine. Urine cultures were negative. He had had inh'rmittent dysuria during the past two years. Cystoscopy prior to hospitalization revealed a urethral stricture for which dilatation was prescribed. Very little infonnation was available about his family and home environment. The mother was described by the referring pbysician as nervous; the patient's 14-year-old sister also has asthma. The patient views himst>lf as different from his peers because he has been unable to keep up with them in physical activities. HI" attributes this to his asthma and more recently to these "spells". Physical examination was unrevealing except for the absence of the lamina dura of thl' teeth and a positive Chvostek's sign bilaterally. Laboratory studies revealed a nonnal hemogram and urinalysis. Electrolytes were nonnal with the exception of a CO, content of 21 and 22 MeqlL on repeated examination. Calcium was 7.7, 8.3 and 8.0 mg percent on repeated l'xaminations. Inorganic phosphate was 8.4 mg perl'l'nt, magnesium was 1.7 mg percent, alkaline phosphatase was 48 and on repeat examination 40 King-Annstrong units. Protein electrophoreses revealed a hyperbeta globulinemia and diffuse hypergamma globulinemia. Creatinine, blood urea nitrogen, fasting glucose and uric acid were within nonnal limits. Creatinine clearances were nonnal. Lumbar puncture and CSF examination were nonnal and electroencephalogram was nonnal. X-rays of the knees, elbows and feet were nonnal. A voiding cystogram was nonnal. Skull X-rays were nonnal. The neurological consultant felt that the patient had an emotional problem and that the "spells" were not typical of any seizure disorder. The psychiatrist consultant noted that the patient was anxious, slightly dppressed and perhaps somnvhat withdrawn because of his chronic asthma and his "spells". However, he did not feel that there was sufficient psychopathology to account for the "spells" on a psychogenic basis. He urged the mpdical staff to reconsider the signi6cance of the absence of lamina dura of the teeth, the positive Chvostek's sign, hypocalcemia, hypomagnesia, hyperphosphatemia and increased alkaline phosphatase, in the context of the absence of any convincing evidence of psychopathology. He suggested that these "spells" could be episodes of tetany. With exercise or hypervpntilation respiratory alkalosis could develop, thus triggering the "spells". The psychiatrist-consultant's observations produced an increased interest in the patient as an "organic problem" and ultimately a diagnosis of hypoparathyroidism with Vitamin D de6ciency rickets was made.
Each consultation experience increases the resident consultant's (and often his faculty supervisor's) knowledge of diseases which fall under the purview of other medical specialties. If we reexamine the lpss remem\'oh"\I(, 1:'\
PSYCHIATRIC
CONSULTATION-WILLIA~IS
bered definition of consult it brings us to a consideration of the educational potential of the consultation for the physician who has requested the consultation. In this discussion we are assuming this is the resident on a service other than psychiatry who has primary responsihility for the care of the patient. If a consultant is skillful enough and if the re
edge and skills available in each. He may have had limited opportunity to observe the comprehensive approach to the patient and his problems. Many of us preach the merits of the comprehensive approach, but the highly trained and experienced specialist may no longer have the ability to conceptualize the total problem when it involves areas other than his own. Thus the collaborative effort of the various physicians to develop a comprehensive picture of the patient may offer the medical student a unique experience in his educational progress. Hopefully such experiences will become less and less unique as some of the exciting curricular innovations are implemented. \Vhen other consultants are also involved in the diagnostic and/or therapeutic problems of a patient they share in the opportunity to learn. This may be dramatic in the complicated problem where a variety of factors are contributing to the patient's morbidity. If he can get their attention, the skillful psychiatric consultant may be able to extend the usefulness of the other consultant's special knowledge and skills by actively engaging them in diagnostic and therapeutic deliberations so that the sum of several contributions may add up to more than the whole. The other health professionals who may be involved have an opportunity to see how various specialists approach a problem. They also learn new ways in which their own knowledge and skills can be more effectively utilized when the comprehensive approach to the patient is achieved. If the clinical psychologist, for example, can be sufficiently involved in a consultation process so that he understands how the consultant and the requesting physician use his test results in arriving at decisions he will certainly learn what kind of information is most useful to the physicians and how best to present it. The sick patient must be the focal person in the consultation interaction. \Vhat about his education? Obviously, the patient's objectives are to learn what is wrong with him and what is to be done about it. Too often the patient leaves the hospital without satisfying either of these objectives. This can happen even when the physicians and others concerned with the patient's care know what's 65
PSYCHOSO~IATICS
wrong with him, and what should be done about it. The patient's family also frequently fails to learn what is wrong and what treatment is being done or is to be done. There may he no statistics to document this observation hut it is well known that many therapeutic failures are the consequence of a hreakdown in the cOllllllunication process for the patient and his family. Current psychiatric treatment requires considerahle education for the patient aIHI his family. The skilled psychiatrist consultant who is ahle to sensitize his colleagues in other fields to the need for education of the patient and his family will often make a significJJlt contribution to the total care of the patient. In pursuing the educational objectives for the patient and his family the physician must he concerned with the sociocultural differences between him and his patient. He must he cautious ahout the language which he uses in attempting to communicate with the patient and his family. The psychiatrist consultant and the requesting physician must he alert to the possihility that the patient and/or
his family may resist psychological considerations in the illness. Although they may appear to listen they often will not hear the message. The consultant and the other memhers of the treatment team must constantly search for ways to demonstrate the validity of their findings to the patient and his family in words and deeds that can he understood and are meaningful. In summary, the psychiatric consultation should be an educational experience for a variety of people including the psychiatric resident consultant, the resident physician requesting the consultation, nursing staff, other health professionals, medical students, the patient and his family. If maximum education is to be achieved, the consultant must not only possess the particular knowledge and skills of his specialty but must also be an effective communicator and the objects of his communication must be good "receivers". Department of Psychiatry College of Medicine University of Florida Gainesvilfe, Florida 32fj()J
SECOND INTERNATIONAL CONGRESS Thc AcadelllY of I'syehosomatic ~Iedicine will hold its Second International Congress in Florence, Italy from Odo!>er 4-14, W6S. Three half-day sessions are planned in which the concepts of t'Omprehensive medicine and recent advances in psychopharmacology will be thoroughly explored by leading clinicians and educators both from the U. S. and Europe. After the sessions in Florenc(' are completed. the group will be transported to Rome by hus, via Perugia, Assisi, and othcr historie sites. A comprehensive tour of Rome and its surroundings will he included iu the itinerary. It should 1)(· emphasized that all arrangements will be made by Professional Scminar Consultants, a well-l'stablished organization sp('cializing in international meetings which has a reputation for arranging many sIH.Tl·ssful meetings abroad. Furtlwr information can be obtained by writing to Professional Sl'minar Consultants, 3194 Lawson Bonlevard, Oceanside, L. I.. N. Y. 11572. Future iSSUI'S of I'SYCIIOSOXIATICS will contain sl'ecifit- details as to the program and the spl·akl·rs.
66
Volnmt'IX
MARCH-APRIL, 1968
PSYCHOSOMATICS ---------------------------------------------OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
-----------------------------------------The follOlcillg paper represellts the !inal illstallment of the serialized pl/I)licatioll of the Symposil/m "Comprehensive Medical Care and the Psychiatric Consl/ltation." The Symposium teas held durillg Nor;ember, 196.5, at the (Tllit;ersity of Califomill Medical Center in Sail Francisco, u;here physicians (/lui researchers met to examille our current assl/llIpthms ahol/t the psyr!liatric consl/ltation.
The Educational Potential of the Psychiatric Consultation ROBERT
L.
\r".LIAl\IS,
• CO:\SULT: To apply for information or illstrtlctioll. This is one definition of consult listed in \rehster's Third International LTnahridged Dictionary. Perhaps as a consequence of tIl(' passage of time and the accelerated pace of modern medical practice the expectations for instruction have hecome Illore implicit than explicit in the consultation relationship. It's important that we do not lose sight of the educational potential of a psychiatric consultation and that we J"{'cognize that the amount of education which is accomplished may have considerahle rek\'ancc to thc therapeutic results of the interaction. If education does take place in the consultation process, who gets educated? The list of lwneficiaries may he long or short depending upon the problem and the skills of the consultant and consultee. Some of the hencficiaries in the list that follows mav he mon'
Dr. Williams is Prnfl·ssor and Chairman, DeparlIlll'nt of Psychiatry. \'oll,'gl' of \ledicin('. tTniv('rsil~' of Florida, CaiJll''''ilh', Florida 32601. \larch-April. I ~ns
M.D.
ohvious than others. If we examint' the consultation process in tIl(' setting of a teaching hospital, the potential list could include a fairly large numher of people. The most ohvious are the psychiatric resident consultant and the resident physician requesting till' consultation. In order to explof(' the full range of the ('(lucational possihilitit's for tht' psychiatric consultation we must include the nursing staff and supporting nmsing pt'rsonnel. the medical student or students concerned with the patient, consultants from other nwdical specialtit's who may ht' involved with the patient's prohlem and various health related professionals whose services are necded iu the total management of the particular prohlem. Last. hut not least in the list of heneficiaries are the patient, his immediate family and at times his extended family which might include his employer, his teacher or other important people in his life. The key persons in the consultation are the resident physician who is giving the consultation and the residt'nt physician who has requested the consultation, For the purpost' of this discussion we are focusing on the
1111111111111111111111 ~II ~CHB1-CCW-XSY7
63
PSYCHOSOMATICS
psychiatric resident as the consultant, but many of the same principles could apply in other consultant-consultee relationships. The educational goal of the psychiatric resident is to learn how to utilize his special knowledge and skills in psychiatry to help solve the problem of the patient whose diagnosis or therapeutic management may extend beyond the competence of the physician requesting the consultation. It is not enough that the psychiatric resident possess special knowledge and skills, but he must also learn how to convey this information in an effective and acceptable manner to the requesting physician and to most or all of the other potential parties in the transaction mentioned above. The first task for the psychiatrist consultant often may be to set up a communication which will facilitate learning with an individual or individuals who at first (and some times at last) may resent the psychiatrist's intrusion and not reallv be interested in what he has to teach. . Frequently the psychiatrist consultant must develop a comprehensive picture of the patient, his problem and a therapeutic plan which can be c1earlv visualized and understood by all the p~rsons mentioned above. This does not mean that the primary physician shouldn't or couldn't develop such a gestalt; often, however, this becomes the task of the consultant. Frequently the primary physician has simply not taken the time. The following vignette of a case historv extracted from a recent consultation experience at the Shands Teaching Hospital of the University of Florida demonstrates how the psychiatrist consultant can serve to develop a comprehensive understanding of the patient. Case I.-eSC, a 12-year-old Negro hoy, was seen for psychiatric evaluation at the request of a resident physician on the medical service who felt that the patient was having hysterical seizures. The boy described "spells" which he had been experiencing for approximately two years. He described a stiffening of his legs, drawing of his arms and dinching of his hands, associated with mild headaches. He related that exercise frt>quently brought them on but that they did occur at other timl>s, particularly during periods of emotional stress. He denied loss of consciousness but said that he did fall to the floor or ground. Review of his past medical history revealed that he suffered from asthma for ahout sewll years and (H
had bt'en hospitalized on six occasions for asthmatic attacks and upper respiratory infections. Five years prior to the present hospitalization hI' was noted to have white blood cells in his urine. Urine cultures were negative. He had had inh'rmittent dysuria during the past two years. Cystoscopy prior to hospitalization revealed a urethral stricture for which dilatation was prescribed. Very little infonnation was available about his family and home environment. The mother was described by the referring pbysician as nervous; the patient's 14-year-old sister also has asthma. The patient views himst>lf as different from his peers because he has been unable to keep up with them in physical activities. HI" attributes this to his asthma and more recently to these "spells". Physical examination was unrevealing except for the absence of the lamina dura of thl' teeth and a positive Chvostek's sign bilaterally. Laboratory studies revealed a nonnal hemogram and urinalysis. Electrolytes were nonnal with the exception of a CO, content of 21 and 22 MeqlL on repeated examination. Calcium was 7.7, 8.3 and 8.0 mg percent on repeated l'xaminations. Inorganic phosphate was 8.4 mg perl'l'nt, magnesium was 1.7 mg percent, alkaline phosphatase was 48 and on repeat examination 40 King-Annstrong units. Protein electrophoreses revealed a hyperbeta globulinemia and diffuse hypergamma globulinemia. Creatinine, blood urea nitrogen, fasting glucose and uric acid were within nonnal limits. Creatinine clearances were nonnal. Lumbar puncture and CSF examination were nonnal and electroencephalogram was nonnal. X-rays of the knees, elbows and feet were nonnal. A voiding cystogram was nonnal. Skull X-rays were nonnal. The neurological consultant felt that the patient had an emotional problem and that the "spells" were not typical of any seizure disorder. The psychiatrist consultant noted that the patient was anxious, slightly dppressed and perhaps somnvhat withdrawn because of his chronic asthma and his "spells". However, he did not feel that there was sufficient psychopathology to account for the "spells" on a psychogenic basis. He urged the mpdical staff to reconsider the signi6cance of the absence of lamina dura of the teeth, the positive Chvostek's sign, hypocalcemia, hypomagnesia, hyperphosphatemia and increased alkaline phosphatase, in the context of the absence of any convincing evidence of psychopathology. He suggested that these "spells" could be episodes of tetany. With exercise or hypervpntilation respiratory alkalosis could develop, thus triggering the "spells". The psychiatrist-consultant's observations produced an increased interest in the patient as an "organic problem" and ultimately a diagnosis of hypoparathyroidism with Vitamin D de6ciency rickets was made.
Each consultation experience increases the resident consultant's (and often his faculty supervisor's) knowledge of diseases which fall under the purview of other medical specialties. If we reexamine the lpss remem\'oh"\I(, 1:'\
PSYCHIATRIC
CONSULTATION-WILLIA~IS
bered definition of consult it brings us to a consideration of the educational potential of the consultation for the physician who has requested the consultation. In this discussion we are assuming this is the resident on a service other than psychiatry who has primary responsihility for the care of the patient. If a consultant is skillful enough and if the re
edge and skills available in each. He may have had limited opportunity to observe the comprehensive approach to the patient and his problems. Many of us preach the merits of the comprehensive approach, but the highly trained and experienced specialist may no longer have the ability to conceptualize the total problem when it involves areas other than his own. Thus the collaborative effort of the various physicians to develop a comprehensive picture of the patient may offer the medical student a unique experience in his educational progress. Hopefully such experiences will become less and less unique as some of the exciting curricular innovations are implemented. \Vhen other consultants are also involved in the diagnostic and/or therapeutic problems of a patient they share in the opportunity to learn. This may be dramatic in the complicated problem where a variety of factors are contributing to the patient's morbidity. If he can get their attention, the skillful psychiatric consultant may be able to extend the usefulness of the other consultant's special knowledge and skills by actively engaging them in diagnostic and therapeutic deliberations so that the sum of several contributions may add up to more than the whole. The other health professionals who may be involved have an opportunity to see how various specialists approach a problem. They also learn new ways in which their own knowledge and skills can be more effectively utilized when the comprehensive approach to the patient is achieved. If the clinical psychologist, for example, can be sufficiently involved in a consultation process so that he understands how the consultant and the requesting physician use his test results in arriving at decisions he will certainly learn what kind of information is most useful to the physicians and how best to present it. The sick patient must be the focal person in the consultation interaction. \Vhat about his education? Obviously, the patient's objectives are to learn what is wrong with him and what is to be done about it. Too often the patient leaves the hospital without satisfying either of these objectives. This can happen even when the physicians and others concerned with the patient's care know what's 65
PSYCHOSO~IATICS
wrong with him, and what should be done about it. The patient's family also frequently fails to learn what is wrong and what treatment is being done or is to be done. There may he no statistics to document this observation hut it is well known that many therapeutic failures are the consequence of a hreakdown in the cOllllllunication process for the patient and his family. Current psychiatric treatment requires considerahle education for the patient aIHI his family. The skilled psychiatrist consultant who is ahle to sensitize his colleagues in other fields to the need for education of the patient and his family will often make a significJJlt contribution to the total care of the patient. In pursuing the educational objectives for the patient and his family the physician must he concerned with the sociocultural differences between him and his patient. He must he cautious ahout the language which he uses in attempting to communicate with the patient and his family. The psychiatrist consultant and the requesting physician must he alert to the possihility that the patient and/or
his family may resist psychological considerations in the illness. Although they may appear to listen they often will not hear the message. The consultant and the other memhers of the treatment team must constantly search for ways to demonstrate the validity of their findings to the patient and his family in words and deeds that can he understood and are meaningful. In summary, the psychiatric consultation should be an educational experience for a variety of people including the psychiatric resident consultant, the resident physician requesting the consultation, nursing staff, other health professionals, medical students, the patient and his family. If maximum education is to be achieved, the consultant must not only possess the particular knowledge and skills of his specialty but must also be an effective communicator and the objects of his communication must be good "receivers". Department of Psychiatry College of Medicine University of Florida Gainesvilfe, Florida 32fj()J
SECOND INTERNATIONAL CONGRESS Thc AcadelllY of I'syehosomatic ~Iedicine will hold its Second International Congress in Florence, Italy from Odo!>er 4-14, W6S. Three half-day sessions are planned in which the concepts of t'Omprehensive medicine and recent advances in psychopharmacology will be thoroughly explored by leading clinicians and educators both from the U. S. and Europe. After the sessions in Florenc(' are completed. the group will be transported to Rome by hus, via Perugia, Assisi, and othcr historie sites. A comprehensive tour of Rome and its surroundings will he included iu the itinerary. It should 1)(· emphasized that all arrangements will be made by Professional Scminar Consultants, a well-l'stablished organization sp('cializing in international meetings which has a reputation for arranging many sIH.Tl·ssful meetings abroad. Furtlwr information can be obtained by writing to Professional Sl'minar Consultants, 3194 Lawson Bonlevard, Oceanside, L. I.. N. Y. 11572. Future iSSUI'S of I'SYCIIOSOXIATICS will contain sl'ecifit- details as to the program and the spl·akl·rs.
66
Volnmt'IX