Involving a psychiatrist in a patient’s care for the first time

The psychiatrist knocks on the door of the patient’s hospital room.

Patient: “Come in.”

Psychiatrist: “Good afternoon, Mrs. Jones. I’m Dr. Moodbetter, one of the psychiatrists here. Your doctor asked me to see you. Did he say anything about this?”

Patient: “No, he didn’t! You know, I’m not nuts. I didn’t think he believed me. Great. Now he just thinks it’s all in my head.”

Psychiatrist: “Well, I don’t think he meant to imply that you were imagining anything. Since there’s a connection between the mind and the body, sometimes issues such as stress can affect our physical health. I do wish he had told you that he had asked me to come by, though. You should have been in the loop. I’m sorry you weren’t told about it. Anyway, would it be okay with you if we talk for a few minutes? Your medical situation sounds complicated, and maybe you and I can put some more of these puzzle pieces together. What do you think?”

Patient: (Hesitating, shrugs shoulders) “I guess. I’m still not happy about this. It’s nothing personal to you. Go ahead.”

Unfortunately, some variation of this conversation is often how psychiatric consultations begin in a hospital setting.

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.

What are the consequences of all this?

  • The patient is angry with his or her referring physician.
  • The psychiatrist does not clearly understand what question(s) he is being asked to answer.
  • The psychiatrist must try to defuse the patient’s anger, apologize for how someone handled the consult request, and must work extra diligently to establish enough rapport with the patient to obtain an adequate history.
  • The patient often feels insulted and demoralized.
  • Bottom line: patient care is compromised

It doesn’t need to be this way.

I think the problem stems from a couple of different issues. One is the lack of understanding that many non-psychiatric physicians have about the seemingly mysterious field of psychiatry. The other is the stigma surrounding psychiatry, psychiatrists, and discussing emotional or mental issues. There is no doubt that involving a psychiatrist in a patient’s care, especially for the first time, is a delicate matter  that needs to be handled respectfully.

I never fault other doctors for not understanding enough about psychiatry to know exactly what question to ask a psychiatrist. But, as any consultant knows, in order to provide a useful consultation, one needs to know what the consult question is. If referring clinicians aren’t sure how to ask, but they know that a psychiatrist is likely needed, then calling the consultant and discussing the case or at least writing out a description of the concern in the progress notes or orders would greatly improve communication.

The second issue–the stigma–could be handled much better with very little effort.

I realize that many non-psychiatric physicians are uncomfortable discussing psychiatric issues with patients. But what I wish they would do is try to put themselves in the patient’s shoes. Not telling a patient that a psychiatric consultation has been requested is just plain disrespectful. So, at some level it needs to be discussed. It doesn’t need to be a lengthy conversation, but how it’s said is what matters. Very frequently, patients will understandably feel invalidated and self-conscious if a suggestion is made that they see a mental health professional.

How should it be handled?

The message that should be conveyed to the patient:

  1. Your symptoms are real; you are not imagining them. We know it’s not “all in your head.”
  2. Your medical situation is complicated, and we need more input to be sure we’re addressing all of your needs. A psychiatrist is a medical doctor who specializes in mental health conditions, and they may be able to help us with your care.
  3. All we’re asking is that you speak with the psychiatrist. You’re not obligating yourself to any ongoing psychiatric treatment or medication.

Not all patients will be satisfied with this explanation, but if it’s delivered respectfully, the therapeutic alliance between the referring doctor and the patient will likely be stronger, the patient’s pride will be less likely to be hurt, and patient care can be improved.

What do you think? Have you had any experience in this situation–either as a psychiatrist, referring doctor, other member of the medical team, or as a patient? Do you have anything to add?

Jeffrey Knuppel is a psychiatrist who blogs at The Positive Medical Blog.

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