20 Things At A Glance
- Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
- Secure patient consent before consulting a psychiatrist.
- Present the psychiatrist’s anticipated insight as a benefit to the patient.
- Ask the patient if it’s all right to discuss their health status and needs with family members.
- Recognize that psychiatric illness is real, not imaginary.
- Realize that not all sadness constitutes depression.
- Don’t gloss over the possibility of delirium.
- Take the time to really listen.
- Always remain conscious of alcohol and substance abuse.
- Monitor patients’ vital signs for autonomic instability.
- Avoid arguments and power struggles with difficult or demanding patients.
- Adapt your vocabulary to the patient’s and family’s level of understanding.
- Be mindful of your nonverbal cues.
- Always take suicide risk seriously.
- Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.
- Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.
- Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.
- Listen to your instincts.
- Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.
- Extend genuine compassion to your patients.
Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.
That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.
“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”
The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”
So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?
1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”
2. Secure patient consent before consulting a psychiatrist.
“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.