3. Present the psychiatrist’s anticipated insight as a benefit to the patient.
Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.
4. Ask the patient if it’s all right to discuss their health status and needs with family members.
Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.
5. Recognize that psychiatric illness is real, not imaginary.
The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”
6. Realize that not all sadness constitutes depression.
“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”
So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.
7. Don’t gloss over the possibility of delirium.
It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”
These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.
8. Take the time to really listen.
Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”
9. Always remain conscious of alcohol and substance abuse.
Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.