INT'L. J. PSYCHIATRY IN MEDICINE, VO1.9(2), 1978-79
EVALUATION OF MEDICALPSYCHIATRIC CONSULTATION
MICHAEL SASSER, M.D.' Resident, Department of Psychiatry
J. DAVID KINZIE, M.D. Associate Professor of Psychiatry Director, Residency TrainingProgram Department of Psychiatry University of Oregon Health Sciences Center
ABSTRACT
This report describes four approaches to the evaluation of hospital psychiatric consultation. These are: 1) a survey of actual consultation use; 2) a house staff attitudinal survey; 3) a patient chart review; and 4) a patient questionnaire. The findings of this project and those previously reported are: 1) The psychiatric consultation is under-utilized and a large number of house staff find it not useful. 2) The psychiatric and non-psychiatric house staff view the functions of consultation in markedly different ways. 3) A high percentage of written consultation reports are too vague to determine if the needs of the referring physician were met. 4) Patients usually respond positively to psychiatric consultation. The implications of these findings are discussed in this report.
INTRODUCTION There is an important need for research in the evaluation and effectiveness of medical-psychiatric consultation [ 11. There is also an increasing demand for medicine and psychiatry to become accountable for their practices [2]. With the current economic realities of health-care delivery, it is incumbent that psychiatric consultation demonstrate its effectiveness [3] . Currently Dr. Sasser is Staff Psychiatrist, Jackson County Mental Health Services, Medford, Oregon. 123 @ 1979,Baywood Publishing Co., Inc.
doi: 10.2190/UFXA-Q8D6-68RN-GFAY http://baywood.com
124 / M. SASSER AND J. D. KlNZlE
Despite the need, there are many problems in the evaluation of psychiatric consultation work. Lipowski states that such an evaluation calls for clearly stated definitions of aims followed by a judgment on the degree of their attainment [ 11. However, despite this straightforward statement, problems are readily apparent in the definition of consultation services. The goals, aims, and scope of consultation vary widely according to the author’s definition of the field. Most authors feel consultation involves assisting non-psychiatric physicians in the diagnosis of their patients and by treatment when appropriate [4-71. However, many give equal importance to the training of the consultee physicians themselves [ 4 , 5 , 8 ] . Others say consultation is intimately related to liaison in which the goals include enhancing the quality of care for the medically ill by using models of primary, secondary, and tertiary prevention. Here the psychiatrist, as part of a team, participates in case detection and provides educational programs for autonomous functioning for the physicians [9]. The psychiatrist can also function as a catalyst and interpreter in a general hospital between patients and doctors [6] , or assist other physicians in using a multidimensional approach in conceptualizing inQvidual problems that are defined as an illness [ 101. Thus, depending on the definition of consultation and liaison work, the scope can be quite narrow or quite broad. In this respect it is difficult to evaluate many of these goals since some may be vague, idealistic, or ambiguous. Furthermore, the lack of consensus about the goals leads to difficulty in applying evaluation techniques applicable to all authors. Hospital psychiatric consultation has other problems in addition to lack of clarity of goals. In a typical university hospital setting, the consultees (i.e., nonpsychiatric physicians) represent many different doctors on different wards, at different levels of training, in different sub-specialties. There are specific nursing staff and patient problems inherent to each ward. Expectations of the physicians are quite varied and their psychological sophistication is additionally variable [ l l ] . The patient population varies not only from ward to ward, but the individuals can have complicated problems that can be psychiatric, medical, social, behavioral, or a combination of these. The psychiatrist’s assessment and his own goals may differ from that of the referring physician, nursing staff, and the patient. As Strain states, the assessment may involve multiple systems which may include assessing the request from the doctor, the chart, the nursing staff, the family, the ward culture, and finally, the patient himself [9]. These may lead to differing definitions of problems by all participants. As an extreme example, the patient may see his problem as unmitigated pain; his physician may see the problem as a behavior disorder inappropriate to a medical floor; and the psychiatric consultant may see the difficulty as poor communication between doctor and patient. Here, goal achievement is difficult to determine since there is a lack of consensus on goal definition. This report is of a simultaneous evaluation of several parameters of psychiatric consultation to indicate the values and limitations of each measure in determining
MEDICAL-PSY CHI ATRlC CONSULTATION I 125
the effectiveness of the consultation, and to suggest ways in which the goals of consultation may be more clearly and unambiguously stated. These measures include: 1. A survey of the actual use of consultation by each department in the hospital. 2. A survey of all residents, psychiatric and non-psychiatric, in a university hospital setting, to determine their use and expectations of psychiatric consultation. 3. A chart review of each consultation to determine the degree to which the written suggestions were actually followed by the consultee. 4. A survey of patients' attitudes regarding psychiatric intervention during their medical or surgical hospitalization.
METHODS AND RESULTS Part I: Survey of Requests for Psychiatric Consultation All requests for psychiatric consultation (n = 1,663) from the adult medical and surgical services in the 400-bed teaching hospital at the University of Oregon Health Sciences Center in Portland, Oregon were reviewed for the calendar years 1973 through 1976. The percentage of utilization of the total number of consultations was determined for each service and the number of consultations by service was also compared to the unit number of hospital admissions for that service in order to determine the relative utilization of psychiatric consultation. To evaluate the requests for consultation during the same period as Parts 11, 111, and IV of the project, information from consultation requests from July 1, 1977 to September 30, 1977 were reviewed as described above. These data were then compared with the previous survey to determine if the profile of consultation utilization during the three-month survey was different from the four-year period. The results of these surveys are shown in Table 1. These results indicate a slight increase in the percentage of consultations going to medicine and a decrease in surgery while others remained the same. In the overall large survey, psychiatric consultations were requested on 2.7 per cent of the total non-psychiatric hospital admissions. They were requested on 6 per cent of all medical admissions, 1.5 per cent of all surgical admissions, and 11.9 per cent of all neurology admissions.
Part I I: Survey of Residents' Use and Attitudes of the ConsultationService A two-part questionnaire was sent through interdepartmental mail to the 240 non-psychiatric residents and house staff in training at the University of Oregon
126 / M. SASSER AND J. D. KlNZlE
Table 1. Use of the Psychiatric Consultation Service Three-month survey 1977
Four-year survey 1973-1977
I. Service
Medicine Surgery Neurology Other
54.6% 9.3% 9.3% 26.8%
48.4% 17.3% 7.9% 26.2%
11. Stated Reason for Consultation Vague, Unclear Depression + OD + Suicide Attempt BehaviorIManagement Other
34.0%
40.7%
46.0% 11 .O% 8.0%
32.1% 6.6% 8.3%
Number of Requests Surveyed
97
1663
Health Sciences Center. In the first part, the forms requested the resident to rate the perceived usefulness of the psychiatric consultation service. They were asked if they had used the consultation service, and if so to rate the service as “never helpful,” “occasionally helpful,” “usually helpful,” or “always helpful.” Additionally, they were asked to rate a seventeen-item questionnaire developed by Karasu that describes the consultation liaison services available to the staff and patients in a general hospital [ 121 . The questionnaire was scored by the method described by Karasu. Each stated function was rated as unimportant, moderately important, or very important and given a value of 0, 1 , or 2 respectively. This questionnaire was also sent to twenty-nine psychiatric residents in training at the University of Oregon Health Sciences Center. Ninetytwo (39.2%) of the non-psychiatric residents completed the form as did twentyone (72.4%) of the twenty-nine psychiatric residents. Of the ninety-two non-psychiatric residents surveyed, twenty-two (23%) had never used the service. Of the seventy individuals who had used the service, ten (14%)felt it was not helpful, thirty-five (50%) felt it was occasionally useful, twenty-four (35%) felt that it was usually helpful, and one individual (1%) felt that it was always helpful. The results of the questionnaire were divided into the main functions of the consultation service. The seventeen functions of the psychiatric consultation service listed in the questionnaire (Table 2) covered three major areas possible in the consultation process: evaluation, direct service to the patient, and mediation with the ward and medical staff. The results of the questionnaire with the
MEDICAL-PSY CH I ATRlC CONSULTATION / 127
Table 2. Psychiatric Consultation Functions-Average Resident Response Score
Psychiatry residents UOHSC
Statement
Non-psychiatry residents UOHSC Karasu
Evaluation Functions To evaluate the mental status of a patient To evaluate a patient's competence To evaluate the psychogenesis of somatic problems
2.0" 1.2
1.4 1.3
1 .o 1.o
1.3
1.2
1.2
1.3
1.3
1.2
1 .o 0.7 1.1* 1.o
1.3 0.8 1.4 1.2
1.o 1.1 1.5 1 .o
1.9*
1.5
1.4
1.8*
1.2
1.7
1.7'
1.1
1.2
1.8***
1.5
1.3
0.8
0.8
0.8
1.6**
1.2
1.o
0.8"
0.3
0.4
1.5"
0.9
0.9
1.6"
0.9
1 .o
Direct Service Functions To make arrangements for the transfer of a patient to a psychiatric ward To make arrangements for commitment of a patient t o a mental institution To do psychotherapy with a patient To conduct follow-up visits with a patient To work with the family of a patient
Mediating Functions To make suggestions concerning the management of a patient on the ward To help the physician understand the psychologic aspects of a patient's illness To help the ward staff understand the psychologic aspects of a patient's illness To give advice on the use of psychiatric medications To teach staff and medical students interviewing techniques To make recommendations concerning additional diagnostic work-up To help resolve conflicts among ward staff that are unrelated to specific patients To help physicians and ward staff understand and deal with their reactions to individual patients To help physicians and ward staff deal with the stresses generated by a patient's behavior
*I*
Note: Significant differences between UOHSC residents: = p < .05.
=p
< .01; * * = p < .02;
128 I M. SASSER AND J. D. KlNZlE
University of Oregon Health Sciences Center non-psychiatric residents and those non-psychiatric residents in Karasu’s study are reported in Table 2. Means for each question were compared using the t-test as the test of significance. The University of Oregon Health Sciences Center residents were in agreement on the importance of two out of three of the evaluation items and four out of five direct service functions of consultation. However, statistically significant attitudinal differences between psychiatric and non-psychiatric house staff respondents are present in eight of the nine mediation functions, with the psychiatric residents placing more emphasis on these functions than did their non-psychiat ric colleagues.
Part I I I : Chart Review All charts (n = 97) of patients receiving psychiatric consultation from July 1, 1977 to September 30, 1977 were reviewed in a manner similar to that of Moses and Barzilay [13] to determine whether or not the consultation suggestions were followed by the house staff. This was determined by reviewing the physician orders, progress notes, nursing notes, and the discharge summaries of the identified ninety-seven patients. Of the ninety-seven charts, no written suggestions were given by the consultant doing the consultation on thirty-two (32.9%) of the patients. Of the sixty-five patients who received written suggestions from the psychiatric resident, it could be determined that the non-psychiatric house staff followed suggestions in forty-one (63%) of the cases. It could also be determined that in twelve (18.5%) of the cases suggestions were not followed, but this was nondeterminable in twelve (18.5%) cases.
Part IV: The Patient Questionnaire Using a modified form of the method developed by Hale and Abram [14], a ten-item questionnaire was sent to the ninety-seven patients described in Part 111. Twenty-four questionnaires were not deliverable and, of the seventy-three delivered, twenty-seven were returned. The responses to selected questions are shown in Table 3. A shift from pre-consultation to post-consultation attitudes was seen. This shift was predominantly related to the fact that three initially neutral individuals became positive, one initially negative responder also became positive, and two initially negative respondents became neutral. Two individuals who were neutral later became negative. Two individuals who had a positive preconsultation attitude toward consultation did not respond, presumably because their attitude did not change. Post-hospital suggestions regarding further psychiatric care was encouraged in seventeen (74%) of the patients. Of this, eleven (65%) followed the recommendation. An overwhelming number, twenty (77%), would accept psychiatric intervention and future hospitalization.
ME DICAL-PSYCH I ATRlC CONSULTATI ON I 129
Table 3. Patient Questionnaire Summary Was the patient informed of the psychiatric consult? N = 26 Yes No Don't remember
19 4 3
(73%) (15%) ( 12%)
Pre-consultationattitude: N = 24 Positive Negative Neutral
9 4 11
(38%) (17%) (45%)
Post-consultationattitude: N = 22 Positive Negative Neutral
12 4 6
(55%) (18%) (27%)
10 14
(38%) (54%)
2
(8%)
Post-hospitalizationsuggestions: N = 23 Psychiatric care encouraged No recommendation given
17 6
(74%) (26%)
Was recommendation followed? N = 17 Yes No
11 6
(65%) (35%)
Acceptance of psychiatry's involvement in future hospitalizations: N = 26 Yes No Unsure
20 5 1
(77%) ( 19%) (4%)
Did hospital care improve? N = 26 Improved No change Worsened
Note: N = the number of respondents who replied to the particular question.
DISCUSSION The major points of t h e findings will be discussedindividually and t h e n the . implications and suggestions for evaluating a consultation-liaisonservice will be discussed.
Utilization Rates of Consultation
In our study of t h e utilization rate of psychiatric consultation in a general hospital, we found, in both a retrospective four-year survey and a three-month survey done one year later, almost identical rates of utilization, i.e., 2.7 per cent of admissions. This low rate of utilization persisted despite the fact that the
130 / M. SASSER AND J. D. KlNZlE
second survey occurred after a year in which the quality of the consultationliaison service was thought to have been improved through teaching of psychiatric residents, faculty back-up, and a concerted effort to teach effective communication both orally and in written record with the referring physician. This rate is especially low when considering a previous study by Denney in the same hospital documenting the high rate of psychiatric disorders among medical and surgical patients [ 151 . Nevertheless, our rates are similar to those reported in the recent literature. Moses and Barzilay found a rate of 2.63 per cent [13], Karasu, Pluchick and Steinmuller found 2.72 per cent [16] ,and Shevitz, Silverfab and Lipowski found 3.3 per cent [17]. Our survey, like these others, also indicated that different services use consultation to varying degrees. Medical patients are the largest recipients, but a higher percentage of neurological patients are seen in consultation.
House Staff Survey on the Value and Function of a Consultation Service Our survey of non-psychiatric house staff revealed 23 per cent who stated they never use the service and 64 per cent who said that services were not helpful or only occasionally helpful. Both of these figures are startling and may account for the low utilization reflected above. It is particularly disturbing that when psychiatric services are used, only 36 per cent find it usually or always helpful. It should be noted that these conclusions are based on data from the ninety-two (of 240) non-psychiatric residents surveyed. It is possible that those with the strongest feelings about the value of psychiatric consultation services are overrepresented in this group. Even more revealing are the functions that nonpsychiatric house staff and psychiatric house staff view as important in psychiatric consultation. The non-psychiatric house staff viewed evaluation and direct services to the patient as the most important function. The psychiatrists viewed liaison education and a mediator role as more important. These marked differences in expectations have only been suggested by previous studies. Cavanaugh has documented the importance consultees give to the medical background of the consultant [3]. He found that physicians want assistance with complex management of patients where medical and psychosocial skills are needed. Karasu also found, as we did, that activities where staff members were recipients of the consultation were the least valued [ 161 . To our knowledge, comparisons between psychiatrists and non-psychiatric house staff have not been reported before. This review shows the marked differences in role expectations and functions of psychiatric consultations.
Chart Review Our review of ninety-seven charts during a three-month period revealed that on a third of consultations no specific suggestions were given or the comments
MEDICAL-PSYCHIATRIC CONSULTATION I 131
were too vague to determine whether or not the physicians actually followed any recommendations given by the consultant. Nevertheless, when consultation suggestions were given in a clear way, it was followed at least 63 per cent of the time. The remainder was divided between those where it was not followed and those where it could not be determined through a chart review. Our chart review led us to conclude that one major difficulty in consultation evaluation is the imprecision and lack of clarity of the specific suggestions given by the consulting psychiatrist. Perhaps an educational or mediator role was performed by the consultant in the one-third of cases where no specific suggestions were given, although this could not be documented by the written note. This high number of charts without written suggestions makes evaluation of consultations extremely difficult. In a prior chart review by Moses and Barzilay [13] ,it was found that the hospital summary indicated that physicians made comments appropriate to the psychiatric report regarding diagnosis 46 per cent of the time and regarding treatment 51 per cent of the time. Our findings suggested that more physicians use the recommendations when they are specific.
Patient Questionnaire Our final method of determining the effects of consultation was to review through a questionnaire the effects on the patients themselves. Although the validity of the results could be questioned because of the small sample, it is important to know that most patients were neutral or positive in pre-consultation expectations and that the neutral patients tended to become positive as a result of the consultation experience. Our response indicates that, in general, the positive individuals remained positive, those who were neutral prior to consultation became more positive, while those who were initially negative remained negative. These findings are consistent with other studies. Schwab reported that 32 per cent of patients found the consultation of distinct value and 34 per cent of mixed value [ 181 . Hale and Abram reported 42 per cent of their patients derived great or some value from consultation [ 141 Hughson and Lyons report 64 per cent of their patients found consultation relevant and 61 per cent found it helpful [19]. These findings lead to a consensus that most patients find consultation of neutral or definite value and usefulness. Therefore, problems in psychiatric consultation utilization do not seem to be related to patients’ acceptance or actual perceived help from the consultation process. The major points regarding the evaluation of a consultation service from this study and those reported above can.be summarized as follows:
.
1. Underutilization of psychiatric consultation in a general hospital is a fact and has been clearly demonstrated in many studies; 2. many house staff do not use psychiatric consultation and a majority find it only occasionally useful or not useful at all; 3. psychiatric and non-psychiatric house staff view the functions and value of
132 I M. SASSER AND J. D. KINZIE
consultation in markedly different ways. Non-psychiatric staff place emphasis on evaluation and management of immediate cases while the psychiatrists tend to view the importance of education and mediation between patients, nursing staff, and doctors; 4. our review of records indicates that a disconcertingly high percentage of psychiatric consultations are too general or vague to determine if they met the needs of the referring physician or if the recommendations were followed by him. Nevertheless, when specific suggestions or plans are offered, these are followed the great majority of the time; 5. patients usually have responded positively to psychiatric consultation and find it of value. It is likely that under-utilization may be the result of many physicians’ decision that psychiatric consultation is not useful. This goes beyond lack of psychiatric sophistication and may involve two problems. First, non-psychiatric house staff and psychiatric house staff view the function of the consultation in markedly different ways which would, therefore, exacerbate conflicts in roles and purposes of the consultation. It is apparent from our survey of psychiatric residents that the consultation model involving mediation, training, and education has been well learned. Our residents espoused these values much as they have been proclaimed by Brown [8] , Strain and Grossman [9] ,and Eaton [ 1 1 3 . Nevertheless, this model is, in fact, in conflict with the needs of physicians who want expertise in the evaluation and treatment of patients. Since expectations of consultation are different, conflicts and mutual dissatisfaction regarding consultation may develop. A second reason, however, may be that the consultation reports are too vague and not specific enough to meet the needs of the referring physician. We feel that for consultation to be effective, it must meet the needs of the physician. Impressions and recommendations must be clearly stated so that the physician will be able to help the patient, and so that it is possible to determine the results of consultation. It seems clear that educationally, residents need to be taught lucid writing of the consultation report with recommendations that represent instructions for dealing with each of the problem areas as has been advocated by Houpt, Weinstein, and Russell [ 2 0 ] . Our evidence indicates that the mediation and educational functions of psychiatric consultations are not highly valued by physicians. Since the goals of mediation and education are vague and multiple, there are many problems in evaluating them. The authors do not want to ignore the thrust of liaison psychiatry in meeting the psychosocial aspects of patient care. Nevertheless, such an approach in meeting a request for consultation may serve to further alienate non-psychiatric physicians by increasing the conflicts in expectation from consultation.
MEDICAL-PSY CH IATRlC CONSU LTATl ON / 133
REFERENCES 1. Z. J. Lipowski, Consultation-Liaison Psychiatry: Past, Present, and Future, Consultation-Liaison Psychiatry, R. 0.Pasnau, (ed.), Grune t Stratton, New York, pp. 1-28, 1975. 2. A. R. Somers, Accountability, Public Policy, and Psychiatry, Amer. J. Psychiat., 134:9, pp. 959-965, 1977. 3. J. L. Cavanaugh and J. Flood, Psychiatric Consultation Services in the Large General Hospital: A Review and A New Report, Int. J. Psychiat. in Med., 7:3, pp. 193-207, 1976-77. 4. A. J. Krakowski, Consultation-Liaison Psychiatry: A Psychosomatic Service in the General Hospital, Int. J. Psychiat. in Med., 6: 1/2, pp. 283-292, 1975. 5. A. J. Krakowski, The Process of Consultation, Psychosomatic Medicine: Its Clinical Applications, E. D. Wittkower and H. Warnes, (eds.), Harper t Row, Inc., Hagerstown, Maryland, pp. 26-39, 1977. 6. J. J. Schwab, Evaluating Psychiatric Consultation Work, Psychosomatics, 8, pp. 309-3 17, 1967. 7. Z. J. Lipowski, Consultation-Liaison Psychiatry: An Overview, Amer. J. Psychiat., 131:6, pp. 623-630, 1974. 8. W. A. Brown and E. M. Jacobson, Consultation-Liaison Psychiatry: Current Responsibilities, Amer. J. Psychiat., 133:3, pp. 326-328, 1976. 9. J. J. Strain and S . Grossman, Psychological Care of the Medically Ill: A Primer in Liaison Psychiatty, Appleton-Century-Crofts, New York, 1975. 10. C. P. Kimball, The Challenge of Liaison Medicine: Conceptual Approach of Liaison Medicine, Consultation-Liaison Psychiatry, R. 0 . Pasnau, (ed.), Grune t Stratton, New York, pp. 269-275, 1975. 11. J. S. Eaton, et al., The Educational Challenge of Consultation-Liaison Psychiatry, Amer. J. Psychiat., 134, (supplement), pp. 20-23, 1977. 12. T. B. Karasu, et al., What Do Physicians Want From a Psychiatric Consultation Service?, Comprehens. Psychiat., 18:1, pp. 73-81, 1977. 13. R. Moses and S. Barzilay, The Influence of Psychiatric Consultation on the Course of Illness of the General Hospital Patient, Comprehens. Psychiat., 8: 1, pp. 16-26, 1967. 14. M. L. Hale and H. S. Abram, Patients Attitudes Toward Psychiatric Consultations in the General Hospital, Virginia Med. Monthly, 94, pp. 342347,1967. 15. D. Denney, et al., Psychiatric Patients on Medical Wards, Arch. Gen. Psychiat.. 14, pp. 530-535, 1966. 16. T. B. Karasu, et al., Patterns of Psychiatric Consultation in a General Hospital, Hosp. Commun. Psychiat., 28.4, pp. 291-294, 1977. 17. S. A. Shevitz, et al., Psychiatric Consultation in a General Hospital: A Report on 1000 Referrals, Dis. Nerv. Sys., 37:5, pp. 295-300, May 1976. 18. J. J. Schwab, et al., Medical Inpatients’ Reactions to Psychiatric Consultations, J. Nerv. Ment. Dis., 142:3, pp. 215-222, 1966. 19. B. Wughson and R. Lyons, Patient Response to Psychiatric Consultation in a General Hospital, Australian and New Zealand J. Psychiat., 7, pp. 279-282, 1973.
134 / M. SASSER AND J. D. KlNZlE
20. J. L. Houpt, et al., The Application of Competency-Based Education to Consultation-Liaison Psychiatry: I. Data Gathering and Case Formulation, 11. Intervention Knowledge and Skills, 111. Implications, Int. J. Psychiat. in Med., 7:4, pp. 295-328, 1976-77.
Direct reprint requests to: Michael Sasser, M.D. Staff Psychiatrist Jackson County Mental Health Services Medford, OR 97501
EVALUATION OF MEDICALPSYCHIATRIC CONSULTATION
MICHAEL SASSER, M.D.' Resident, Department of Psychiatry
J. DAVID KINZIE, M.D. Associate Professor of Psychiatry Director, Residency TrainingProgram Department of Psychiatry University of Oregon Health Sciences Center
ABSTRACT
This report describes four approaches to the evaluation of hospital psychiatric consultation. These are: 1) a survey of actual consultation use; 2) a house staff attitudinal survey; 3) a patient chart review; and 4) a patient questionnaire. The findings of this project and those previously reported are: 1) The psychiatric consultation is under-utilized and a large number of house staff find it not useful. 2) The psychiatric and non-psychiatric house staff view the functions of consultation in markedly different ways. 3) A high percentage of written consultation reports are too vague to determine if the needs of the referring physician were met. 4) Patients usually respond positively to psychiatric consultation. The implications of these findings are discussed in this report.
INTRODUCTION There is an important need for research in the evaluation and effectiveness of medical-psychiatric consultation [ 11. There is also an increasing demand for medicine and psychiatry to become accountable for their practices [2]. With the current economic realities of health-care delivery, it is incumbent that psychiatric consultation demonstrate its effectiveness [3] . Currently Dr. Sasser is Staff Psychiatrist, Jackson County Mental Health Services, Medford, Oregon. 123 @ 1979,Baywood Publishing Co., Inc.
doi: 10.2190/UFXA-Q8D6-68RN-GFAY http://baywood.com
124 / M. SASSER AND J. D. KlNZlE
Despite the need, there are many problems in the evaluation of psychiatric consultation work. Lipowski states that such an evaluation calls for clearly stated definitions of aims followed by a judgment on the degree of their attainment [ 11. However, despite this straightforward statement, problems are readily apparent in the definition of consultation services. The goals, aims, and scope of consultation vary widely according to the author’s definition of the field. Most authors feel consultation involves assisting non-psychiatric physicians in the diagnosis of their patients and by treatment when appropriate [4-71. However, many give equal importance to the training of the consultee physicians themselves [ 4 , 5 , 8 ] . Others say consultation is intimately related to liaison in which the goals include enhancing the quality of care for the medically ill by using models of primary, secondary, and tertiary prevention. Here the psychiatrist, as part of a team, participates in case detection and provides educational programs for autonomous functioning for the physicians [9]. The psychiatrist can also function as a catalyst and interpreter in a general hospital between patients and doctors [6] , or assist other physicians in using a multidimensional approach in conceptualizing inQvidual problems that are defined as an illness [ 101. Thus, depending on the definition of consultation and liaison work, the scope can be quite narrow or quite broad. In this respect it is difficult to evaluate many of these goals since some may be vague, idealistic, or ambiguous. Furthermore, the lack of consensus about the goals leads to difficulty in applying evaluation techniques applicable to all authors. Hospital psychiatric consultation has other problems in addition to lack of clarity of goals. In a typical university hospital setting, the consultees (i.e., nonpsychiatric physicians) represent many different doctors on different wards, at different levels of training, in different sub-specialties. There are specific nursing staff and patient problems inherent to each ward. Expectations of the physicians are quite varied and their psychological sophistication is additionally variable [ l l ] . The patient population varies not only from ward to ward, but the individuals can have complicated problems that can be psychiatric, medical, social, behavioral, or a combination of these. The psychiatrist’s assessment and his own goals may differ from that of the referring physician, nursing staff, and the patient. As Strain states, the assessment may involve multiple systems which may include assessing the request from the doctor, the chart, the nursing staff, the family, the ward culture, and finally, the patient himself [9]. These may lead to differing definitions of problems by all participants. As an extreme example, the patient may see his problem as unmitigated pain; his physician may see the problem as a behavior disorder inappropriate to a medical floor; and the psychiatric consultant may see the difficulty as poor communication between doctor and patient. Here, goal achievement is difficult to determine since there is a lack of consensus on goal definition. This report is of a simultaneous evaluation of several parameters of psychiatric consultation to indicate the values and limitations of each measure in determining
MEDICAL-PSY CHI ATRlC CONSULTATION I 125
the effectiveness of the consultation, and to suggest ways in which the goals of consultation may be more clearly and unambiguously stated. These measures include: 1. A survey of the actual use of consultation by each department in the hospital. 2. A survey of all residents, psychiatric and non-psychiatric, in a university hospital setting, to determine their use and expectations of psychiatric consultation. 3. A chart review of each consultation to determine the degree to which the written suggestions were actually followed by the consultee. 4. A survey of patients' attitudes regarding psychiatric intervention during their medical or surgical hospitalization.
METHODS AND RESULTS Part I: Survey of Requests for Psychiatric Consultation All requests for psychiatric consultation (n = 1,663) from the adult medical and surgical services in the 400-bed teaching hospital at the University of Oregon Health Sciences Center in Portland, Oregon were reviewed for the calendar years 1973 through 1976. The percentage of utilization of the total number of consultations was determined for each service and the number of consultations by service was also compared to the unit number of hospital admissions for that service in order to determine the relative utilization of psychiatric consultation. To evaluate the requests for consultation during the same period as Parts 11, 111, and IV of the project, information from consultation requests from July 1, 1977 to September 30, 1977 were reviewed as described above. These data were then compared with the previous survey to determine if the profile of consultation utilization during the three-month survey was different from the four-year period. The results of these surveys are shown in Table 1. These results indicate a slight increase in the percentage of consultations going to medicine and a decrease in surgery while others remained the same. In the overall large survey, psychiatric consultations were requested on 2.7 per cent of the total non-psychiatric hospital admissions. They were requested on 6 per cent of all medical admissions, 1.5 per cent of all surgical admissions, and 11.9 per cent of all neurology admissions.
Part I I: Survey of Residents' Use and Attitudes of the ConsultationService A two-part questionnaire was sent through interdepartmental mail to the 240 non-psychiatric residents and house staff in training at the University of Oregon
126 / M. SASSER AND J. D. KlNZlE
Table 1. Use of the Psychiatric Consultation Service Three-month survey 1977
Four-year survey 1973-1977
I. Service
Medicine Surgery Neurology Other
54.6% 9.3% 9.3% 26.8%
48.4% 17.3% 7.9% 26.2%
11. Stated Reason for Consultation Vague, Unclear Depression + OD + Suicide Attempt BehaviorIManagement Other
34.0%
40.7%
46.0% 11 .O% 8.0%
32.1% 6.6% 8.3%
Number of Requests Surveyed
97
1663
Health Sciences Center. In the first part, the forms requested the resident to rate the perceived usefulness of the psychiatric consultation service. They were asked if they had used the consultation service, and if so to rate the service as “never helpful,” “occasionally helpful,” “usually helpful,” or “always helpful.” Additionally, they were asked to rate a seventeen-item questionnaire developed by Karasu that describes the consultation liaison services available to the staff and patients in a general hospital [ 121 . The questionnaire was scored by the method described by Karasu. Each stated function was rated as unimportant, moderately important, or very important and given a value of 0, 1 , or 2 respectively. This questionnaire was also sent to twenty-nine psychiatric residents in training at the University of Oregon Health Sciences Center. Ninetytwo (39.2%) of the non-psychiatric residents completed the form as did twentyone (72.4%) of the twenty-nine psychiatric residents. Of the ninety-two non-psychiatric residents surveyed, twenty-two (23%) had never used the service. Of the seventy individuals who had used the service, ten (14%)felt it was not helpful, thirty-five (50%) felt it was occasionally useful, twenty-four (35%) felt that it was usually helpful, and one individual (1%) felt that it was always helpful. The results of the questionnaire were divided into the main functions of the consultation service. The seventeen functions of the psychiatric consultation service listed in the questionnaire (Table 2) covered three major areas possible in the consultation process: evaluation, direct service to the patient, and mediation with the ward and medical staff. The results of the questionnaire with the
MEDICAL-PSY CH I ATRlC CONSULTATION / 127
Table 2. Psychiatric Consultation Functions-Average Resident Response Score
Psychiatry residents UOHSC
Statement
Non-psychiatry residents UOHSC Karasu
Evaluation Functions To evaluate the mental status of a patient To evaluate a patient's competence To evaluate the psychogenesis of somatic problems
2.0" 1.2
1.4 1.3
1 .o 1.o
1.3
1.2
1.2
1.3
1.3
1.2
1 .o 0.7 1.1* 1.o
1.3 0.8 1.4 1.2
1.o 1.1 1.5 1 .o
1.9*
1.5
1.4
1.8*
1.2
1.7
1.7'
1.1
1.2
1.8***
1.5
1.3
0.8
0.8
0.8
1.6**
1.2
1.o
0.8"
0.3
0.4
1.5"
0.9
0.9
1.6"
0.9
1 .o
Direct Service Functions To make arrangements for the transfer of a patient to a psychiatric ward To make arrangements for commitment of a patient t o a mental institution To do psychotherapy with a patient To conduct follow-up visits with a patient To work with the family of a patient
Mediating Functions To make suggestions concerning the management of a patient on the ward To help the physician understand the psychologic aspects of a patient's illness To help the ward staff understand the psychologic aspects of a patient's illness To give advice on the use of psychiatric medications To teach staff and medical students interviewing techniques To make recommendations concerning additional diagnostic work-up To help resolve conflicts among ward staff that are unrelated to specific patients To help physicians and ward staff understand and deal with their reactions to individual patients To help physicians and ward staff deal with the stresses generated by a patient's behavior
*I*
Note: Significant differences between UOHSC residents: = p < .05.
=p
< .01; * * = p < .02;
128 I M. SASSER AND J. D. KlNZlE
University of Oregon Health Sciences Center non-psychiatric residents and those non-psychiatric residents in Karasu’s study are reported in Table 2. Means for each question were compared using the t-test as the test of significance. The University of Oregon Health Sciences Center residents were in agreement on the importance of two out of three of the evaluation items and four out of five direct service functions of consultation. However, statistically significant attitudinal differences between psychiatric and non-psychiatric house staff respondents are present in eight of the nine mediation functions, with the psychiatric residents placing more emphasis on these functions than did their non-psychiat ric colleagues.
Part I I I : Chart Review All charts (n = 97) of patients receiving psychiatric consultation from July 1, 1977 to September 30, 1977 were reviewed in a manner similar to that of Moses and Barzilay [13] to determine whether or not the consultation suggestions were followed by the house staff. This was determined by reviewing the physician orders, progress notes, nursing notes, and the discharge summaries of the identified ninety-seven patients. Of the ninety-seven charts, no written suggestions were given by the consultant doing the consultation on thirty-two (32.9%) of the patients. Of the sixty-five patients who received written suggestions from the psychiatric resident, it could be determined that the non-psychiatric house staff followed suggestions in forty-one (63%) of the cases. It could also be determined that in twelve (18.5%) of the cases suggestions were not followed, but this was nondeterminable in twelve (18.5%) cases.
Part IV: The Patient Questionnaire Using a modified form of the method developed by Hale and Abram [14], a ten-item questionnaire was sent to the ninety-seven patients described in Part 111. Twenty-four questionnaires were not deliverable and, of the seventy-three delivered, twenty-seven were returned. The responses to selected questions are shown in Table 3. A shift from pre-consultation to post-consultation attitudes was seen. This shift was predominantly related to the fact that three initially neutral individuals became positive, one initially negative responder also became positive, and two initially negative respondents became neutral. Two individuals who were neutral later became negative. Two individuals who had a positive preconsultation attitude toward consultation did not respond, presumably because their attitude did not change. Post-hospital suggestions regarding further psychiatric care was encouraged in seventeen (74%) of the patients. Of this, eleven (65%) followed the recommendation. An overwhelming number, twenty (77%), would accept psychiatric intervention and future hospitalization.
ME DICAL-PSYCH I ATRlC CONSULTATI ON I 129
Table 3. Patient Questionnaire Summary Was the patient informed of the psychiatric consult? N = 26 Yes No Don't remember
19 4 3
(73%) (15%) ( 12%)
Pre-consultationattitude: N = 24 Positive Negative Neutral
9 4 11
(38%) (17%) (45%)
Post-consultationattitude: N = 22 Positive Negative Neutral
12 4 6
(55%) (18%) (27%)
10 14
(38%) (54%)
2
(8%)
Post-hospitalizationsuggestions: N = 23 Psychiatric care encouraged No recommendation given
17 6
(74%) (26%)
Was recommendation followed? N = 17 Yes No
11 6
(65%) (35%)
Acceptance of psychiatry's involvement in future hospitalizations: N = 26 Yes No Unsure
20 5 1
(77%) ( 19%) (4%)
Did hospital care improve? N = 26 Improved No change Worsened
Note: N = the number of respondents who replied to the particular question.
DISCUSSION The major points of t h e findings will be discussedindividually and t h e n the . implications and suggestions for evaluating a consultation-liaisonservice will be discussed.
Utilization Rates of Consultation
In our study of t h e utilization rate of psychiatric consultation in a general hospital, we found, in both a retrospective four-year survey and a three-month survey done one year later, almost identical rates of utilization, i.e., 2.7 per cent of admissions. This low rate of utilization persisted despite the fact that the
130 / M. SASSER AND J. D. KlNZlE
second survey occurred after a year in which the quality of the consultationliaison service was thought to have been improved through teaching of psychiatric residents, faculty back-up, and a concerted effort to teach effective communication both orally and in written record with the referring physician. This rate is especially low when considering a previous study by Denney in the same hospital documenting the high rate of psychiatric disorders among medical and surgical patients [ 151 . Nevertheless, our rates are similar to those reported in the recent literature. Moses and Barzilay found a rate of 2.63 per cent [13], Karasu, Pluchick and Steinmuller found 2.72 per cent [16] ,and Shevitz, Silverfab and Lipowski found 3.3 per cent [17]. Our survey, like these others, also indicated that different services use consultation to varying degrees. Medical patients are the largest recipients, but a higher percentage of neurological patients are seen in consultation.
House Staff Survey on the Value and Function of a Consultation Service Our survey of non-psychiatric house staff revealed 23 per cent who stated they never use the service and 64 per cent who said that services were not helpful or only occasionally helpful. Both of these figures are startling and may account for the low utilization reflected above. It is particularly disturbing that when psychiatric services are used, only 36 per cent find it usually or always helpful. It should be noted that these conclusions are based on data from the ninety-two (of 240) non-psychiatric residents surveyed. It is possible that those with the strongest feelings about the value of psychiatric consultation services are overrepresented in this group. Even more revealing are the functions that nonpsychiatric house staff and psychiatric house staff view as important in psychiatric consultation. The non-psychiatric house staff viewed evaluation and direct services to the patient as the most important function. The psychiatrists viewed liaison education and a mediator role as more important. These marked differences in expectations have only been suggested by previous studies. Cavanaugh has documented the importance consultees give to the medical background of the consultant [3]. He found that physicians want assistance with complex management of patients where medical and psychosocial skills are needed. Karasu also found, as we did, that activities where staff members were recipients of the consultation were the least valued [ 161 . To our knowledge, comparisons between psychiatrists and non-psychiatric house staff have not been reported before. This review shows the marked differences in role expectations and functions of psychiatric consultations.
Chart Review Our review of ninety-seven charts during a three-month period revealed that on a third of consultations no specific suggestions were given or the comments
MEDICAL-PSYCHIATRIC CONSULTATION I 131
were too vague to determine whether or not the physicians actually followed any recommendations given by the consultant. Nevertheless, when consultation suggestions were given in a clear way, it was followed at least 63 per cent of the time. The remainder was divided between those where it was not followed and those where it could not be determined through a chart review. Our chart review led us to conclude that one major difficulty in consultation evaluation is the imprecision and lack of clarity of the specific suggestions given by the consulting psychiatrist. Perhaps an educational or mediator role was performed by the consultant in the one-third of cases where no specific suggestions were given, although this could not be documented by the written note. This high number of charts without written suggestions makes evaluation of consultations extremely difficult. In a prior chart review by Moses and Barzilay [13] ,it was found that the hospital summary indicated that physicians made comments appropriate to the psychiatric report regarding diagnosis 46 per cent of the time and regarding treatment 51 per cent of the time. Our findings suggested that more physicians use the recommendations when they are specific.
Patient Questionnaire Our final method of determining the effects of consultation was to review through a questionnaire the effects on the patients themselves. Although the validity of the results could be questioned because of the small sample, it is important to know that most patients were neutral or positive in pre-consultation expectations and that the neutral patients tended to become positive as a result of the consultation experience. Our response indicates that, in general, the positive individuals remained positive, those who were neutral prior to consultation became more positive, while those who were initially negative remained negative. These findings are consistent with other studies. Schwab reported that 32 per cent of patients found the consultation of distinct value and 34 per cent of mixed value [ 181 . Hale and Abram reported 42 per cent of their patients derived great or some value from consultation [ 141 Hughson and Lyons report 64 per cent of their patients found consultation relevant and 61 per cent found it helpful [19]. These findings lead to a consensus that most patients find consultation of neutral or definite value and usefulness. Therefore, problems in psychiatric consultation utilization do not seem to be related to patients’ acceptance or actual perceived help from the consultation process. The major points regarding the evaluation of a consultation service from this study and those reported above can.be summarized as follows:
.
1. Underutilization of psychiatric consultation in a general hospital is a fact and has been clearly demonstrated in many studies; 2. many house staff do not use psychiatric consultation and a majority find it only occasionally useful or not useful at all; 3. psychiatric and non-psychiatric house staff view the functions and value of
132 I M. SASSER AND J. D. KINZIE
consultation in markedly different ways. Non-psychiatric staff place emphasis on evaluation and management of immediate cases while the psychiatrists tend to view the importance of education and mediation between patients, nursing staff, and doctors; 4. our review of records indicates that a disconcertingly high percentage of psychiatric consultations are too general or vague to determine if they met the needs of the referring physician or if the recommendations were followed by him. Nevertheless, when specific suggestions or plans are offered, these are followed the great majority of the time; 5. patients usually have responded positively to psychiatric consultation and find it of value. It is likely that under-utilization may be the result of many physicians’ decision that psychiatric consultation is not useful. This goes beyond lack of psychiatric sophistication and may involve two problems. First, non-psychiatric house staff and psychiatric house staff view the function of the consultation in markedly different ways which would, therefore, exacerbate conflicts in roles and purposes of the consultation. It is apparent from our survey of psychiatric residents that the consultation model involving mediation, training, and education has been well learned. Our residents espoused these values much as they have been proclaimed by Brown [8] , Strain and Grossman [9] ,and Eaton [ 1 1 3 . Nevertheless, this model is, in fact, in conflict with the needs of physicians who want expertise in the evaluation and treatment of patients. Since expectations of consultation are different, conflicts and mutual dissatisfaction regarding consultation may develop. A second reason, however, may be that the consultation reports are too vague and not specific enough to meet the needs of the referring physician. We feel that for consultation to be effective, it must meet the needs of the physician. Impressions and recommendations must be clearly stated so that the physician will be able to help the patient, and so that it is possible to determine the results of consultation. It seems clear that educationally, residents need to be taught lucid writing of the consultation report with recommendations that represent instructions for dealing with each of the problem areas as has been advocated by Houpt, Weinstein, and Russell [ 2 0 ] . Our evidence indicates that the mediation and educational functions of psychiatric consultations are not highly valued by physicians. Since the goals of mediation and education are vague and multiple, there are many problems in evaluating them. The authors do not want to ignore the thrust of liaison psychiatry in meeting the psychosocial aspects of patient care. Nevertheless, such an approach in meeting a request for consultation may serve to further alienate non-psychiatric physicians by increasing the conflicts in expectation from consultation.
MEDICAL-PSY CH IATRlC CONSU LTATl ON / 133
REFERENCES 1. Z. J. Lipowski, Consultation-Liaison Psychiatry: Past, Present, and Future, Consultation-Liaison Psychiatry, R. 0.Pasnau, (ed.), Grune t Stratton, New York, pp. 1-28, 1975. 2. A. R. Somers, Accountability, Public Policy, and Psychiatry, Amer. J. Psychiat., 134:9, pp. 959-965, 1977. 3. J. L. Cavanaugh and J. Flood, Psychiatric Consultation Services in the Large General Hospital: A Review and A New Report, Int. J. Psychiat. in Med., 7:3, pp. 193-207, 1976-77. 4. A. J. Krakowski, Consultation-Liaison Psychiatry: A Psychosomatic Service in the General Hospital, Int. J. Psychiat. in Med., 6: 1/2, pp. 283-292, 1975. 5. A. J. Krakowski, The Process of Consultation, Psychosomatic Medicine: Its Clinical Applications, E. D. Wittkower and H. Warnes, (eds.), Harper t Row, Inc., Hagerstown, Maryland, pp. 26-39, 1977. 6. J. J. Schwab, Evaluating Psychiatric Consultation Work, Psychosomatics, 8, pp. 309-3 17, 1967. 7. Z. J. Lipowski, Consultation-Liaison Psychiatry: An Overview, Amer. J. Psychiat., 131:6, pp. 623-630, 1974. 8. W. A. Brown and E. M. Jacobson, Consultation-Liaison Psychiatry: Current Responsibilities, Amer. J. Psychiat., 133:3, pp. 326-328, 1976. 9. J. J. Strain and S . Grossman, Psychological Care of the Medically Ill: A Primer in Liaison Psychiatty, Appleton-Century-Crofts, New York, 1975. 10. C. P. Kimball, The Challenge of Liaison Medicine: Conceptual Approach of Liaison Medicine, Consultation-Liaison Psychiatry, R. 0 . Pasnau, (ed.), Grune t Stratton, New York, pp. 269-275, 1975. 11. J. S. Eaton, et al., The Educational Challenge of Consultation-Liaison Psychiatry, Amer. J. Psychiat., 134, (supplement), pp. 20-23, 1977. 12. T. B. Karasu, et al., What Do Physicians Want From a Psychiatric Consultation Service?, Comprehens. Psychiat., 18:1, pp. 73-81, 1977. 13. R. Moses and S. Barzilay, The Influence of Psychiatric Consultation on the Course of Illness of the General Hospital Patient, Comprehens. Psychiat., 8: 1, pp. 16-26, 1967. 14. M. L. Hale and H. S. Abram, Patients Attitudes Toward Psychiatric Consultations in the General Hospital, Virginia Med. Monthly, 94, pp. 342347,1967. 15. D. Denney, et al., Psychiatric Patients on Medical Wards, Arch. Gen. Psychiat.. 14, pp. 530-535, 1966. 16. T. B. Karasu, et al., Patterns of Psychiatric Consultation in a General Hospital, Hosp. Commun. Psychiat., 28.4, pp. 291-294, 1977. 17. S. A. Shevitz, et al., Psychiatric Consultation in a General Hospital: A Report on 1000 Referrals, Dis. Nerv. Sys., 37:5, pp. 295-300, May 1976. 18. J. J. Schwab, et al., Medical Inpatients’ Reactions to Psychiatric Consultations, J. Nerv. Ment. Dis., 142:3, pp. 215-222, 1966. 19. B. Wughson and R. Lyons, Patient Response to Psychiatric Consultation in a General Hospital, Australian and New Zealand J. Psychiat., 7, pp. 279-282, 1973.
134 / M. SASSER AND J. D. KlNZlE
20. J. L. Houpt, et al., The Application of Competency-Based Education to Consultation-Liaison Psychiatry: I. Data Gathering and Case Formulation, 11. Intervention Knowledge and Skills, 111. Implications, Int. J. Psychiat. in Med., 7:4, pp. 295-328, 1976-77.
Direct reprint requests to: Michael Sasser, M.D. Staff Psychiatrist Jackson County Mental Health Services Medford, OR 97501
