International Journal of Psychiatry in Clinical Practice
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Physical examination performed by psychiatrists Richard Hodgson & Olubukola Adeyemo To cite this article: Richard Hodgson & Olubukola Adeyemo (2004) Physical examination performed by psychiatrists, International Journal of Psychiatry in Clinical Practice, 8:1, 57-60 To link to this article: http://dx.doi.org/10.1080/13651500310004830
Published online: 13 Sep 2010.
Submit your article to this journal
Article views: 13
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Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [University of Birmingham]
Date: 05 November 2015, At: 13:04
# 2004 Taylor & Francis
International Journal of Psychiatry in Clinical Practice 2004
Volume 8
Pages 57 /60
57
Physical examination performed by psychiatrists RICHARD HODGSON1 AND OLUBUKOLA ADEYEMO2
Too little, too late? Physical examinations performed by trainee psychiatrists on newly admitted psychiatric patients.
1
To assess the comprehensiveness of the physical examination carried out by psychiatric trainees on acute in-patient units. To quantify delays in undertaking physical examination on psychiatric inpatients.
Academic Department of Psychiatry, Lyme Brook MHC (Bradwell Hospital Site), Stoke on Trent, UK and 2Department of Psychiatry, Harplands Hospital, Stoke on Trent, UK
OBJECTIVES:
A prospective case note study of 60 consecutive admissions to acute psychiatric wards in North Staffordshire. Information regarding demography, details of physical examination and routine blood investigations was collected.
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
METHOD:
Correspondence Address Richard Hodgson, Academic Department of Psychiatry, Lyme Brook MHC (Bradwell Hospital Site), Talke Road, Stoke on Trent, Staffordshire ST5 7TL , UK Tel: /(44) 1782 425350 Fax: /(44) 1782 425355 E-mail [email protected]
The case notes of 60 inpatients were studied. Mean age was 38.7 years and the sex ratio equal. A delay in performing a physical occurred in 17 (28.8%) patients. No explanation for a delay was given in six (10.0%) cases. The mean time to physical examination from admission was 61.8 h (range 0 612 h). The standard of physical examination was variable. The central nervous system (CNS) was reported as ‘grossly intact’ in six (10.2%) cases with only 34 (57.6%) of patients having a comprehensive CNS examination.
RESULTS:
/
CONCLUSIONS: Psychiatric patients are not receiving a comprehensive physical examination. Whilst the patient’s ability to co-operate may account for a delay in the examination, it is unlikely to be the reason for the CNS being examined in just half the patients. Opportunities to reduce the physical morbidity associated with mental illness may be being lost. (Int J Psych Clin Pract 2004; 8: 57 60) /
Received 21 March 2003; accepted for publication 13 November 2003
Keywords physical examination hospital patient medical audit
INTRODUCTION
T
here is a clear association between mental illness and poor physical health1. Standardized mortality ratios show an increased risk of death for many psychiatric illnesses including schizophrenia, substance misuse, unipolar depression and bipolar affective disorder.2 Physical illness may cause or exacerbate psychiatric symptoms.3,4 Psychotropic medication may cause iatrogenic disease such as diabetes, cardiac arrythmias, galactorrhoea and tardive dyskinesia.5 Marshall6 reported that 44% of psychiatric inpatients at St George’s Hospital, London had physical comorbidity that required intervention. Hall et al7 studied 100 consecutive admissions to a research ward that were screened for physical illness. Eighty percent of these patients had physical illness
mental patient psychiatrist
requiring treatment and 4% had precancerous conditions or lesions. The authors suggested a routine physical screen for all inpatients including an ECG and urinalysis. Rigby and Oswald8 investigated the physical examination carried out by junior psychiatrists and found it to be ‘‘uniformly poor’’. Fifty of the patients were re-examined by one the authors within 48 h of admission. Significant unrecorded positive findings noted, especially in the locomotor and neurological systems. Poor routine physical examinations may not be confined to psychiatrists.9 The National Service Framework for mental health recommends that the physical health of patients who suffer from mental illness needs to be addressed.1 Some of the symptoms of mental illness may pose difficulty in access to care. When patients do present for medical care, stigma and DOI: 10.1080/13651500310004830
58
R Hodgson and O Adeyemo
lack of social skills make it less likely for any physical illness present to be detected.1 It is therefore important that prompt assessment of physical health be carried out in this population. An inpatient stay presents an opportunity for physical health to be reviewed.
METHODS
Table 1 Primary diagnosis (n /60) Diagnosis
N
%
Schizophrenia and allied states Mood disorder Personality disorder Adjustment disorder Alcohol/substance misuse
24 22 9 3 2
40.0 36.7 15.0 5.0 3.3
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
STUDY SETTING North Staffordshire has a population of 460 000 served by one secondary mental health provider, North Staffordshire Combined Healthcare NHS Trust (NSCHT). There are 60 acute beds available on one hospital site. Forty-eight community beds supplement these beds.10 Junior staff are responsible for admitting inpatients and out of hours cover is provided by one doctor. NSCHT operates a hybrid partial shift for out of hours cover with junior doctors having the day off after a night on-call. The on-call doctor covers any colleagues who are on leave (prospective cover).
POLICY NSCHT policy indicates a physical examination should be carried out within one hour of admission. Doctors are provided with a handbook at induction that gives detailed guidance on the expected standard of physical examination. Also, all inpatients should have a full blood count and biochemical profile. Junior doctors do not carry out phlebotomy routinely but are expected to initiate the process by completing the appropriate forms. Other tests are done at the discretion of the patient’s medical team. This study was carried out to see if these standards are met and to investigate the comprehensiveness of the physical examination for acute psychiatric inpatients.
METHOD Sixty consecutive case notes of newly admitted inpatients were reviewed between January and February 2001. Only patients admitted to the three general adult psychiatric wards were included. Patients assessed on the wards but not admitted were excluded. Basic demographic data was collected as well as information relating to the physical examination. Dr Adeyemo reviewed the admitting doctor’s clerking to ascertain whether a physical examination was indicated from the history. The results were analysed using SPSS version. 10.1.
Fifteen doctors admitted patients in the study period. Male doctors performed 80% of the physical examinations. There was no association between the sexes of the admitting doctor and that of the patient with respect to delays in the physical examination. Senior House Officers carried out 91.7% of the physical examination, Specialist Registrars 1.7%, Staff Grade doctors 5.0% and Consultants 1.7%. The one physical examination performed by a Consultant was excluded from further analysis. The range for the years of experience in psychiatry was between 0.16 and 4.0 years. (Mean 1.51, SD 1.46). There was no difference between locum doctors and substantive doctors relating to delays physical examination. All patients did have a physical examination during their inpatient stay. A delay in performing a physical occurred in 17 (28.8%) cases. No explanation for the delay was given in six (10.2%) of cases. Reasons for not carrying out a physical examination at admission were stated in 13 (22.0) cases. In two (3.4%) of the delayed cases the admitting doctor did record a brief physical examination. Table 2 gives the relationship between delay in the physical examination and patient agitation. This was statistically significant (x2 /12.8, d.f. /2, P /0.002). The mean time to physical examination from admission was 61.8 h (range 0 /612). The detail of physical examination was variable. A comprehensive examination of the cardiovascular system and respiratory systems occurred in 48 (81.4%) and 49 (83.1%) of patients, respectively. The patient’s abdomen was examined in 45 (76.3%) cases. The central nervous system (CNS) was reported as ‘‘grossly intact’’ in six (10.2%) cases with only 34 (57.6%) of patients having a detailed CNS examination. On review of the case notes, it is the opinion of the authors that a physical examination was indicated from the history in 51 (86.4%) of patients. The most common indications were to exclude physical illness suggested by Table 2 Level of agitation and delay in physical examination
RESULTS
N /59
Delay (%)
The case notes of 60 inpatients were studied. The mean age was 38.7 years and the sex ratio equal. Diagnostic categories are shown in Table 1.
Agitated Not agitated Total
13 (22.0) 4 (6.7) 17
No delay (%) 14 (23.7) 29 (47.5) 42
Physical examination performed by psychiatrists
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
Table 3 Routine blood investigations (n /59) Time to investigation (days)
N
%
1 /2 3 /4 5 /6 /7 Not done
19 7 3 9 21
32.2 11.9 5.1 15.3 35.6
the history or differential diagnosis (42 (71.2%) cases) and possible sequalae of self-harm in eight (13.6%) cases. Table 3 shows delays in performing blood investigations. The mean delay in ordering investigations was 3.1 days (SD 1.7) Blood investigations were not carried out during inpatient stay for 35.6% of the patients. There was no statistically significant relationship between the patient being agitated and a delay in performing routine investigations (x2 /9.14, d.f. /8, P /0.331).
DISCUSSION The results from our study indicate that there are delays in undertaking physical examinations of inpatients. Whilst some of the delays are explained by the patient’s mental state in 10% of cases, there was no apparent reason for a delay. When a physical examination is performed it is rarely comprehensive with the central nervous system receiving the least attention. This omission is worrying as neurological conditions are prominent in the differential diagnosis of mental illnesses. In addition when findings from physical examination are recorded as grossly intact, it is difficult to tell if the examination was carried out with potential medicolegal consequences.11 Although a physical examination was carried out on all psychiatric inpatients in this study, the accuracy of the examination was not tested. The average age of the psychiatrists in the study was relatively young and their length of training in psychiatry brief, so it may be anticipated that their physical examination skills were relatively fresh. However, as trainees progress through their training they may become deskilled in physical examination skills due to lack of practice when compared to trainees in other medical specialities and, as a result, may become more reluctant to carry out physical examinations.12 There was insufficient variation in length of psychiatry experience and age to explore this within our study. Psychoanalytic reasoning and
59
boundary issues which dictate that the therapist focus on psychotherapeutic issues, as physical examination may cause transference issues, may account for some of the reluctance to carry out physical examinations. Therefore, together with the deskilling issue, there may be an argument that trainees may not be the best option for carrying out physical examination. However, psychiatry is a medical specialty and to abrogate responsibility for physical evaluation has implications for the profession as a whole.7 In the UK, The Royal College of Psychiatrists requirement that candidates perform a physical examination in the both parts of the Membership Examination demonstrates the importance the College place on physical evaluation. When the patient’s mental state on admission precludes physical examination, there is a danger that the patient may not be examined during their inpatient stay. In the review of the case notes it was evident that not all such patients were routinely revisited to ensure a physical examination is performed. In some cases it was only after a ward round that a training grade psychiatrist was asked to perform a physical examination. The use of prospective cover and the hybrid partial shift system compound the problem, as the junior doctor may only be present on the ward for half the working week. Undoubtedly these problems, along with unfilled posts, are not unique to North Staffordshire. Similar considerations also apply to delays in obtaining routine blood investigations. Possible ways by which the process of physical examination can be improved include the use of algorithms13 that can double detection rates. Emphasis should not be placed solely on the physical examination itself but also a systematic physical symptom enquiry. Finally, one novel solution under consideration in North Staffordshire is to use the ‘modern matron’ role to enhance the physical care of psychiatric patients by co-ordinating nursing and medical contributions to the physical health needs of this patient group.
KEY POINTS . Physical comorbidity is common in psychiatric inpatients . Delays occur in examining newly admitted patients . These delays are, in part, related to the patient’s mental state . The central nervous system is poorly examined in many psychiatric inpatients
REFERENCES 1.
Phelan M, Stradins L, Morrison S (2001) Physical health of people with severe mental illness. Br Med J 322: 443 /4.
2.
Harris E, Barraclough B (1998) Excess mortality of mental disorder. Br J Psychiatry 173: 11 /53.
60
3.
4. 5. 6. 7.
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
8.
R Hodgson and O Adeyemo
Murray D, Hodgson RE (1991) Polycythaemia rubra vera, cerebral ischaemia and depression. Br J Psychiatry 158: 842 /4. Hodgson RE, Murray D, Woods MR (1992) Othello’s syndrome and hyperthyroidism. J Nerv Ment Dis 180: 663 /4. Jeste DV, Gladsjo JA, Lindamar LA et al (1996) Medical comorbidity in schizophrenia. Schizophr Bull 22: 413 /30. Marshall HES (1949) Incidence of physical disorders among psychiatric inpatients. Br Med J 2: 468 /70. Hall R, Gardner ER, Popkin MK et al (1981) Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry 138: 629 /35. Rigby JC, Oswald AG (1987) An evaluation of the performing and recording of physical examinations by psychiatric trainees. Br J Psychiatry 150: 533 /5.
9. 10.
11.
12.
13.
Doherty M, Abawi J, Pattrick M (1990) audit of medical inpatient examination: a cry from the joint. J R Coll Phys London 24: 115 /8. Boardman AP, Hodgson RE, Lewis M et al (1999) The North Staffordshire Community Beds Study. Longitudinal evaluation of beds attached to community mental health centres. I. Methods, outcome and patient satisfaction. Br J Psychiatry 175: 70 /8. Medical Defence Union (2002) Medical Records and reports. http://www.the-mdu.com/gp/advice/ medical_records_and_reports/index.asp Kick SD, Morrison M, Kathol RG (1997) Medical training in psychiatry residence. A proposed curriculum. Gen Hosp Psychiatry 19: 259 /66. Sox HC Jr, Koran L, Sox CH et al (1989) A medical algorithm for detecting physical disease in psychiatric patients. Hosp Community Psychiatry 12: 1270 /6.
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Physical examination performed by psychiatrists Richard Hodgson & Olubukola Adeyemo To cite this article: Richard Hodgson & Olubukola Adeyemo (2004) Physical examination performed by psychiatrists, International Journal of Psychiatry in Clinical Practice, 8:1, 57-60 To link to this article: http://dx.doi.org/10.1080/13651500310004830
Published online: 13 Sep 2010.
Submit your article to this journal
Article views: 13
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [University of Birmingham]
Date: 05 November 2015, At: 13:04
# 2004 Taylor & Francis
International Journal of Psychiatry in Clinical Practice 2004
Volume 8
Pages 57 /60
57
Physical examination performed by psychiatrists RICHARD HODGSON1 AND OLUBUKOLA ADEYEMO2
Too little, too late? Physical examinations performed by trainee psychiatrists on newly admitted psychiatric patients.
1
To assess the comprehensiveness of the physical examination carried out by psychiatric trainees on acute in-patient units. To quantify delays in undertaking physical examination on psychiatric inpatients.
Academic Department of Psychiatry, Lyme Brook MHC (Bradwell Hospital Site), Stoke on Trent, UK and 2Department of Psychiatry, Harplands Hospital, Stoke on Trent, UK
OBJECTIVES:
A prospective case note study of 60 consecutive admissions to acute psychiatric wards in North Staffordshire. Information regarding demography, details of physical examination and routine blood investigations was collected.
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
METHOD:
Correspondence Address Richard Hodgson, Academic Department of Psychiatry, Lyme Brook MHC (Bradwell Hospital Site), Talke Road, Stoke on Trent, Staffordshire ST5 7TL , UK Tel: /(44) 1782 425350 Fax: /(44) 1782 425355 E-mail [email protected]
The case notes of 60 inpatients were studied. Mean age was 38.7 years and the sex ratio equal. A delay in performing a physical occurred in 17 (28.8%) patients. No explanation for a delay was given in six (10.0%) cases. The mean time to physical examination from admission was 61.8 h (range 0 612 h). The standard of physical examination was variable. The central nervous system (CNS) was reported as ‘grossly intact’ in six (10.2%) cases with only 34 (57.6%) of patients having a comprehensive CNS examination.
RESULTS:
/
CONCLUSIONS: Psychiatric patients are not receiving a comprehensive physical examination. Whilst the patient’s ability to co-operate may account for a delay in the examination, it is unlikely to be the reason for the CNS being examined in just half the patients. Opportunities to reduce the physical morbidity associated with mental illness may be being lost. (Int J Psych Clin Pract 2004; 8: 57 60) /
Received 21 March 2003; accepted for publication 13 November 2003
Keywords physical examination hospital patient medical audit
INTRODUCTION
T
here is a clear association between mental illness and poor physical health1. Standardized mortality ratios show an increased risk of death for many psychiatric illnesses including schizophrenia, substance misuse, unipolar depression and bipolar affective disorder.2 Physical illness may cause or exacerbate psychiatric symptoms.3,4 Psychotropic medication may cause iatrogenic disease such as diabetes, cardiac arrythmias, galactorrhoea and tardive dyskinesia.5 Marshall6 reported that 44% of psychiatric inpatients at St George’s Hospital, London had physical comorbidity that required intervention. Hall et al7 studied 100 consecutive admissions to a research ward that were screened for physical illness. Eighty percent of these patients had physical illness
mental patient psychiatrist
requiring treatment and 4% had precancerous conditions or lesions. The authors suggested a routine physical screen for all inpatients including an ECG and urinalysis. Rigby and Oswald8 investigated the physical examination carried out by junior psychiatrists and found it to be ‘‘uniformly poor’’. Fifty of the patients were re-examined by one the authors within 48 h of admission. Significant unrecorded positive findings noted, especially in the locomotor and neurological systems. Poor routine physical examinations may not be confined to psychiatrists.9 The National Service Framework for mental health recommends that the physical health of patients who suffer from mental illness needs to be addressed.1 Some of the symptoms of mental illness may pose difficulty in access to care. When patients do present for medical care, stigma and DOI: 10.1080/13651500310004830
58
R Hodgson and O Adeyemo
lack of social skills make it less likely for any physical illness present to be detected.1 It is therefore important that prompt assessment of physical health be carried out in this population. An inpatient stay presents an opportunity for physical health to be reviewed.
METHODS
Table 1 Primary diagnosis (n /60) Diagnosis
N
%
Schizophrenia and allied states Mood disorder Personality disorder Adjustment disorder Alcohol/substance misuse
24 22 9 3 2
40.0 36.7 15.0 5.0 3.3
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
STUDY SETTING North Staffordshire has a population of 460 000 served by one secondary mental health provider, North Staffordshire Combined Healthcare NHS Trust (NSCHT). There are 60 acute beds available on one hospital site. Forty-eight community beds supplement these beds.10 Junior staff are responsible for admitting inpatients and out of hours cover is provided by one doctor. NSCHT operates a hybrid partial shift for out of hours cover with junior doctors having the day off after a night on-call. The on-call doctor covers any colleagues who are on leave (prospective cover).
POLICY NSCHT policy indicates a physical examination should be carried out within one hour of admission. Doctors are provided with a handbook at induction that gives detailed guidance on the expected standard of physical examination. Also, all inpatients should have a full blood count and biochemical profile. Junior doctors do not carry out phlebotomy routinely but are expected to initiate the process by completing the appropriate forms. Other tests are done at the discretion of the patient’s medical team. This study was carried out to see if these standards are met and to investigate the comprehensiveness of the physical examination for acute psychiatric inpatients.
METHOD Sixty consecutive case notes of newly admitted inpatients were reviewed between January and February 2001. Only patients admitted to the three general adult psychiatric wards were included. Patients assessed on the wards but not admitted were excluded. Basic demographic data was collected as well as information relating to the physical examination. Dr Adeyemo reviewed the admitting doctor’s clerking to ascertain whether a physical examination was indicated from the history. The results were analysed using SPSS version. 10.1.
Fifteen doctors admitted patients in the study period. Male doctors performed 80% of the physical examinations. There was no association between the sexes of the admitting doctor and that of the patient with respect to delays in the physical examination. Senior House Officers carried out 91.7% of the physical examination, Specialist Registrars 1.7%, Staff Grade doctors 5.0% and Consultants 1.7%. The one physical examination performed by a Consultant was excluded from further analysis. The range for the years of experience in psychiatry was between 0.16 and 4.0 years. (Mean 1.51, SD 1.46). There was no difference between locum doctors and substantive doctors relating to delays physical examination. All patients did have a physical examination during their inpatient stay. A delay in performing a physical occurred in 17 (28.8%) cases. No explanation for the delay was given in six (10.2%) of cases. Reasons for not carrying out a physical examination at admission were stated in 13 (22.0) cases. In two (3.4%) of the delayed cases the admitting doctor did record a brief physical examination. Table 2 gives the relationship between delay in the physical examination and patient agitation. This was statistically significant (x2 /12.8, d.f. /2, P /0.002). The mean time to physical examination from admission was 61.8 h (range 0 /612). The detail of physical examination was variable. A comprehensive examination of the cardiovascular system and respiratory systems occurred in 48 (81.4%) and 49 (83.1%) of patients, respectively. The patient’s abdomen was examined in 45 (76.3%) cases. The central nervous system (CNS) was reported as ‘‘grossly intact’’ in six (10.2%) cases with only 34 (57.6%) of patients having a detailed CNS examination. On review of the case notes, it is the opinion of the authors that a physical examination was indicated from the history in 51 (86.4%) of patients. The most common indications were to exclude physical illness suggested by Table 2 Level of agitation and delay in physical examination
RESULTS
N /59
Delay (%)
The case notes of 60 inpatients were studied. The mean age was 38.7 years and the sex ratio equal. Diagnostic categories are shown in Table 1.
Agitated Not agitated Total
13 (22.0) 4 (6.7) 17
No delay (%) 14 (23.7) 29 (47.5) 42
Physical examination performed by psychiatrists
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
Table 3 Routine blood investigations (n /59) Time to investigation (days)
N
%
1 /2 3 /4 5 /6 /7 Not done
19 7 3 9 21
32.2 11.9 5.1 15.3 35.6
the history or differential diagnosis (42 (71.2%) cases) and possible sequalae of self-harm in eight (13.6%) cases. Table 3 shows delays in performing blood investigations. The mean delay in ordering investigations was 3.1 days (SD 1.7) Blood investigations were not carried out during inpatient stay for 35.6% of the patients. There was no statistically significant relationship between the patient being agitated and a delay in performing routine investigations (x2 /9.14, d.f. /8, P /0.331).
DISCUSSION The results from our study indicate that there are delays in undertaking physical examinations of inpatients. Whilst some of the delays are explained by the patient’s mental state in 10% of cases, there was no apparent reason for a delay. When a physical examination is performed it is rarely comprehensive with the central nervous system receiving the least attention. This omission is worrying as neurological conditions are prominent in the differential diagnosis of mental illnesses. In addition when findings from physical examination are recorded as grossly intact, it is difficult to tell if the examination was carried out with potential medicolegal consequences.11 Although a physical examination was carried out on all psychiatric inpatients in this study, the accuracy of the examination was not tested. The average age of the psychiatrists in the study was relatively young and their length of training in psychiatry brief, so it may be anticipated that their physical examination skills were relatively fresh. However, as trainees progress through their training they may become deskilled in physical examination skills due to lack of practice when compared to trainees in other medical specialities and, as a result, may become more reluctant to carry out physical examinations.12 There was insufficient variation in length of psychiatry experience and age to explore this within our study. Psychoanalytic reasoning and
59
boundary issues which dictate that the therapist focus on psychotherapeutic issues, as physical examination may cause transference issues, may account for some of the reluctance to carry out physical examinations. Therefore, together with the deskilling issue, there may be an argument that trainees may not be the best option for carrying out physical examination. However, psychiatry is a medical specialty and to abrogate responsibility for physical evaluation has implications for the profession as a whole.7 In the UK, The Royal College of Psychiatrists requirement that candidates perform a physical examination in the both parts of the Membership Examination demonstrates the importance the College place on physical evaluation. When the patient’s mental state on admission precludes physical examination, there is a danger that the patient may not be examined during their inpatient stay. In the review of the case notes it was evident that not all such patients were routinely revisited to ensure a physical examination is performed. In some cases it was only after a ward round that a training grade psychiatrist was asked to perform a physical examination. The use of prospective cover and the hybrid partial shift system compound the problem, as the junior doctor may only be present on the ward for half the working week. Undoubtedly these problems, along with unfilled posts, are not unique to North Staffordshire. Similar considerations also apply to delays in obtaining routine blood investigations. Possible ways by which the process of physical examination can be improved include the use of algorithms13 that can double detection rates. Emphasis should not be placed solely on the physical examination itself but also a systematic physical symptom enquiry. Finally, one novel solution under consideration in North Staffordshire is to use the ‘modern matron’ role to enhance the physical care of psychiatric patients by co-ordinating nursing and medical contributions to the physical health needs of this patient group.
KEY POINTS . Physical comorbidity is common in psychiatric inpatients . Delays occur in examining newly admitted patients . These delays are, in part, related to the patient’s mental state . The central nervous system is poorly examined in many psychiatric inpatients
REFERENCES 1.
Phelan M, Stradins L, Morrison S (2001) Physical health of people with severe mental illness. Br Med J 322: 443 /4.
2.
Harris E, Barraclough B (1998) Excess mortality of mental disorder. Br J Psychiatry 173: 11 /53.
60
3.
4. 5. 6. 7.
Downloaded By: [informa internal users] At: 15:13 7 September 2010 Downloaded by [University of Birmingham] at 13:04 05 November 2015
8.
R Hodgson and O Adeyemo
Murray D, Hodgson RE (1991) Polycythaemia rubra vera, cerebral ischaemia and depression. Br J Psychiatry 158: 842 /4. Hodgson RE, Murray D, Woods MR (1992) Othello’s syndrome and hyperthyroidism. J Nerv Ment Dis 180: 663 /4. Jeste DV, Gladsjo JA, Lindamar LA et al (1996) Medical comorbidity in schizophrenia. Schizophr Bull 22: 413 /30. Marshall HES (1949) Incidence of physical disorders among psychiatric inpatients. Br Med J 2: 468 /70. Hall R, Gardner ER, Popkin MK et al (1981) Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry 138: 629 /35. Rigby JC, Oswald AG (1987) An evaluation of the performing and recording of physical examinations by psychiatric trainees. Br J Psychiatry 150: 533 /5.
9. 10.
11.
12.
13.
Doherty M, Abawi J, Pattrick M (1990) audit of medical inpatient examination: a cry from the joint. J R Coll Phys London 24: 115 /8. Boardman AP, Hodgson RE, Lewis M et al (1999) The North Staffordshire Community Beds Study. Longitudinal evaluation of beds attached to community mental health centres. I. Methods, outcome and patient satisfaction. Br J Psychiatry 175: 70 /8. Medical Defence Union (2002) Medical Records and reports. http://www.the-mdu.com/gp/advice/ medical_records_and_reports/index.asp Kick SD, Morrison M, Kathol RG (1997) Medical training in psychiatry residence. A proposed curriculum. Gen Hosp Psychiatry 19: 259 /66. Sox HC Jr, Koran L, Sox CH et al (1989) A medical algorithm for detecting physical disease in psychiatric patients. Hosp Community Psychiatry 12: 1270 /6.
