CONCEPTS, COMPONENTS, AND CONFIGURATIONS
Psychiatric Training for Emergency Medicine Residents On a Multidisciplinary Team Louis Spitz, MD* H. Thomas Blum, M D t Melvin S. Gale, MD* Steven Beck, M S , Cincinnati, Ohio
The C i n c i n n a t i G e n e r a l H o s p i t a l E m e r g e n c y D e p a r t m e n t has a training p r o g r a m for e m e r g e n c y m e d i c i n e r e s i d e n t s on a m u l t i d i s c i p l i n a r y e m e r g e n c y p s y c h i a t r y t e a m . This e s s e n t i a l t r a i n i n g s h o u l d o c c u r in the e m e r g e n c y d e p a r t m e n t s e t t i n g rather t h a n in p s y c h i a t r i c i n p a t i e n t units of state h o s p i t a l settings. T h e r e are a d v a n t a g e s and d i s a d v a n t a g e s to this a r r a n g e m e n t . N o n m e d i c a l m e m b e r s of the e m e r g e n c y p s y c h i a t r y t e a m train a n d s u p p o r t e m e r g e n c y m e d i c i n e r e s i d e n t s in a multidisc i p l i n a r y a p p r o a c h to t r e a t m e n t . S o m e o b s e r v a t i o n s are m a d e a b o u t h o w the e m e r g e n c y m e d i c i n e r e s i d e n t s deal w i t h e m o t i o n a l l y d i s t u r b e d patients. Finally, 80% of e m e r g e n c y m e d i c i n e r e s i d e n t s r e s p o n d e d to a q u e s t i o n n a i r e o n t h e i r r e a c t i o n s to the m u l t i d i s c i p l i n a r y e m e r g e n c y psychiatry team.
Spitz L, Blum HT, Gale MS, Beck S: Psychiatric training for emergency medicine residents on a multidisciplinary team. JACEP 5:694-697, September 1976. emergency medicine residents, training; training, psychiatric. INTRODUCTION In the Medical hospital, tal, t h e r e
U n i v e r s i t y of C i n c i n n a t i Center's major teaching C i n c i n n a t i G e n e r a l Hospiwere a p p r o x i m a t e l y 135,000
From the Psychiatric Emergency Service,*$ and Emergency Department,t Cincinnati General Hospital; Department of Psychiatry,* and Division of Emergency Medicine;t University of Cincinnati College of Medicine. Address for reprints: H. Thomas Blum, MD, Director, Emergency Department, Cincinnati General Hospital, 231 Bethesda Avenue, Cincinnati, Ohio 45229.
Page 694 VoLume 5 Number 9
e m e r g e n c y d e p a r t m e n t p a t i e n t visits in 1975, i n c l u d i n g 40,000 p e d i a t r i c visits, 30,000 m i n o r m e d i c a l visits, and 5,550 p s y c h i a t r i c visits. The e m e r g e n c y d e p a r t m e n t is divided into t h r e e p a t i e n t care areas: the A c u t e C a r e Section (ACS), the P r i m a r y C a r e Section (PCS), and the P e d i a t r i c Section. The medical staff c o n s i s t s of m e d i c a l a n d s u r g i c a l teams staffed by residents and n u r s e s . S u p p l e m e n t a r y t e a m s include the e m e r g e n c y p s y c h i a t r y t e a m and the social services team. Laborat o r y and r a d i o l o g y t e c h n i c i a n s and c h a p l a i n s a r e also in the d e p a r t m e n t . F a c u l t y p h y s i c i a n s are p r e s e n t dur-
ing most hours for supervision and teaching. The ACS physical p l a n t is not spacious for t h e n u m b e r s and k i n d s of p a t i e n t s seen - - 60,000 p a t i e n t visits per y e a r in 9,200 s q u a r e feet. For a n u m b e r of reasons, overall '~in-out" t i m e s in t h e ACS t e n d to be long, ave r a g i n g 220 minutes. The n u m b e r of support personne ! is i n a d e q u a t e and the house staff g e n e r a l l y lacks the experience n e c e s s a r y to m a k e rapid p a t i e n t dispositions. A h i g h percentage of p a t i e n t s have chronic multisystem diseases, and m a n y h a v e alcohol and/or drug overdose problems r e q u i r i n g l e n g t h y stays in the emergency d e p a r t m e n t prior to discharge. These factors c o n t r i b u t e to a n intense, highly charged atmosphere t h a t o c c a s i o n a l l y r e s u l t s in house staff, a n d p a t i e n t , f r u s t r a t i o n with the p o t e n t i a l of overflowing in staffp a t i e n t a n d staff-staff discord.
THE EMERGENCY MEDICINE RESIDENCY P o s t g r a d u a t e e m e r g e n c y medicine t r a i n i n g c a m e of age w h e n the first r e s i d e n t p h y s i c i a n b e g a n a two-year p r o g r a m on J u l y 1, 1970 at the Univ e r s i t y of C i n c i n n a t i Medical Center. D u r i n g the e n s u i n g five years, more t h a n 35 residency p r o g r a m s have de-
September 1976 J ~ P
veloped in the United States. In a d d i t i o n , a s u b s t a n t i a l n u m b e r of residency p r o g r a m s a p p e a r to be in the p l a n n i n g stage. W h a t is this new breed of physician like? A n e m e r g e n c y p h y s i c i a n can be called a R e n a i s s a n c e person because of the b r e a d t h of knowledge r e q u i r e d to effectively m a n a g e pat i e n t s w i t h the s p e c t r u m of illnesses e n c o u n t e r e d in e m e r g e n c y d e p a r t ments. E m e r g e n c y p h y s i c i a n s m u s t h a v e k n o w l e d g e c o m m o n to a l l p h y s i c i a n s r e n d e r i n g p r i m a r y care. However, t h e i r technical skills m u s t be more s h a r p l y developed and maint a i n e d since t h e i r e n v i r o n m e n t affords t h e o p p o r t u n i t y for r e p e a t e d use of t h e s e skills. This new actionoriented p h y s i c i a n provides episodic and i n i t i a l care. The e m e r g e n c y medicine residency was e s t a b l i s h e d w i t h the following goals in mind: 1) To come broad lems gency
t r a i n t h e p h y s i c i a n to bee x p e r t in m a n a g i n g t h e s p e c t r u m of m e d i c a l probe n c o u n t e r e d in t h e e m e r department,
2) To develop a d m i n i s t r a t i v e and o r g a n i z a t i o n a l s k i l l s n e c e s s a r y to provide l e a d e r s h i p in this field. 3) To stress the physician's role as a t e a c h e r in all aspects of emergency medical care. 4) To e n c o u r a g e h e a l t h s e r v i c e s r e s e a r c h a s s e s s i n g the efficacy of e m e r g e n c y medical care, Six f i r s t - y e a r and six second-year r e s i d e n t s are t r a i n e d for 24 months b e y o n d i n t e r n s h i p , in c o n j u n c t i o n w i t h s p e c i a l t y d e p a r t m e n t s , in t h e management of e m e r g e n c y a n d episodic p r i m a r y care problems. T h e r e s i d e n t s a r e e x p o s e d to a broad r a n g e of psychiatric problems in the C i n c i n n a t i G e n e r a l H o s p i t a l Emergency Department when they r o t a t e for one m o n t h with the multidisciplinary emergency psychiatry team.
Profile of Emergency Medicine Resident These r e s i d e n t s are h a r d working, ambitious, conscientious physicians. They expect a lot of t h e m s e l v e s and hope to h a v e an i m p a c t upon t h e i r patients, their emergency department, and their community. They
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September 1976
anticipate a one-time relationship w i t h a p a t i e n t d u r i n g which t h e y do all t h e y can for him. They see themselves as k n o w l e d g e a b l e and potent and expect the p a t i e n t - t o respond to their intervention_ The residents have a "take charge" attitude and feel t h e y should be a b l e to h a n d l e w h a t e v e r p r o b l e m arises. Most are comfortable in the role of physician, h a v i n g h a d experience either in the m i l i t a r y , f u l l - t i m e practice, i n t e r n ship, or d u r i n g one or more y e a r s of other s p e c i a l t y t r a i n i n g . Most residents have attained an organizational maturity that helps them function effectively on a multidiscip l i n a r y team_ Some have h a d prior experience in d e l e g a t i n g responsibility to m i l i t a r y medics and o t h e r support personnel.
The Emergency Psychiatry Team The e m e r g e n c y p s y c h i a t r y t e a m is a s e p a r a t e divimon of the U n i v e r s i t y of C i n c i n n a t i College Of M e d i c i n e , D e p a r t m e n t of P s y c h i a t r y . The t e a m consists of a director, a d m i n i s t r a t i v e support personnel, mental health professionals (psychiatrists, psychologists, social workers, psychiatric nurses) and v a r i o u s r o t a t i n g t r a i n ees, eg, p s y c h i a t r i c a n d e m e r g e n c y medicine residents, master level n u r s i n g a n d social work students. M a n y p s y c h i a t r i c e m e r g e n c y dep a r t m e n t s e r v i c e s h a v e b e e n described in the l i t e r a t u r e 1-~ r a n g i n g from those r u n by p s y c h i a t r i c residents to t h e h i g h l y complex "medical psychosocial teams" described by B a r t o l u c c i a n d D r a y e r . 4 On s o m e services, p e r m a n e n t m e n t a l h e a l t h professionals support psychiatric residents, w h i l e on others the distinction between the psychiatric residents a n d other personnel has blurred and all workers perform s i m i l a r tasks. This type is the model for our p s y c h i a t r i c team. W h e r e , in t h e p a s t , p s y c h i a t r i c emergency services provided only e v a l u a t i o n and disposition, new psychiatric e m e r g e n c y services h a v e developed a d d i t i o n a l flexibility by adding both brief treatment and brief hospitalization options. This new flexibility has e n h a n c e d p a t i e n t care. It has c h a n g e d conscious and unconscious a t t i t u d e s from, "Where can I send t h i s p a t i e n t ? " to "How c a n I help this patient?"
Psychiatric Training For Emergency Medicine Residents at the University of Cincinnati The residents' rotation with the e m e r g e n c y psychiatric t e a m is spent in t h e e m e r g e n c y d e p a r t m e n t except w h e n p a t i e n t s a r e a d m i t t e d briefly to t h e i n p a t i e n t psychiatric unit. The residents a r e f a m i l i a r with the needs of e m e r g e n c y p a t m n t s with intense, often severe, p s y c h i a t r i c disturbances. Prior to r o t a t i n g t h r o u g h p s y c h i a t r y , often they would quickly refer such p a t i e n t s to t h e psychiatric t e a m because t h e y were too busy or found the patients uninteresting. Less often, t h e r e f e r r a l h a d to do w i t h t h e i r own discomfort w i t h cert a i n patients, most often those who were hostile, bizarre, or disorganized. E m e r g e n c y physicians referred some p a t i e n t s because of conscious or unconscious n e g a t i v e a t t i t u d e s toward, for e x a m p l e , alcoholic, d r u g abuse, and d r u g overdose patients. One goal of t h e rotation is to m a k e the r e s i d e n t s more comfortable w i t h severely d i s t u r b e d patients. A n o t h e r is to begin to g e n t l y confront t h e m with their feelings and biases and t h e w a y s t h e y m a n i f e s t t h e s e attitudes. The e m e r g e n c y medicine residents, like p s y c h i a t r i c r e s i d e n t s and other m e n t a l h e a l t h professionals, a r e app r e h e n s i v e a b o u t d e a l i n g w i t h sev e r e l y disturbed, often psychotic, patients. In p a r t i c u l a r , agitated, defensive, o v e r t l y h o s t i l e p a t i e n t s who seem on t h e verge of losing control evoke considerable anxiety_ W o r k i n g with more experienced psychiatric team members helps the residents l e a r n how to deal with these p a t i e n t s more effectively. The focus is, in an e m p a t h i c way, on the residents' pers o n a l r e a c t i o n s to t h e s e p a t i e n t s . Learning that most interviewers r e a c t to such p a t i e n t s in a predictable w a y helps residents relax. They u n d e r s t a n d t h e i r own reactions better, are more t o l e r a n t of the patient, and find s u b s e q u e n t interviews more rewarding. In dealing with neurotic and character-disordered patients, the r e s i d e n t s feel t h e r e is little to learn. They often t h i n k simply t e l l i n g the p a t i e n t w h a t to do w i l l s o l v e h i s problem_ M o s t p s y c h i a t r i c p a t i e n t s do not w a n t this advice, which t h e y
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probably have already heard many times, y e t t h e y m a y provoke the resi d e n t to m a k e suggestions, only to respond w i t h why the suggestion will not work. The r e s i d e n t m a y b e g i n such interviews calm and confident b u t leave f r u s t r a t e d and weary. The f r u s t r a t i o n of not b e i n g able to s o l v e p a t i e n t s ' p r o b l e m s o f t e n m o u n t s to u n c o m f o r t a b l e l e v e l s . The r e s i d e n t f r e q u e n t l y experiences the "first-year psychiatric resident syndrome" of hopelessness, i n a d e q u a cy, a n d d e p r e s s i o n . 5 T h e r e s i d e n t has little expertise in h a n d l i n g psychiatric p a t i e n t s and it is difficult to simplify technique to a point where it is e a s i l y mastered. Some r e s i d e n t s h a n d l e t h e i r f r u s t r a t i o n by "distancing" t h e m s e l v e s from patients. They rely more on m e d i c a t i o n and less on their relationship with patients. Others r e a c t by s p e n d i n g excessive t i m e w i t h the p a t i e n t to t r y to provide what they think the patient needs. Occasionally, the outcome is the f e e l i n g t h a t t h e i r i n t e r v e n t i o n was useless. A n o t h e r major goal of e m e r g e n c y medicine residency is i m p r o v i n g the residents' psychiatric interview skills. T h e i r " t a k e - c h a r g e a t t i t u d e " i n t e r f e r e s w i t h t h e d e v e l o p m e n t of these skills. In p s y c h i a t r i c diagnostic interviews, the t h e r a p i s t m u s t listen in a n o n d i r e c t i v e m a n n e r . Controll i n g t h e i n t e r v i e w often r e s u l t s in m i s s i n g significant topics. Residents l e a r n to r e s t r a i n themselves. Observing interviews by more experienced psychiatric t e a m m e m b e r s is of g r e a t value. A n o t h e r helpful a p p r o a c h to l e a r n i n g interview techniques is role p l a y i n g u n d e r group and i n d i v i d u a l supervision. Prior to t h e i r rotation, some residents t h i n k p s y c h i a t r i s t s are permissive, allowing p a t i e n t s both to say or do w h a t they please. This misconception o c c a s i o n a l l y p r o m p t s r e s i d e n t s to allow p a t i e n t s g r e a t e r freedom to act on t h e i r impulses, sometimes to the p a t i e n t s ' and the e m e r g e n c y dep a r t m e n t ' s d e t r i m e n t . In t h e emergency e n v i r o n m e n t , limits set by the p s y c h i a t r i s t are v i t a l l y i m p o r t a n t for specific conditions_ P h y s i c i a n s ' p e r s o n a l responses to p a t i e n t s are significant b u t most of the residents are r e l u c t a n t to share t h e i r r e a c t i o n s • T h e d i s c u s s i o n of
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these reactions and perceptions among the emergency psychiatry t e a m m e m b e r h a s been a very valuable e x p e r i e n c e for the e m e r g e n c y medicine residents.
Structure of the Teaching The r e s i d e n t s are t a u g h t by several methods while on the rotation. They f r e q u e n t l y have informal consultations with other psychiatric t e a m members. They are exposed to different i n t e r v i e w i n g techniques by o b s e r v i n g o t h e r t e a m m e m b e r s in order to promote s h a r i n g of diagnostic and t h e r a p e u t i c t h i n k i n g . There are four t e a m m e e t i n g s per w e e k for f o r m a l s u p e r v i s i o n . H e r e r e s i d e n t s p r e s e n t t h e i r own cases and h e a r others p r e s e n t theirs. There are two w e e k l y i n d i v i d u a l s u p e r v i s o r y sessions with a staff psychiatrist. In t h i s m o r e p r i v a t e s e t t i n g t h e residents are more likely to discuss t h e i r p a t i e n t s and t h e i r reactions to them.
Content of Teaching In addition to the major goals mentioned, other goals involve i m p a r t i n g skills t h a t allow residents to help pat i e n t s d u r i n g a b r i e f encounter. This m i n i m i z e s r e f e r r i n g or t r a n s f e r r i n g p a t i e n t s who a r e often u n l i k e l y to complete referrals. A n e m p a t h i c a p p r o a c h is p r o moted. The r e s i d e n t learns t h a t list e n i n g e m p a t h i c a l l y a n d t a l k i n g is useful to both calm the p a t i e n t and help h i m feel understood. The r e s i d e n t ' s s u p e r v i s o r s t r y to i m p a r t a g e n e r a l o v e r v i e w of t h e r a n g e of acute e m o t i o n a l problems, i n c l u d i n g m e t h o d s of d e a l i n g w i t h p a t i e n t s who are e x t r e m e l y a g i t a t e d and those w i t h impulse control problems. Suicidal p a t i e n t s are discussed in depth. Indications for, a n d proper use of, t h e b a s i c p s y c h o p h a r m a c o logic agents are reviewed. The t r a i n ing is a i m e d a t quick a s s e s s m e n t and s h o r t - t e r m m a n a g e m e n t . Less attention is p a i d to d y n a m i c formulations, studies of defense mechanisms, and e a r l y childhood conflicts.
Multidisciplinary Aspects of the Emergency Psychiatry Team T h e r e s i d e n t ' s e x p e r i e n c e of actively p a r t i c i p a t i n g in an e m e r g e n c y d e p a r t m e n t based '~multidisciplinary t e a m " model is v a l u a b l e . The residents are the newest m e m b e r s of this
team. Other team members, both physicians and nonphysicians, with m o n t h s or y e a r s of e x p e r i e n c e in helping patients with emotional crises guide the resident. Receiving help from nonphysicians, however, is a r e v e r s a l of the more u s u a l situation. Most residents are comfortable o b t a i n i n g advice from t h e nonphysiclan t e a m m e m b e r s a l t h o u g h occasionally a r e s i d e n t prefers w o r k i n g w i t h p s y c h i a t r i c r e s i d e n t s . A few e m e r g e n c y medicine r e s i d e n t s have completely avoided the nonphysiclans. P a t i e n t s a r e r a n d o m l y assigned to the p s y c h i a t r i c t e a m m e m b e r s and whoever i n i t i a l l y sees a p a t i e n t has full responsibility. E m e r g e n c y medicine r e s i d e n t s t e n d to "go it alone" more often t h a n o t h e r t e a m members, p a r t i c u l a r l y if t h e a l t e r n a t i v e is to discuss t h e case w i t h a nonphysiclan. One p r o g r a m goal is to facilit a t e the r e s i d e n t ' s use of the other t e a m m e m b e r s ' skills which is promoted by a s s i g n i n g two of the most experienced n o n p h y s i c i a n t h e r a p i s t s as '~supervisors." This formalizes the supervisors' role m a k i n g it more acceptable for t h e r e s i d e n t to seek assistance_ T h e n o n p h y s i c i a n s u p e r visors m e e t t w i c e m o n t h l y w i t h a s t a f f p s y c h i a t r i s t to d i s c u s s t h e i r supervisory role. In a m u l t i d i s c i p l i n a r y e m e r g e n c y p s y c h i a t r y t e a m is a m i c r o c o s m of the issues a n d problems t h a t arise in the whole emergency department. T h r o u g h t h e i r e x p e r i e n c e s on t h e multidisciplinary psychiatry team, the emergency medicine residents f u r t h e r t h e i r a p p r e c i a t i o n of multid i s c i p l i n a r y problems.
Attitudes Toward the Psychiatry Rotation Twelve of 15 (80%) former and current emergency medicine residents replied to a q u e s t i o n n a i r e assessing t h e i r experience w i t h the emergency p s y c h i a t r y team. E i g h t y - t h r e e percent of the respondents considered the emergency p s y c h i a t r y r o t a t i o n a good l e a r n i n g experience. All the respondents, except one, believed the r o t a t i o n to be r e l e v a n t to t h e practice of emergency medicine_ N i n e t y - t w o p e r c e n t t h o u g h t t h e i r supervision on the p s y c h i a t r y rot a t i o n w a s ~ f a i r l y good" or " v e r y good."
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Table E M E R G E N C Y M E D I C I N E RESIDENTS A S S E S S M E N T OF THEIR F A M I L I A R I T Y AND INSTRUCTION IN PSYCHIATRIC ISSUES Subject Matter
Percentage
Delirium tremens
58 75
Alcoholic hallucinosis
92
Paranoid states
100
Psychological manifestations
83 100
Hallucinations and delusions Depression and suicide
100
Ac.ute psychosis
92 75 75
Differential diagnosis of emotional disorders Emergency psychiatric drug therapy
58 75
When and when not to use mechanical restraints Medicolegal issues surrounding emotionally ill patient Some aspects of psychosomatic illness
W h e n asked how t h e experience could be improved, the respondents noted t h e s h o r t a g e of p s y c h i a t r i c beds and the difficulty in m a k i n g appropriate dispositions. W h e n asked what they liked least about their experience, the most frequent response concerned their inability to solve the patient's problem. Some comments were: "I became extremely tired of l i s t e n i n g to people's problems," "My e m p a t h y decreased as the m o n t h increased," " . . . inability to m a k e a p p r o p r i a t e d i s p o s i tions," "._. u n s a t i s f a c t o r y a t t e m p t s at hospitalization." Every respondent did agree, however, to the s t a t e m e n t ' ~ I m p r o v e m e n t c a n be m a d e i n a short time span with the p a t i e n t who is i n the m i d s t of a crisis." W h e n asked what they liked most, the res p o n d e n t s g e n e r a l l y agreed it was the wide v a r i e t y of p a t i e n t problems seen and b e i n g a part of the emergency psychiatry team. W i e g e n s t e i n states t h a t the edu-
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catlonal content of emergency training s h o u l d i n c l u d e e x p e r i e n c e a n d f a m i l i a r i t y with various psychiatric illnesses a n d issues (Physician Skills S t u d y , E m e r g e n c y M e d i c i n e Resource Book, A m e r i c a n College of E m e r g e n c y Physicians, 1973). Emergency medicine residents were asked to assess their f a m i l i a r i t y with the various disorders listed i n the core c u r r i c u l u m of e m e r g e n c y m e d i c i n e (Table), E l e v e n of the 12 (92%) r e s i d e n t s t h o u g h t emergency psychiatry services were a vital emergency departm e n t component_ N i n e (75%) said they would like an emergency p s y c h i a t r y t e a m s i m i l a r to the one with which they trained_ Some respondents were a t t u n e d to the difficulties involved i n o p e r a t i n g a 24hour multidisciplinary emergency p s y c h i a t r y team. For example, one former r e s i d e n t stressed the import a n c e of h a v i n g 2 4 - h o u r m e d i c a l backup for the n o n m e d i c a l staff for purposes of medical consultation and
p r e s c r i p t i o n w r i t i n g . A n o t h e r resident had difficulty accepting the m u l t i d i s c i p l i n a r y approach, stating, " T h e s e r v i c e w o u l d h a v e to be m o d i f i e d i n t e r m s of space a n d m o n e y allocated after d e t e r m i n i n g the p h y s i c i a n / n o n p h y s i c i a n ratio of the service." W h e n asked if the psychiatry service should be outside or inside the emergency department, their replies were as varied as the possibilities. Seven former residents (58~) indicated the service could exist w i t h i n the e m e r g e n c y d e p a r t m e n t b u t all had different opinions r e g a r d i n g to whom the service should be administ r a t i v e l y responsible. A few t h o u g h t the service should exist outside but a d j a c e n t to the e m e r g e n c y departm e n t while a few suggested i n i t i a l visits in the emergency d e p a r t m e n t with subsequent visits conducted outside. One former resident believed the service should be conducted in a community center with medical backup_
The assistance of Ms. Barbara Griffin and Ms. Phyllis Burger in manuscript preparation is gratefully acknowledged. REFERENCES 1. Chafetz ME: The effect of a psychiatric emergency service on moLivation for psychiatric treatment. J Nerv M e n t Dis 140-442-448, 1965. 2. Guido JA, Payne DH: 72-hour psychiatric detenLion: clinical observation and treatment in a county general hospital. Arch Gen Psychiatry 16:233-238, 1967. 3. Schwartz MD: A non-hospital in a hospital. A m J Public Health 61:2376-2382, 1971. 4. Bartolucci G, Drayer CS: An overview of crisis intervention in the emergency rooms of general hospitals. A m J Psychiatry 130:953-960, 1973. 5. Merklen L: Beginning psychiatry t r a i n i n g syndrome. A m J P s y c h i a t r y 124:193-197.
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Psychiatric Training for Emergency Medicine Residents On a Multidisciplinary Team Louis Spitz, MD* H. Thomas Blum, M D t Melvin S. Gale, MD* Steven Beck, M S , Cincinnati, Ohio
The C i n c i n n a t i G e n e r a l H o s p i t a l E m e r g e n c y D e p a r t m e n t has a training p r o g r a m for e m e r g e n c y m e d i c i n e r e s i d e n t s on a m u l t i d i s c i p l i n a r y e m e r g e n c y p s y c h i a t r y t e a m . This e s s e n t i a l t r a i n i n g s h o u l d o c c u r in the e m e r g e n c y d e p a r t m e n t s e t t i n g rather t h a n in p s y c h i a t r i c i n p a t i e n t units of state h o s p i t a l settings. T h e r e are a d v a n t a g e s and d i s a d v a n t a g e s to this a r r a n g e m e n t . N o n m e d i c a l m e m b e r s of the e m e r g e n c y p s y c h i a t r y t e a m train a n d s u p p o r t e m e r g e n c y m e d i c i n e r e s i d e n t s in a multidisc i p l i n a r y a p p r o a c h to t r e a t m e n t . S o m e o b s e r v a t i o n s are m a d e a b o u t h o w the e m e r g e n c y m e d i c i n e r e s i d e n t s deal w i t h e m o t i o n a l l y d i s t u r b e d patients. Finally, 80% of e m e r g e n c y m e d i c i n e r e s i d e n t s r e s p o n d e d to a q u e s t i o n n a i r e o n t h e i r r e a c t i o n s to the m u l t i d i s c i p l i n a r y e m e r g e n c y psychiatry team.
Spitz L, Blum HT, Gale MS, Beck S: Psychiatric training for emergency medicine residents on a multidisciplinary team. JACEP 5:694-697, September 1976. emergency medicine residents, training; training, psychiatric. INTRODUCTION In the Medical hospital, tal, t h e r e
U n i v e r s i t y of C i n c i n n a t i Center's major teaching C i n c i n n a t i G e n e r a l Hospiwere a p p r o x i m a t e l y 135,000
From the Psychiatric Emergency Service,*$ and Emergency Department,t Cincinnati General Hospital; Department of Psychiatry,* and Division of Emergency Medicine;t University of Cincinnati College of Medicine. Address for reprints: H. Thomas Blum, MD, Director, Emergency Department, Cincinnati General Hospital, 231 Bethesda Avenue, Cincinnati, Ohio 45229.
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e m e r g e n c y d e p a r t m e n t p a t i e n t visits in 1975, i n c l u d i n g 40,000 p e d i a t r i c visits, 30,000 m i n o r m e d i c a l visits, and 5,550 p s y c h i a t r i c visits. The e m e r g e n c y d e p a r t m e n t is divided into t h r e e p a t i e n t care areas: the A c u t e C a r e Section (ACS), the P r i m a r y C a r e Section (PCS), and the P e d i a t r i c Section. The medical staff c o n s i s t s of m e d i c a l a n d s u r g i c a l teams staffed by residents and n u r s e s . S u p p l e m e n t a r y t e a m s include the e m e r g e n c y p s y c h i a t r y t e a m and the social services team. Laborat o r y and r a d i o l o g y t e c h n i c i a n s and c h a p l a i n s a r e also in the d e p a r t m e n t . F a c u l t y p h y s i c i a n s are p r e s e n t dur-
ing most hours for supervision and teaching. The ACS physical p l a n t is not spacious for t h e n u m b e r s and k i n d s of p a t i e n t s seen - - 60,000 p a t i e n t visits per y e a r in 9,200 s q u a r e feet. For a n u m b e r of reasons, overall '~in-out" t i m e s in t h e ACS t e n d to be long, ave r a g i n g 220 minutes. The n u m b e r of support personne ! is i n a d e q u a t e and the house staff g e n e r a l l y lacks the experience n e c e s s a r y to m a k e rapid p a t i e n t dispositions. A h i g h percentage of p a t i e n t s have chronic multisystem diseases, and m a n y h a v e alcohol and/or drug overdose problems r e q u i r i n g l e n g t h y stays in the emergency d e p a r t m e n t prior to discharge. These factors c o n t r i b u t e to a n intense, highly charged atmosphere t h a t o c c a s i o n a l l y r e s u l t s in house staff, a n d p a t i e n t , f r u s t r a t i o n with the p o t e n t i a l of overflowing in staffp a t i e n t a n d staff-staff discord.
THE EMERGENCY MEDICINE RESIDENCY P o s t g r a d u a t e e m e r g e n c y medicine t r a i n i n g c a m e of age w h e n the first r e s i d e n t p h y s i c i a n b e g a n a two-year p r o g r a m on J u l y 1, 1970 at the Univ e r s i t y of C i n c i n n a t i Medical Center. D u r i n g the e n s u i n g five years, more t h a n 35 residency p r o g r a m s have de-
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veloped in the United States. In a d d i t i o n , a s u b s t a n t i a l n u m b e r of residency p r o g r a m s a p p e a r to be in the p l a n n i n g stage. W h a t is this new breed of physician like? A n e m e r g e n c y p h y s i c i a n can be called a R e n a i s s a n c e person because of the b r e a d t h of knowledge r e q u i r e d to effectively m a n a g e pat i e n t s w i t h the s p e c t r u m of illnesses e n c o u n t e r e d in e m e r g e n c y d e p a r t ments. E m e r g e n c y p h y s i c i a n s m u s t h a v e k n o w l e d g e c o m m o n to a l l p h y s i c i a n s r e n d e r i n g p r i m a r y care. However, t h e i r technical skills m u s t be more s h a r p l y developed and maint a i n e d since t h e i r e n v i r o n m e n t affords t h e o p p o r t u n i t y for r e p e a t e d use of t h e s e skills. This new actionoriented p h y s i c i a n provides episodic and i n i t i a l care. The e m e r g e n c y medicine residency was e s t a b l i s h e d w i t h the following goals in mind: 1) To come broad lems gency
t r a i n t h e p h y s i c i a n to bee x p e r t in m a n a g i n g t h e s p e c t r u m of m e d i c a l probe n c o u n t e r e d in t h e e m e r department,
2) To develop a d m i n i s t r a t i v e and o r g a n i z a t i o n a l s k i l l s n e c e s s a r y to provide l e a d e r s h i p in this field. 3) To stress the physician's role as a t e a c h e r in all aspects of emergency medical care. 4) To e n c o u r a g e h e a l t h s e r v i c e s r e s e a r c h a s s e s s i n g the efficacy of e m e r g e n c y medical care, Six f i r s t - y e a r and six second-year r e s i d e n t s are t r a i n e d for 24 months b e y o n d i n t e r n s h i p , in c o n j u n c t i o n w i t h s p e c i a l t y d e p a r t m e n t s , in t h e management of e m e r g e n c y a n d episodic p r i m a r y care problems. T h e r e s i d e n t s a r e e x p o s e d to a broad r a n g e of psychiatric problems in the C i n c i n n a t i G e n e r a l H o s p i t a l Emergency Department when they r o t a t e for one m o n t h with the multidisciplinary emergency psychiatry team.
Profile of Emergency Medicine Resident These r e s i d e n t s are h a r d working, ambitious, conscientious physicians. They expect a lot of t h e m s e l v e s and hope to h a v e an i m p a c t upon t h e i r patients, their emergency department, and their community. They
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anticipate a one-time relationship w i t h a p a t i e n t d u r i n g which t h e y do all t h e y can for him. They see themselves as k n o w l e d g e a b l e and potent and expect the p a t i e n t - t o respond to their intervention_ The residents have a "take charge" attitude and feel t h e y should be a b l e to h a n d l e w h a t e v e r p r o b l e m arises. Most are comfortable in the role of physician, h a v i n g h a d experience either in the m i l i t a r y , f u l l - t i m e practice, i n t e r n ship, or d u r i n g one or more y e a r s of other s p e c i a l t y t r a i n i n g . Most residents have attained an organizational maturity that helps them function effectively on a multidiscip l i n a r y team_ Some have h a d prior experience in d e l e g a t i n g responsibility to m i l i t a r y medics and o t h e r support personnel.
The Emergency Psychiatry Team The e m e r g e n c y p s y c h i a t r y t e a m is a s e p a r a t e divimon of the U n i v e r s i t y of C i n c i n n a t i College Of M e d i c i n e , D e p a r t m e n t of P s y c h i a t r y . The t e a m consists of a director, a d m i n i s t r a t i v e support personnel, mental health professionals (psychiatrists, psychologists, social workers, psychiatric nurses) and v a r i o u s r o t a t i n g t r a i n ees, eg, p s y c h i a t r i c a n d e m e r g e n c y medicine residents, master level n u r s i n g a n d social work students. M a n y p s y c h i a t r i c e m e r g e n c y dep a r t m e n t s e r v i c e s h a v e b e e n described in the l i t e r a t u r e 1-~ r a n g i n g from those r u n by p s y c h i a t r i c residents to t h e h i g h l y complex "medical psychosocial teams" described by B a r t o l u c c i a n d D r a y e r . 4 On s o m e services, p e r m a n e n t m e n t a l h e a l t h professionals support psychiatric residents, w h i l e on others the distinction between the psychiatric residents a n d other personnel has blurred and all workers perform s i m i l a r tasks. This type is the model for our p s y c h i a t r i c team. W h e r e , in t h e p a s t , p s y c h i a t r i c emergency services provided only e v a l u a t i o n and disposition, new psychiatric e m e r g e n c y services h a v e developed a d d i t i o n a l flexibility by adding both brief treatment and brief hospitalization options. This new flexibility has e n h a n c e d p a t i e n t care. It has c h a n g e d conscious and unconscious a t t i t u d e s from, "Where can I send t h i s p a t i e n t ? " to "How c a n I help this patient?"
Psychiatric Training For Emergency Medicine Residents at the University of Cincinnati The residents' rotation with the e m e r g e n c y psychiatric t e a m is spent in t h e e m e r g e n c y d e p a r t m e n t except w h e n p a t i e n t s a r e a d m i t t e d briefly to t h e i n p a t i e n t psychiatric unit. The residents a r e f a m i l i a r with the needs of e m e r g e n c y p a t m n t s with intense, often severe, p s y c h i a t r i c disturbances. Prior to r o t a t i n g t h r o u g h p s y c h i a t r y , often they would quickly refer such p a t i e n t s to t h e psychiatric t e a m because t h e y were too busy or found the patients uninteresting. Less often, t h e r e f e r r a l h a d to do w i t h t h e i r own discomfort w i t h cert a i n patients, most often those who were hostile, bizarre, or disorganized. E m e r g e n c y physicians referred some p a t i e n t s because of conscious or unconscious n e g a t i v e a t t i t u d e s toward, for e x a m p l e , alcoholic, d r u g abuse, and d r u g overdose patients. One goal of t h e rotation is to m a k e the r e s i d e n t s more comfortable w i t h severely d i s t u r b e d patients. A n o t h e r is to begin to g e n t l y confront t h e m with their feelings and biases and t h e w a y s t h e y m a n i f e s t t h e s e attitudes. The e m e r g e n c y medicine residents, like p s y c h i a t r i c r e s i d e n t s and other m e n t a l h e a l t h professionals, a r e app r e h e n s i v e a b o u t d e a l i n g w i t h sev e r e l y disturbed, often psychotic, patients. In p a r t i c u l a r , agitated, defensive, o v e r t l y h o s t i l e p a t i e n t s who seem on t h e verge of losing control evoke considerable anxiety_ W o r k i n g with more experienced psychiatric team members helps the residents l e a r n how to deal with these p a t i e n t s more effectively. The focus is, in an e m p a t h i c way, on the residents' pers o n a l r e a c t i o n s to t h e s e p a t i e n t s . Learning that most interviewers r e a c t to such p a t i e n t s in a predictable w a y helps residents relax. They u n d e r s t a n d t h e i r own reactions better, are more t o l e r a n t of the patient, and find s u b s e q u e n t interviews more rewarding. In dealing with neurotic and character-disordered patients, the r e s i d e n t s feel t h e r e is little to learn. They often t h i n k simply t e l l i n g the p a t i e n t w h a t to do w i l l s o l v e h i s problem_ M o s t p s y c h i a t r i c p a t i e n t s do not w a n t this advice, which t h e y
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probably have already heard many times, y e t t h e y m a y provoke the resi d e n t to m a k e suggestions, only to respond w i t h why the suggestion will not work. The r e s i d e n t m a y b e g i n such interviews calm and confident b u t leave f r u s t r a t e d and weary. The f r u s t r a t i o n of not b e i n g able to s o l v e p a t i e n t s ' p r o b l e m s o f t e n m o u n t s to u n c o m f o r t a b l e l e v e l s . The r e s i d e n t f r e q u e n t l y experiences the "first-year psychiatric resident syndrome" of hopelessness, i n a d e q u a cy, a n d d e p r e s s i o n . 5 T h e r e s i d e n t has little expertise in h a n d l i n g psychiatric p a t i e n t s and it is difficult to simplify technique to a point where it is e a s i l y mastered. Some r e s i d e n t s h a n d l e t h e i r f r u s t r a t i o n by "distancing" t h e m s e l v e s from patients. They rely more on m e d i c a t i o n and less on their relationship with patients. Others r e a c t by s p e n d i n g excessive t i m e w i t h the p a t i e n t to t r y to provide what they think the patient needs. Occasionally, the outcome is the f e e l i n g t h a t t h e i r i n t e r v e n t i o n was useless. A n o t h e r major goal of e m e r g e n c y medicine residency is i m p r o v i n g the residents' psychiatric interview skills. T h e i r " t a k e - c h a r g e a t t i t u d e " i n t e r f e r e s w i t h t h e d e v e l o p m e n t of these skills. In p s y c h i a t r i c diagnostic interviews, the t h e r a p i s t m u s t listen in a n o n d i r e c t i v e m a n n e r . Controll i n g t h e i n t e r v i e w often r e s u l t s in m i s s i n g significant topics. Residents l e a r n to r e s t r a i n themselves. Observing interviews by more experienced psychiatric t e a m m e m b e r s is of g r e a t value. A n o t h e r helpful a p p r o a c h to l e a r n i n g interview techniques is role p l a y i n g u n d e r group and i n d i v i d u a l supervision. Prior to t h e i r rotation, some residents t h i n k p s y c h i a t r i s t s are permissive, allowing p a t i e n t s both to say or do w h a t they please. This misconception o c c a s i o n a l l y p r o m p t s r e s i d e n t s to allow p a t i e n t s g r e a t e r freedom to act on t h e i r impulses, sometimes to the p a t i e n t s ' and the e m e r g e n c y dep a r t m e n t ' s d e t r i m e n t . In t h e emergency e n v i r o n m e n t , limits set by the p s y c h i a t r i s t are v i t a l l y i m p o r t a n t for specific conditions_ P h y s i c i a n s ' p e r s o n a l responses to p a t i e n t s are significant b u t most of the residents are r e l u c t a n t to share t h e i r r e a c t i o n s • T h e d i s c u s s i o n of
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these reactions and perceptions among the emergency psychiatry t e a m m e m b e r h a s been a very valuable e x p e r i e n c e for the e m e r g e n c y medicine residents.
Structure of the Teaching The r e s i d e n t s are t a u g h t by several methods while on the rotation. They f r e q u e n t l y have informal consultations with other psychiatric t e a m members. They are exposed to different i n t e r v i e w i n g techniques by o b s e r v i n g o t h e r t e a m m e m b e r s in order to promote s h a r i n g of diagnostic and t h e r a p e u t i c t h i n k i n g . There are four t e a m m e e t i n g s per w e e k for f o r m a l s u p e r v i s i o n . H e r e r e s i d e n t s p r e s e n t t h e i r own cases and h e a r others p r e s e n t theirs. There are two w e e k l y i n d i v i d u a l s u p e r v i s o r y sessions with a staff psychiatrist. In t h i s m o r e p r i v a t e s e t t i n g t h e residents are more likely to discuss t h e i r p a t i e n t s and t h e i r reactions to them.
Content of Teaching In addition to the major goals mentioned, other goals involve i m p a r t i n g skills t h a t allow residents to help pat i e n t s d u r i n g a b r i e f encounter. This m i n i m i z e s r e f e r r i n g or t r a n s f e r r i n g p a t i e n t s who a r e often u n l i k e l y to complete referrals. A n e m p a t h i c a p p r o a c h is p r o moted. The r e s i d e n t learns t h a t list e n i n g e m p a t h i c a l l y a n d t a l k i n g is useful to both calm the p a t i e n t and help h i m feel understood. The r e s i d e n t ' s s u p e r v i s o r s t r y to i m p a r t a g e n e r a l o v e r v i e w of t h e r a n g e of acute e m o t i o n a l problems, i n c l u d i n g m e t h o d s of d e a l i n g w i t h p a t i e n t s who are e x t r e m e l y a g i t a t e d and those w i t h impulse control problems. Suicidal p a t i e n t s are discussed in depth. Indications for, a n d proper use of, t h e b a s i c p s y c h o p h a r m a c o logic agents are reviewed. The t r a i n ing is a i m e d a t quick a s s e s s m e n t and s h o r t - t e r m m a n a g e m e n t . Less attention is p a i d to d y n a m i c formulations, studies of defense mechanisms, and e a r l y childhood conflicts.
Multidisciplinary Aspects of the Emergency Psychiatry Team T h e r e s i d e n t ' s e x p e r i e n c e of actively p a r t i c i p a t i n g in an e m e r g e n c y d e p a r t m e n t based '~multidisciplinary t e a m " model is v a l u a b l e . The residents are the newest m e m b e r s of this
team. Other team members, both physicians and nonphysicians, with m o n t h s or y e a r s of e x p e r i e n c e in helping patients with emotional crises guide the resident. Receiving help from nonphysicians, however, is a r e v e r s a l of the more u s u a l situation. Most residents are comfortable o b t a i n i n g advice from t h e nonphysiclan t e a m m e m b e r s a l t h o u g h occasionally a r e s i d e n t prefers w o r k i n g w i t h p s y c h i a t r i c r e s i d e n t s . A few e m e r g e n c y medicine r e s i d e n t s have completely avoided the nonphysiclans. P a t i e n t s a r e r a n d o m l y assigned to the p s y c h i a t r i c t e a m m e m b e r s and whoever i n i t i a l l y sees a p a t i e n t has full responsibility. E m e r g e n c y medicine r e s i d e n t s t e n d to "go it alone" more often t h a n o t h e r t e a m members, p a r t i c u l a r l y if t h e a l t e r n a t i v e is to discuss t h e case w i t h a nonphysiclan. One p r o g r a m goal is to facilit a t e the r e s i d e n t ' s use of the other t e a m m e m b e r s ' skills which is promoted by a s s i g n i n g two of the most experienced n o n p h y s i c i a n t h e r a p i s t s as '~supervisors." This formalizes the supervisors' role m a k i n g it more acceptable for t h e r e s i d e n t to seek assistance_ T h e n o n p h y s i c i a n s u p e r visors m e e t t w i c e m o n t h l y w i t h a s t a f f p s y c h i a t r i s t to d i s c u s s t h e i r supervisory role. In a m u l t i d i s c i p l i n a r y e m e r g e n c y p s y c h i a t r y t e a m is a m i c r o c o s m of the issues a n d problems t h a t arise in the whole emergency department. T h r o u g h t h e i r e x p e r i e n c e s on t h e multidisciplinary psychiatry team, the emergency medicine residents f u r t h e r t h e i r a p p r e c i a t i o n of multid i s c i p l i n a r y problems.
Attitudes Toward the Psychiatry Rotation Twelve of 15 (80%) former and current emergency medicine residents replied to a q u e s t i o n n a i r e assessing t h e i r experience w i t h the emergency p s y c h i a t r y team. E i g h t y - t h r e e percent of the respondents considered the emergency p s y c h i a t r y r o t a t i o n a good l e a r n i n g experience. All the respondents, except one, believed the r o t a t i o n to be r e l e v a n t to t h e practice of emergency medicine_ N i n e t y - t w o p e r c e n t t h o u g h t t h e i r supervision on the p s y c h i a t r y rot a t i o n w a s ~ f a i r l y good" or " v e r y good."
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Table E M E R G E N C Y M E D I C I N E RESIDENTS A S S E S S M E N T OF THEIR F A M I L I A R I T Y AND INSTRUCTION IN PSYCHIATRIC ISSUES Subject Matter
Percentage
Delirium tremens
58 75
Alcoholic hallucinosis
92
Paranoid states
100
Psychological manifestations
83 100
Hallucinations and delusions Depression and suicide
100
Ac.ute psychosis
92 75 75
Differential diagnosis of emotional disorders Emergency psychiatric drug therapy
58 75
When and when not to use mechanical restraints Medicolegal issues surrounding emotionally ill patient Some aspects of psychosomatic illness
W h e n asked how t h e experience could be improved, the respondents noted t h e s h o r t a g e of p s y c h i a t r i c beds and the difficulty in m a k i n g appropriate dispositions. W h e n asked what they liked least about their experience, the most frequent response concerned their inability to solve the patient's problem. Some comments were: "I became extremely tired of l i s t e n i n g to people's problems," "My e m p a t h y decreased as the m o n t h increased," " . . . inability to m a k e a p p r o p r i a t e d i s p o s i tions," "._. u n s a t i s f a c t o r y a t t e m p t s at hospitalization." Every respondent did agree, however, to the s t a t e m e n t ' ~ I m p r o v e m e n t c a n be m a d e i n a short time span with the p a t i e n t who is i n the m i d s t of a crisis." W h e n asked what they liked most, the res p o n d e n t s g e n e r a l l y agreed it was the wide v a r i e t y of p a t i e n t problems seen and b e i n g a part of the emergency psychiatry team. W i e g e n s t e i n states t h a t the edu-
~ : ] ~ P September 1976
catlonal content of emergency training s h o u l d i n c l u d e e x p e r i e n c e a n d f a m i l i a r i t y with various psychiatric illnesses a n d issues (Physician Skills S t u d y , E m e r g e n c y M e d i c i n e Resource Book, A m e r i c a n College of E m e r g e n c y Physicians, 1973). Emergency medicine residents were asked to assess their f a m i l i a r i t y with the various disorders listed i n the core c u r r i c u l u m of e m e r g e n c y m e d i c i n e (Table), E l e v e n of the 12 (92%) r e s i d e n t s t h o u g h t emergency psychiatry services were a vital emergency departm e n t component_ N i n e (75%) said they would like an emergency p s y c h i a t r y t e a m s i m i l a r to the one with which they trained_ Some respondents were a t t u n e d to the difficulties involved i n o p e r a t i n g a 24hour multidisciplinary emergency p s y c h i a t r y team. For example, one former r e s i d e n t stressed the import a n c e of h a v i n g 2 4 - h o u r m e d i c a l backup for the n o n m e d i c a l staff for purposes of medical consultation and
p r e s c r i p t i o n w r i t i n g . A n o t h e r resident had difficulty accepting the m u l t i d i s c i p l i n a r y approach, stating, " T h e s e r v i c e w o u l d h a v e to be m o d i f i e d i n t e r m s of space a n d m o n e y allocated after d e t e r m i n i n g the p h y s i c i a n / n o n p h y s i c i a n ratio of the service." W h e n asked if the psychiatry service should be outside or inside the emergency department, their replies were as varied as the possibilities. Seven former residents (58~) indicated the service could exist w i t h i n the e m e r g e n c y d e p a r t m e n t b u t all had different opinions r e g a r d i n g to whom the service should be administ r a t i v e l y responsible. A few t h o u g h t the service should exist outside but a d j a c e n t to the e m e r g e n c y departm e n t while a few suggested i n i t i a l visits in the emergency d e p a r t m e n t with subsequent visits conducted outside. One former resident believed the service should be conducted in a community center with medical backup_
The assistance of Ms. Barbara Griffin and Ms. Phyllis Burger in manuscript preparation is gratefully acknowledged. REFERENCES 1. Chafetz ME: The effect of a psychiatric emergency service on moLivation for psychiatric treatment. J Nerv M e n t Dis 140-442-448, 1965. 2. Guido JA, Payne DH: 72-hour psychiatric detenLion: clinical observation and treatment in a county general hospital. Arch Gen Psychiatry 16:233-238, 1967. 3. Schwartz MD: A non-hospital in a hospital. A m J Public Health 61:2376-2382, 1971. 4. Bartolucci G, Drayer CS: An overview of crisis intervention in the emergency rooms of general hospitals. A m J Psychiatry 130:953-960, 1973. 5. Merklen L: Beginning psychiatry t r a i n i n g syndrome. A m J P s y c h i a t r y 124:193-197.
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