The Use of the Psychiatric Consultation Record for Residency Training Shepard J. Kantor, M.D. Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, and Attending, Consultation Psychiatry Service, St. Luke’s Hospital, New York, New York
Irene Chiarandini, M. D. Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, and Attending, Consultation Psychiatry Service, St. Luke’s Hospital, New York, New York
Stanley S. Heller, M.D. Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, and Director, Consultation Psychiatry Service, St. Luke‘s Hospital, New York, New York Abstract: The Psychiatric Consultation Record (PCR) is an instrument developed to aid in the teaching of consultation psychiatry, to evaluate the impact of this teaching, and to provide an overall assessment of the consultation training program at St. Luke’s Hospital. The PCR both structures the resident‘s training experienceand provides a tool with which he or she can integrate theoretical and practical knowledgepertaining to consultation work. Its use has enabled supervisors to detect the degreeto which didactic material has become integrated into residents’ thinking and has provided data through which the scope and quality of each resident’s work can be rapidly assessed. Finally, its use has brought to light deficiencies in service delivery which, beforethe use of this instrument, had not been apparent.
Becoming a skilled consultant to a general medical or surgical service is a particularly stressful experience for psychiatric residents. Not only must the resident obtain a thorough understanding of individual and group psychology as well as psychopharmacology, but he or she must be well enough versed in medicine to understand thoroughly the diverse contributions physical illness and medication make to the clinical conditions he or she is asked to evaluate (1). The time pressure This work was supported in part by NIMH-Psychiatry Brunch, Grant No. MH 15707.
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Education
under which the residents work is exacerbated by the emergent nature of many of the psychiatric problems they must assess. Such consultations demand a wide variety of psychiatric skills including the rapid evaluation, diagnosis, and treatment of, at times, severely disturbed and extremely ill medical-surgical patients (2). A further problem which confronts the consultation trainees is that of assimilating an extensive body of new material that stands at the interface between medicine and psychiatry. Didactic seminars devoted to such diverse topics as organic mental syndromes, personality styles and their interaction with medical illness, psychosomatic medicine, and the consultation-liaison process itself are major elements of any substantial consultation training program. Unfortunately, this material may present the resident with a bewildering set of new ideas and concepts (3-6) which must be thoroughly integrated in order for the consultant to function as effectively as possible. Because of these difficulties, structuring the training experience of psychiatric residents during their rotations as consultant to medical-surgical units has been an area of particular concern to those involved with teaching consultation-liaison psychiatry (7-14). The Psychiatric Consultation Record (PCR) was developed by one of the authors (S.
General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
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J. K.) in an attempt to overcome some of the difficulties intrinsic to teaching in this complex area. This paper describes the PCR and reports findings after one year’s use on the consultation service at St. Luke’s Hospital. St. Luke’s is a 700-bed hospital which is a major teaching affiliate of the Columbia University College of Physicians and Surgeons. The consultations reported in this paper were all performed on patients admitted to the ward services. These patients were predominantly from a Black and Hispanic, low and lower-middle class population.
Method The PCR is a two-part form (see Appendix). It was designed to allow comparisons to be made between psychiatric and medical house officers’ perception of psychiatric illnesses in medical-surgical patients, to evaluate service delivery by the consultation department, and to better assess residents’ consultation skills and practices. This report is limited to Part II of the PCR and concerns the use of this instrument in program evaluation and in the training of residents in consultation psychiatry. Part II is a checklist form with 10 major areas of inquiry. These include description of the clinical problem, psychiatric findings, case formulation, intervention, follow-up, disposition, and training value to the resident. Questions concerning psychiatric assessment address themselves to such historical events as hospitalization, somatic or psychologic treatments, and suicide attempts or gestures. Current psychologic functioning is assessed in terms of psychosis, neurosis, and character disorder as well as in terms of the seven basic categories of personality types and attitudes as developed by Kahana and Bibring (15). These categories emphasize the different meanings physical illness has to particular patients, as well as the kind of defensive and adaptive behaviors that become intensified under the stress of illness. Their basic personality types are described as: dependent, demanding, (oral); orderly, controlled, (compulsive); dramatizing, emotionally involved, (hysterical); long-suffering, self-sacrificing, (masochistic); guarded, (paranoid); aloof, (schizoid); superior, (narcissistic). The presence or absence of organic impairment is assessed through use of the Cognitive Function Scale of Jacobs et al. (16).The resident must formulate the overall consultation problem in terms of intrapsychic conflict (failure of normal coping
Consultation
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mechanisms), interpersonal conflict (disordered interaction between patient and staff), or impersonal (toxic or metabolic) etiology. The consultant is also asked whether or not patients were hospitalized for conditions thought to be a direct consequence of psychologic factors. Patients who reacted to stress with a particular somatic symptom or with an exacerbation of some psychophysiologic or latent somatic condition such as angina, colitis, or asthma, and for whom the source of stress is obviously demonstrable and acknowledged, are included here. Also in this group are patients admitted for complications of suicide attempts and those with a medical illness that stemmed from psychiatric disturbances such as alcoholism. Patients whose manifest illness could be linked to psychologic factors only through speculative formulations or whose illness was related to a “weakened condition” secondary to psychologic stress were considered to have minimal or absent psychologic precipitants to their hospitalization. Questions concerning the consultation process itself address themselves to the type of psychiatric intervention, number of visits, time commitment, and disposition. Disposition is dichotomized in terms of patients whose illnesses were and were not expected to resolve within 6 weeks of hospital discharge. Finally, educational value of each case was assessed with questions about the adequacy and type of supervision obtained, the type of reading stimulated, and the balance between service and Iearning. Psychiatric residents using the PCRs were serving on the consultation service for 6 months during their PGY-3 year. During this study, six different residents completed forms on 58 patients selected randomly from 400 consultations initiated during one academic year. The forms were reviewed during supervisory sessions by the three authors. Not all questions were answered on every form. Results will therefore be reported in terms of total responses for each particular question.
Results More than 60% (37158) of the consultations were requested to assist with the management of nondisruptive patients. Diagnostic assistance, questions about the uses and side effects associated with psychotropic drugs, management of anxiety and depression, and assessment of suicidal risk all fell within this category. The remaining consultation 203
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requests (21/58) included threats to sign out against medical advice, refusals to cooperate with diagnostic or treatment procedures, and assaultive or unmanageable behavior. Almost 60% (32154) of the consultations seemed to stem from the inability of patients to cope adequately with the stress of “a more or less routine illness.” An additional 30% (17154) came as a consequence of toxic metabolic states such as organic psychoses, drug withdrawal, or pulmonary failure, whereas less than 10% (5/54) seemed to have their origin in patient-staff conflict. In this series of 57 patients, nearly 50% (26157) were found to be psychotic: 13 had organic psychoses (four associated with alcoholism) and 13 had functional psychoses. Nearly 40% (21157) were thought to have neurosis or personality disorders. Residents classified two-thirds of their patients using a single or two or three seemingly compatible Kahana and Bibring personality diagnoses. In the remaining third, they either did not know how to classify a patient using these criteria or, in four cases, simultaneously used several mutually exclusive diagnoses. Residents attempted to use the Jacobs Scale for organicity in 37 patients. Two patients were found to be severely organic (rating l-lo), nine moderately organic (rating 11-19) and 13 not organic (rating 2030). In 13, the Jacobs Scale could not be used because patients were unable to cooperate. This was accounted for by severe medical problems (4 patients), language barrier (2 patients), and depression, anxiety, psychosis, or interpersonal difficulties in the remainder. The consultants elected not to use the Jacobs Scale in 19 cases. Clinical judgment found 15 of these to be nonorganic and four organic. Roughly 30% (17147) of the patients in this series were considered to have a psychologic precipitant for their hospitalization. Almost all of these were admitted as a direct consequence of alcoholism (withdrawal, suicide attempts, alcohol-induced exacerbation of pancreatitis or liver disease, debilitation) or due to the disorganizing effects of schizophrenia (autoamputation, exposure to temperature extremes). A single case of ulcerative colitis was the lone example of a classic “psychosomatic” disease seen in this series. The primary treating physician was contacted by the consultant in 47 of the 56 cases seen. In nine others there was no contact with the treating physician and information was exchanged through secretaries, charts, and others. Social workers were
contacted 12 times, other staff members 24, outside physicians 5, immediate family 13, and other relatives or friends 5. Sixty percent (33155) of the patients were continuously followed by the consultant throughout their entire hospitalization. For 10 patients no psychiatric intervention was necessary beyond the implementation of the consultant’s initial recommendations. Of the remaining 12, four needed transfer to the inpatient psychiatric unit, seven were referred to social workers, and one to a private psychiatrist. Sixty percent (33155) of the cases required one to three visits by the consultant while 40% (22/55) required four or more visits. While 60% (33/54) of the cases could be managed in l-3 hours of the consultant’s time, 20% (10154) took 4-5 hours and another 20% (U/54) took 6 or more hours each. Residents found 50% (28156) of their cases “routine,” almost 40% (21156) “more difficult than most” and 10% “less difficult than most.” The consultants believed that continued psychiatric intervention beyond the time of hospital discharge was necessary in the overwhelming majority of cases (48/57). Of the nine patients for whom follow-up was not recommended, three died, two were transferred to the inpatient psychiatry service, and one signed out AMA. Whether the medical condition for which the patient was hospitalized could be expected to resolve (return to normal function within 6 weeks of discharge) or persist (impaired function beyond 6 weeks after discharge) did not seem to affect the perceived need for outpatient psychiatric treatment. More than 40% (26/56) of the cases were discussed with a supervisor and an additional 30% (17/56) were directly interviewed by supervisors. The remaining 13 cases were unsupervised. Residents considered supervision adequate in all but two cases, both a consequence of a lack of resident initiative. Residents found “service equal to learning” in almost 70% (39157) of the cases; they found “service greater than learning” in 20% (11157) and “learning greater than service” in 10% (7/57). Five of the seven cases in which “learning was greater than service” were interviewed directly by supervisors, whereas none of the “service greater than learning” had direct supervisor interviews. There appeared to be no distinction between these two groups in terms of medical and psychiatric diagnoses, number of visits, time consumed, or degree of difficulty. It also
Psychiatric
did not seem to matter which psychiatric resident had done the consultation. Reading was done on only 12 of 56 cases. While this tended to be done in cases seen as “more difficult” (8112) half of the reading was accounted for by one resident. Most of the time (40/51), the PCR could be filled out by the consultant in 10 minutes or less (17 of these were completed in less than 5 minutes). In 11 instances, the PCR took more than 10 minutes to complete.
Discussion Proficiency in clinical interviewing, thoroughness and rapidity of case formulations, and appropriate and comprehensive treatment planning are major goals in the training of consultation psychiatrists (11, 12, 14, 17). While clinical conferences, didactic seminars, and individual supervision are the core experiences of consultation-liaison training programs (18), the optimal method for teaching consultation skills and evaluating the resident’s acquisition of these skills is currently uncertain. As a consequence, innovative methods of teaching and program evaluation continue to evolve. One such innovation is Kimball’s Clinical Case Method (10). A prepared, detailed, and carefully referenced clinical history is used to prompt discussion about a great variety of issues that routinely confront the psychiatric consultant. These issues include illness onset situation, reaction to illness, patient management, and treatment planning. Criteria for ascertaining the degree to which the principles taught through this method are actually incorporated and utilized by the consultant trainee are not included. Houpt et al. (7, 8) and Russell et al. (9) have developed a Competency Based Model for training in consultation psychiatry. This is a detailed, carefully thought out attempt to segment consultation activities into discrete areas which can then be carefully observed and measured. These areas include data gathering, case formulation, intervention skills, special patient problems, special areas of knowledge, and liaison attitudes. Explicit objectives are established within each area as are guidelines for assessing the degree to which residents actually meet these objectives. The elucidation of such objectives within each step of the consultation process serves as a focus for overall program design and as a guide to supervisors. Further, in providing the resident with an outline of the program in which he or she will be involved as
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well as with explicit objectives of the program, the Competency Based Model serves to lessen the anxiety intrinsic to rotations on psychiatric consultation services. As does the Competency Based Model, the PCR serves to organize the consultation learning experience and to provide a guide for supervision. It also provides information which can be used for program evaluation. Further, its structure enables the resident to have a clear sense of what information must be gathered on each consultation and of the way in which it should be organized. Using the PCR for program evaluation has enabled us to teach more adequately some of the concepts necessary for the consultant psychiatrist. A major finding was that one-third of the time, the residents could not use or incorrectly used Kahana and Bibring diagnostic classifications. This indicated that a lecture on this topic-perceived as excellent by the faculty-had done little to enable the residents to integrate the use of these formulations into their daily contact with patients. A consequence of this finding is that supervisors have begun to use these formulations more directly in their individual case supervision. Despite what faculty believed had been excellent didactic instruction on delirium, and despite frequent clinical conferences centered on organic patients, residents tended to limit their assessment of cognitive function to be “oriented x 3” prior to using these forms. The inclusion of the Jacobs Scale in the PCR enabled the residents to sharpen their ability to detect organicity and to follow its course throughout a patient’s hospitalization. Residents did, however, seem reluctant to use the scale when they judged patients’ disorders to be nonorganic. A number of lectures in our didactic seminar are devoted to classic psychosomatic illnesses such as ulcerative colitis, migraine, and asthma. Only one such case was seen in this series. Instead, the “psychosomatic” illnesses our consultants saw were medical conditions that arose as a consequence of such psychiatric illnesses as alcoholism and schizophrenia. While our didactic work also emphasized principles of liaison psychiatry, and in particular systems approaches to management problems, the PCR responses indicated that residents perceived relatively few cases as stemming from staff-patient conflict. The forms again enabled us to refine our teaching and hence the residents’ thinking. Patient follow-up and disposition was an area that had not been systematically evaluated by this 205
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consultation service. The findings here indicated that almost all patients seen in consultation were thought to be in need of psychiatric follow-up after hospital discharge. Attempting to follow through led to the discovery of an inadequate referral system for patients in need of treatment by other units. This finding has enabled us to take the steps necessary to correct these administrative deficiencies. Members of the department had been dimly aware that residents seemed little motivated to pursue literature relevant to their clinical problems. The PCR revealed that this problem had been much greater than we had imagined and that the academic interests of the faculty as well as their function as role models seemed to have little influence over resident attitudes in this particular area. This problem is currently a subject of discussion within the department. Despite the pressure of service demands, the PCR indicated that residents were getting as much supervision as they wanted and that cases that required a great deal of service but provided little learning were compensated for by cases that demanded relatively little service in return for a great deal of learning. Cases viewed as providing more “learning than service” were more often seen by supervisors than were cases providing “more service than learning.” It is unclear if cases were presented for supervisor interviews because they had greater potential to provide a good learning experience, or if the direct presentation to the supervisor caused learning value to exceed service demands. In addition to providing guidelines for obtaining particular factual information, it was found that the PCR forced the resident to conceptualize medically ill patients in psychologic terms and reinforced didactic material addressed to the mind-body continuum. Questions regarding follow-up and disposition further structured the learning experience by emphasizing the longitudinal aspects of consultation work. For the supervisor, the PCR served as a vehicle for rapidly evaluating resident performance. The department’s own consultants see an average of five new patients per week while they receive 1 hour of individual supervision each week. It is thus impossible for the supervisor to see every case. It is also often quite difficult for the supervisor to keep track of all the patients the consultant may be following or to be aware of long-term follow-up needs. The PCR did much to overcome these difficulties in that at a glance, the supervisor could get a sense of the scope and quality of each resident’s
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work. Thus, in terms of data collection, case formulation, and therapeutic intervention, the PCR facilitated the teaching done in direct supervision of clinical work. Overall, the use of the PCR greatly enhanced the ability to teach and supervise residents, evaluate the results of teaching, and get an overview of residents’ activities during the consultation experience. In addition, by structuring the residents’ training experience, the PCR seemed to diminish the anxiety normally associated with training in consultation psychiatry.
References 1.Meyer E, Mendelson M: Psychiatric consultation 2. 3. 4. 5. 6.
7.
8.
9.
10. 11. 12. 13. 14.
with patients on medical and surgical wards: Patterns and processes. Psychiatry 24:197-220, 1961 Mendelson M, Meyer E: Countertransference problems of the liaison psychiatrist. Psychosom Med 23:115-122, 1961 Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosom Med 29:153-171, 1968 Lipowski ZJ: Review of consultation psychiatry and psychosomtic medicine: II. Clinical aspects. Psychosom Med 29:201-224, 1968 Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: III. Theoretical issues. Psychosom Med 29:395-422, 1968 Reiser MF: Changing theoretical concepts in psychosomatic medicine. In Silvano Arieti (ed). American Handbook of Psychiatry, Vol. IV: Organic Disorders and Psychosomatic Medicine. New York, Basic Books Inc., 1975 Houpt JL, Weinstein HM, Russell ML: The Application of corn etency based education to consultation liaison psyc K.iatry: I. Data gathering and case formulation. Int J Psychiatry Med 7:295307, 1976-77 Houpt JL, Weinstein HM, Russell ML: The application of competency based education and consultation liaison psychiatry: II. Intervention knowledge and skills. Int J Psychiatry Med 7:309-320, 1976-77 Russell ML, Weinstein HM, Houpt JL: The application of competency based education and consultation liaison psychiatry: III. Implications. Int J Psychiatry Med 7:321328, 1976-77 Kimball CP: The clinical case method in teaching comprehensive approaches to illness behavior. Psychosom Med 37:454467, 1975 Schwab JJ, Clemmons RS, Marder L: Training psychiatric residents in consultation work. J Med Educ 41:1077-1082, 1966 Reichsman F: Teaching psychosomatic medicine to medical students, residents, and postgraduate fellows. Int J Psychiatry Med 6:307316, 1975 Deutsch F, Kaufman R, Flumgart HL: Present methods of teaching. Psychosom Med 2:213-222, 1940 McKegney FP: The teaching of psychosomatic
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medicine: Consultation liaison psychiatry. In Silvano Arieti (ed). American Handbook of Psychiatry, Vol. IV. New York, Basic Books Inc., 1975 15. Kahana R, Bibring GL: Personality types in medical management. In Zinberg NE (ed). Psychiatry and Medical Practice in a General Hospital. New York, International Universities Press, 1964 16. Jacobs JW, Bernhard MR, Delgado A, Strain JJ: Screening for organic mental syndromes in the medically ill. Ann Intern Med 86:4046, 1977 17. Lipowski ZJ: Consultation-liaison psychiatry: An overview. Am J Psychiatry 131:623-630, 1974
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18. Eaton JS, Goldberg R, Rosinski E, Allerton WS: The educational challenge of consultation-liaison psychiatry. Am J Psychiatry 134 (Suppl): 20-23, 1977
Direct reprint requests to: Shepard J. Kantor, M.D. Consultation Psychiatry Service St. Luke’s Hospital Amsterdam Avenue at 114th Street New York, NY 10025
Appendix Psychiatric
Consultation Part I
Record
1. Patient information Name Hospital No. Location Age Sex Race Marital Status S-tiW_DService Admission date Surgery date Admission diagnosis Severity of medical diagnosis -Severe -Moderate -Mild or less Degree of distress -Severe -Moderate -Mild 2. Consultation A. Urgency
Procedure Treatment includes: -Diuretic/antihypertensive/cardiac -Steroids -Cytotoxic/immunosuppressive -Narcotics/methadone -None of the above
drugs
information B.
-Immediate -Today -This week D. The person first suggesting -Patient Nurse -Social worker Medical student E.
drugs
a psychiatric
The person actually requesting Nurse -Social worker -Medical student
Severity of psychiatric condition
C. Duration of problem
-Extreme -Moderate -Mild
Hours -Days -Week
evaluation was: -Intern -Resident -Fellow -Attending
-Family -Other Name
this consultation is: -Fellow -Intern Resident
or more member
-Attending -Ward clerk -Other Name
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F. The patient was told of this consultation -Yes -No Patient’s attitude toward consultation --_-Positive Neutral -Negative 3. Reason for consultation request A. No active problem Routine for program Academic interest only History of psychiatric illness -Patient requested it -B.
Diagnostic assistance
_C.
Patient management -Suicidal -Disturbed behavior -Extreme emotional reaction (depression, anxiety, fear) -Psychiatric symptom from drug therapy -Selection or preparation for procedure Refusal to cooperate -Threat to sign out AMA -Refusal of diagnostic procedure aefusal of surgery
-D.
Name of program
-Delayed convalescence -Conflict with staff _.Pain -Organic&y alcoholism -Drug abuse -Disposition -Other
The patient is suffering from depression or anxiety but not enough to interfere with management.
E. Please describe the problem in 1 sentence or less 4. Overall impression A. The cause of this hospitalization was a medical-surgical illness which appears to have had a major psychological precipitant. The cause of this hospitalization was a medical-surgical illness with minimal or absent psychological _B. contribution. C. This patient has significant psychopathology which may or may not be related to his/her cause for hospitalization. -Yes No D. At the time of admission I suspected this patient would need a psychiatric evaluation at some time during his/her hospitalization. -Yes No -Don’t know-1 picked up this case more than 48 hours after admission. 5. Date
and time
this consultation request was phoned in (x-1089).
Part II: To be filled in by consultant Patient’s name I. Consultant’s name
-Resident -Fellow -Attending 208
I’CR No.
Day of week Date of consultation Time consultation initiated Total time consumed to initially evaluate situation-Include chart review, interviews, etc. (should be less than item 9B)
Psychiatric
-Less -Three -Greater 2. Consultant’s
general assessment
of situation-medical
situation
diagnosis
Severity of psychiatric condition -Extreme -Moderate Mild
Duration -Hours -Days -Week
or more
Reason for consultation request (as you perceive it) a) No active problem Routine for program Name of program Academic interest only History of psychiatric illness -Patient requested it _B) Diagnostic assistance _C) Patient management -Suicidal -Delayed convalescence -Disturbed behavior -Conflict with staff -Extreme emotional reaction -Pain (depression, anxiety, fear) -0rganicity -Psychiatric symptom from drug therapy Alcoholism -Selection or preparation for procedure -Drug abuse -Refusal to cooperate -Disposition -Threat to sign out AMA -Other -Refusal of diagnostic procedure -Refusal of surgery _D) The patient is suffering from depression or anxiety but not enough to interfere with management.
3. Psychiatric evaluation of patient A. Psychiatric history -1. No previous psychiatric history 2. History positive for alcohol/drug abuse Positive psychiatric history for: (check all which apply) -3. -Hospitalization -Suicide attempt -Suicide gesture -Drug treatment (for longer than one week) Antidepressant (tricyclic, MAO) Antipsychotic (phenothiazine, etc.) -Antianxiety (diazepam, etc.) -Hypnotic (flurazepam, etc.) _Prescribed drugs, type unknown -Self-medication -Psychotherapy (brief, long-term, supportive, insight, group, etc.) -Behavior therapy (hypnosis, conditioning, etc.) -Electroshock therapy -Other B.
Record
than three months on service to six months on service than six months on service
A. Urgency of psychiatric -Immediate -Today -This week B.
Consultation
Psychiatric findings (check all which apply) 1. Personality configuration -Phobic anxiety -0verdemanding (oral) -Controlled (anal, compulsive) -Dramatic (hysterical) -Self-sacrificing (masochistic) -..__Guarded (paranoid)
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-Superior (narcissistic) aloof (schizoid) -Don’t know or can’t fit into this formulation 2. Psychosis A. Absent B. -Present _unctional -Schizophrenic -Manic -Depressive -Other -Organic 3. Neurosis/character disorder -Absent Lresent -Conversion reaction -Depression Anxiety state alcohol abuse -Drug abuse -Other 4. Cognitive function A. Rating-Jacob’s Scale -Patient unable to cooperate l-10 -11-19 7030 -0rganicity absent -0rganicity present -Chronic Acute (delirium) -Both B. Apparent cause -1) Toxic (fever) -2) CNS involvement with disease process -3) Drug induced -4) Metabolic (electrolytes, liver function abnormalities, -5) Environmental (CCU, ICU, Sundowner, etc.) C. EEG -Not done -Normal _Focally abnormal -Diffusely abnormal
etc.)
4. Overall formulation of problem (pick one only) A. Intrapsychic The patient’s normal coping mechanisms are inadequate to deal with the stress or a more or less routine illness and hospitalization, i.e., to deal with the average expectable hospital environment, or to deal with illness related problems in addition to his/her life situation outside the hospital. -B
. Interpersonal
While intrapsychic factors are apparent, tween the patient and the staff. -C.
the major difficulties lie with the interactions
be-
Impersonal While intrapsychic and interpersonal factors are evident, the overwhelming nature of the patient’s illness, environment, toxic metabolic state, or some other factors not at all, indirectly, or only minimally related to interpersonal or intrapsychic issues seem to be the major source of this patient’s problem.
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5. Psychiatric intervention _A. Single evaluation sufficient for total management -B. Transfer to inpatient psychiatric service _C. Further intervention necessary 1. With patient -Pharmacologic ---Antipsychotic (phenothiazine, etc.) Antianxiety (diazepam, etc.) --Antidepressant (tricyclic, MAO) hypnotic (flurazepam, barbiturate, etc.) Alteration in medically indicated drugs (e.g., -Other -Psychotherapeutic (supportive or insight) -Behavioral (conditioning, hypnosis, etc.) -Other 2. With primary physician -None -Explained -Information gathering Advised 3. With social service -None -Explained -Information gathering -Advised 4. With other staff __..._Explained -None -Information gathering -Advised 5. With outside M.D./therapist -Explained -None -Information gathering Advised 6. With patient’s family (first-degree relatives) -Information -None -Explaining -Telephone contact -Advised -Interview 7. With other relatives or friends -Information -None -Telephone contact -Explained -Interview -Advised
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Record
steroids)
what you were doing him/her to do something
different
what you were doing him/her to do something
different
what you were doing him/her to do something
different
what you were doing him/her to do something
different
gathering what you are doing him/her to do something
different
gathering what you are doing him/her to do something
different
6. Consultation follow-up _-_-A. Continuous consultation by me throughout hospitalization. _B. No further psychiatric intervention necessary after consultant’s recommendations were implemented, patient remained in the hospital beyond the time that consultant’s participation was necessary. -C. Patient transferred to inpatient psychiatric unit. -D. Patient transferred to _ Social worker, Other -Private psychiatrist Name _E. Continued psychiatric intervention needed but not possible due to: -Consultant -Patient -Staff -Other -Patient’s family _F. Patient still in hospital when I went off service. .-.-Transferred to private psychiatrist -No follow-up needed -Other -Transferred to incoming resident -Transferred to social service
i.e.,
7. Ultimate psychiatric disposition at time of hospital discharge A. Medical condition expected to resolve. . . (return to normal function expected within 6 weeks of discharge, 1. -Psychiatric intervention definitive e.g., acute abdomen, diabetic coma). 2. -Further psychiatric follow-up:
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-Indicated, -Indicated, -Indicated,
not desired desired, not available desired, available A specific appointment was not made A specific appointment was made how long after discharge? -Days -Weeks -Indefinite Where?
B. Medical condition expected to persist. . . . (specific impaired function beyond six weeks of discharge ex1 . -Psychiatric intervention definitive petted, e.g., CVA, mutilative surgery). 2. -Further psychiatric follow-up: -Indicated, but not desired -Indicated, desired, not available -Indicated, desired, available A specific appointment was not made A specific appointment was made -How long after discharge? -Days -Weeks -Indefinite Where? 8. Overall impression The major cause of this hospitalization was a medical-surgical illness which appears to have had a major A. psychological precipitant. (Patients who react to stress with a particular somatic symptom or with an exacerbation of some psychophysiologic or latent somatic condition, such as angina, colitis, ulcer disease, or asthma and where the source of stress is obviously demonstrable and acknowledged by the patient. Also include patients admitted for complications of suicide attempts/gestures.) The major cause of this hospitalization was a medical-surgical illness with minimal or absent psychological _B, contribution. (A patient whose manifest illness can only be linked to psychological factors through speculative psychological formulations or whose illness may be related to a “weakened condition” secondary to psychological stresses should be included here.) _C. This patient has significant psychopathology which may or may not be related to his/her cause for hospitalization. -Yes -No 9. Consultant involvement A. Total number of visits -1 2-3 -4-5 -6 or more
B. Total number of hours -1 23 -4-5 -6 or more (This should always be greater than “time to evaluate” from Part II, page 1)
C. This consultation was -Easier than most Routine More difficult than most 10. Training value A. _T received no supervision on this case Patient verbally presented to supervisor
212
-Once -More
than once
Psychiatric
-Patient
verbally presented
to more than one supervisor
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Record
-Separately -Or at conference
Patient interviewed by supervisor -Patient interviewed at conference with more than one supervisor (None may sometimes be adequate) B. -I received adequate supervision _I received inadequate supervision -Because of me -Because of my supervisor C. This case prompted me to read something in the literature -No _Yes What? D. This consultation provided: More service than learning More learning than service -Equal learning and service How long did it take to fill out this form?
213
Irene Chiarandini, M. D. Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, and Attending, Consultation Psychiatry Service, St. Luke’s Hospital, New York, New York
Stanley S. Heller, M.D. Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, and Director, Consultation Psychiatry Service, St. Luke‘s Hospital, New York, New York Abstract: The Psychiatric Consultation Record (PCR) is an instrument developed to aid in the teaching of consultation psychiatry, to evaluate the impact of this teaching, and to provide an overall assessment of the consultation training program at St. Luke’s Hospital. The PCR both structures the resident‘s training experienceand provides a tool with which he or she can integrate theoretical and practical knowledgepertaining to consultation work. Its use has enabled supervisors to detect the degreeto which didactic material has become integrated into residents’ thinking and has provided data through which the scope and quality of each resident’s work can be rapidly assessed. Finally, its use has brought to light deficiencies in service delivery which, beforethe use of this instrument, had not been apparent.
Becoming a skilled consultant to a general medical or surgical service is a particularly stressful experience for psychiatric residents. Not only must the resident obtain a thorough understanding of individual and group psychology as well as psychopharmacology, but he or she must be well enough versed in medicine to understand thoroughly the diverse contributions physical illness and medication make to the clinical conditions he or she is asked to evaluate (1). The time pressure This work was supported in part by NIMH-Psychiatry Brunch, Grant No. MH 15707.
202 ISSN 0163~8343/79/030202-lZ$O2.25
Education
under which the residents work is exacerbated by the emergent nature of many of the psychiatric problems they must assess. Such consultations demand a wide variety of psychiatric skills including the rapid evaluation, diagnosis, and treatment of, at times, severely disturbed and extremely ill medical-surgical patients (2). A further problem which confronts the consultation trainees is that of assimilating an extensive body of new material that stands at the interface between medicine and psychiatry. Didactic seminars devoted to such diverse topics as organic mental syndromes, personality styles and their interaction with medical illness, psychosomatic medicine, and the consultation-liaison process itself are major elements of any substantial consultation training program. Unfortunately, this material may present the resident with a bewildering set of new ideas and concepts (3-6) which must be thoroughly integrated in order for the consultant to function as effectively as possible. Because of these difficulties, structuring the training experience of psychiatric residents during their rotations as consultant to medical-surgical units has been an area of particular concern to those involved with teaching consultation-liaison psychiatry (7-14). The Psychiatric Consultation Record (PCR) was developed by one of the authors (S.
General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
Psychiatric
J. K.) in an attempt to overcome some of the difficulties intrinsic to teaching in this complex area. This paper describes the PCR and reports findings after one year’s use on the consultation service at St. Luke’s Hospital. St. Luke’s is a 700-bed hospital which is a major teaching affiliate of the Columbia University College of Physicians and Surgeons. The consultations reported in this paper were all performed on patients admitted to the ward services. These patients were predominantly from a Black and Hispanic, low and lower-middle class population.
Method The PCR is a two-part form (see Appendix). It was designed to allow comparisons to be made between psychiatric and medical house officers’ perception of psychiatric illnesses in medical-surgical patients, to evaluate service delivery by the consultation department, and to better assess residents’ consultation skills and practices. This report is limited to Part II of the PCR and concerns the use of this instrument in program evaluation and in the training of residents in consultation psychiatry. Part II is a checklist form with 10 major areas of inquiry. These include description of the clinical problem, psychiatric findings, case formulation, intervention, follow-up, disposition, and training value to the resident. Questions concerning psychiatric assessment address themselves to such historical events as hospitalization, somatic or psychologic treatments, and suicide attempts or gestures. Current psychologic functioning is assessed in terms of psychosis, neurosis, and character disorder as well as in terms of the seven basic categories of personality types and attitudes as developed by Kahana and Bibring (15). These categories emphasize the different meanings physical illness has to particular patients, as well as the kind of defensive and adaptive behaviors that become intensified under the stress of illness. Their basic personality types are described as: dependent, demanding, (oral); orderly, controlled, (compulsive); dramatizing, emotionally involved, (hysterical); long-suffering, self-sacrificing, (masochistic); guarded, (paranoid); aloof, (schizoid); superior, (narcissistic). The presence or absence of organic impairment is assessed through use of the Cognitive Function Scale of Jacobs et al. (16).The resident must formulate the overall consultation problem in terms of intrapsychic conflict (failure of normal coping
Consultation
Record
mechanisms), interpersonal conflict (disordered interaction between patient and staff), or impersonal (toxic or metabolic) etiology. The consultant is also asked whether or not patients were hospitalized for conditions thought to be a direct consequence of psychologic factors. Patients who reacted to stress with a particular somatic symptom or with an exacerbation of some psychophysiologic or latent somatic condition such as angina, colitis, or asthma, and for whom the source of stress is obviously demonstrable and acknowledged, are included here. Also in this group are patients admitted for complications of suicide attempts and those with a medical illness that stemmed from psychiatric disturbances such as alcoholism. Patients whose manifest illness could be linked to psychologic factors only through speculative formulations or whose illness was related to a “weakened condition” secondary to psychologic stress were considered to have minimal or absent psychologic precipitants to their hospitalization. Questions concerning the consultation process itself address themselves to the type of psychiatric intervention, number of visits, time commitment, and disposition. Disposition is dichotomized in terms of patients whose illnesses were and were not expected to resolve within 6 weeks of hospital discharge. Finally, educational value of each case was assessed with questions about the adequacy and type of supervision obtained, the type of reading stimulated, and the balance between service and Iearning. Psychiatric residents using the PCRs were serving on the consultation service for 6 months during their PGY-3 year. During this study, six different residents completed forms on 58 patients selected randomly from 400 consultations initiated during one academic year. The forms were reviewed during supervisory sessions by the three authors. Not all questions were answered on every form. Results will therefore be reported in terms of total responses for each particular question.
Results More than 60% (37158) of the consultations were requested to assist with the management of nondisruptive patients. Diagnostic assistance, questions about the uses and side effects associated with psychotropic drugs, management of anxiety and depression, and assessment of suicidal risk all fell within this category. The remaining consultation 203
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requests (21/58) included threats to sign out against medical advice, refusals to cooperate with diagnostic or treatment procedures, and assaultive or unmanageable behavior. Almost 60% (32154) of the consultations seemed to stem from the inability of patients to cope adequately with the stress of “a more or less routine illness.” An additional 30% (17154) came as a consequence of toxic metabolic states such as organic psychoses, drug withdrawal, or pulmonary failure, whereas less than 10% (5/54) seemed to have their origin in patient-staff conflict. In this series of 57 patients, nearly 50% (26157) were found to be psychotic: 13 had organic psychoses (four associated with alcoholism) and 13 had functional psychoses. Nearly 40% (21157) were thought to have neurosis or personality disorders. Residents classified two-thirds of their patients using a single or two or three seemingly compatible Kahana and Bibring personality diagnoses. In the remaining third, they either did not know how to classify a patient using these criteria or, in four cases, simultaneously used several mutually exclusive diagnoses. Residents attempted to use the Jacobs Scale for organicity in 37 patients. Two patients were found to be severely organic (rating l-lo), nine moderately organic (rating 11-19) and 13 not organic (rating 2030). In 13, the Jacobs Scale could not be used because patients were unable to cooperate. This was accounted for by severe medical problems (4 patients), language barrier (2 patients), and depression, anxiety, psychosis, or interpersonal difficulties in the remainder. The consultants elected not to use the Jacobs Scale in 19 cases. Clinical judgment found 15 of these to be nonorganic and four organic. Roughly 30% (17147) of the patients in this series were considered to have a psychologic precipitant for their hospitalization. Almost all of these were admitted as a direct consequence of alcoholism (withdrawal, suicide attempts, alcohol-induced exacerbation of pancreatitis or liver disease, debilitation) or due to the disorganizing effects of schizophrenia (autoamputation, exposure to temperature extremes). A single case of ulcerative colitis was the lone example of a classic “psychosomatic” disease seen in this series. The primary treating physician was contacted by the consultant in 47 of the 56 cases seen. In nine others there was no contact with the treating physician and information was exchanged through secretaries, charts, and others. Social workers were
contacted 12 times, other staff members 24, outside physicians 5, immediate family 13, and other relatives or friends 5. Sixty percent (33155) of the patients were continuously followed by the consultant throughout their entire hospitalization. For 10 patients no psychiatric intervention was necessary beyond the implementation of the consultant’s initial recommendations. Of the remaining 12, four needed transfer to the inpatient psychiatric unit, seven were referred to social workers, and one to a private psychiatrist. Sixty percent (33155) of the cases required one to three visits by the consultant while 40% (22/55) required four or more visits. While 60% (33/54) of the cases could be managed in l-3 hours of the consultant’s time, 20% (10154) took 4-5 hours and another 20% (U/54) took 6 or more hours each. Residents found 50% (28156) of their cases “routine,” almost 40% (21156) “more difficult than most” and 10% “less difficult than most.” The consultants believed that continued psychiatric intervention beyond the time of hospital discharge was necessary in the overwhelming majority of cases (48/57). Of the nine patients for whom follow-up was not recommended, three died, two were transferred to the inpatient psychiatry service, and one signed out AMA. Whether the medical condition for which the patient was hospitalized could be expected to resolve (return to normal function within 6 weeks of discharge) or persist (impaired function beyond 6 weeks after discharge) did not seem to affect the perceived need for outpatient psychiatric treatment. More than 40% (26/56) of the cases were discussed with a supervisor and an additional 30% (17/56) were directly interviewed by supervisors. The remaining 13 cases were unsupervised. Residents considered supervision adequate in all but two cases, both a consequence of a lack of resident initiative. Residents found “service equal to learning” in almost 70% (39157) of the cases; they found “service greater than learning” in 20% (11157) and “learning greater than service” in 10% (7/57). Five of the seven cases in which “learning was greater than service” were interviewed directly by supervisors, whereas none of the “service greater than learning” had direct supervisor interviews. There appeared to be no distinction between these two groups in terms of medical and psychiatric diagnoses, number of visits, time consumed, or degree of difficulty. It also
Psychiatric
did not seem to matter which psychiatric resident had done the consultation. Reading was done on only 12 of 56 cases. While this tended to be done in cases seen as “more difficult” (8112) half of the reading was accounted for by one resident. Most of the time (40/51), the PCR could be filled out by the consultant in 10 minutes or less (17 of these were completed in less than 5 minutes). In 11 instances, the PCR took more than 10 minutes to complete.
Discussion Proficiency in clinical interviewing, thoroughness and rapidity of case formulations, and appropriate and comprehensive treatment planning are major goals in the training of consultation psychiatrists (11, 12, 14, 17). While clinical conferences, didactic seminars, and individual supervision are the core experiences of consultation-liaison training programs (18), the optimal method for teaching consultation skills and evaluating the resident’s acquisition of these skills is currently uncertain. As a consequence, innovative methods of teaching and program evaluation continue to evolve. One such innovation is Kimball’s Clinical Case Method (10). A prepared, detailed, and carefully referenced clinical history is used to prompt discussion about a great variety of issues that routinely confront the psychiatric consultant. These issues include illness onset situation, reaction to illness, patient management, and treatment planning. Criteria for ascertaining the degree to which the principles taught through this method are actually incorporated and utilized by the consultant trainee are not included. Houpt et al. (7, 8) and Russell et al. (9) have developed a Competency Based Model for training in consultation psychiatry. This is a detailed, carefully thought out attempt to segment consultation activities into discrete areas which can then be carefully observed and measured. These areas include data gathering, case formulation, intervention skills, special patient problems, special areas of knowledge, and liaison attitudes. Explicit objectives are established within each area as are guidelines for assessing the degree to which residents actually meet these objectives. The elucidation of such objectives within each step of the consultation process serves as a focus for overall program design and as a guide to supervisors. Further, in providing the resident with an outline of the program in which he or she will be involved as
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well as with explicit objectives of the program, the Competency Based Model serves to lessen the anxiety intrinsic to rotations on psychiatric consultation services. As does the Competency Based Model, the PCR serves to organize the consultation learning experience and to provide a guide for supervision. It also provides information which can be used for program evaluation. Further, its structure enables the resident to have a clear sense of what information must be gathered on each consultation and of the way in which it should be organized. Using the PCR for program evaluation has enabled us to teach more adequately some of the concepts necessary for the consultant psychiatrist. A major finding was that one-third of the time, the residents could not use or incorrectly used Kahana and Bibring diagnostic classifications. This indicated that a lecture on this topic-perceived as excellent by the faculty-had done little to enable the residents to integrate the use of these formulations into their daily contact with patients. A consequence of this finding is that supervisors have begun to use these formulations more directly in their individual case supervision. Despite what faculty believed had been excellent didactic instruction on delirium, and despite frequent clinical conferences centered on organic patients, residents tended to limit their assessment of cognitive function to be “oriented x 3” prior to using these forms. The inclusion of the Jacobs Scale in the PCR enabled the residents to sharpen their ability to detect organicity and to follow its course throughout a patient’s hospitalization. Residents did, however, seem reluctant to use the scale when they judged patients’ disorders to be nonorganic. A number of lectures in our didactic seminar are devoted to classic psychosomatic illnesses such as ulcerative colitis, migraine, and asthma. Only one such case was seen in this series. Instead, the “psychosomatic” illnesses our consultants saw were medical conditions that arose as a consequence of such psychiatric illnesses as alcoholism and schizophrenia. While our didactic work also emphasized principles of liaison psychiatry, and in particular systems approaches to management problems, the PCR responses indicated that residents perceived relatively few cases as stemming from staff-patient conflict. The forms again enabled us to refine our teaching and hence the residents’ thinking. Patient follow-up and disposition was an area that had not been systematically evaluated by this 205
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consultation service. The findings here indicated that almost all patients seen in consultation were thought to be in need of psychiatric follow-up after hospital discharge. Attempting to follow through led to the discovery of an inadequate referral system for patients in need of treatment by other units. This finding has enabled us to take the steps necessary to correct these administrative deficiencies. Members of the department had been dimly aware that residents seemed little motivated to pursue literature relevant to their clinical problems. The PCR revealed that this problem had been much greater than we had imagined and that the academic interests of the faculty as well as their function as role models seemed to have little influence over resident attitudes in this particular area. This problem is currently a subject of discussion within the department. Despite the pressure of service demands, the PCR indicated that residents were getting as much supervision as they wanted and that cases that required a great deal of service but provided little learning were compensated for by cases that demanded relatively little service in return for a great deal of learning. Cases viewed as providing more “learning than service” were more often seen by supervisors than were cases providing “more service than learning.” It is unclear if cases were presented for supervisor interviews because they had greater potential to provide a good learning experience, or if the direct presentation to the supervisor caused learning value to exceed service demands. In addition to providing guidelines for obtaining particular factual information, it was found that the PCR forced the resident to conceptualize medically ill patients in psychologic terms and reinforced didactic material addressed to the mind-body continuum. Questions regarding follow-up and disposition further structured the learning experience by emphasizing the longitudinal aspects of consultation work. For the supervisor, the PCR served as a vehicle for rapidly evaluating resident performance. The department’s own consultants see an average of five new patients per week while they receive 1 hour of individual supervision each week. It is thus impossible for the supervisor to see every case. It is also often quite difficult for the supervisor to keep track of all the patients the consultant may be following or to be aware of long-term follow-up needs. The PCR did much to overcome these difficulties in that at a glance, the supervisor could get a sense of the scope and quality of each resident’s
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work. Thus, in terms of data collection, case formulation, and therapeutic intervention, the PCR facilitated the teaching done in direct supervision of clinical work. Overall, the use of the PCR greatly enhanced the ability to teach and supervise residents, evaluate the results of teaching, and get an overview of residents’ activities during the consultation experience. In addition, by structuring the residents’ training experience, the PCR seemed to diminish the anxiety normally associated with training in consultation psychiatry.
References 1.Meyer E, Mendelson M: Psychiatric consultation 2. 3. 4. 5. 6.
7.
8.
9.
10. 11. 12. 13. 14.
with patients on medical and surgical wards: Patterns and processes. Psychiatry 24:197-220, 1961 Mendelson M, Meyer E: Countertransference problems of the liaison psychiatrist. Psychosom Med 23:115-122, 1961 Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosom Med 29:153-171, 1968 Lipowski ZJ: Review of consultation psychiatry and psychosomtic medicine: II. Clinical aspects. Psychosom Med 29:201-224, 1968 Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: III. Theoretical issues. Psychosom Med 29:395-422, 1968 Reiser MF: Changing theoretical concepts in psychosomatic medicine. In Silvano Arieti (ed). American Handbook of Psychiatry, Vol. IV: Organic Disorders and Psychosomatic Medicine. New York, Basic Books Inc., 1975 Houpt JL, Weinstein HM, Russell ML: The Application of corn etency based education to consultation liaison psyc K.iatry: I. Data gathering and case formulation. Int J Psychiatry Med 7:295307, 1976-77 Houpt JL, Weinstein HM, Russell ML: The application of competency based education and consultation liaison psychiatry: II. Intervention knowledge and skills. Int J Psychiatry Med 7:309-320, 1976-77 Russell ML, Weinstein HM, Houpt JL: The application of competency based education and consultation liaison psychiatry: III. Implications. Int J Psychiatry Med 7:321328, 1976-77 Kimball CP: The clinical case method in teaching comprehensive approaches to illness behavior. Psychosom Med 37:454467, 1975 Schwab JJ, Clemmons RS, Marder L: Training psychiatric residents in consultation work. J Med Educ 41:1077-1082, 1966 Reichsman F: Teaching psychosomatic medicine to medical students, residents, and postgraduate fellows. Int J Psychiatry Med 6:307316, 1975 Deutsch F, Kaufman R, Flumgart HL: Present methods of teaching. Psychosom Med 2:213-222, 1940 McKegney FP: The teaching of psychosomatic
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medicine: Consultation liaison psychiatry. In Silvano Arieti (ed). American Handbook of Psychiatry, Vol. IV. New York, Basic Books Inc., 1975 15. Kahana R, Bibring GL: Personality types in medical management. In Zinberg NE (ed). Psychiatry and Medical Practice in a General Hospital. New York, International Universities Press, 1964 16. Jacobs JW, Bernhard MR, Delgado A, Strain JJ: Screening for organic mental syndromes in the medically ill. Ann Intern Med 86:4046, 1977 17. Lipowski ZJ: Consultation-liaison psychiatry: An overview. Am J Psychiatry 131:623-630, 1974
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18. Eaton JS, Goldberg R, Rosinski E, Allerton WS: The educational challenge of consultation-liaison psychiatry. Am J Psychiatry 134 (Suppl): 20-23, 1977
Direct reprint requests to: Shepard J. Kantor, M.D. Consultation Psychiatry Service St. Luke’s Hospital Amsterdam Avenue at 114th Street New York, NY 10025
Appendix Psychiatric
Consultation Part I
Record
1. Patient information Name Hospital No. Location Age Sex Race Marital Status S-tiW_DService Admission date Surgery date Admission diagnosis Severity of medical diagnosis -Severe -Moderate -Mild or less Degree of distress -Severe -Moderate -Mild 2. Consultation A. Urgency
Procedure Treatment includes: -Diuretic/antihypertensive/cardiac -Steroids -Cytotoxic/immunosuppressive -Narcotics/methadone -None of the above
drugs
information B.
-Immediate -Today -This week D. The person first suggesting -Patient Nurse -Social worker Medical student E.
drugs
a psychiatric
The person actually requesting Nurse -Social worker -Medical student
Severity of psychiatric condition
C. Duration of problem
-Extreme -Moderate -Mild
Hours -Days -Week
evaluation was: -Intern -Resident -Fellow -Attending
-Family -Other Name
this consultation is: -Fellow -Intern Resident
or more member
-Attending -Ward clerk -Other Name
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F. The patient was told of this consultation -Yes -No Patient’s attitude toward consultation --_-Positive Neutral -Negative 3. Reason for consultation request A. No active problem Routine for program Academic interest only History of psychiatric illness -Patient requested it -B.
Diagnostic assistance
_C.
Patient management -Suicidal -Disturbed behavior -Extreme emotional reaction (depression, anxiety, fear) -Psychiatric symptom from drug therapy -Selection or preparation for procedure Refusal to cooperate -Threat to sign out AMA -Refusal of diagnostic procedure aefusal of surgery
-D.
Name of program
-Delayed convalescence -Conflict with staff _.Pain -Organic&y alcoholism -Drug abuse -Disposition -Other
The patient is suffering from depression or anxiety but not enough to interfere with management.
E. Please describe the problem in 1 sentence or less 4. Overall impression A. The cause of this hospitalization was a medical-surgical illness which appears to have had a major psychological precipitant. The cause of this hospitalization was a medical-surgical illness with minimal or absent psychological _B. contribution. C. This patient has significant psychopathology which may or may not be related to his/her cause for hospitalization. -Yes No D. At the time of admission I suspected this patient would need a psychiatric evaluation at some time during his/her hospitalization. -Yes No -Don’t know-1 picked up this case more than 48 hours after admission. 5. Date
and time
this consultation request was phoned in (x-1089).
Part II: To be filled in by consultant Patient’s name I. Consultant’s name
-Resident -Fellow -Attending 208
I’CR No.
Day of week Date of consultation Time consultation initiated Total time consumed to initially evaluate situation-Include chart review, interviews, etc. (should be less than item 9B)
Psychiatric
-Less -Three -Greater 2. Consultant’s
general assessment
of situation-medical
situation
diagnosis
Severity of psychiatric condition -Extreme -Moderate Mild
Duration -Hours -Days -Week
or more
Reason for consultation request (as you perceive it) a) No active problem Routine for program Name of program Academic interest only History of psychiatric illness -Patient requested it _B) Diagnostic assistance _C) Patient management -Suicidal -Delayed convalescence -Disturbed behavior -Conflict with staff -Extreme emotional reaction -Pain (depression, anxiety, fear) -0rganicity -Psychiatric symptom from drug therapy Alcoholism -Selection or preparation for procedure -Drug abuse -Refusal to cooperate -Disposition -Threat to sign out AMA -Other -Refusal of diagnostic procedure -Refusal of surgery _D) The patient is suffering from depression or anxiety but not enough to interfere with management.
3. Psychiatric evaluation of patient A. Psychiatric history -1. No previous psychiatric history 2. History positive for alcohol/drug abuse Positive psychiatric history for: (check all which apply) -3. -Hospitalization -Suicide attempt -Suicide gesture -Drug treatment (for longer than one week) Antidepressant (tricyclic, MAO) Antipsychotic (phenothiazine, etc.) -Antianxiety (diazepam, etc.) -Hypnotic (flurazepam, etc.) _Prescribed drugs, type unknown -Self-medication -Psychotherapy (brief, long-term, supportive, insight, group, etc.) -Behavior therapy (hypnosis, conditioning, etc.) -Electroshock therapy -Other B.
Record
than three months on service to six months on service than six months on service
A. Urgency of psychiatric -Immediate -Today -This week B.
Consultation
Psychiatric findings (check all which apply) 1. Personality configuration -Phobic anxiety -0verdemanding (oral) -Controlled (anal, compulsive) -Dramatic (hysterical) -Self-sacrificing (masochistic) -..__Guarded (paranoid)
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-Superior (narcissistic) aloof (schizoid) -Don’t know or can’t fit into this formulation 2. Psychosis A. Absent B. -Present _unctional -Schizophrenic -Manic -Depressive -Other -Organic 3. Neurosis/character disorder -Absent Lresent -Conversion reaction -Depression Anxiety state alcohol abuse -Drug abuse -Other 4. Cognitive function A. Rating-Jacob’s Scale -Patient unable to cooperate l-10 -11-19 7030 -0rganicity absent -0rganicity present -Chronic Acute (delirium) -Both B. Apparent cause -1) Toxic (fever) -2) CNS involvement with disease process -3) Drug induced -4) Metabolic (electrolytes, liver function abnormalities, -5) Environmental (CCU, ICU, Sundowner, etc.) C. EEG -Not done -Normal _Focally abnormal -Diffusely abnormal
etc.)
4. Overall formulation of problem (pick one only) A. Intrapsychic The patient’s normal coping mechanisms are inadequate to deal with the stress or a more or less routine illness and hospitalization, i.e., to deal with the average expectable hospital environment, or to deal with illness related problems in addition to his/her life situation outside the hospital. -B
. Interpersonal
While intrapsychic factors are apparent, tween the patient and the staff. -C.
the major difficulties lie with the interactions
be-
Impersonal While intrapsychic and interpersonal factors are evident, the overwhelming nature of the patient’s illness, environment, toxic metabolic state, or some other factors not at all, indirectly, or only minimally related to interpersonal or intrapsychic issues seem to be the major source of this patient’s problem.
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5. Psychiatric intervention _A. Single evaluation sufficient for total management -B. Transfer to inpatient psychiatric service _C. Further intervention necessary 1. With patient -Pharmacologic ---Antipsychotic (phenothiazine, etc.) Antianxiety (diazepam, etc.) --Antidepressant (tricyclic, MAO) hypnotic (flurazepam, barbiturate, etc.) Alteration in medically indicated drugs (e.g., -Other -Psychotherapeutic (supportive or insight) -Behavioral (conditioning, hypnosis, etc.) -Other 2. With primary physician -None -Explained -Information gathering Advised 3. With social service -None -Explained -Information gathering -Advised 4. With other staff __..._Explained -None -Information gathering -Advised 5. With outside M.D./therapist -Explained -None -Information gathering Advised 6. With patient’s family (first-degree relatives) -Information -None -Explaining -Telephone contact -Advised -Interview 7. With other relatives or friends -Information -None -Telephone contact -Explained -Interview -Advised
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steroids)
what you were doing him/her to do something
different
what you were doing him/her to do something
different
what you were doing him/her to do something
different
what you were doing him/her to do something
different
gathering what you are doing him/her to do something
different
gathering what you are doing him/her to do something
different
6. Consultation follow-up _-_-A. Continuous consultation by me throughout hospitalization. _B. No further psychiatric intervention necessary after consultant’s recommendations were implemented, patient remained in the hospital beyond the time that consultant’s participation was necessary. -C. Patient transferred to inpatient psychiatric unit. -D. Patient transferred to _ Social worker, Other -Private psychiatrist Name _E. Continued psychiatric intervention needed but not possible due to: -Consultant -Patient -Staff -Other -Patient’s family _F. Patient still in hospital when I went off service. .-.-Transferred to private psychiatrist -No follow-up needed -Other -Transferred to incoming resident -Transferred to social service
i.e.,
7. Ultimate psychiatric disposition at time of hospital discharge A. Medical condition expected to resolve. . . (return to normal function expected within 6 weeks of discharge, 1. -Psychiatric intervention definitive e.g., acute abdomen, diabetic coma). 2. -Further psychiatric follow-up:
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-Indicated, -Indicated, -Indicated,
not desired desired, not available desired, available A specific appointment was not made A specific appointment was made how long after discharge? -Days -Weeks -Indefinite Where?
B. Medical condition expected to persist. . . . (specific impaired function beyond six weeks of discharge ex1 . -Psychiatric intervention definitive petted, e.g., CVA, mutilative surgery). 2. -Further psychiatric follow-up: -Indicated, but not desired -Indicated, desired, not available -Indicated, desired, available A specific appointment was not made A specific appointment was made -How long after discharge? -Days -Weeks -Indefinite Where? 8. Overall impression The major cause of this hospitalization was a medical-surgical illness which appears to have had a major A. psychological precipitant. (Patients who react to stress with a particular somatic symptom or with an exacerbation of some psychophysiologic or latent somatic condition, such as angina, colitis, ulcer disease, or asthma and where the source of stress is obviously demonstrable and acknowledged by the patient. Also include patients admitted for complications of suicide attempts/gestures.) The major cause of this hospitalization was a medical-surgical illness with minimal or absent psychological _B, contribution. (A patient whose manifest illness can only be linked to psychological factors through speculative psychological formulations or whose illness may be related to a “weakened condition” secondary to psychological stresses should be included here.) _C. This patient has significant psychopathology which may or may not be related to his/her cause for hospitalization. -Yes -No 9. Consultant involvement A. Total number of visits -1 2-3 -4-5 -6 or more
B. Total number of hours -1 23 -4-5 -6 or more (This should always be greater than “time to evaluate” from Part II, page 1)
C. This consultation was -Easier than most Routine More difficult than most 10. Training value A. _T received no supervision on this case Patient verbally presented to supervisor
212
-Once -More
than once
Psychiatric
-Patient
verbally presented
to more than one supervisor
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-Separately -Or at conference
Patient interviewed by supervisor -Patient interviewed at conference with more than one supervisor (None may sometimes be adequate) B. -I received adequate supervision _I received inadequate supervision -Because of me -Because of my supervisor C. This case prompted me to read something in the literature -No _Yes What? D. This consultation provided: More service than learning More learning than service -Equal learning and service How long did it take to fill out this form?
213
