consultation liaison psychiatrist – Page 5

Whatever Happened to the Janus Head Logo for ACLP?

I got an email from Don R. Lipsitt, MD yesterday which reminded me of the Janus Head logo for the Academy of Consultation-Liaison Psychiatry (ACLP). It was changed to another sort of nondescript logo several years ago for reasons I didn’t understand.

Dr. Lipsitt is a luminary in C-L Psychiatry and recently published a definitive history of the field, Foundations of C-L Psychiatry: The Bumpy Road to Specialization (2016).

I posted a blog or two about Don and his book in a previous blog, The Practical C-L Psychiatrist. We’ve never formally met. A few years ago, he noticed that I had written about him and his book. I had sent him an email message about it at around the same time the APM was considering the name change for the organization, telling him that I had plugged his book and asking him what he thought of the name change. Incidentally, he thought both of our books made a great package, so I guess I’m allowed to plug mine, strangely titled Psychosomatic Medicine: An Introduction to C-L Psychiatry, editors James Amos and Robert Robinson (2010).

Don expressed his opinion about the name change:

“I feel I have dealt with that at some length in my book. I still feel C-L is most fitting and that the Board made a big mistake naming it PM. Who were they? Any C-L psychiatrists among them? Any Psychosomaticists? Why are not the “complex medically ill” a special population? And why is APA now offering courses on “integrated” care (which is what C-L psychiatry has always been about? The notion that C-L was not declared a specialty because it was considered a skill of ALL psychiatrists (with minimal training), then how do geriatric or child psychiatry become specialties (that all psychiatrists also have training in)? Don’t get me started.”

He considered his book, in large part, a “polemic” against the name “Psychosomatic Medicine.”

Anyway, the ACLP was formerly the Academy of Psychosomatic Medicine (APM) until a couple of years ago when the organization responded robustly to the membership (of which I was one at the time) to abandon the term “Psychosomatic Medicine” and adopt what rank and file practitioners preferred—Consultation-Liaison Psychiatry.

It was a kind of rebranding and it was not the first time the academy had considered a name change. I and a lot of other C-L Psychiatrists cringed at the term “psychosomatic,” not so much because of the word itself in terms of its true denotation, but because of the unfortunate negative connotations it had acquired.

Another luminary of C-L Psychiatry, Dr. Thomas Hackett, MD, wrote about the term “psychosomatic” in the Massachusetts General Hospital: Handbook of general hospital psychiatry: edited by Hackett and Ned Cassem (1978):

“The term ‘psychosomatic service’ has had a variable history. The term generally leaves a bad taste in the mouths of physicians. It reminds them of the 1930s, 1940s, and 1950s, when various psychosomatic schools espoused doctrines linking specific psychological conflicts or unique personality profiles with diseases designated as psychosomatic. Compounding this misunderstanding has been the term’s abuse by the general public, who regard anything psychosomatic as either imaginary or nervous in origin. As a consequence, most people believe that a psychosomatic disease is not to be taken seriously.”

Well, anyway, because of my anecdotage, I’ve strayed a little from my original story about the Janus head logo.

I already mentioned that the logo was abandoned in favor of something that looks like waves and could lead to seasickness. I inquired about the history of the use of the Janus head logo.

In addition to my curiosity about why the logo was changed, I also wondered why it was chosen in the first place and when. According to Don, it was part of the organization’s journal, Psychosomatics, in the late ‘60s and ‘70s. What was interesting is that it was already in use by the Journal of Geriatric Psychiatry when the Psychosomatics editors started using it. However, a conflicting view was that it was not introduced to the cover until 2010. Hmmmm.

I saw the 2012 issue of the APM Newsletter had a pretty funny picture of Drs. Shuster and Rosenstein posing as Janus and the statement “Thank you, Janus. You served us well for over 50 years.” That might put the origin of the logo, at least, around 1962 although my understanding is that APM was started in 1953 (TN Wise, A Tale of Two Societies, Psychosomatics 1995).

Time to say “Hello, again, Janus?”

It’s just my opinion, but because Janus is the ancient god of beginnings and transitions, gates, doorways, endings and time, and typically depicted as two-faced because he looks to the future and the past, I think the symbol is a better image for what C-L Psychiatry has been through over the years.

Anyone for re-rebranding and go retro back to the Janus head logo?

Hoofing it Around the Hospital

Again today, I hoofed it around the hospital. I put 43 floors and a little over 4 miles on my step counter.

I don’t like waiting for elevators so I take the stairs. And a Consult-Liaison Psychiatrist is like a fireman, running all over putting out fires.

I did other things today. I gave the usual lecture on delirium and dementia to the medical students. I notice that as I have gotten older, I tend to tell more anecdotes about my experiences managing delirium in patients on the medical side of the hospital.

I’m in my anecdotage, as I told the students today.

I also lamented the decision by the powers that be to copyright the Montreal Cognitive Assessment (MoCA). The medical students will be able to use it for free, but faculty won’t.

I think that’s ageism. I won’t pay so I won’t use the MoCA anymore.

Back in the Saddle

Well, I’m pretty tapped out, so it’ll be a short post today. I’m back in the saddle, running around the hospital on the psychiatry consult service. This is my last year of phased retirement and in 11 months—I’ll be fully retired.

I put 36 floors and 3 miles on the step counter. I’m feeling every one of those. Sena bought me some banded collar shirts and I’m wearing those instead of a shirt with a necktie. I don’t need a tie bar.

And I don’t worry about a delirious, violent patient strangling me with my necktie.

We had a small scare tonight. We were looking at my total compensation statement (the last one) and got the Sharp Elsi Mate EL-505 vintage calculator out to crunch some figures. The calculator went dead.

I put some new batteries in it, hopeful. It still didn’t work. We’ve had this calculator for over 30 years and it ran more than a decade on the first set of AA batteries.

I tried another pair of batteries. It worked! The vintage calculator lasted longer than the batteries. It’s nice to know that just because something’s old doesn’t mean it’s useless.

That’s all I got.

Informal Bedside Tests for Delirium

Most of this post is an updated redux from years ago about an informal bedside test for delirium called the oral trails test. I learned about it from my senior resident when I was a junior psychiatry resident in training at the VA Medical Center.

There was an elderly patient admitted to the psychiatry unit who was thought to be psychiatrically ill but who actually seemed confused to me and the senior resident. We consulted medicine in order to get him transferred to the general medicine unit but it was tough going. I think the medicine resident disagreed with our clinical impression that he was confused and didn’t think medical transfer was necessary.

Anyway, my senior resident showed me her version of the oral version of the mixed Trails A and B Test for executive function. There is a written form which is part of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). First, she asked him to count from 1 to 7; then she asked him to recite the letters of the alphabet from A to J. She then asked him to try reciting those letters in alternating sequence. Of course, he failed miserably and was eventually transferred to internal medicine. The Trails actually is a paper and pencil test and it looks like a dot to dot game, like the example below:

My senior resident told me she learned the oral Trails test from her senior resident and couldn’t remember anything else about it. I used the test for years but a neuropsychologist criticized the practice, questioning the test’s validity, and rightly so.

Of course, I’d been doing it wrong. You’re supposed to have the patient count to 25, then recite the letters of the alphabet, then recite the numbers and letters in alternating sequence from 1 to 13 and A to M. More than two errors in pairings indicate cognitive impairment.

There are limitations to the verbal Trails and caution is advised in more recent literature, indicating that there are moderate education effects in older patients and that it may be wiser to use both paper and pencil and oral versions together.

Still the search goes on for quick and dirty ways to screen for cognitive impairment in the elderly because this and advanced age are two main risk factors for delirium.

Nowadays, I do the Mini-Cog (shown in the video below) or the Single Question in Delirium (SQiD) test, which just involves asking a family member if the patient seems confused lately.

References:

Mrazik, M., Millis, S., & Drane, D. L. (2010). The oral trail making test: effects of age and concurrent validity. Archives of clinical neuropsychology: the official journal of the National Academy of Neuropsychologists, 25(3), 236–243. doi:10.1093/arclin/acq006

Ricker, J. H., & Axelrod, B. N. (1994). Analysis of an Oral Paradigm for the Trail Making Test. Assessment, 1(1), 47–51. https://doi.org/10.1177/1073191194001001007

Sands, M., Dantoc, B., Hartshorn, A., Ryan, C., & Lujic, S. (2010). Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliative Medicine, 24(6), 561–565. https://doi.org/10.1177/0269216310371556

Coach’s Corner: Somatoform Illness

This is a short Coach’s Corner video on somatoform and related abnormal illness behaviors which prompt physicians to request psychiatric consultation. Medically unexplained physical symptoms are not rare in the hospital and in medical clinics.

The general idea is to remember Stephen Covey’s caution about effectiveness and efficiency, which is that you have a lot better chance being effective rather than efficient with people.

“With people, slow is fast and fast is slow.”
Stephen Covey

The point is that it’s very important to listen for understanding and to validate pain and suffering. That means sitting with patients and taking time to hear what they tell you.

There is an excellent presentation on conversion disorder (also known as functional neurological disorder) on the National Neuroscience Curriculum Initiative (NNCI) web site. It’s very helpful for clinicians and patients.

Just an Introduction

Hello again

Well, it has been about 3 months since I opened this blog. My YouTube channel needed an updated channel trailer, so I’m posting it here as well. Why not?

I was surprised at how long a minute and a half channel trailer took to make, even with the aid of video editing software (maybe because of it, partly).

In my situation, a channel trailer is sort of a mini biography. It’s hard to compress a career into a short clip that takes about 5 minutes to upload to YouTube–after a few hours of what was essentially cut and paste.

As you can gather, my path is changing. Over the next 12 months, I’ll be half off and half on the consultation-liaison psychiatry service. That’s according to the terms of my phased retirement contract.

This is really a re-introduction, of course. I’m slowly evolving–not in any big way. I’m still a geezer.

On the other hand, I have found that I’m much more comfortable being on some kind of schedule. I still get up early, only by about an hour later. I generally arise between 5:30 and 6:00 a.m. That may seem very early to some.

I eat less when I’m off service (which I’ll call “retired” for simplicity). That’s probably why my trousers fit more loosely.

I need to have something to do. I exercise daily, for about 20 minutes. I do mindfulness meditation and yoga. I blog. I photograph and film, mainly birds, which I post to YouTube.

The only reason I ‘m not a disaster in the kitchen is because you generally can’t get me within 10 yards of it unless I need a snack I can immediately eat (like an apple). I still don’t cook–not really. It’s embarrassing.

I trim the lawn and by that, I mean just around the walkway edges and some of the garden margins. I don’t mow the lawn because my wife does a much better job, by mutual agreement.

I’m not a gardener. I’m a garden appreciation expert. That means I watch gardening that is done by others.

I suppose a lot of this adds up to laziness.

Coach’s Corner On Delirium

I’m anticipating a busy time next month on the psychiatry consultation service. I suspect delirium will be the main event, as it is most of the time.

So I made a very short YouTube video on delirium. It’s cast in the style of a coach’s corner because I was one of the many clinicians who won the Excellence in Clinical Coaching Award this year.

I’m honored to be in such distinguished company and congratulate all the winners.

Coach’s Corner on Delirium

Time for July Psychiatry Consults

It’s getting close to the busiest time of the academic year in a teaching hospital–July. The residents have a steep learning curve during that month. Some hospitals have a sort of boot camp to get the upcoming first year internal medicine residents prepared for July.

I’m looking at my retirement countdown timer and it’s showing I have 12 months to go. I’ll be back in the saddle July 1st.

July is usually the time for the most interesting psychiatry consultation questions. Many years ago, the psychiatry residents used to keep a list of the weirdest ones. At least that’s what they claimed. Actually, I think most of them were simply made up–maybe all of them. Even though there is no way to know for sure, there is very low probability that any item on the list below could identify any patient.

We used to call it the “wailing wall” of strange and difficult to answer psychiatry consultation questions sometimes asked by our non-psychiatry colleagues from internal medicine and surgery. Questions have been and still are sometimes ambiguous (worse in July) and often need to be reframed so that the psychiatric consultant can be helpful to both customers—the patient and the consult requester. Here are some “quotes” from probably fictitious consultation requests tacked to wailing wall in the distant past, certainly embellished in some cases by frustrated psychiatry residents:

1. “EEG shows no brain activity.”

2. “The patient doesn’t like me.”

3. “We want to know if the patient who believes they are Sponge Bob and wants to leave the MICU to start filming a new movie—is competent.”

4. “I’m a humanitarian but can you transfer this patient to Mexico?”

5. “The patient looked at me funny.”

6. “We are wondering whether to discharge to their own apartment a patient who is oriented only to self, cannot perform activities of daily living, and is actively hallucinating?”

7. “I prefer not to speak with my patients.”

8. “I prefer not to speak with families.”

9. “Patient gets irritable during “that time of the month.”

10. “We are wondering if the patient should be taken off sedation before getting a history from them?”

11. “Patient swallowed their narcotic sobriety pin and is upset that morphine was discontinued.”

12. “The patient is eating their fingers off.”

13. “Cardiac arrest.”

14. “Consult for bilateral disorder or generalized panic disorder.”

15. “Anxiety and agitation 5 minutes before Code Blue.”

16. “Please evaluate for catatonia versus brain death on intubated patient.”

17. “Patient was fine yesterday but now unresponsive. Please rule out catatonia before we work up. If catatonia ruled out, we’ll then get a head CT and labs.”

18. “We want the consult for our own safety.”

19. “We need psychiatry’s blessing before we can feel comfortable discharging the patient.”

20. “Patient admitted for renal failure after being gored by a bull at a rodeo, please evaluate if this was a suicide attempt.”

Some are humorous and a few are mind-boggling. What they all speak to is the omnipresent opportunity for the C-L psychiatrist to excel as an educator. Reframing the question is a skill that requires patience, diplomacy, and credibility as an expert in this field.

What this may also indicate is the necessity to include a bit more about psychiatry in medical school clerkship programs.

The Medical-Psychiatry Unit

I guess I’m incorrigible; there are now 4 eggs in the robins’ nest. Progress there reminded me of another kind of progress–in integrated health care.

On that note, this is just a brief update on the Medical-Psychiatry Unit (MPU). I thought it would be a good time to do this since a hard-working Pennsylvania psychiatrist notified me of the very successful Medical Complexity Unit (MCU) in operation at Reading Hospital. See my post from May 23, 2019.

I co-attended on our MPU for 17 years before I chose to concentrate on the Consultation-Liaison Psychiatry (CLP) service. The health insurance payer system challenges have probably not changed much. I still believe that the MPU is a great place to teach trainees to appreciate the rewards and challenges of caring for patients with complex, comorbid psychiatric and medical issues.

I hope the video makes the case for that. I decided it didn’t need a voice over. I welcome any comments and questions.

Organ Transplant Overview

Occasionally, despite my being in phased retirement, I get a reminder that my colleagues may need some advice about an issue for which I might be a useful source of institutional memory.

One of them is the psychiatric consultation for assessment of candidates for organ transplant. I have a slide set and a YouTube video that are still useful as long as viewers remember that some of the slides and the text are dated.

For example, the video refers to my former blog The Practical Psychosomaticist (which l later renamed the Practical C-L Psychiatrist), and which I cancelled June 1, 2018. The references are also old, but much of the information is still useful.

I’ve included both the video and the slides for the Dirty Dozen on Psychosocial Assessments for Organ Transplant. You can view the slides and just listen to the audio like a voice over in the video. That way you don’t have to giggle at the back of my head and my camera comically reflected in the office window behind me. Turn on the video, click in the slide set to open it, and listen to my prompts for which slide I’m on.

Use this as a voice over for slide set below

The most frequent question that consultees from the transplant team ask is whether the candidate is a good risk for receiving an organ that is in short supply, which therefore must be allocated carefully, and of which the candidate must be prepared to be a good steward. Psychosocial screening is a feature of most transplant programs. Rather than seeing ones self as a gatekeeper, most experts agree that the most useful part of the psychosocial screening process is to identify psychosocial factors that would interfere with the candidate’s successful adaptation to life posttransplant, and to develop a plan for managing them using available resources.

The evaluation phase is critical to diagnosis of major psychiatric problems and to treatment planning for evidence-based interventions. However, providing follow-up through the other phases of transplant allow optimizing the development of a therapeutic alliance to foster adherence to both psychiatric and medical treatment and further evaluation of psychosocial challenges as well. The waiting phase is a very stressful time and often the candidate must tolerate deteriorating health while watching others transplanted sooner. In the post-transplant period, about 20% of patients develop any psychiatric disorder, most notably depression and PTSD.

There’s a triple advocacy role for evaluators conducting organ transplant assessments: advocacy for the patient; for the persons on the waiting list; and for society in general in terms of husbanding allocation of scarce resource (“organ stewardship”).

That makes it critically important to examine the nature of the therapeutic alliance.

Transactional/Adversarial or Transformational?

Transactional/Adversarial:

Atmosphere is typically highly charged emotionally, with a sense of urgency.

Interrogation mode rather than exploration of motivations and feelings. Focus is on past rather than future, exclusive approach with emphasis on utilitarian paradigm and wait list advocacy. Methodically and meticulously confrontive; blaming. Team asks “Who else could we help?” Little or no interpersonal room to witness the patient make sense of impending death.

Withholding, rejecting, paternal, authoritarian (rather than shared) experience.

Win/Lose or Lose/Win.

Transformational:

Atmosphere of created space for calmer review and listening for understanding.

More likely to have focus on future rather than past, and an inclusive approach with emphasis on medical necessity paradigm and patient advocacy. Affirming and supportive of change. The team asks, “What would we need to do in order to help?” May be a better opportunity to be a witness to coming to terms with imminent death.

Shared experience, with both participants on a more level playing field.

Win/Win.

This is a very complex and challenging aspect of Consultation-Liaison Psychiatry and, probably in part because we’re in short supply in many areas, many transplant centers rely on written assessment batteries or checklists. It’s hard to do justice to the topic in a blog post. I hope it’s helpful.

References:

1. Anne M. Larson, J.P.R.J.F.T.J.D.E.L.L.S.H.J.S.R.F.V.S.G.O.A.O.S.W., Acetaminophen-induced acute liver failure: Results of a United States multicenter, prospective study. Hepatology, 2005. 42(6): p. 1364-1372.

2. DiMartini, A.F., M.D.,, M.A. Dew, M.D.,, and P.T. Trzepacz, M.D.,, Organ Transplantation, in Textbook of Psychosomatic Medicine, J.L.M.D. Levenson, Editor. 2005, American Psychiatric Publishing, Inc.: Washington, DC. p. 675-700.

3. Huffman, J.C., M.K. Popkin, and T.A. Stern, Psychiatric considerations in the patient receiving organ transplantation: a clinical case conference. General Hospital Psychiatry, 2003. 25(6): p. 484-491.

4. Klapheke, M.M., The Role of the Psychiatrist in Organ Transplantation. Bulletin of the Menninger Clinic, 1999. 63(1): p. 13-39.

5. Novack, V., et al., Deliberate self-poisoning with acetaminophen: A comparison with other medications. European Journal of Internal Medicine, 2005. 16(8): p. 585-589.

6. Turjanski, N. and G.G. LLoyd, Transplantation, in Psychosomatic Medicine, M.J. Blumenfield, M.D. and J.J. Strain, M.D., Editors. 2006, Lippincott Williams & Wilkins: New York. p. 389-399.