Category: Consult-Liaison

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Consult-Liaison Education Informal-curriculum Medicine Nonfiction Observations Reflection

Teaching Moment.

The Chief of Service ushered me into the room, but said nothing. His staff of fifteen looked at the Chief with expectation and, upon realizing that he was looking at me and probably wasn’t go to say anything—including my name or the reason for my visit—the fifteen people joined him in looking at me.

“Hi,” I said, taking the cue and flashing The Winning Smile. This is my name, this is my title, and this is why I’m here: As a psychiatrist, I think there is overlap in the work that we do and in the patients that we see—

“Is it okay if we refer to your patients as ‘wackos’?” the Chief blurted out. Nervous laughter twittered among his staff.

“I’d prefer that you didn’t.” My voice was light; my face was dark.

“Oh. I guess another psychiatrist should have told me that.” He was still smiling.

“I hope I’m not the first one to do so.” When he finally saw the lasers shooting from my eyes, his smile dissolved and he looked down.

There are several reasons why I believe that social skills are not his forte:

  • He either chose not to or did not think he needed to introduce me to his staff.
  • As a Chief of Service he should have known better than to say such things in front of his entire staff.
  • This exchange occurred within five minutes of us meeting each other.

I think his question—“Is it okay if we refer to your patients as ‘wackos’?”—was his honest effort to connect his staff and me together. Everyone would have a good laugh, we’d share something in common, and we could move forward with greater ease. He thought his comment was benign.

It makes me wonder, though: Had he made a similar comment in the past to another psychiatrist? And had that psychiatrist laughed? Did a ridiculous repartee follow?

Did another psychiatrist reinforce this sort of behavior?

He’s not a “schizophrenic”. He’s a guy with a diagnosis of schizophrenia. Maybe he’s even a guy who is skilled guitar player, a father of two children, and has a degree in political science who happens to have a diagnosis of schizophrenia.

She’s not a “brittle diabetic”. She’s a woman with a diagnosis of diabetes. Maybe she has a knack for training dogs, has a remarkable talent for singing, and was on her way to law school when she was first diagnosed with diabetes.

People are people with various interests, talents, and potentials. They are not their medical conditions.

No one is a “wacko”.

The Chief of Service sent me an e-mail later:

Thank you for visiting us and also for your gentle way of reminding me of my crudeness and insensitivity. I am sure you hear enough negative attitudes towards your clients that you would welcome the opportunity to create a more positive attitude towards mental health issues.

I actually don’t hear many “negative attitudes” about my patients. Perhaps this is because every moment can be a teaching moment and, over time, people learn not to use such language (at least around me). As I noted several years ago:

Doc­tors, like most peo­ple, often assign adjec­tives to patients because it can be hard to iden­tify and then acknowl­edge emo­tions. It is much eas­ier to say, “She is such a dif­fi­cult patient! She is never happy with her care!” than to say, “I feel angry and help­less when I see her because it seems like noth­ing improves her symp­toms!” Leav­ing out the sub­jec­tive “I” gives the illu­sion of objec­tiv­ity and professionalism.

I can only hope that the Chief of Service shared his reflection about his “crudeness and insensitivity” with his staff.

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Consult-Liaison Reflection

Questions about the Throwing of Urine.

If a man throws an open container of his own urine at another person, does he have a mental illness?

  • What if he throws an open container of water at another person?
  • What if he throws a closed container of his own urine at another person?

If a man throws an open container of his own urine at a nurse in a hospital, does he have a mental illness?

  • What if he throws his urine at a nurse who is trying to inject him with a medication he doesn’t want?
  • What if he throws his urine at a nurse who is trying to give him food and drink?

If a man throws an open container of his own urine at a nurse on a surgical ward, does he have a mental illness?

  • What if he throws his urine at a nurse while on a psychiatric ward?
  • What if he throws his urine at a nurse while in jail?

If a man throws an open container of his own urine at the police when they charge into his home, does he have a mental illness?

  • What if he throws his urine at the police because he has multiple containers holding his urine and those are the closest things he can grab?
  • What if he throws his urine at the police because he hates the police?
  • What if he throws his urine at the police because he hears voices that tell him to do this to protect himself?

If a man collects his urine into a container over time for the purpose of throwing it at another person, does he have a mental illness?

  • What if he believes his urine is holy water and believes that his urine will baptize others and save their souls?
  • What if he wants to witness the anger and disgust of others when his urine splashes all over their faces?

If a man throws an open container of his own urine at himself, does he have a mental illness?

  • What if he throws his urine on himself because he is in solitary confinement and cannot throw the urine at the person he is angry with?
  • What if he throws his urine on himself because he is in solitary confinement and this is the only way he can have contact with another person?

If a man throws an open container of his own urine at another person, does he have a mental illness? or is he just a jerk?

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Consult-Liaison Medicine Observations

Chart Notes.

While reviewing old chart notes, I frowned as I learned how distressed the patient had been while he was in the emergency department. Without realizing it I murmured a line from a physician’s note:

Rambling historian, only clear complaint is hunger.

A colleague, who is often hungry, overheard me and responded, “That would be my mental status exam.”

A different chart provided this information:

Patient started getting agitated and threw a bagel at staff.

I couldn’t help but snort with amusement[1. All of us who must write clinical notes often dilute details because they’re often not relevant to clinical care, though these details often add context to what happened. Like the writer of this note, I often include factual details without intending to be funny. Sometimes we laugh because we otherwise would feel overwhelmed with sadness, anger, or helplessness.], though then wondered:

  • Was it a whole bagel?
  • Was it an old, stale, and hard bagel?
  • Did the bagel have cream cheese on it?
  • Was it thrown like a frisbee or like a baseball?
  • Did the bagel actually hit anyone?
  • What happened that led the patient to throw the bagel?
  • Did the patient elect to throw the bagel instead of an open carton of milk? or a single serving of jelly?

Yet another chart included this terse note from a medicine resident in the early hours of the morning:

Interval exam changes. Agitated overnight. Double middle finger to providers. Haldol 5mg IV ordered and given.[2. For those of you who are interested, Haldol 5mg IV equals Haldol 10mg PO (by mouth), which is a standard dose for someone with a diagnosis of schizophrenia. The thing about Haldol 5mg IV is that sometimes doctors order this with the intention of inducing calm in a patient so he doesn’t punch staff, destroy property, hurt himself… but, sometimes, the patient instead becomes sedated and is in a deep sleep for many hours. The goal should be to calm, not snow, the patient.] PRN Ativan.

One would hope that a patient doesn’t receive a sedating antipsychotic medication simply for extending both middle fingers to doctors and nurses!

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Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….

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Consult-Liaison Education Medicine Reading

DSM-5: Malingering.

My DSM-5 group has lost its previous vitality for the same reasons my blog has lost its previous verve (pending job change, ongoing family health concerns). But! The DSM-5 group has had a few updates; the most recent edition is below. If you’re interested in subscribing to the DSM-5 e-mail group, you can sign up here.

Malingering in DSM-5, like in DSM-IV, is a “V code”. “V codes” (in ICD-9) will turn into “Z codes” (in ICD-10) and these are considered “other conditions that may be a focus on clinical attention”. This means two things:

(1) Conditions listed as “V codes” are not diagnoses because

(2) Conditions listed as “V codes” are not mental disorders.

Therefore, malingering is not a mental disorder.

In crass terms, malingering means that people are faking or *really* embellishing physical or psychological symptoms. People who are malingering do this “consciously” (hat tip to the analysts) because there is an external incentive to do so. These external incentives might include:

a) avoiding military duty
b) avoiding work
c) obtaining financial compensation
d) evading criminal prosecution
e) obtaining drugs

Malingering can be hugely adaptive: If you were homeless and the temperatures outside are below freezing and a winter wind is whipping the frost off of the trees and there are no open shelter beds and you are hungry because the last time you ate was two days ago and that was a soggy, half-eaten sandwich you found in the trashcan–

–wouldn’t you consider going to the hospital and say that you want to kill yourself so you could be in a warm place for a few hours and get some non-soggy food?

DSM-5 argues that if “any combination” of the following four items is present in a patient, you should consider the condition of malingering:

(1) Medicolegal context of presentation (a lawyer sends the client for evaluation or the patient presents for care in the midst of criminal charges)

(2) There is a “marked discrepancy” between the individual’s “claimed stress or disability” and “objective findings and observations”

(3) “Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen” (some tired clinicians would summarize this as “a difficult patient”, though I much prefer DSM-5’s description)

(4) The presence of antisocial personality disorder

I applaud DSM-5’s efforts in keeping the description of malingering neutral. Some people have strong reactions towards (translation: self-righteous fury at) people who present with malingering. Keeping the focus on the behaviors helps temper the emotional reactions.

DSM-5 then clarifies the differences between malingering and factitious disorder, conversion disorder, and related conditions. Malingering is the only condition here where symptoms appear solely because there is an external incentive.

On a somewhat related note, the condition that follows malingering in DSM-5 is “wandering associated with a mental disorder”. This is apparently limited to walking (where the “desire to walk about leads to significant clinical management or safety concerns”).

The next post will hopefully show up less than one month away.