CPCP: Transplant Psychosocial Assessment and the SIPAT

We had  a special Clinical Problems in Consultation Psychiatry (CPCP) recently, in which the residents presented a paper by Dr. Jose Maldonado about his new psychosocial assessment tool, the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT; also see research link at The “Stanford Integrated Psychosocial Assessment for Transplant” (SIPAT) – Full Text View – ClinicalTrials.gov) [1]. The idea for this one was suggested by my receiving a Terms of Use form for use of the SIPAT from Dr. Maldonado, since the SIPAT is copyright-protected. I noticed that it would need to be signed by the surgical director of the transplant service. This would have been a good topic for the Online Journal Club as well, but I couldn’t find an open access copy of the article.

That led to my reflecting on the history of psychiatry’s relationship with the transplant service over the years. We used to be much more involved with pre-transplant psychosocial assessments than we are now. That role has been taken by a psychologist who is embedded in the transplant surgery department, which offers obvious advantages in terms of access to psychosocial evaluations. However, as I examined the SIPAT and compared it with the Psychosocial Assessment of Candidates for Transplantation (PACT), an assessment tool psychiatrists used here in the past, and because I’m not sure whether any such instrument is used nowadays, I wondered how (and perhaps whether) psychiatrists could re-establish a collaborative relationship with the transplant team, including its psychologist.

Could the SIPAT be a point of departure for opening a conversation with the transplant service? This could counter the tendency for siloing of medical and surgical departments in academic medical centers and lead to more collaborative relationships with the goal of not just maintaining our excellent patient care record, but improving it.

This approach could also enhance the education of our residents, who currently have few opportunities for learning about the important role psychiatrists play in transplant evaluations. The whole field of transplant psychiatry naturally lends itself to teaching and evaluating all the core competencies including Medical Knowledge, Patient Care, Professionalism, Systems-Based Practice, Interpersonal Skills and Communication, and Practice-Based Learning and Improvement. They can learn how challenging it is to fulfill the psychiatrist’s tripartite role as patient servant, transplant team member, and steward of a limited organ supply for those on transplant wait lists.

This CPCP itself is much more relevant to my practice than any “activity” or “product” currently promoted by the American Board of Psychiatry and Neurology (ABPN) toward Maintenance of Certification (MOC). In fact, what the ABPN offers seems trivial compared to this single instance of a CPCP case conference. It tends to highlight the wastefulness of MOC and further entrenches my view that MOC is not the best way (and could be the worst way) to operationalize the principle of lifelong learning and improvement of a psychiatrist’s skills and knowledge base.

I urged the residents, Drs. Paul Thisayakorn, Tom Salter, and Mohammad Z Ali to think in those terms about this particular CPCP. It would have been easy to simply review Maldonado’s paper. It was much more challenging for them to think of it as a point of departure for critically evaluating their role in a complex branch of medicine and surgery and searching for ways to improve it that don’t just involve academic political maneuvering, but to reach beyond that to emphasize the important role of collaboration in health care generally.

As usual, the trainees made some excellent slides to get the point across. In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view the annotations.

1. Maldonado, J. R., H. C. Dubois, et al. (2012). “The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A New Tool for the Psychosocial Evaluation of Pre-Transplant Candidates.” Psychosomatics 53(2): 123-132.

Background While medical criteria have been well established for each end-organ system, psychosocial listing criteria are less standardized. To address this limitation, we developed and tested a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT). Methods The SIPAT was developed from a comprehensive review of the literature on the psychosocial factors that impact transplant outcomes. Five examiners blindly applied the SIPAT to 102 randomly selected transplant cases, including liver, heart, and lung patients. After all subject’s files had been rated by the examiners, the respective transplant teams provided the research team with the patient’s outcome data. Results Univariate logistic regression models were fit in order to predict the transplant psychosocial outcome (positive or negative) using each rater’s SIPAT scores. These results show that SIPAT scores are highly predictive of the transplant psychosocial outcome (P < 0.0001). The instrument has excellent inter-rater reliability (Pearson’s correlation coefficient = 0.853), even among novice raters. Conclusions The SIPAT is a comprehensive screening tool to assist in the psychosocial assessment of organ transplant candidates. Its strengths includes the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient’s candidacy. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used in combination with organ-specific medical listing criteria in order to establish standardized criteria for the selection of transplant recipients.