This is a reminder about the upcoming Academy of Psychosomatic Medicine Annual Meeting 2015 in New Orleans. I may be biased (in fact I am) but I’m highlighting a couple of presentations by colleagues, one of them Dr. Vicki Kijewski, MD, and Dr. Jeanne Lackamp, MD.:
Jeanne Lackamp, MD, FAPA
Assistant Professor of Psychiatry, University Hospitals Case Medical Center, Cleveland, Ohio
Dr Lackamp has been an Assistant Professor and psychiatrist at University Hospitals Case Medical Center since 2008. Dr Lackamp attended medical school at Northeast Ohio Medical University. She completed her Psychiatry residency at the University of Iowa, and her Psychosomatic Medicine fellowship through George Washington University. Dr Lackamp’s clinical interests lie in the management of psychiatric issues within the general medical arena. She is a core attending on the inpatient Psychiatry consultation service at UHCMC, where she participates in direct patient care, as well as Psychiatry resident and fellowship training. She has hosted rotating trainees in Internal Medicine, Family Medicine, Neurology, Podiatry, and Bioethics. Dr Lackamp also is the clerkship director for third year medical students rotating on Psychiatry service at University Hospitals. Dr Lackamp’s daily goals are to provide excellent patient care, while educating other clinicians about the challenges of caring for and about patients with psychiatric symptomatology in the general medical hospital setting.
Vicki Kijewski, MD, FAPA, FACP
Clinical Professor, Psychiatry, Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Vicki Kijewski is currently a Clinical Professor in the Departments of Psychiatry and Internal Medicine at the University of Iowa Hospitals and Clinics where she also serves as the residency program director for the combined internal medicine/psychiatry residency program. She is also the medical director of the internal medicince/psychiatry unit at the University of Iowa.
Their presentations are right on target given this year’s theme, “The Art and Science of Communication in Psychosomatic Medicine.”
The one on November 13, Friday with Dr. Kijewski as one of the lead speakers is entitled “Medical Psychiatric Inpatient Integrated Care Models: History, Challenges and Benefits Shared by Four Institutions.” Dr. Kijewski will talk about the University of Iowa’s Medical Psychiatry Unit MPU). I always cringe a little because Dr. Roger Kathol, MD, one of my former teachers and the creator of our MPU prefers to call it the Complexity Intervention Unit (CIU). I’m always calling it the MPU because it’s easier to say, although admittedly, CIU is arguably a better way to convey what issues the unit actually addresses. The abstract for her talk:
Starting from 1980’s, a medical psychiatry unit has been a success for treatment of complicated patients. We have two models, one with one attending physician with double board, and another with two attending physicians with one psychiatrist and one internist. Vicki Kijewski, MD, a double board physician in psychiatry and medicine and Director of the unit, will present the history, administrative challenge, benefit for patients and its educational value for both psychiatry and medicine residents.
But all of the leaders of these units send the same message, which is that integrated care is safer and more effective than dis-integrated (sequential) care. I was a co-attending on our MPU for 17 years and can attest to its power as a training venue and a place where concurrent medical and psychiatric interventions were frequently the most effective way to help patients heal.
The November 14, Saturday presentation by both, “Doc to Doc: Maximizing the Impact of Consultation Documentation,” is one that all Psychosomatic Medicine (PM) specialists cope with every day. What sounds great about this one is the audience participation in small groups, making for interactive learning. I wonder if they’ll discuss Dragon Unnaturally Speaking? Dr. Lackamp will present along with Dr. Kijewski and the abstract is:
Consultation-liaison psychiatrists clarify key elements of the consultation question; review available information and interview patient/collaterals; and strive to create clear, comprehensible documentation so communication with primary teams is meaningful and accurate.
The present workshop addresses how to author documents which are meaningful to the parties involved – and how to teach others this skill. Participants will be given examples of various consultation questions (and the challenges therein). They will be given examples of problematic documentation. Finally, they will have the chance to participate in editing problematic documentation so that it becomes more useful within each clinical context.
Dr. Lackamp trained at Iowa, is a very hard worker and is also the author of a very amusing paper on how residents progress through the stages of becoming a proficient psychiatric consultant:
Lackamp, J. (2015). “The Stages of Consultation-Liaison Psychiatry.” Academic Psychiatry 39(2): 217-219. The process of learning, no matter how rewarding, can be daunting. It is important to recognize various stages, in order to identify stress (and its manifestations) on Psychiatry residents—and the patients and teams with whom they work. Humor can help residents cope and can bring levity to an admittedly exhausting training experience. The following tongue-in-cheek essay was informed by countless consultations and hours of resident supervision. It is written in the spirit of the New Yorker’s “Shouts and Murmurs” column, with inspiration from Elisabeth Kübler-Ross’s “Stages of Grief.”
It’s worth buying.
When I can make it to the APM Annual Meetings, I always find my batteries recharged, about like Dr. George Dawson’s are by attending the University of Wisconsin Annual Updates and Advances in Psychiatry.
Often enough, when the days are long, I find myself ruminating on Dr. Hackett’s quote:
“A consultation service is a rescue squad. At worst, consultation work is nothing more than a brief foray into the territory of another service…the actual intervention is left to the consultee. Like a volunteer firefighter, a consultant puts out the blaze and then returns home… (However), a liaison service requires manpower, money, and motivation. Sufficient personnel are necessary to allow the psychiatric consultant time to perform services other than simply interviewing troublesome patients in the area assigned to him.”—Dr. Thomas P. Hackett Jr., MD.
Or I can get into the habit of focusing on Dr. George Henry’s observation:
See you in New Orleans.
Desan, P. H., et al. (2011). “Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team.” Psychosomatics 52(6): 513-520.
BACKGROUND: Some studies suggest intensive psychiatric consultation services facilitate medical care and reduce length of stay (LOS) in general hospitals. OBJECTIVE: To compare LOS between a consultation-as-usual model and a proactive consultation model involving review of all admissions, rapid consultation, and close follow-up. METHODS: LOS was compared in an ABA design between a 33-day intervention period and 10 similar control periods, 5 before and 5 after the intervention, on an internal medical unit. During the intervention period, a staff psychiatrist met with the medical team each weekday, reviewed all admissions, provided immediate consultation as needed, and followed all cases throughout their hospital stay. RESULTS: Time required for initial case review was brief, 2.9 +/- 2.2 minutes per patient (mean +/- S.D.). Over 50% of admissions had mental health needs: 20.3% were estimated to require specialist consultation to avoid potential delay of discharge. The consultation rate for the intervention sample was 22.6%, significantly greater than in the control sample, 10.7%. Mean LOS was significantly shorter in the intervention sample, 2.90 +/- 2.12 versus 3.82 +/- 3.30 days, and the fraction of cases with LOS > 4 days was significantly lower, 14.5% versus 27.9%. A rough cost benefit analysis was favorable with at least a 4.2 ratio of financial benefit to cost. CONCLUSIONS: Psychiatric review of all admissions is feasible, indicates a high incidence of mental health barriers to discharge, identifies more necessary consultations than typically requested, and results in earlier consultation. A proactive consultation model can reduce hospital LOS.
Kathol, R. G., et al. (2009). “Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface.” Psychosomatics 50(2): 93-107.
BACKGROUND: In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.
Beach, S. R., et al. (2013). “Educational impact of a psychiatric liaison in the medical intensive care unit: effects on attitudes and beliefs of trainees and nurses regarding delirium.” Prim Care Companion CNS Disord 15(3).
OBJECTIVE: Despite high rates and increased risk of mortality, delirium remains underdiagnosed and a minimal focus of formal medical education. This is the first study to examine the educational impact of a psychiatric liaison on beliefs and knowledge about delirium among both nurses and residents. METHOD: One psychiatrist spent 9 months rounding weekly in the medical intensive care unit, interacting with critical care nurses and internal medicine residents. Preintervention and postintervention surveys were distributed in July 2009 and June 2010, respectively, to staff (critical care nurses: n = 23 and n = 25, respectively; internal medicine residents: n = 31 and n = 23, respectively) and a comparison group (psychiatry residents: n = 29 and n = 23, respectively). Participants responded to 12 statements regarding delirium on a 5-point Likert scale. RESULTS: There were no statistically significant differences between the presurveys and postsurveys for any item when examining all respondents together, as well as psychiatry and internal medicine residents as individual groups. Critical care nurses showed a significant change between surveys for the statements, “Patients with new-onset anxiety or depression in the intensive care unit most commonly have delirium” (17.4% agree presurvey vs 56.0% agree postsurvey, chi(2) = 7.62, P = .006) and “Delirium is diagnosed less often than it actually occurs” (100% agree presurvey vs 80% agree postsurvey, chi(2) = 5.13, P = .023). CONCLUSIONS: Though introduction of a psychiatric liaison was very well received by clinical staff, we did not meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium. Robust and lasting changes in attitudes regarding delirium may require more intensive efforts involving longer intervention periods, greater rounding frequency, or additional didactic teaching.