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.

Gunslingers and Chessmasters

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat”—Sun Tzu.

In 2003 the American Board of Medical Specialties approved the subspecialty status of Psychiatry now known as Psychosomatic Medicine. Long before that, the field was known as Consultation-Liaison Psychiatry. In 2005, the first certification examination was offered by the American Board of Psychiatry and Neurology. This important point in the history of psychiatry began many decades ago, probably in the early 19th century, when the word “psychosomatic” was first used by Johann Christian Heinroth when discussing insomnia.

Psychosomatic Medicine began as the study of psychophysiology which in some quarters led to a reductionistic theory of psychogenic causation of disease. However, the evolution of a broader conceptualization of the discipline as the study of mind and body interactions in patients who are ill and the creation of effective treatments for them probably was a parallel development. This was called Consultation-Liaison Psychiatry and it was considered the practical application of the principles and discoveries of Psychosomatic Medicine. Two major organizations grew up in the early and middle parts of the 20th century that seemed to formalize the distinction (and possibly the eventual separation) between the two ideas: the American Psychosomatic Society (APS) and the Academy of Psychosomatic Medicine (APM). The name of the subspecialty finally approved in 2003 was largely because of its historic roots in the origin of the interaction of the mind and body paradigm.

The impression that the field was dichotomized into research and practical application was noted by members of both organizations. At a symposium at the APM annual meeting in Tucson, AZ in 2006, one speaker remarked that practitioners of “…psychosomatic medicine may well be lost in thought while…C-L psychiatrists are lost in action.”

It is ironic how organizations that are both devoted to teaching physicians how to think both/and instead of either/or about medical and psychiatric problems could have become so dichotomized themselves.

The motive for writing this post evokes a few quotations about psychiatry in general hospitals:

“Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods” [1].

“All staff conferences in general hospitals should be attended by the psychiatrist so that there might be    a mutual exchange of medical experience and frank discussion of those cases in which there are psychiatric problems”[1].

“The time should not be too long delayed when psychiatrists are required on all     our medical and surgical wards and in all our general and surgical clinics” [2].

The first two quotes, modern as they sound, are from 1929 in one of the first papers ever published about Consultation Psychiatry, by George W. Henry, A.B., M.D. The third is from 1936 by Helen Flanders Dunbar, M.D., in an article about the substantial role psychological factors play in the etiology and course of cardiovascular diseases, diabetes, and fractures in 600 patients. Although few hospital organizations actually practice what these physicians recommended, the recurring theme is the need to improve outcomes, processes, and education in health care by integrating medical and psychiatric delivery care systems. Further, Roger Kathol, M.D., has written persuasively of the need for a sea change in the way our health care delivery and insurance systems operate in order to improve the quality of health care in this country so that it compares better with that of other nations [3]. Change is sometimes slow in coming.

Some of the barriers to change, with respect to just one specific area, organ transplant, for example, by Wolcott (paraphrased and italics mine) [4]:

  • Limited number of psychiatrists and other mental health care providers with sufficient knowledge, skills, interest, and time (manpower)
  • Smaller transplant programs cannot support a full organ transplant psychiatry program (money)
  • Variable emphasis and priority placed on psychiatric outcomes (and by extension, their value) by organ transplant programs themselves (motivation)

“Manpower, money, and motivation” will be a familiar echo to some psychiatrists who still believe it is worthwhile to make a distinction between a consultation service and a consultation-liaison alliance with the rest of medicine and surgery. A consultation service is a rescue squad; like a volunteer fire brigade, it “puts out the blaze and then returns home”. A liaison service “sets up fire prevention programs and educates the citizenry about fireproofing” [5].

While it is worthwhile to make the distinction, it is still important to prize both. The need for research in Psychosomatic Medicine is critical and gives the field vitality. Those who conduct research are the chess masters. However, the patients don’t always read the medical literature, and don’t always fit the predictions of chess masters. Out on the wards, there is a need for consultants to intuitively create responses to novelty that cannot always be found in journals or books. These are the gunslingers. They know that the clinical world outside of what the Institutional Review Board allows is “inherently unpredictable and messy and nonlinear” [6]. Change is always coming.

In this field there are chess masters and gunslingers. Both are needed. One needs to be a gunslinger to react quickly and effectively on the wards and in the emergency room during crises. One  also needs to be a chess master after the smoke has cleared, to reflect on what one did, how it was done—and analyze why it was done and whether that was in accord with the best medical evidence.

This post is for the gunslinger—who relies on the chess master. It is also for the chess master—who needs to be a gunslinger.


1.         Henry, G.W., SOME MODERN ASPECTS OF PSYCHIATRY IN GENERAL HOSPITAL PRACTICE. Am J Psychiatry, 1929. 86(3): p. 481-499.

2.         Dunbar, H.F., T.P. Wolfe, and J.M. Rioch, PSYCHIATRIC ASPECTS OF MEDICAL PROBLEMS: The Psychic Component of the Disease Process (Including Convalescence), in Cardiac, Diabetic, and Fracture Patients. Am J Psychiatry, 1936. 93(3): p. 649-679.

3.         Kathol, R.G. and S. Gatteau, Healing body and mind : a critical issue for health care reform. Praeger series in health psychology. 2007, Westport, Conn.: Praeger Publishers. xviii, 190 p.

4.         Wolcott, D.L., Organ transplant psychiatry: psychiatry’s role in the second gift of life. Psychosomatics, 1990. 31(1): p. 91-97.

5.         Strain, J.J., M.D., Liaison Psychiatry, in Textbook of Consultation-Liaison Psychiatry, J.R. Rundell, M.D., and M.G. Wise, M.D., Editors. 1996, American Psychiatric Press, Inc.: Washington, D.C. p. 38-51.

6.         Gladwell, M., Blink : the power of thinking without thinking. 1st ed. 2005, New York: Little, Brown and Co. viii, 277 p.

“We Need a Journal of Practical Psychiatry”, He said…

The other day one of my residents remarked that “We need a Journal of Practical Psychiatry,” or something like that in order to more effectively guide psychiatrists in the every day clinical world in which we practice, specifically consultation psychiatry. He doesn’t have anything against theory or research psychiatry.

I tend to agree with him. Realizing he was just pulling what he thought was an imaginary journal name off the top of his head to illustrate what he meant, I googled “The Journal of Practical Psychiatry” on a whim.

I found it, much to my surprise. Well, I sort of found it. Actually what I discovered was an old journal called “The Journal of Practical Psychiatry and Behavioral Health (JPPBH)”. It was published between 1995 and 1999. My immediate thought was, “that’s not a very long life for a journal.”

In fact, the JPPBH lives on in the Journal of Psychiatric Practice. Those of us in academia have full electronic access to it through an institutional subscription, though it is designed for psychiatrists and psychologists in private practice.

I’m not trying to fuel any “town and gown” conflict, but I had a quick look at the July 2013 issue which contained an intriguing article, “The 100 Top-Cited Articles Published in Psychiatric Journals” by Shahrzad Mazahri, MD, PhD [1]. The list was what I wanted to see, after all, but there was a problem.

The table containing the list was illegible. Also, the original articles were classified into several categories including “medical psychiatry”…but none of the articles fit that category, though, of course, that was not the author’s fault.

However, the top ten list of most influential journals was legible and included Psychosomatic Medicine, the journal of the American Psychosomatic Society (AMS), an international society which has been more focused on research. Somehow, Psychosomatics, the journal of the Academy of Psychosomatic Medicine (APM, traditionally an organization of very practical psychiatrists working as consultants in general hospitals), didn’t make the cut. Dang. The Journal of Psychiatric Practice is not on the list, either.

It’s a bit ironic that the AMS periodical is listed in a practical journal, since the AMS has been informally distinguished from the APM (and maybe by extension, its journal Psychosomatics) by the more practical focus of the latter.

The AMS and the APM made a formal agreement to collaborate more closely at the 2006 APM Annual Meeting in Tucson, Arizona. The theme of the meeting was “Defining the Scope of Psychosomatic Medicine.” By the way, the 2013 Annual Meeting is also in Tucson, see the APM web site for details, Academy of Psychosomatic Medicine — Home Page.

The impression that the field was dichotomized into research and practical applications was noted by members of both organizations. This was highlighted at the 2006 APM Annual Meeting, an important milestone because it was three years after the Psychosomatic Medicine subspecialty status was approved by the Accreditation Council of Graduate Medical Education (ACGME). I think it was during either the Presidential Address or the Presidential Symposium, one speaker remarked that practitioners of “…psychosomatic medicine may well be lost in thought while…C-L psychiatrists are lost in action.”

I can think of another practical journal, Annals of Clinical Psychiatry, and not just because it published a case report I wrote about sedative-hypnotic-induced withdrawal catatonia [2]. In fact, there’s a very practical article in the very same issue about how to distinguish neuroleptic malignant syndrome (NMS) from serotonin syndrome [3].

I almost forgot the article I wrote on Maintenance of Certification (MOC) and Maintenance of Licensure (MOL), published by The Carlat Report: Psychiatry [4]. The Carlat Report is a very practical subscription monthly, mainly for mental health care professionals in private practice, but also very useful for academicians.

The bottom line is we need both theory and practical application, knowledge on the right thing to do and instruction on how to do the thing right.

We need the inspiration for the music…and the performance.


1. Mazhari, S. (2013). “The 100 top-cited articles published in psychiatric journals.” J Psychiatr Pract 19(4): 327-338.
An examination of top-cited articles is a tool that can be used to identify and monitor outstanding scientific research. The goal of this study was to identify and analyze the characteristics of the 100 top-cited articles published in international journals dedicated to psychiatry. The Science Citation Index Expanded provided by the Thomson Reuters Institute for Scientific Information Web of Knowledge was searched in December, 2011, and 128 journals were identified in the subject category “Psychiatry.” Each journal was searched on the Web of Science under “Publication Name” and the results were sorted by category “Times Cited.” The 100 top-cited articles were recorded, and the list was analyzed with regard to journals, number of citations, authors, year, institution, and country of origin. The original research articles of the 100 top-cited articles were classified into one of five categories: scale/measurement, descriptive/epidemiology, mechanism, management, and imaging. The 100 top-cited articles were cited between 26,578 and 781 times; they were published between 1957 and 2005, with the largest number (35) published in the 1990s. The articles appeared in 24 journals, with more than half published in the Archives of General Psychiatry (56), followed by the American Journal of Psychiatry (6), and Psychological Medicine (6). Articles that dealt with the development, application, or validity of measurements led the list of top-cited psychiatric publications (43) and had a significantly higher number of citations compared with the rest of the articles. The time and language of publication, field of study, country of origin, and journal in which the paper appeared are possible determinants of the likelihood of citation and impact. (Journal of Psychiatric Practice 2013;19:327-338).

2. Amos, James J., M.D., (2012). “Lorazepam withdrawal-induced catatonia.” Annals of Clinical Psychiatry 24(2).
Catatonia can be associated with a number of medical and psychiatric disorders including sedative-hypnotic withdrawal. The mechanism is unclear but may involve γ-aminobutyric acid (GABA) transmission changes. I report a case of lorazepam withdrawal-induced catatonia in a postsurgical patient who had been taking lorazepam at home as prescribed by her psychiatrist. This case begs the question of whether to continue previously prescribed benzodiazepines in the intensive care unit (ICU) postoperatively in light of a recent study showing that lorazepam administration in this context is an independent risk factor for delirium.

3. Perry, P. J. and C. A. Wilborn (2012). “Serotonin syndrome vs neuroleptic malignant syndrome: A contrast of causes, diagnoses, and management.” Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists 24(2): 155-162.
BACKGROUND: Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are uncommon but potentially life-threatening adverse reactions associated with psychotropic medications. Polypharmacy and the similar presentation of SS and NMS make diagnosis of the 2 syndromes problematic. METHODS: A MEDLINE search was performed for the period 1960 to 2011 for case reports, review articles, and studies pertaining to SS and NMS. RESULTS: The majority of available literature on SS and NMS consists of case reports, case-control studies, and retrospective reviews. In addition, diagnostic criteria have been developed to aid in the diagnosis and management of SS and NMS. CONCLUSIONS: SS presents as mental status changes, autonomic nervous system disturbances, neurologic manifestations, and hyperthermia. Similarly, NMS presents as muscle rigidity, hyperpyrexia, mental status changes, and autonomic instability. However, the clinical laboratory profile of elevations in creatine kinase, liver function tests (lactate dehydrogenase, aspartate transaminase), and white blood cell count, coupled with a low serum iron level, distinguishes NMS from SS among patients taking neuroleptic and serotonin agonist medications simultaneously. For both SS and NMS, immediate discontinuation of the causative agent is the primary treatment, along with supportive care. For NMS, dantrolene is the most effective evidence-based drug treatment whereas there are no evidence-based drug treatments for SS. A 2-week washout of neuroleptic medication minimizes the chance of recurrence.

4. Amos, J. J., M.D., (2013). Maintenance of Certification and Maintenance of Licensure, The Carlat Report: Psychiatry. 11.

Might As Well Face It, You’re Addicted to Psychiatry

I fell asleep in front of an episode of public TV’s Nova the other night and had this nightmare about wormholes and time travel. I thought I woke up at the hospital, but everything looked different. On my way to my office I kept seeing directional signs to what was apparently a continuing medical education (CME) conference about Psychiatry Addiction. I was interested because I thought it was just a clumsy wording for Addiction Psychiatry. When I arrived at the auditorium, I saw a lot of doctors in shirtsleeves sitting on folding chairs listening to someone at the podium:

“Hi, I’m Bill and I’m addicted to Psychiatric consultation. For years I thought I needed to call a psychiatrist to diagnose delirium. I couldn’t stop myself.”

A woman with a grimy and peeling name tag with an indecipherable scribble on it was sweating profusely in the front row. She suddenly jumped out and starting running for the door, screaming, “I can’t do decisional capacity assessment without a psychiatrist!”. Someone tackled her.

Bill continued, “My life was a mess. I couldn’t get through rounds without thinking about ways I could get a psychiatric consultation. A patient would cry in front of me–I’d call. If I saw an antidepressant on a medication list–I’d call.”

I was bewildered. This wasn’t about Addiction Psychiatry. I glanced at a calendar taped to the podium; the year on it was 2012. What happened? I figured it might be a good idea to sneak out, since I’m a consulting psychiatrist. My hand was on the doorknob and I heard a voice cry out,

“There he is; a psychiatric consultant! Grab him!”

Before I could get out, I felt a trembling hand on my shoulder and someone whispered hoarsely, “I need a consult; Please help. My patient doesn’t want surgery. What’ll I do?”

I managed to get away after I mumbled I’d get him a fix later. He was so grateful he cried. As I walked past the pharmacy, something caught my eye. A pharmaceutical representative was arranging bottles containing giant capsules on his stand. A tripod with a flipchart showed a dose response curve with a legend below–something about guaranteed reduction in craving for psychiatric consultation in 6 weeks or your money back. He looked at me suspiciously. I remembered my ID badge and quickly swept it into my pocket.

I hurried outside for some air. What could it all mean? As I hunched past an alley, trying to avoid being spotted, a raspy whisper from my left, “Dude, how’bout some psychiatric consultations–they’re hot.” I whipped around and said, “What’s going on, has everyone gone mad?”

The shadowy man stepped out and smiled, revealing a two rows of solid gold teeth. “What rock you been hidin’ under, son? You act like you never heard of–psych consult prohibition. This isn’t madness to most. Most doctors nowadays know they don’t need psychiatric consultants as much as they thought they did. For others..well, kicking the habit ain’t for everybody.”

As I fled from the pusher, he shouted after, “You can run, but you can’t hide! Baby, I got Columbian Consultations!”

I stumbled into the middle of what looked like a small group of medical students. The faculty physician leader was using an approach that sounded a lot like he was teaching motivational interviewing. “Now, what you have to realize is that it isn’t a matter of simply telling your impaired colleagues that they don’t need a psychiatric consultant to assess the difference between hypoactive delirium and depression. Hey, if they’re at the precontemplation level of readiness to change, you have to roll with resistance. Beatings are rarely helpful.”

As I  headed across the quad, I saw a bedraggled man stumbling out of  a place called “The Annex”.

The Annex

He looked around wildly and seized a sensitive looking man in a tweed jacket, screaming, “I know you! You’re a psychiatric consultant. You gotta help me. I can’t tell my patient he has terminal illness. You’re the only one who can do it!”

And then I woke up in a sweat because my pager went off. It was a text page, “consult on patient in a coma, please assess competence, thanks.”

The Postman Brings Me Another Jewel

Every once in while, I get something practical and interesting in my mailbox. I posted about what the mailman brought me on November 15, 2011, (Bumpy the Bipolar Bear), shortlink http://wp.me/p1glcu-1rc . The postman brought me another jewel. I received the Fall 2011 marketing newsletter called the Chair’s Report from the Department of Psychiatry at The Mount Sinai Medical Center in New York. There were a couple of notable items. In the article entitled, “Accelerating Science–Advancing Medicine”, Dr. Wayne K. Goodman, Chair of the Department of Psychiatry and the Esther and Joseph Kingenstein Professor of Psychiatry updated the ongoing saga about the U.S. Food and Drug Administration (FDA) meeting of the Neurological Devices Advisory Panel held in January 2011 to decide on how to classify Electroconvulsive Therapy (ECT) devices. Dr. Goodman was a member of the FDA panel. More than half the members of the panel recommended keeping ECT classified as Class III, the highest risk category, which may require pre-market approval (PMA) applications. This means that the FDA could require the two small companies  that manufacture ECT devices to conduct large-scale randomized clinical trials with a sham control for each indication for the use of ECT.

If you’re asking what’s wrong with that, than one answer might be whether it’s ethical or feasible to run such studies enrolling “subjects” who are suffering from a psychiatric condition in which the risk for suicide is relatively high, such as major depression. If the manufacturers fail to submit an application  within 30 months of the issuance of PMA requirements, ECT devices could be pulled from the market. We could lose a life-saving treatment for thousands of patients. I’ve posted about this issue previously, so see shortlink http://wp.me/p1glcu-8a.

Further, because I’m a psychiatric hospitalist, I occasionally see a condition called catatonia in the general hospital. It’s a complex neuropsychiatric disorder in which patients most often look mute, immobile, sometimes with posturing ranging from uncomfortable positions such as the “pillow sign” (see shortlink http://wp.me/p1glcu-81 ) to waxy flexibility. I’ve sometimes had to work quickly with other physicians, the courts, and families to make ECT available urgently (occasionally for patients in the intensive care unit) in an effort to save the lives of people who suffer from catatonia, which can be caused by both medical and psychiatric syndromes, and can lead to life-threatening complications including dehydration and blood clots. Catatonia can resolve quickly and dramatically in response to ECT.

And that segues into the next interesting article in the newsletter, which announces Mount Sinai’s Department of Psychiatry introduction of the “…first-of-its-kind fellowship in Hospitalist Psychiatry…” Aside from the thorny issue of the American Board of Psychiatry and Neurology (ABPN) complicated requirements for Maintenance of Certification (MOC) and Performance in Practice (PIP) documentation for new subspecialties in medicine (see the menu above for MOC/PIP and a representative post at shortlink http://wp.me/p1glcu-O2) , this is an intriguing development for another reason. I’ve been a Psychosomatic Medicine specialist for virtually my entire career, staffing the general hospital consultation service and co-staffing with an internist our Medical-Psychiatry Unit. I wonder how the Psychiatric Hospitalist and the Psychosomaticist differ, although I suspect they are both practical (see shortlink http://wp.me/p1glcu-as).

By the way, did I ever tell you the story about my mailbox? We recently moved into a newer house and the mailbox had to be replaced. I chose to do this myself.

Don’t ever try to install your own mailbox. Let a professional do it. I first slipped the old, leaning tower of mailbox off the 4X4 wood post. Then I didn’t follow directions for installing the new one, which fell apart after about a week, exposing a new colony of lethargic bees. I’m not complaining about their lethargy. That’s the reason I was able to escape them without injury. Thanks for asking.

Difficult Psychiatry Consult Questions: Go Ask Alice?

I wrote a blog post about unusual psychiatry consultation questions for Cambridge University Press way back in the fall of 2010 and I thought it was worth revisiting. As a psychiatric consultant, I sometimes get questions that I think might be better for Alice in Wonderland. I often wonder what somebody must have been smoking when they filled out the consultation request form. It’s important to every consultant in medicine and surgery to get a clear question from the physician requesting a consultation. A question that is difficult to decipher or is not a question at all is probably even more difficult to cope with than the curbside question in the stairwell (see the post at shortlink http://wp.me/p1glcu-1ft). It helps to have the overall treatment goal in mind when asking a consultant for help in how to help patients move forward and recover in the hospital. Further, the more specific a question is, the more likely it is that a consultant will have a helpful recommendation. In the spirit of helping doctors frame answerable questions that will yield practical advice, here’s a list of actual consultation questions received by our psychiatry service over the years:

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”

So the key is to remember the short and long-term goals for patients so as to emphasize high quality medical and psychiatric care, and keep the questions keyed to the goals.

“In the Beginning, When Green Came On the Pasture….”

Today, the selection from Dr. Jenny Lind  Porter’s “The Lantern of Diogenes and Other Poems” is one that could be about the loss of innocence [1].

In the Beginning, When Green Came On the Pasture….

In the beginning, when green came on the pasture,

And on the meadow, and on the farthest hill,

When the dew first fell on the morning’s cheek,

And the warmth began, and the chill,

We do not know whose eyes came first, whether it was the mole

Or leopard’s ancestor, or the great-great grandmother

Of a magpie who first wondered at the rain;

We do not know how it was with our first brother,

How he felt the soft earth breathing beneath his feet,

Nor whether he fixed with holy stare

The world’s first ant–red, bustling creature,

Who was doubtless too busy to care.

How he couched himself, how the vines grew tangled,

How the ape swung screaming and was grown to fear,

How one eye first in secret watched another,

Nor who it was let fall the world’s first tear.

In the beginning, green came on the pasture,

And on the meadow, and on the farthest hill,

And the dew first fell on the morning’s cheek,

And the warmth began, and the chill.

A long time ago, in my first days as a resident on the Medical-Psychiatry Unit, I saw death for the first time. Oh, yes, just like everyone else in my medical school class I poked and chopped at the cadaver in Gross Anatomy. And there was the obligatory observation of an autopsy in Pathology class. I heard a dull thud behind me and guessed what it was. When I glanced back, one of my classmates was picking himself up off the floor and pale as snow, pretending the faint had never happened.

But in my first encounter with death on the ward, the shock felt brutal. We had rounded as we always did, seeing patients as a group in the Keystone Cops style we still use, moving from patient to patient in the day room, murmuring good mornings, interrupting breakfasts, asking orientation questions (confident that cheating was out of the question for, as always, the date on the bulletin board was wrong), assessing the obvious and guessing at the ineffable. We stopped to greet the gaunt and trembling man struggling to eat his breakfast, his partner sitting next to him with a look of fear on his face. The man really was not eating and as he stared at us and mumbled he was “OK”, I didn’t believe him. There was something missing in his gaze and I remember wondering if he could even see us.

A couple of hours later when we were seated in the doctor’s conference room, his nurse informed us that the man had died in his room. Our attending directed us to the bedside. The purpose was clear. Innocence was also dying on rounds that day. The man was as pale as my classmate had been, but very still and his eyes were wide open in the same empty stare he had at breakfast. The immediately obvious difference was the large reddish-black stain on his white shirt just below his chin, which bore the same stain.

I think it was then the first chill came, at least for me. The pasture was a little less green after that…still precious nevertheless. In the beginning, young doctors are driven by ideals. By and by enthusiasm is tempered by sorrow.

1. Porter, J. L. (1954). The Lantern of Diogenes and Other Poems. San Antonio, The Naylor Company Book Publishers.