Jon Streltzer and Hoyle Leigh
CONTENTS
27.1 Vignette
27.2 Overview
27.3 Preparation Phase
27.4 Introductory Phase
27.4.1 Cognitively Intact Patient
27.4.2 Cognitively Impaired Patient
27.4.3 The Presence of Visitors
27.5 Discussion of Findings and Recommendations
27.6 Follow-Up Interviews
27.7 Psychotherapeutic Aspects of Consultation Interviews
27.1 Vignette
After being informed by the consultation-liaison (CL) service receptionist that there was a consultation request for evaluation of suicidality and psychosis for Melinda Smith in room 302, the psychiatric consultant rushed into the four-bed room. The curtains were drawn around one bed, and it seemed a procedure was being performed. Another patient was snoring. Another patient was eating lunch but looked at the consultant curiously. The fourth patient had a nasogastric tube and was surrounded by several visitors. The consultant looked around the room, and asked in a loud voice, "Which one of you is Melinda Smith?" One of the visitors of the fourth patient pointed to the woman with the nasogastric tube. The consultant approached the bed, and said, "I am Dr. Jones, the psychiatrist. Your doctor tells me that you are having hallucinations and delusions and want to kill yourself. Is that correct?"
What is wrong with this scene?
27.2 Overview
The psychiatric consultation interview that occurs in a medical setting often requires special techniques that distinguish it from interviews in other psychiatric settings. The referring physician, or sometimes a nurse, is more likely to recognize a psychiatric symptom and seek assistance with it than is the patient. As the consultation request comes from someone other than the patient, the consultant must first establish rapport with the patient, who might not have been aware of the need for psychiatric evaluation; then assess the psychopathology, if present in the context of the medical situation; and then answer the referral question being asked or solve the underlying problem that may or may not be clearly stated or even recognized.
The psychiatric consultation interview generally consists of six phases: (1) preparation phase, (2) introductory phase, (3) history, (4) mental status examination, (5) discussion of findings and recommendations, and (6) follow-up visits. This chapter focuses primarily on phase 1, 2, 5, and 6, as well as the process rather than the content of phases 4 and 5, which are covered in detail in Chapter 3.
27.3 Preparation Phase
It is a mistake to think that there is an advantage to interviewing the patient without any prior knowledge about the patient, ostensibly to avoid being biased. The CL psychiatrist needs to perform an assessment and make recommendations in a timely manner, keeping up with the fast pace of contemporary hospital care. To do this, the consultant must work as efficiently as possible, and this requires being well prepared going into the interview. Much of the work of the consultation, in fact, is done prior to seeing the patient.
The information that has been gathered from the referring physician, the nursing staff, the medical records, and sometimes from old records and family members or other interested parties should prepare CL psychiatrists for what they are likely to encounter in the patient interview. The consultant should also plan the probable duration of the interview. The initial interview for the cognitively intact patient usually takes 20 to 50 minutes. Before interviewing the patient, the consultant should obtain as much privacy as possible, such as drawing the curtains in a multibed room. The consultant should also plan for contingencies, such as a patient who seems grossly confused or agitated. If there are visitors in the room, should the visitors be asked to leave? What if the patient is in the middle of a meal? What if the patient is asleep?
The rule of thumb for such contingencies is to do what the primary responsible physician would do under the circumstances. When consultants interrupt a meal or awaken the patient, they should apologize for doing so. "Ms. Jones, I am sorry to wake you, but your doctor wanted me to speak with you in order to help in your care..." We will discuss the visitor issue later in this chapter.
27.4 Introductory Phase
The introductory phase is approached differently for cognitively intact than for cognitive impaired patients.
27.4.1 Cognitively Intact Patient
The CL psychiatrist should introduce him-/herself with a brief statement regarding the reason for the consultation. It may also be useful to inquire if the patient was expecting a consultation. For example, "Hello, Mr. Jones, my name is Dr. Smith. I'm the psychiatric consultant that your doctor has called to see if I can be of help. Were you told to expect me?" If the patient says no, the consultant might say, "Your primary doctor asked me to see you as he was concerned that you might be experiencing depression or anxiety or other concerns." This line of approach will not offend or upset most patients. If they had been informed ahead of time, which is preferable, or even if they had not, they may realize that the consultation is appropriate. Only a small percent of patients become distressed or resist the consultation at this point. This most often occurs with patients who are paranoid, or who are drug abusers who are afraid that the psychiatrist may cut off the narcotic analgesics or tranquilizers that they are demanding.
Notice that in the example above the consultant mentioned depression or anxiety. If the patient is in fact concerned about depression or anxiety, or is aware of having a psychological problem, rapport will be established as easily as in any other psychiatric setting. If the patient issues are of a different nature, however, such as a personality disorder, a somatoform disorder, a behavioral problem on the ward, or a communication problem with the doctor or staff, rapport will be much more difficult to establish. In this case, the following approach often allows rapport to develop quickly.
The brief introduction need only mention that you are a psychiatric consultant whom the primary doctor asked to assist. Then it is very useful to immediately begin talking to the patient, providing information, rather than asking questions. For example, "Mr. Jones, I understand that you hurt your back more than eight years ago and subsequently have had two operations on it. You are in the hospital now for diagnostic testing because the pain has been getting worse." By reviewing the patient's pertinent medical history and reason for being in the hospital, you have established that you are interested in the same things that the patient is interested in. Patients quickly realize that you are familiar with their case, that you are part of the medical team, and that they will have the opportunity to talk in detail about their specific problems. In contrast, an opening such as "What kind of problems are you having?" is occasionally irritating to the patient, particularly the more difficult patient who is more likely to have a psychiatric consultation requested.
At this point the consultant can pause in the interview, giving the patient a chance to expand on the problem, or to correct what the patient considers to be misinformation on the part of the consultant. Then the consultant takes an expanded history of the present illness. Patients commonly describe their experience, beliefs, reactions, and contextual issues around the symptoms. Another medical specialist may try to focus the history on the symptoms that are important in sorting out the differential diagnosis. In contrast, for the psychiatric consultant, the focus is not the differential medical diagnosis, but rather understanding the patient's experience of what is going on in the patient's life and how this influences the presentation of symptoms, the experience of illness, the response to medical care, and the doctor-patient relationship. Thus we encourage patients to give us an expanded history. Often patients appreciate this chance to tell their story, without too much interruption and without being diverted from what they want to say. If, as the patient tells the story, the consultant is attentive, empathetic, and facilitating, a positive rapport is likely to be established, which is crucial in a short interview. Diagnostically important information is more likely to emerge, and the interview is often therapeutic in and of itself.
27.4.2 Cognitively Impaired Patient
When the information obtained about the patient prior to the interview suggests that the patient may be confused or disoriented, one must consider the probability that the patient might be delirious or demented. Sometimes delirium or dementia has already been diagnosed, but in perhaps half the cases where this is ultimately found, this will not have been done. In such an instance, the stated reason for referral may be, for example, depression or agitation. Even in these cases, the nurses' notes often reveal that the patient is confused, at least at times. One must be careful not to uncritically accept the nurse's notation "A&O x3" (alert and oriented in three spheres) as being indicative of no cognitive dysfunction, however. Sometimes the patients are clearly delirious.
If a cognitive disturbance is suspected, the interview proceeds differently than if it is not. A delirious or seriously demented individual cannot give a reliable history. Attempting to obtain history from such patients may stress them beyond their capabilities and may be a waste of time. Asking questions that are beyond the patient's capabilities of comprehending may result in a catastrophic reaction, in which the patient becomes anxious, agitated, and defensive, and may even refuse to communicate. The interviewer may be in doubt as to whether the patient is uncooperative or has a cognitive disturbance.
A good way to start the interview when significant cognitive disturbance seems to be present is by indirectly testing orientation. Instead of introducing oneself immediately, one might say, "Hello, Mr. Jones, have we met before?" If patients are disoriented to person, they will not know that you are a doctor seeing them in the hospital. They may say, "Yes, I think I've seen you down the hall." A follow-up question might be, "How long have you been here?" This question is testing for orientation to time but it does so subtly, in a manner that is not likely to antagonize the patient with a mild cognitive deficit or no deficit. If the patient says, "Three years," when in fact it has been three days, one can conclude that there is disorientation to time. On the other hand, if patients in the intensive care unit have been comatose or under sedation for an extended period of time, they may well not know where they are or how long they have been there. Then patients can be told, "You are in the Memorial Hospital, and you have been here for 6 weeks following a motor vehicle accident." A few minutes later patients can be asked if they remember the name of this place and how long they have been here. If they cannot remember, they should be oriented again and asked once more about a minute later. If they then answer correctly, they can be asked again, about 5 minutes later. In this way memory span can be tested without having to bother giving patients three words to remember.
If the memory span is less than 30 seconds, it is unlikely the patient will be able to remember anything that the nurses say. The nurses can be informed about this, so that they don't accuse the patient of being uncooperative for failing to follow their instructions. If the memory span is a minute or longer, the patient should be capable of learning and remembering after multiple repetitions. If the memory span approaches 5 minutes, the patient is likely to have minimal cognitive impairment.
Thus, the interview for the suspected cognitively impaired patient consists primarily of a mental status examination that can confirm the diagnosis of delirium or dementia within a few minutes. If the cognitive abilities appear intact, the rest of the interview should proceed as usual.
27.4.3 The Presence of Visitors
When the consultant enters the patient's room, there may be visitors present, since visiting hours ordinarily have few restrictions in contemporary hospitals, and since the patient is likely to be seen at the consultant's convenience, not by appointment.
What if the patient's spouse is present? If the consultant ignores the spouse, and just begins to interview the patient, it will be awkward and impolite, which makes it harder to establish rapport with the patient. It is prudent not to identify yourself as a psychiatrist in the presence of visitors initially, as some patients may feel embarrassed. For a psychiatric interview to be conducted, the consultant must have the patient's permission for others, even the spouse, to be present. The consultant should introduce him-/herself to the patient, "Hello, Ms. Smith, I am Dr. Jones," and then ask visitors what their relationship is to the patient. At this point, the interview can proceed in two ways, depending on the context of the situation and the inclination of the consultant. If the consultant suspects, based on prior knowledge of the clinical issues, that it will be necessary or helpful for the patient to talk privately without the presence of significant others, he or she might say to the visitor, "I am going to talk to your husband/wife for a while. Would you excuse us for a few minutes?" When the visitor has left the room, the consultant should introduce him-/herself as a psychiatrist and ask, "Would you mind my speaking with your wife/husband/relative/friend after we finish?"
At times, however, the consultant may judge that the presence of a significant other may be of great advantage. If the consultant is experienced in interviewing couples (and families), he or she may directly ask, "Ms. Smith, would you prefer Mr. Smith to be present while we talk, or would you like to talk with me alone?" Most of the time, a patient will feel more comfortable in the presence of a loved one, unless there is something to hide.
The presence of a spouse/significant other is particularly helpful if the patient has dementia, severe psychosis, chronic illness, or drug abuse problems. The spouse/significant other can often correct or corroborate the patient's story. The history that is then obtained is often much richer and more complete. In addition, the consultant can assess the relationship for the degree of support that exists within it and for how well a couple communicates.
To bring the spouse/significant other into the conversation, the consultant may turn to him/her and say, "I can see how difficult this illness has been for Mr. Jones. How has it affected you?" Another way to bring the spouse into the conversation, particularly with elderly couples who may be more reticent to talk, is to ask, "How long have you two been married?" For elderly couples who have been married a long time, the consultant can respond, "That's wonderful. What is the secret of your success?" A couple that gets along well often responds with laughter; and the husband might say, "She's the boss and I do what she says." The couple usually enjoys this banter, which enhances rapport with the consultant. The consultant now knows that the marital relationship is one that provides significant support.
If there are significant problems of the relationship, they are likely to emerge at this juncture, and the consultant can assess how much the marital conflict interferes with the medical care or the response to illness.
In general, interviewing the patient with the significant other present is much more likely to give the consultant a good sense of what the patient is like as a person. On the other hand, some patients may be reluctant to reveal conflicts with the significant other present. The consultant should make a judicious decision concerning whether to interview the patient alone or with the significant other. Sometimes it may be appropriate to ask the patient to invite the significant other to be there for a later time when the consultant can interview them together.
27.5 Discussion of Findings and Recommendations
After the history has been obtained and the mental status examination performed, the consultant should discuss with the patient and significant other, if present, the relevant findings and recommendations. This should be done in lay terms and with recognition of the patient's and family's sensitivities. It is often useful simply to acknowledge the symptoms and signs that the patient has already reported to the consultant: "As you said, Ms. Jones, you have been feeling blue and depressed, and you have trouble falling asleep and sleeping through the night. You also lost considerable weight in the last several months. For these symptoms, I will recommend to your doctor an antidepressant medication called mirtazapine that you take at night. This medication is likely to help you sleep better, and increase your appetite, too. Do you have any questions?" It is always a good idea to allow the patient to ask questions, and discuss any concerns or misgivings about the psychiatric diagnosis or treatment.
For patients whose psychiatric condition is intimately related to the medical condition or its treatment, leaving the interview on a positive note is often very helpful and comforting to the patient. For example, the consultant might say, "I know it has been rough, but your blood tests show definite improvement. Your job right now is to be as patient as you can while your treatment [specify it] continues. I expect that you will be feeling better soon." The more the psychiatric consultant has learned about the patient, the more he or she will be able to conclude in a meaningful, supportive manner. Patients are very sensitive to the words and nuances of their doctor's communications when they are sick. Many patients take great comfort in anything positive the doctor says.
27.6 Follow-Up Interviews
At least one follow-up interview is desirable for all consultations, if the patient remains in the hospital. As the initial consultation interview was a cross-sectional slice of patients' mental state and behavior, it is necessary to observe them at another point in time. Quite often, the difference is astounding, especially when a patient is emerging from delirium. A visit from a family or friend sometimes dramatically changes a suicidal patient's mood.
As with the initial interview, the consultant needs to prepare ahead of time for the follow-up interview. The consultant needs to know how the medical treatment is proceeding, and what further treatment is being planned. The consultant should also know the patient's responses and behaviors since the last interview When the patient realizes that the consultant is knowledgeable and up-to-date about the medical course, further trust is engendered and misunderstandings or miscommunications, which are all too frequent, can be clarified and corrected.
27.7 Psychotherapeutic Aspects of Consultation Interviews
The purpose of the initial consultation interview is primarily evaluative, but any interview conducted by a psychiatrist has inherent psychotherapeutic aspects. By deliberately making the effort to establish rapport with patients, the patients feel respected and valued, which is, unfortunately, not always what they experience in the hospital setting. In the course of history taking, the psychiatrist elicits information about the patient's emotions and emotional responses to important events that allows the patient to express pent-up feelings. By discussing the assessment and recommendations with the patient, in a language that the patient can understand, the patient feels reassured that the consultant now has a handle on the emotional problem that had been difficult to describe or express. Through follow-up visits, the patient feels that the consultant continues to be interested.