Intro to CL

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Intro to C-L

• The Dynamics of the Competency Consult

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Meaning of C-L
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Different Relationship

• Body
• Mind

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Possible Questions to Explore

• How recognize real depression amidst myriad
  medical symptoms.
• It there any evidence for any Psychiatric
  Disorder DIRECTLY caused by a medical disease or
  insult (not including cognitive disorders, of
  course).
• What is the best approach to understanding
  somatoform/factitious/malingering symptoms.
• What is the psychiatrists role in pain treatment?
  Is pain ever really a psychiatric disorder.
• How do I approach delirium in the hospital
  setting?
• Is there any real evidence for stress/depression/e
  tc. causing a medical disorder (cancer).
• How to deal with substance abuse in the medical
  setting.
• How to deal with personality disorders in the
  medical setting.

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For today A Story
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How an old, seemingly fossilized paper breathed
new life into nagging problem
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The problem

• Residents HATE competency consults

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Resident hate doing them

• Debate appropriateness
• Mom says
• Semantics

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Case1 62 YO ?

• Competency
• Refuse treatment
• Disposition

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A Case 62 YO ?

• Resident interview
• Hosp LE Cellulitis
• Poorly controlled diabetes
• Need IV treatment
• Post hospital rehab
• Instead
• Refusing meds
• Staying in bed
• Threatening AMA

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Going to the unit..

• Nurses
• Thank God youre here
• Awful, abusive, non cooperative
• On purpose
• Something needs to be done NOW
• Caseworker
• Home situation bad
• You need to
• Let go
• ? hosp.

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• MD
• Really angry
• Family
• No contact

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Patient Interview

• Obese, in bed
• Alert
• Insight (why Im here?)
• Good
• Refusing meds?
• Mistrust
• Disposition?
• Knows should stay, but
• Mental Status
• Good on memory other tasks
• Except concentration

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The 1 Minute Consult

• (cha-ching)

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Recommendations

• Yes, competent
• meet criteria
• Probably some resolving delirium
• Will get better with tx
• Not appropriate for psych
• Not committable
• Not wanting to go home.

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Case 2 70 YO ?

• Competency
• Refuse treatment
• Disposition

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Resident Interview

• In for SSS
• Fell at home
• Needs pacemaker
• Post hospital rehab
• Instead
• Inconsistently Refusing

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Going to the unit..

• Nurses
• He know what hes doing
• on purpose
• Caseworker
• Home situation bad
• Nephew bugging her
• You need to
• Let go
• ? hosp.

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• MD
• Really frustrated
• Family
• Nephew
• VIP
• have to do something (or else)

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(No Transcript)
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The 1 Minute Consult

• (cha-ching)

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Recommendations

• Competent?
• Why problems?
• Not appropriate for psych
• Not committable
• Not wanting to go home.
• (Staff reaction)

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Whats wrong

• Staff reaction
• Questioning
• Reconsults
• Urgency (pages)
• And why does it happen so often?

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Whats wrong

• Staff reaction
• Questioning
• Reconsults
• Urgency (pages)
• And why does it happen so often?

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Psychiatric Consultations with Patients on
Medical and Surgical Wards Patterns and Processes
Eugene Meyer and Myer Mendelson
T HIS PAPER presents some of our observations of
patterns of disturbed behavior blah blah blah
blah medical and surgical wards blah blah blah
Johns Hopkins blah blah blah blah blah blah blah
blah blah blahblah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blahblah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah in the structuring of
patients total perceptions.2
These initial studies blah blah blah blah blah
blah blah blah blah blah blah blah 60 consecutive
requests for psychiatric consultation blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah blah
blah
Psychiatry 24197-220, 1961
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Meyer and Mendelson

• Experience _at_ Osler Clinic
• 60 consecutive requests for consults
• Predictable processes
• Interpersonal approach
• Whos the focus?
• Not just the patient.
• Breakdown in relationship

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The process of consultation
Redefinition
Request
Participates In Group
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Request for Consult

• 2 conditions
• Uncertainty
• Relative to normal for that unit
• Responsibility
• Disturbed behavior should be treated
• If not, behavior is dismissed
• Combination
• Anxiety
• Lots of other emotions (anger, resentment, guilt)
• avoidance

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In This Case

• Uncertainty
• Patient not complying
• Even though should
• Antagonistic
• Even though theyre trying to help
• Responsibility
• Needs treatment, but isnt getting
• Will get worse
• Extra responsibility nephew.
• Need to resolve
• Try to be nice, but

• Result
• Alienation
• Anger
• Neglect
• Mistakes
• Unprofessional
• Desire to discharge
• Relieve responsibility
• Group disruption
• Blaming each other
• (night nurse)

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Redefinition

• Collects information
• Often important things missing
• Ex. Emotional reactions to patient
• Expanded psych interview
• Result
• Psychodynamic formulation of the patient

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Collecting info

• Navy Nurse
• Never married, no S.O.
• BF died 40 yo (FUI)
• Lived alone, few social contacts.
• Really scared
• Invalid
• Losing legs
• Dying

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Redefining case

• What they thing they want
• Competency
• Force treatment
• Take responsibility
• Get rid of her
• Relieve responsible
• What they need
• Understand difficult patient
• Predict a better change approach

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Psychiatrist as Participant in the operational
group

• Participant observer
• Group dynamics _at_ difficult patient (pitfall)
• Take on responsibility
• Need to demonstrate self worth
• With expected magical solution
• Really clue to staff-patient interaction

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In this case

• Pitfalls
• Oh there you are
• Transfer to psych
• Dynamics-dyadic tensions
• Instead
• Collect more info

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How does this help?

• Act of calling ?
• Catalyst to de-escalate emergency
• Transmittal of understand of patient to group
• Reduce uncertainty/anxiety
• Promote professional detachment
• Promote interchange with patient
• Ultimately goal is
• Not solve, but restore environment
• They can do the rest
• Sort of like psychotherapy

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In this case

• Help patient understand
• gee, this happens a lot to me
• Help staff understand
• Personality
• Organicity
• Adjustment
• Not personal but clinical
• Restore communication

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Outcome

• Good things
• Better interactions (nurses)
• Patient completed treatment
• Disposition rehab
• Nephew didnt sue
• Bad things
• Physician

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As for the resident