The Customer is Always Partly Right

Blog Post by James J. Amos MD, University of Iowa, USA  

Recently our Psychosomatic Medicine/Consultation Psychiatry (PM/CLP) service received a request to evaluate a patient on the Bone Marrow Transplantation (BMT) inpatient unit. There are no worries about revealing personally identifying characteristics of the patient. The issue was general enough to apply to many thousands of patients and inpatient general and specialty medical units everywhere. As the BMT specialist saw it, the patient was severely depressed and needed an antidepressant. As the patient saw it according to the junior psychiatry resident, depression was not the issue and antidepressant was unnecessary and unwanted, adding that nearly all of the vegetative symptoms of fatigue, appetite and sleep disturbance as well as other somatic suffering could be explained by the medical illness and its treatment. After the resident’s excellent presentation and my visit, there seemed to be no difficulty. The patient simply denied feeling depressed and declined the offer of antidepressant. Aside from the vague sense I got that the patient was indifferent even to visits from our psychiatric nurses, I had no reason to doubt the resident’s conclusion, which was that supportive psychotherapy from psychiatric nurses continue and to call us back if there were a change.

It was the interaction with the consultee afterward that changed my mind. We almost left the unit before I thought to ask the resident if she had touched base with any member of the primary team about our conclusions and recommendations. She had not yet. The consultee looked stunned when we described our findings. We then discovered that the patient had been in the hospital a very long time and had steadily declined in the context of a long battle with many of the usual medical complications of a BMT, including graft versus host disease. The primary team described a giving up, given up attitude with nearly no effort to participate meaningfully in recovery. The consultee was surprised that the patient had declined antidepressant, noting that there’d been tacit agreement to it in a discussion the very morning of the consultation request. I could see that the team was convinced that clinically severe depression fully explained the patient’s decline and I sensed doubt in the room, doubt about our conclusions and perhaps doubt regarding the expertise and helpfulness of the psychiatric consultants. Careful observation of the “nonverbals” of the consultee in response to the resident’s reiteration of our assessment led to me to a different approach.  Painfully aware of the barrier of inconvenience that led me to awkwardly reopen the door to discuss what might be going on, I handed a copy of the scale to the consultee asking the primary team to administer it after which we’d go over it with the patient. It had not even occurred to me to take a depression rating scale with me into the room, partly because the patient was in isolation, making it necessary to gown and glove as well as not take anything into the room that wouldn’t stay there. I acknowledged the need to gather more information that might allow us to distinguish between depression per se and the all too common “sick and tired of being sick and tired” attitude so prevalent in long-hospitalized patients. I also remarked that perhaps it was possible to apply the principles of the readiness to change scale in this situation, suggesting that maybe the patient could be in a pre-contemplation or contemplation stage about depression. And this seemed to lead to a subtle change for the better in our interaction, along with my saying firmly, “We’re not done yet”. This was apparently much more acceptable than our earlier stance, which foreshadowed the signoff, viewed by some consultees as peremptory.  In my comments in the consultation note, I mentioned the need to differentiate between depression, apathy, and hypoactive delirium, which I had failed to point out to the resident initially. Later I also reminded both of us that the PM/CLP specialist always has two customers. One of them is the patient, and the other is the requesting medical team. And I find that occasionally I must relearn that the customer is always at least partly right.

I can think of similar situations in other transplant consultations. If the heart transplant team requests psychiatric consultation for patients with a history of recurrent depression and tell us that they want us to deliver the message that unless they start antidepressant they will not be listed for transplant, should we deliver the ultimatum? What if these patients do not believe they’re depressed and are at best ambivalent about restarting antidepressant? How to balance the growing knowledge of the psychophysiological link between heart disease and depression, the need to optimize the survival of post-transplant patients both for their own sake and for the sake of continued accreditation of transplantation centers—and respect for patient autonomy?  These are difficult conversations and call for listening and communication skills that are critical for PM/CLP specialists to have. The Consensus Statement with the European Association of Consultation-Liaison Psychiatry and Psychosomatic Medicine (EACLPP) and the Academy of Psychosomatic Medicine (APM) of 2010 clearly identifies communication and collaboration as key competencies of PM/CLP psychiatrists.  It’s tough to find current specific guidelines for how the PM/CLP specialist is supposed to interact with their medical colleagues under the aforementioned circumstances. The most recent was published in 2006 in the May-June issue of Encephale. Unfortunately I couldn’t read the entire article because I’ve not learned French. But the authors point out in the abstract, “The question is no longer to know why the subject has a problem but to know how to resolve it”(Cottencin, Versaevel et al. 2006). Further, “…like the patients, the medical staff must feel understood to be able to cooperate”.

This theme of the need to appreciate the consultation process using a systems approach is not new, though little has been written about it for decades. The pragmatic approach described by Cottencin was outlined in a landmark paper by Meyer and Mendelson in 1961(Meyer and Mendelson 1961). The consultation process consists of the consultation request, the psychiatrist’s redefinition of the patient situation, and the experience of the psychiatrist in the operational group. The psychiatrist is a successful consultant to the extent that she reduces strain in the operational group, i.e., patient, consultee, and psychiatrist, by declining to magically solve the group disorganization, and by promoting interpersonal and intrapersonal communication through simply gathering information. Another way of describing this theme is to review the role of group process in liaison psychiatry meetings. Psychiatrists used to talk about Bion’s observations on group dynamics involving dependency (expecting the psychiatrist to fix the patient), pairing, and fight-flight (the operational group fighting or fleeing patient “noncompliance”) and they’re probably still relevant to practice today(Cutler 1980).It’s possible as some say that medical specialists are all but ineducable about the role of psychiatric illness in medical disease, although that has not been my experience nowadays—just the opposite as the scenarios above illustrate. What might be missing from these conversations and guidelines is the need for the psychiatric consultant to walk a mile in the consultee’s shoes. But what’s the best way to imagine how stressful it is to work day in and day out on a BMT or heart transplant unit where it’s common for people to die, sometimes after prolonged emotional and physical suffering? Because doctors and nurses sometimes get very close to their patients, the loss is grieved much the same way as anyone grieves the death of someone he cared deeply about. I remember standing in the line of mourners at my mother’s funeral to view her for the last time. The goodbyes were brief. When it was my turn, I lingered far too long gazing at her although I didn’t realize it as I wrestled with old images, regrets, broken promises, and impossible wishes—all the lava of the complicated relationship of mother and son. Finally, my Uncle behind me took my arm and steered me away from the maelstrom.   

Maybe the pain my medical colleagues feel is a little like that, the price of the complicated relationship between doctor and patient.   

James Amos is editor of Psychosomatic Medicine, An Introduction to Consultation-Liaison Psychiatry, published by Cambridge University Press   

Cottencin, O., C. Versaevel, et al. (2006). “[In favour of a systemic vision of liaison psychiatry].” Encephale 32(3 Pt 1): 305-14. Cutler, M. O. (1980). “Group process in liaison-staff meetings.” Psychosomatics 21(3): 241-243. Meyer, E. and M. Mendelson (1961). “Psychiatric consultations with patients on medical and surgical wards: patterns and processes.” Psychiatry 24: 197-220.


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