Keeping the Hospital Happy

July was a month of consultation/liaison work, which is sort-of-but-not-exactly "psychiatry for patients who are medically ill". The concept is simple -- something is off in the mental function of patients who are in the hospital for something else, be it medical or surgical. The primary doctors feel like they can't quite diagnose and manage the problem on their own, so they call psychiatry for advice. I go see the patient, think very hard, then provide that advice.

In practice, it's not that simple, because the problem could be anything. In the first week alone, I saw patients who are delirious because neurosurgeons have taken a tennis-ball-sized tumor out of their brain, patients who are depressed in the context of complex life-threatening cancers that put them in the hospital for months, and patients who simply are frustrating for their medical team to deal with. This is one of the reasons I like consultation work -- you never know what you'll find until you walk into the patient's room and sit down. It offers a lot more of a general-psychiatry experience than the chronically mentally ill who tend to be our population on the locked inpatient wards, and I find the change of pace refreshing.

The other really fun part of the job is the way we function as sort of "ambassadors for psychiatry". Fact is, most docs outside the specialty don't quite get what it is we do, or how we do it. When they call us, they're experiencing a problem where they feel out of their league, and we're able to come in and (usually) offer something, even if it's only reassurance that there isn't a serious problem going on. It takes psychiatry from being a bunch of jargon-slinging "fake doctors" to being a specialty with a meaningful role to play, and I like proving that my training is useful. That's particularly important in my own personal situation, given that I'm an engineering-oriented psychiatrist who needs collaborators in other disciplines (especially neurology and neurosurgery) to make my ideas translate to projects and clinical applications. That same first week put me back into contact with a neurosurgical attending who I haven't seen in over a year, but who's directly involved in a couple projects that I needed to know about. It's a rare day for a resident when the clinical cases line up with research interests, and it's made the job particularly satisfying of late.

The third cool piece is that we don't just treat the patients. A huge part of the consult psychiatry job is taking care of doctors' mental health. I don't mean in the sense of "sit down for an hour and talk about your feelings". Instead, unsurprisingly, a "difficult patient" doesn't exist in isolation. The patient might have an angry or help-rejecting or demanding or dependent personality, but they don't become "difficult" until their doctors come into the picture and have trouble coping with that personality. When we get called because of a patient like that, there isn't anything we're going to do for/to the patient themselves. Psychiatric drugs treat major mental disturbances; they don't do jack for personality structure. Psychotherapy helps, but most patients aren't in the hospital for months in order to build therapeutic rapport and do the work, and most inpatient psychiatrists aren't trained therapists anyway. So, we're left to intervene on the doctors and nurses instead.

For a stressed-out medical team, the simple act of validating their feelings helps. A lot of the folks in this business really do have a near-boundless love for humanity, and it deeply disturbs them when they find themselves angry at a patient. There's usually a part of them that feels like a failure for simply not being loving enough or patient enough. It helps them to hear from us us that yes, we agree, there's just something not quite right with their patient, and it's OK to be mad at them. In some patients, we'll even go so far as to mediate communication, if that really seems beneficial. In other patients, their fundamental need is just more time with their doctor, and we can be a pretty reasonable substitute. The beauty of psychiatry is that for us, the one-hour or at least half-hour patient encounter is still possible and expected; we can spend time that others teams can't. And then, in some patients, all we can do is suggest ways for the physicians to act in order to avoid triggering too many tantrums. Even that helps -- we see a lot more personality pathology than anyone else, so even if it's just trial and error, we have a sense of what to try first. We usually don't get the team out of the woods on the first try, but just having a guide instead of wandering blindly seems to make things easier for them. Even if we don't make the patient better in these particular encounters, we still walk away having made someone else's day go a little easier.