Redesigning the surgery clerkship at MCP Hahnemann School of Medicine to address the educational needs of generalists.

This article describes how the surgery clerkship at MCP Hahnemann School of Medicine was redesigned to provide all students a well-rounded general professional education and to address the specific educational needs of generalists. During the 12-week clerkship, students spend eight weeks on two different general surgery rotations, which include significant experiences in outpatient settings. The evaluation and management of common general surgical problems, as well as the holistic approach to patient care, are emphasized. A nurse educator, recruited through funding obtained from The Robert Wood Johnson Foundation's Generalist Physician Initiative, provides formal instruction in holistic care and teaches bedside procedures. Two weeks are devoted to focused surgical subspecialty experiences addressing common conditions and are conducted primarily in outpatient settings. The remaining two weeks include an integrated musculoskeletal disease rotation, including orthopaedic surgery, rheumatology, physiatry, and radiology. Didactic teaching includes criteria for referral of patients from generalists to specialists. The new clerkship model has been well received by the students. Review of student logs for the first six months indicates the breadth of surgical experience has been maintained and appropriate balance achieved between simple and complex surgical cases. Further evaluation of the model will continue through longitudinal follow-up.

Competency evaluations on the consultation-liaison service. Some overt and covert aspects.

Competency assessments are a growing function of the consultation-liaison (C-L) psychiatrist. Such consultation requests often mask a variety of psychosocial issues that are a source of frustration to the referring physician responding to the pressures of the changing health care delivery system in the acute care setting. This study identifies the issues and the outcome of psychiatric consultation in these patients. The implications of this burgeoning role for the C-L psychiatrist are also explored.

The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. The Academy of Psychosomatic Medicine.

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the field, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and revised prior to final approval. Some of the topics discussed include qualifications of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations.

The chronically mentally ill on a general hospital consultation-liaison service. Their needs and management.

The consultation-liaison (C-L) psychiatrist often sees chronic mentally ill patients when they are admitted to the medical-surgical services of the general hospital. Little research has been directed to the special needs and concerns of these patients in the general hospital. This area has become more relevant now that many of these patients are no longer cared for in the safety of the state hospital setting, often making baseline medical histories inaccessible. They have an overall higher mortality rate than the general population, cannot give adequate histories, and their psychotic illness can mask an underlying medical illness. In this preliminary investigation of the problems of this special population, the authors examined the issues concerning nursing needs, length of hospital stay, medical diagnosis, and possible complicating problems encountered during these patients' hospital stays in the setting of an urban university hospital. The authors discuss the implications of the role of the C-L psychiatrist in addressing their patients' acute problems.

What, why, and how of consultation-liaison psychiatry. An analysis of the consultation process in the 1990s at five urban teaching hospitals.

There is controversy about the role and function of a consultation-liaison (C-L) psychiatrist, as reflected in the ongoing debate about what to call ourselves. To clarify the essential elements of our function, the authors analyzed the process and content of the entire consultation experience from the time of initial consultation to the time of discharge in 50 patients across 5 urban teaching hospitals. The common components of the C-L process, in this pilot study, were identified to be facilitative, consensus-seeking, and interpretative. Implications of these findings for the C-L psychiatrist's role in the general hospital are discussed.

Funding for consultation-liaison services in public sector-managed care plans. The experience of the Consultation-Liaison Association of Philadelphia.

Recently, the Commonwealth of Pennsylvania initiated plans to implement a mandated behavioral health carve-out program for Medicaid-eligible persons. The Consultation-Liaison Association of Philadelphia (CLAP) discovered that there was no provision for the coverage of psychiatric services for patients with concomitant medical illness. As a result, the authors responded by initiating a series of actions aimed at ensuring inclusion of such services as part of mental health services to be delivered. CLAP developed a brief position paper that includes a description of the need for such services, the types of services typically delivered, the impact of psychiatric input in the medical setting on costs and other outcomes, and a specific set of recommendations. These efforts have lead to the inclusion of consultation-liaison services in the new plan. A description of recent changes in Medicaid, including expansion of managed care plans, the status of mental health carve outs, and the possibility for inclusion of psychiatric consultations for the medically ill within these plans, is detailed.

Neurobehavior rounds. Their role in promoting psychiatric liaison in a neurology inpatient unit.

A joint neurobehavior conference was established utilizing the models of Lipowski's Montreal conference and Geschwind's aphasia and neurobehavior rounds at the Boston VA Hospital in 1991. The authors report on the usefulness of this conference in promoting the goals of psychiatric consultation and liaison on a neurology inpatient unit, specifically on patient care, education, and collegiality. The value of the multidisciplinary approach in solving complex neuropsychiatric problems is also discussed.

The lithium toxic patient in the medical hospital: diagnostic and management dilemmas.

OBJECTIVE: Patients with lithium toxicity can pose difficulties in diagnosis and management in the general hospital setting. The authors examined patients who were referred to the Psychiatric Consultation-Liaison Service with suspicion of lithium overdose to delineate and characterize medical and psychiatric risk factors for toxicity and to follow the course and resolution of their toxicity. METHOD: The authors reviewed the charts of patients with lithium levels > 1.5 mEq/L who were admitted consecutively to a general hospital over an 18-month period. RESULTS: Of twelve patients, eight were found to have developed lithium toxicity due to incidental and iatrogenic factors. These patients presented with a variety of confusing signs and symptoms. Hypothyroidism and coexisting organic illness contributed to the lack of clarity in their clinical picture. CONCLUSION: The widening scope of indication for lithium therapy leads to increased risk of toxic reactions which challenge the diagnostic skills of the consulting psychiatrist in a general hospital setting.

Distinguishing features of pseudocomplex partial seizures.

The authors identify common features in the clinical presentations of three patients whose pseudoseizures mimicked complex partial seizures. All three had suffered the recent traumatic loss of a significant love object, and all manifested unconscious feelings of guilt and the use of defense mechanisms of denial, dissociation, introjection, identification, and symbolization. The authors explore the diagnostic, treatment, and etiological implications of these findings.

Psychologic factors associated with peptic ulcer disease.

Peptic ulcer disease provides an excellent model for the study of mind-body interactions in the pathogenesis and course of an illness. Early psychodynamic explanations of the role of personality factors in the evolution of peptic ulcer disease have been supplemented in recent years by more scientifically based studies on the role of stress and coping ability. Multiple psychosocial variables have confounded the outcome of many of these studies. Yet, a clear need and guidelines exist for the comprehensive medical and psychosocial evaluation and treatment of patients with peptic ulcer disease. Concomitant psychiatric assessment and management, including psychotherapeutic and psychopharmacologic approaches, for those patients with refractory symptoms or ongoing psychiatric symptoms carried out in close collaboration with primary caregivers will significantly decrease overall morbidity and mortality.

Hypnosis on a consultation-liaison service.

The use of hypnosis was demonstrated on a psychiatric consultation-liaison service (CLS) in a broad spectrum of medically hospitalized patients. Hypnosis was employed as an adjuvant measure to traditional medical and psychologic treatment modalities. Tapes for autohypnosis were used for reinforcement. Twenty-nine women and eight men from 24 to 75 years of age were hypnotized for relief of depression, pain, anxiety, or side-effects from chemotherapy. Results were excellent (total to almost total relief of symptoms) in 68% of the patients, fair in 22%, and poor in 11% with no differences among the results with the various conditions. This report demonstrates that hypnotherapy can be an extremely useful tool in the medical management of patients on a CLS.

Beneficial effects of psychiatric intervention on recovery after coronary artery bypass graft surgery.

The effects of perioperative psychiatric intervention were studied in 33 patients undergoing coronary artery bypass graft (CABG) surgery. All patients were evaluated preoperatively using the Mini-Mental State Exam and the Psychological Adjustment to Illness Scale-Self-Report. Participants in the study group (N = 16) had a structured psychiatric interview prior to surgery and were followed daily with supportive psychotherapy throughout their hospitalization. The number of medical complications was higher in the control group. No significant differences were found in neurologic or psychologic complications. The study group used significantly more oxycodone-acetaminophen (Percocet), but less morphine-sulfate or benzodiazepine on postoperative days 3, 4, and 6. The mean length of stay was 3 days shorter for patients in the study group. In the current era of escalating health care costs and high technology, clinical protocols and research studies that evaluate the cost effectiveness and efficacy of psychiatric intervention in medically ill patients should be pursued.

Noncompliance in the treatment of endocarditis. The medical staff as co-conspirators.

Intravenous drug abusers with endocarditis present difficult problems in both medical and psychiatric management. A retrospective chart survey revealed that eight of nine such patients with endocarditis signed out against medical advice before antibiotic therapy was completed. Reasons for premature discharge included the patient's underlying psychopathology as well as the emotional response of the staff to these patients. Understanding both of these factors may help to prevent these premature discharges.

The psychiatric disorders of midlife.

The midlife phase of adult development, once viewed as a period of stagnation and involution, is now seen as a time with the potential for significant psychologic growth and development. The concept that women's psychologic health and physical health are closely tied to her reproductive function is coming under close scrutiny. The menopause is only one variable, along with other biologic, psychologic, and sociocultural stressors, that increases the individual woman's vulnerability to several psychiatric disorders. Careful attention to the patient's presenting symptoms and the specific diagnostic criteria for psychiatric illnesses allows for accurate diagnosis and treatment and avoids the pitfall of attributing these symptoms to the "menopausal syndrome."

Stress, affective disorders, and immune function.

Increasing scientific evidence supports age-old observations that psychosocial factors are closely associated with the pathogenesis of certain physical and mental illnesses. The immune system appears to play a primary mediating role. Whereas acute stress may initiate a transient immunologically protective response, prolonged or poorly controlled psychosocial stressors may result in depression of different components of the immune system. These responses may be related to, or independent of, changes in the neuroendocrine system. As the rather prolific literature in this infant area of psychoneuroimmunology reveals, there are many complex levels of interaction that require further investigation. There is clearly a need for long-term prospective studies that will identify individuals at risk for those numerous diseases in which psychosocial factors and impaired immune function play a pathogenic role. In addition to correlating altered immune function over time with changes in the physical environment, these studies should include psychologic profiles, life-event inventories, and psychiatric interviews in an effort to delineate the role of psychosocial factors as the stimulus for and as the response to the disease process. One of the many positive outcomes of this multifactorial approach to illness is that it will alter the physician's approach to disease and thus to patients as they are evaluated and treated in the psychosocial context in which they live. As Hippocrates said, "It is more important to know what sort of a person has a disease than to know what sort of disease a person has."