TO THE EDITOR: The psychiatrist is often faced with the term "medically cleared," which has come to mean that the patient has been adequately screened for serious medical problems and can now safely enter the psychiatry unit. It is easy to take comfort in this concept, breathe a sigh of relief, and let down your guard. Often the result is that our residents do not follow the physical findings along with the psychiatric findings during the patient's hospitalization. Our colleagues pick up on this, and one result is endless jokes about whether we are real doctors or not. More important, it places patients at risk who may have medical or neurological illness contributing to their psychiatric symptoms.
Many factors contribute to this situation. The first may relate to countertransference. We are aware of this process in therapy, but we may not be aware of the same process in the emergency room. Psychiatric patients, especially if they are disturbed, can evoke many negative emotions in medical clinicians, including fear, anger, and avoidance. There are many reasons for such countertransference. Physicians are not immune to the negative stereotypes that are addressed to many of our patients. They may fear patients who show a lack of emotional control. Although trained to intervene, they may feel ill equipped to know how to respond to such behavior. Psychiatric patients may have abnormalities in self-care skills, thought process, thought content, and perceptions. These are hard to localize with a test and thus may further the clinician's anxiety. Another factor that may obscure the clinical picture is the false distinction between brain and behavior, a concept that would never arise if the heart and blood pressure or the liver and metabolism were being considered.
Acutely ill psychiatric patients, unfortunately, are poorly equipped to advocate for themselves in the same way as someone who presents with chest pain or fever. When physicians rely only on vital signs and routine lab work to give them the assurance that all is well, many subtle and not so subtle signs may be missed, leading to large problems down the line. The following two cases demonstrate how psychiatry residents who have been empowered to consistently perform complete physical examinations can prevent catastrophes from occurring. Both residents were able to pick up serious neurological problems involving patient's who were medically cleared by emergency room physicians.
The first patient was referred to psychiatry for catatonia because he would not move his legs or lift his head up from the bed. He had no previous medical history and was on chlorpromazine for chronic paranoid schizophrenia. He was medically cleared and no significant workup was initiated. The neurology resident was called in consultation and made a diagnosis of an acute dystonic reaction, despite the atypical symptoms and the patient's already having been on chlorpromazine for many years. The psychiatry resident was called to admit the patient. She noted the patient to have quadriparesis and increased reflexes with clonus in all four limbs and bilateral Babinski signs. A cervical MRI displayed a herniated disk at the third and forth cervical interspace, with moderate cord compression. A neurosurgery consult was obtained and the patient received a laminectomy the next day. At 3-month follow-up the patient is walking without assistance.
The second patient was a 50-year-old man with a history of hypertension who presented with a 3-week history of depression. His psychiatric history was unremarkable, and the only medication that he was taking was atenolol 50 mg per day for hypertension. The patient was very withdrawn on admission and was screened by the emergency room physician and referred to psychiatry for admission. The psychiatry resident noted that the patient had increased reflexes on the right and upgoing toes on the right. He requested a cranial CT without contrast. The scan revealed a left hemispheric subdural hematoma with mass effect. Neurosurgery was called, and the patient had a successful removal of the clot and recovered completely.
The above cases demonstrate how important it is to encourage psychiatrists to retain their physical and neurological examination skills. Assuming that the patient has been medically cleared can lead to large problems when organic etiologies are missed. Such assumptions may stem from the evaluating physician's countertransference about the patient who presents with psychiatric symptoms. However, the psychiatrist who has accepted a patient then becomes responsible for the patient's ongoing medical care. From my perspective as a residency director, it is essential to have psychiatry residents continue to perform complete physical examinations on their patients. There are infrequent exceptions to this rule with individual patients when boundary issues are extraordinarily prominent.
Our experience at the University of Mississippi has shown that having residents exercise these skills builds rapport and actually solidifies the psychiatrist's role as a physician. If residents are not encouraged to continue to perform physical examinations, it is unlikely they will reestablish this practice after their training is complete. Overall, I believe this is detrimental to our patients and also to our specialty. One of the clearest ways we can solidify our true role as physicians is by our ability to evaluate and treat the concurrent medical problems with which our patients present.
There are several practical ways to address this problem. The first is to expect residents to continue to examine and address the medical aspects of their patients even after they complete their intern year. As residents progress they often become removed from these problems and then lose confidence and competence in this area. Many other departments schedule psychiatry topics as part of their core curriculum. We are initiating formal medical and neurological topics as part of our core curriculum. I have also requested the departments in family practice, emergency medicine, obstetrics and gynecology, internal medicine, and neurology to give lecture series in psychiatry. I am able to convey to residents that patients they may see in an acute psychosis or depression may have a medical etiology to their symptoms. Talking to them in non-DSM-IV terms that communicate our commonality as fellow physicians gives credence to this point.
In the end, perhaps the most effective influence that we psychiatric educators can have on our residents is as role models. Continuing, or in some cases polishing up, our physical examination skills will send a message to our residents and colleagues that this is an important goal. Our specialty is unique in having the best opportunity to institute the complete biopsychosocial model in what we do. Performing examinations is the cornerstone of the first part of this model. We hope our experience will encourage other programs to establish or continue to maintain their residents' physical diagnosis skills by having the residents performing regular physical and neurological examinations on their patients.