Consultation-Liaison Psychiatry: Contributions to Medical Practice

In 1958, Weissman and Hackett (1) reported that the delirium following cataract surgery was related to the sensory deprivation produced by bilateral patching and immobilization used postoperatively at that time. While that may appear obvious to us today and to Weissman and Hackett at the time, in 1958, it required this observation by two consultation-liaison psychiatrists to make it apparent to ophthalmologists, who then revised their postoperative management techniques.

This is true of much of the research reviewed here: obvious to consultation-liaison psychiatrists because of their training and interest but not apparent to their colleagues until it was pointed out to them, at which time it became obvious to them as well. Significant changes in medical management have usually followed.

In 1965, Kornfeld et al. (2) reported delirium occurring after open-heart surgery, which appeared after a brief lucid interval and disappeared shortly after the patient left the cardiac surgery recovery room. After a review of preoperative, intraoperative, and postoperative data, they concluded that postcardiac delirium was probably the result of a combination of factors. These included preoperative brain dysfunction secondary to chronic heart disease, intraoperative effects of the bypass machine (the longer the time using the pump, the more likely the patient would experience delirium), and the stressors of the recovery room, such as sleep deprivation and sensory monotony, since patients were immobilized by catheters and cables and exposed to the constant noise of monitors and the oxygen tent. To reduce the incidence of delirium, a series of procedural changes was recommended: provide more periods of uninterrupted sleep, provide orientation as to time and place, and transfer patients out of the setting as soon as possible.

This article had an impact beyond the management of cardiac surgery patients since it also influenced the design of intensive care units (ICUs) and patient management. For example, hospital architects tried to provide outside windows, clocks were hung on the walls, and nursing procedures were reorganized to provide more uninterrupted sleep. The term “ICU psychosis” was coined at the time and, unfortunately, often misapplied. As a consequence, consultation-liaison psychiatrists were required to point out to house staff that every psychosis in the ICU is not an “ICU psychosis”—i.e., it is not induced by that environment. In fact, most are more likely related to the medical problems that brought the patient to the ICU in the first place. This error provides a good opportunity for consultation-liaison psychiatrists to teach the differential diagnosis of delirium.

Subsequently, Hackett et al. (3) studied patients in the cardiac care unit and pointed out that in contrast to the cardiac surgery recovery room, the cardiac care unit, with its close observation by knowledgeable staff and sophisticated technology, was perceived by most patients as a supportive setting. Therefore, they alerted our medical colleagues that while the psychological effects of the transfer out of a cardiac surgery recovery room may be helpful, transfer out of a cardiac care unit to standard hospital care could be stressful for some patients, with serious cardiac consequences. Klein et al. (4) provided physiological confirmation when they reported an increase in patients’ catecholamine levels at the time of such transfers. Hackett and Cassem (5) had specific recommendations on how that transfer process could best be managed to minimize these stresses.

Hackett and Cassem also explored the effects of denial in patients with myocardial infarcts (5). In its most extreme self-destructive form, denial was observed in the cardiac care unit when a patient would demand to be discharged from the hospital since he knew that he had not had “a heart attack.” They pointed out techniques by which cardiologists can diminish the fears that underlie such denial. They also observed that another form of denial or, more specifically, isolation of affect could play a useful role by reducing anxiety and its cardiac consequences, such as arrhythmias. This work was based on their Denial Scale, which has served as a useful instrument in the study of the role of denial as a prognostic factor or predictor of noncompliance.

Another acute management problem to be studied was when patients demand to sign out of the hospital against medical advice. This behavior usually elicits an emergency call for a psychiatric consultation. Albert and Kornfeld (6) reviewed a series of such consultation requests. The question usually asked of the psychiatric consultant by the referring physician was, “Does this patient have the mental capacity to sign out against medical advice?” The apparent requirement was a note from a psychiatrist in the patient’s chart that would have allowed the physician to legally discharge the patient or force the patient to stay.

Instead, consultation-liaison psychiatrists asked, “Why would someone make such an apparently self-destructive request?” A review of these hospital records revealed four possible explanations: these patients were either very angry, very anxious, psychotic, or demented. In 24 of 26 such situations, with appropriate interventions based on the consultation-liaison psychiatrist’s advice, the patients remained in the hospital.

Therefore, an important lesson to be taught to future consultation-liaison psychiatrists, as well as future surgeons and internists, is not to first ask if this patient is legally competent, but rather why this is happening. The opportunity to watch consultation-liaison psychiatrists find constructive solutions to this problem is an important learning experience for inexperienced medical or surgical house officers.

In 1971, Friedman and his colleagues (7) explored the effects of sleep deprivation on the performance of interns. At the time, interns traditionally worked every other night and every other weekend. In a busy teaching hospital, they could work for 48–72 hours with very little sleep. In retrospect, it was obviously harmful to both patients and interns, but that had never been studied and documented.

The study required that interns review a prerecorded ECG strip and note the randomly distributed arrhythmias they contained. Their responses after a weekend on call were then compared with those after a night off. A significantly higher number of errors, plus significant shifts in affect with dysphoric moods, was found after the prolonged sleep deprivation period. This article (7), published in the New England Journal of Medicine, had a significant effect on medical training. Most training programs soon switched their on-call schedules from every other night to every third night.

Everyone takes for granted that patients undergoing cancer surgery have special psychological needs. But it was not always the universal concern that it is today. Consultation-liaison psychiatrists have made an important contribution in defining these problems and how to best deal with them. In 1952, Sutherland (8) published “The Psychological Impact of Cancer and Cancer Surgery” in Cancer. This was his first paragraph:

The major impetus for the development of formal psychiatric consultation-liaison services began in 1933 with funding from the Rockefeller Foundation for full-time teachers of psychiatry in six academic medical centers. Concerns about the dollar value of such services began long before the current era of managed care. In 1937, Billings et al. (54) reported that their psychiatric consultation service at Denver General Hospital reduced the overall length of patients’ stays from 28 to 16 days. They calculated that the savings, based on 1937 per diem costs, was $8,400 ($102,564 in 2002 dollars).

Forty-four years later, Levitan and I (55) studied the effect of a liaison psychiatrist assigned to an orthopedic service. Every patient over the age of 65 admitted for the surgical treatment of a fractured femur was screened postoperatively. The study demonstrated that with the prompt identification and treatment of psychiatric problems, length of stay could be shortened and the likelihood of returning home could be increased—outcomes that produced a significant lowering of medical costs. This work was replicated by Strain et al. (56) 10 years later. A more recent study by Levenson et al. (57) of a consultation-liaison psychiatrist working in a general hospital population did not demonstrate a cost savings, but the authors suggested that this could be related to a variety of factors, such as the nature of the population studied and the intervention. In another study of hospitalized patients, Jin et al. (58) reported that consultation-liaison expertise can reduce the large cost of providing private-duty aides for patients requiring close observation.

In 1986, Smith et al. (59) reported the results of teaching primary care practitioners how to apply psychiatric principles to the treatment of outpatients with hypochondriasis. The application of these methods reduced medical costs by 49% to 53% without any changes in the health status or satisfaction of the patients. These findings demonstrate that a consultation-liaison psychiatry service has the ability to improve quality of care and simultaneously reduce costs.

The changes in medical practice created by managed care policies can have clinical implications that consultation-liaison psychiatrists are particularly well equipped to study. For example, with the increasing emphasis on ambulatory or same-day surgery, what is the difference, if any, in the psychological state of patients admitted for coronary bypass or mastectomy who in the past spent the night in the hospital before surgery with a preoperative visit from an anesthesiologist, their surgeon, their cardiologist, and a nurse and today’s patients, who spend the night at home and then drive to the hospital at 6:00 a.m. and walk into the operating room? What is the effect on anesthetic management, postoperative pain, speed of recovery, and quality of life?

Physicians today, as in the past, are exhorted to introduce more humanism into medical practice. This is a well-intentioned plea for doctor-patient relationships that more effectively meet patients’ emotional needs. Therefore, medical schools have introduced innovations in their curricula in an effort to overcome whatever may be lacking that contributes to this professional failing. For example, first-year students at some schools participate in a “white coat” ceremony in which they wear their first doctor’s coat and listen to a lecture on the importance of humanism in medical care. While well intended, this symbolic initiation rite will never be able to inoculate these students against the impact of what lies ahead any more than donning a khaki uniform and a pep talk from an experienced sergeant prepares a soldier for battle.

Mitchell Rabkin, an internist and former director of Boston Beth Israel Hospital, has recently written, “Humanism in medicine goes beyond compassion for the suffering of the patient. It extends to empathy and a personal connection with the situation, feelings, and motives of the patient” (60)—and, I would add, the physician. There probably has been inadequate acknowledgment of the complexity of the doctor-patient relationship and the importance of understanding the specific emotional needs and psychological defenses of both parties to this dyad. It is with the application of such knowledge that patients can feel that they are truly understood, which is the highest form of caring.

The education of medical practitioners has always been a high priority for consultation-liaison psychiatrists. In 1956, the New England Journal of Medicine published “Psychiatry and Medical Practice in a General Hospital” (61). In a later elaboration (62), Bibring and Kahana categorized patients into personality types, e.g., the dependent, overdemanding personality (oral); the orderly, controlled personality (obsessive); the dramatizing, emotionally involved, captivating personality (hysterical); and so on. They avoided psychiatric terminology and used language that would allow practitioners to quickly identify these patients in their daily experience. They went on to explain what illness meant to each type of patient and how physicians can best deal with their predictable reactions. Two articles by Groves, “Taking Care of the Hateful Patient” (63) and “Management of the Borderline Patient on a Medical or Surgical Ward” (64), were similar efforts to help our colleagues deal with difficult clinical problems using our understanding of psychopathology and psychodynamics in jargon-free language.

Perhaps the most influential theoretical article on patient management was written by George Engel, titled, “The Need for a New Medical Model: A Challenge for Biomedicine” (65). Engel made the case for the incorporation into medical practice of what he called the “biopsychosocial model.” This concept has become a cornerstone of basic clinical teaching in medical schools.

Undoubtedly, when we have helped physicians develop the skills needed to efficiently and effectively communicate with patients so they can, for example, distinguish between unhappiness and depression, ask questions that will reveal a patient’s true concerns, and make an effective psychiatric referral, then psychiatry will have contributed to the well-being of countless patients.

What I believe is required to accomplish this goal is to infuse medical education—from medical school through residency training—with bedside teaching in which physicians learn to better understand their patients and themselves. These lessons cannot be taught in the classroom. I maintain that consultation-liaison psychiatrists, by virtue of the specific interpersonal skills they must acquire in a medical setting, remain those most qualified to teach medical students and house staff how to do that most effectively. However, there are not enough consultation-liaison psychiatrists today to meet these needs, and these numbers will diminish without an increase in consultation-liaison fellowships.

Consultation-liaison training also plays a unique role in the training of psychiatric residents. I believe that there is nothing more powerful than a good consultation-liaison experience to reinforce young psychiatrists’ perception of themselves as members of the medical profession. They soon realize that they have acquired a unique fund of knowledge during their psychiatric residency that can be immensely useful in a medical setting.

In recent years, increasing attention has been paid to clinical medical ethics. Physicians have always prided themselves as members of a profession that has held itself to the highest ethical standards. However, in recent years, the advent of technology that allows extended prolongation of life and clinical research that may incur serious risk have fostered the establishment of medical ethics as a discipline, the clinical ethics committee as a requirement of the Joint Commission on Accreditation of Healthcare Organizations, and the clinical ethicist as an important figure in decision making.

It has been suggested that consultation-liaison psychiatrists are particularly well equipped, by virtue of their training and experience, to play a leadership role in this discipline (66). Youngner and colleagues (67, 68), Leeman (69), Lederberg (70), and Steinberg and Youngner (71) have written of the need for greater attention to the psychological factors in these ethical issues. A clinical ethics consultation must go beyond issues of legal competency and theoretical ethical principles such as “autonomy” and “beneficence.” It requires a knowledgeable clinician who has an understanding of the role of psychological factors in the resolution of the conflicts that are inherent in making these life-and-death decisions: e.g., conflict between medical staff and a patient or family, conflict within families, conflict within a medical staff, and, of course, unconscious conflict in all of these individuals. What also is required is an understanding of what it means to be in the shoes of the physician who must ultimately implement the decision. It is therefore when clinical ethics moves from the seminar and classroom to the bedside that clinicians are needed who have the training and experience of the consultation-liaison psychiatrist. That is why consultation-liaison psychiatrists can—and should—be playing leadership roles in hospital ethics programs.

End-of-life care has received a great deal of deserved attention from both laymen and the health care professions. Perhaps the most contentious issue has been physician-assisted suicide. In 1998, Muskin (72), writing in the Journal of the American Medical Association, pointed out that discussions on this subject in the medical literature, state legislatures, the mass media, and the courts have revolved around questions of religious values, professional responsibility, and legal standards of competency. What had been lacking is the question of the true meaning of such a request from any given patient. The role of the psychiatrist in right-to-die legislation, if any, has usually been limited to the determination of competency. Muskin pointed out the need to introduce the potential complexity of the motivation into such a request and the role psychiatric principles can play in understanding its true meaning.

A problem for such patients can be the undertreatment of pain by our medical colleagues. They tell us of their fear of addicting patients and the development of drug tolerance. Our reassurances to the contrary do not appear to help. Numerous articles have been written on the problem, and at least two NIH consensus conferences have been held that issued guidelines recommending more vigorous analgesic treatment. Have these efforts succeeded? Only partially. The first reference usually cited in most articles dealing with this subject is “Treatment of Medical In-Patients with Narcotic Analgesics,” a lead article in a 1973 issue of the Annals of Internal Medicine, written by consultation-liaison psychiatrists Marks and the late Edward Sachar (73). It is the consultation-liaison psychiatrist who is in the best position to deliver this important message to physicians in training because they are present at the bedside.

There is thus an increasing emphasis on the need for physicians to do a better job in managing the process of dying. Patients expect that of their physician. I suspect that most physicians expect that of themselves. But it is not easy. As Sherwin Nuland, a Yale surgeon, wrote in How We Die, “Physicians think of death as a defeat and often react accordingly” (74). We have all witnessed the physician who spends less and less time with a patient for whom “There is nothing more I can do.” That physician must learn what more there is to do once “doing” is redefined as including comforting, in its various forms, as an appropriate role for a physician. I believe consultation-liaison psychiatrists, physicians who by disposition and training are reasonably comfortable with the emotional needs of physically ill patients, can assume a leadership role in training young physicians how to better deal with dying patients and their families. I think most of them will be grateful for our help.

Medicine is now faced with the ethical dilemmas and psychological consequences of rapidly expanding genetic knowledge. As new gene markers appear, clinicians must decide how to best deal with this new tool. When and how should such knowledge be used? What are the consequences of its use?

Consultation-liaison psychiatrists, such as Mary Jane Massie at Memorial Sloan Kettering, have established services to deal with the emotional dilemmas faced by women found to be at high risk of breast cancer (75). Their questions include the following: Should I have a prophylactic mastectomy or annual mammograms? Should I have both breasts removed? Should I also have an oophorectomy since in some women there is a genetic link with ovarian cancer? What effect will this have on my marriage, or even, in some cases, my marriageability?

These are difficult questions without easy answers. Each genetic test carries its own emotional baggage. Therefore, as more genetic links are found, problems multiply, and answers for many individual patients often do not exist in statistical projections of probability provided by a genetic counselor. Consultation-liaison psychiatrists can be there to treat the dysphoria and help patients find the answers that are best for them.

What then has been accomplished by this review of consultation-liaison contributions to medical practice and these musings about its future? First, it should be noted that this brief review contains 11 articles from the New England Journal of Medicine, four from the Journal of the American Medical Association, and others from Science, Lancet, the American Journal of Medicine, the Annals of Internal Medicine, the American Journal of Cardiology, Cancer, the Journal of Clinical Oncology, Circulation, Pacing and Clinical Electrophysiology: PACE, and Transplantation. We know such publications can influence medical practice in the United States and around the world.

The psychiatric needs of patients will always exist, astute clinical observations remain to be made and studied, and new effective interventions will need to be instituted. In this technological age, the need to contribute to the education of our colleagues is also greater than ever. Therefore, consultation-liaison psychiatry or, as suggested, psychosomatic medicine should survive and flourish because the substantial presence of this subspecialty means better medical care through the direct clinical work of its practitioners as well as their teaching and research.

Presented in part as a Distinguished Psychiatrist Lecture at the 154th annual meeting of the American Psychiatric Association, New Orleans, May 5–10, 2001, and as a T.P Hackett lecture at the 42nd annual meeting of the Academy of Psychosomatic Medicine, Palm Springs, Calif., Nov. 9–12, 1995. Received Oct. 16, 2001; revision received March 20, 2002; accepted May 13, 2002. From Columbia University College of Physicians and Surgeons. Address all correspondence to Dr. Kornfeld, Columbia Presbyterian Medical Center, 622 West 168 St., Box 341, New York, NY 10032; [email protected] (e-mail).