Drs. Yager and Rabjohn Reply

To the Editor: We appreciate the comments by Drs. Caplan, Querques, Freudenreich, and Kontos on the consultation-liaison psychiatrist’s perspective regarding the effect of work-hour regulation on the declining “ownership” of patients by non-psychiatrist physicians. One potential cost of work-hour regulations is that these requirements may further fragment the already complex and confusing team-based care that often occurs in general hospital services. In these settings, multiple teams of consultants, residents, and fellows and rotating hospitalist-physicians strive to provide comprehensive, 24-hour, 7-day-per-week care to very sick patients who are often cognitively impaired by the nature of their medical and surgical conditions. Many patients have difficulty knowing who their “doctor” is.

Beyond the consultation-liaison environment, how certain are we that the fragmentation of medical services described by Drs. Caplan, Querques, Freudenreich, and Kontos has not transpired in psychiatric units as well? Imposing strict work-hour regulations has, in some settings, further fostered team-based care by psychiatric residents and their co-workers. What are we doing in our own shops to prevent physician-patient relationships between our residents and psychiatric inpatients from being diluted? To what extent do fragmented psychiatric resident work schedules contribute to situations in which non-physician mental health professionals rather than psychiatric residents are—de facto—the ones who provide the primary clinician-patient relationships for psychiatric inpatients? We wouldn’t do that, would we?