Dilip Ramchandani

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 psychiatrists role in the general hospital are discussed.

Constant Observation in a Medical-Surgical Setting: The Role of Consultation-Liaison Psychiatry

Constant observation (CO) is commonly used in general hospital settings to protect patients who are at risk for harming themselves or others. The role of consultation-liaison psychiatry in the implementation of this procedure is often assumed, but has not been well studied. The authors report the findings of a 6-month study of the use of CO in a general hospital and discuss its implications for quality of care and, possibly, cost-effectiveness.

Neurobehaviour rounds and interdisciplinary education in neurology and psychiatry

Increasing emphasis on interdisciplinary medical treatment and education suggests that something valuable has arisen from medical specialization beyond the further development of specialty knowledge: an integration of specialty knowledge that compliments and extends the integrating aspects of the primary care approach to medicine. Several educational models have been described which serve this function. In this paper the authors describe interdisciplinary clinical teaching, and research team linking neurology, neuroradiology, psychiatry and neuropsychology. The team provides neurobehavioural evaluations and sponsors monthly Neurobehaviour Rounds, an interdisciplinary patient conference that is the main formal teaching vehicle for the programme. After the model had been in place for 1 year, eight of nine neurology residents had Residency In‐Service Training Examination scores in behavioural neurology that exceeded their overall average scores. This suggests that encouraging neurology residents to see patients through the eyes of different specialists may have contributed to improvement in their performance on a test of interdisciplinary knowledge. A neurobehavioural programme anchored to a formal neurobehaviour conference may encourage interdisciplinary learning within the related disciplines of neurology, neuropsychology and psychiatry.

Meprobamate-tranquilizer or anxiolytic? A historical perspective

Meprobamate was the first successful anti-anxiety drug of the modern era. On the 50th anniversary of its introduction, the authors trace the development of its synthesis, marketing and runaway success to understand the scientific and socio-political factors that may have shaped its use in clinical psychiatry. The relationship of this drug to the earlier development of chlorpromazine is explored to clarify the imperatives of drug classification in modern psychiatry.

The ADMSEP Milestones Project

ObjectiveCredentialing bodies mandate that a medical school’s curriculum be based upon recognized guidelines. Within the field of psychiatry, the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) has previously published recommended guidelines for the pre-clinical and clerkship curriculum. Ongoing changes within the Liaison Committee on Medical Education’s requirements for medical school curricula, and the publication of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, necessitated review of these guidelines.MethodsADMSEP convened a task force of psychiatric educators to develop a consensus report outlining new guidelines. The ADMSEP membership reviewed and approved this final document.ResultsThe guidelines outline six core learning objectives with corresponding competencies. Each of these competencies specifies accompanying milestones to be achieved through the course of medical school.ConclusionsADMSEP believes these guidelines will aid educators in crafting a school’s psychiatric curriculum. Clearly articulated milestones may foster the further development of validated educational and assessment tools by ADMSEP and other organizations.

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.

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.

End of Third-Year Objective Structured Clinical Examination: Boon or Bane?

ConclusionThus, by encouraging students to hasten the task of arriving at a psychiatric diagnosis in 10–15 minute long, contrived, integrative Objective Structured Clinical Examination exercises, the process of learning might itself be short-circuited. Groopman (20) has eloquently pointed out the “representativeness” and “availability” type errors based upon thinking that is overly influenced by what is typically true, and, upon the ease with which relevant examples come to mind, respectively. The resulting failure to consider possibilities that contradict existing mental templates may well be reinforced by representative standardized patients. The consequences of learning promoted by such mechanistic exercises are dubious enough for the acquisition of general medical skills but may be disastrous for the fostering of psychiatric problem-solving skills in the medical context.

Grading medical students in a psychiatry clerkship: correlation with the NBME subject examination scores and its implications.

Background/ObjectiveThe author analyzed and compared various assessment methods for assessment of medical students; these methods included clinical assessment and the standardized National Board of Medical Education (NBME) subject examination.MethodStudents were evaluated on their 6-week clerkship in psychiatry by both their clinical supervisors and the NBME exam. Results on clinical parameters and the standardized test were analyzed by correlation measures.ResultsThe total clinical grade did not correlate with the shelf-examination (NBME) scores. Knowledge-base scores correlated weakly with NBME examination scores. The shelf-examination scores showed a stronger correlation with the interpersonal component of the clinical grade than with the faculty assessment of the students’ medical knowledge, history-taking skills, or clinical skills.ConclusionGrades received by the students in clinical reasoning and data-synthesis, history-taking skills, and the total clinical grade, did not predict students’ standardized examination score. Surprisingly, students with stronger interpersonal attributes performed better on the shelf-examination.

Fooling Others or Oneself? A History of Therapeutic Fads and Its Current Relevance

The author addresses the consequences of therapeutic overzealousness in light of the early 20th century historical accounts of Dr. Serge Voronoff’s ill fated adventure in restoring potency in European males and Dr. Henry Cotton’s misguided foray into the physical treatment of schizophrenia in New Jersey. The implications of these mishaps for the modern practice of psychiatry are discussed in view of the challenges that continue to beset the field.