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Psychiatric News Special Report: Barriers to Rehabilitation After Discharge · The Medical Mind

• 0:12
  All right, everybody, welcome back to Psychiatric News Special Report podcast.
• 0:17
  I am the host for today.
• 0:19
  My name is Dr.
• 0:20
  Salman Aziz-Merza, triple board certified adult psychiatry, child adolescent psychiatry, and addiction medicine, working in Northern Virginia with Innova Health System and also my
• 0:30
  own private practice.
• 0:31
  My second month kind of hosting the special report, so we're going along with it and I think it's been okay so far.
• 0:38
  Let us know if there's anything that we need to be doing.
• 0:41
  different and we will definitely make sure to incorporate that as much as we can.
• 0:45
  So this month we are doing a little something different.
• 0:49
  have Dr.
• 0:50
  James Bourgeois here with us today.
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  He is not the author of our special report.
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  He's kind of filling in for the authors who were unable to make it with us today.
• 0:59
  The special report for February was Barriers to Rehabilitation After Discharge, a Consultation Liaison Perspective.
• 1:07
  So basically a review of CL
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  Psychiatry, Consul Liaison Psychiatry, and we have Dr.
• 1:13
  Borjua here as our fill-in.
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  So I'll let him introduce himself and a little bit of his bio and background, and then we'll kind of jump on into a discussion.
• 1:24
  Thank you.
• 1:25
  I'm Jim Bush.
• 1:27
  Well, I'm vice chair of hospital psychiatry services at University of California Davis, which is in Sacramento.
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  I'm a professor in the department.
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  I am certified in both general psychiatry and CL psychiatry.
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  My role for the APA is I'm the CL section editor for psychiatric news, meaning I accumulate.
• 1:51
  submissions and curate them and work with the editor in chief on publications.
• 1:57
  Awesome.
• 1:58
  All right.
• 1:59
  So a little review of this article.
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  So the authors are Uchiyach et al.
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  um And articles talks about psychorehabilitation, why it fails after discharge, particularly for patients with severe serious mental illness, despite clinical
• 2:19
  stabilization in an inpatient stay.
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  So the discussion is around stale psychiatry,
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  what discharge means for a medically hospitalized patient, why this can be a little bit complicated for patients with a psychiatric history, what are some of the barriers that
• 2:40
  are there?
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  The article focuses on three main barriers that are identified, systemic structural barriers, clinical barriers, four barriers, sorry, patient-related barriers, and then
• 2:52
  social and cultural barriers.
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  and the role of CL psychiatry as a whole.
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  So what do you think about that, Dr.
• 3:02
  Bourgeois?
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  Are these some of the barriers that you're seeing in your work as a CL psychiatrist?
• 3:08
  oh
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  certainly.
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  I suspect that's a generally common experience.
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  This, this article was actually sort of unsolicited.
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  I was very pleased to, to get it because this sort of approach is rarely taken.
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  Usually the articles submitted are more patient care focused about an unusual illness or some, something about the clinical care that we need to give, which of course is the
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  emphasis.
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  This is, this is different.
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  This is about once patient is
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  done with implicitly medical hospitalization, uh what happens to them in the transition back to outpatient care.
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  And I want to emphasize that in the draft in this article, they're focusing on patients with serious chronic mental illness, which is actually a minority of patients we see in
• 3:55
  hospital.
• 3:56
  So these would be patients with chronic schizophrenia, bipolar disorder, recurrent major depression.
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  I think we all kind of collectively agree on the definition.
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  And when these folks are admitted to the general hospital, of course, it's for a wide variety of things.
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  But the discharge readiness decision is really made solely by the medical surgical service admitting them.
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  Um, and as many of us in background and see now, we'll, we'll relate to these, uh, decisions for diagnosed for discharge are kind of rigidly based on functional status,
• 4:33
  vis-a-vis the admitting illness.
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  And there was no mechanism to mitigate that discharge date because of the comorbid psychiatric illness.
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  Whereas if a patient submitted to a psychiatric inpatient unit, of course it's all about that.
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  So that, that dilemma would really not, not happen.
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  So that was the broader context.
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  And I think what we're kind of getting at here, which the authors really illustrate nicely.
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  Is that you have sort of readiness for discharge from a general medical stability perspective.
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  That may or may not mean you're ready to discharge from a psychiatric stability perspective.
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  And this, since those are discordant, that's the source of the difficulty.
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  Now the reflexive response to that dilemma in many cases is to say, well, if the patient is psychiatrically unstable, despite being physically improved.
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  Well, it's rather clear they should be evaluated for admission to an inpatient psychiatry unit for management of the second problem.
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  And that's intuitive, but limited.
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  main reason for that is the psychiatric inpatient units have extremely limited medical and frankly nursing capacity.
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  So things I see on a daily, if not hourly basis that limits transfer to psychiatric inpatient units when it would be clinically appropriate are.
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  mobility problems, patient requires a walker, patient requires wound care, somewhat complex diabetic self-management and on and on.
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  And the medical and more importantly, nursing care at psychiatric inpatient units does not allow for that.
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  And thus those patients cannot be transferred to psychiatry even though it would be clinically desirable.
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  So that's the source of the dilemma in many cases.
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  I think for psychiatrists and people in the field, they're able to very easily point out why those barriers exist, why it is complicated for somebody who's on a walker to get
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  admitted to psych floor, but for maybe non-psychiatrists who may be listening, are some reasons that may be less immediately apparent?
• 6:50
  Well, again, uh the concern that is stated by the psychiatry units is the walker interferes with nursing routines.
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  The walker could be used as a weapon for the patient to hit another patient or a staff member.
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  And their own internal safety regulations are kind of rigid understandably about that.
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  Where to the medical units, that's not relatable because they see patients with walkers all the time.
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  So they say, what's the problem?
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  And that's where you end up a lot of the time.
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  Yeah.
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  It's, complicated because I think there is this idea of like what psychiatry is and what medicine is.
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  And these things are for some reason separated, even though they're being housed in the same hospital building and they should be treated the same, but it's like, there are
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  unique qualities of each one that in unique challenges and unique opportunities, I guess you could say that make them unique in their own way.
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  Let's talk a little bit about, um,
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  systemic barriers.
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  you you said I had the benefit when during my training over at VCU to work under Dr.
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  James Levinson.
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  Yes.
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  Yeah, it was, you know, wrote the book.
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  Highly regarded uh senior leader in CL psychiatry, I quite agree.
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  Yeah, so it was a great blessing to work under him for a bit.
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  We also had Dr.
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  Sharif Meghede and Dr.
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  Chris Koga.
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  It's a wonderful CL psychiatrist.
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  think that was one of the strong points of being over there was, again, wonderful, wonderful mentors over there.
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  um So I always appreciated the field.
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  And then as I'm doing more outpatient work, I'm not doing much of that nowadays.
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  We don't have to do hospital coverage as much nowadays.
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  So we get a little siloed out in the world, but you know, every, once in a while we're on call and we have to kind of run into an hospital and be like, Oh, here we are again.
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  Um, but what, what are some overall kind of like systemic structural, we'll break them down each one by one, guess.
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  So systemic and structural barriers.
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  What are some ones that you commonly kind of come across?
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  we didn't talk about already.
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  In terms of what boundary like handing a patient off to outpatient care or what exactly do mean?
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  So the main things that they were looking at is, again, what the author is saying is hospitals are optimized for stabilization, non-continuity of psychiatric care.
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  So making that structural mismatch per se.
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  So maybe things like trouble between hospital services, community services, not involving CL early enough, or maybe inappropriate kind of consultations.
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  Yeah, so something like that.
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  I could go on and on about that one sentence, oh but there's components to what you just said.
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  So if I can separate them out a little bit.
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  um One is kind of a point I made earlier is that uh medical surgical discharge readiness is often rather concretely described.
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  know, once patient doesn't need certain medical nursing intervention, they are to be discharged.
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  one can, of course, one can resist that, but at the same time, you have to appreciate
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  the demands on hospitals right now.
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  I just got a message from my ED colleagues yesterday that they have a hundred bed capacity with only 344 patients in it.
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  So these things are accentuated very reasonably.
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  And thus, think to um make your main approach to lobby for longer inpatient stays just to consolidate outpatient plans, that's seen as a non-starter most places.
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  And I fully...
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  appreciate that.
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  To that end, what has been shown in some sort of semi-perspective studies is that if you can identify what the term is cliche, but it's high risk patients.
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  If you can identify high risk patients sort of preemptively, know, day of admission or the day after, somehow one flag significant psychiatric comorbidity.
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  What really should
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  happen in a optimized environment is the admitting medical surgical services should identify that quickly and call for consultation right away, uh not wait until discharge is
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  imminent.
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  Numerous reasons for that.
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  One is most uh obviously is we can be involved in medical co-management of the patient throughout hospitalization.
• 11:30
  uh Of course, they need to be daily adjustments and so forth.
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  That's a detail.
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  But while you're doing that, the discharge mechanism of this medical surgical service can be mobilized far earlier, knowing particular patients gonna need a particularly uh
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  designed discharge plan.
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  Rather than waiting till the last minute and expecting to accomplish this all in one day, or sometimes it's on a weekend and so forth.
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  So you can see the inefficiency of that.
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  So another system to be kind of aware of is called proactive psychiatric consultation.
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  That takes us a model to a slightly higher level and it's a very desirable model.
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  What this means is that this intimate involvement of the CL psychiatrist as sort of teammates of the medical surgical services.
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  And they're involved in the surveillance of what the admissions are.
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  with predictions of who's going to need psychiatric co-management and sort of encouraging the consultation earlier, as opposed to waiting until the home team ascertains that and
• 12:41
  then call us.
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  So I would be happy if people just called us in an early way to get this going.
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  The highest level of this would be proactive, which has been, there's a literature on that.
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  And it's, it's quite clear that it helps to decrease overall length of stay, get patients out sooner.
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  which is I think what we all have a goal here.
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  Yeah.
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  Pivoting like a little bit, one of the things when I was reading this article and one of the things I always found really interesting with the field as a whole is from the
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  historical aspect of the biopsychosocial model.
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  And from my understanding was George Engel, University of Rochester, who's attributed with being the founder, I guess, of this idea or mindset, which is I think a lot of...
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  psychiatric training is based on this.
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  A lot of formulation is based on the biopsychosocial slash spiritual model that's out there.
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  And, you know, again, the little story, and again, correct me if I'm wrong, but it was, he's an internist and he's seeing that like, we're admitting people, then treating them in
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  the hospital, then sending them out, and then they're getting readmitted and we're, you know, for surgical reasons or for medical reasons and
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  they're saying what's going on, what's happening, what's the situation, why are these patients keep coming back to us despite us doing everything in the hospital that we're to
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  do.
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  which led to the whole idea of like, wait, we have to look at what's going on in their lives and in their patients' lives and when they go home, when they leave the hospital,
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  right?
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  Yeah, since you mentioned the angle who I never met, he's from some decades ago, I always, whenever he's mentioned, I always remind people that 18 years before he wrote the
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  biopsychosocial model, he wrote the definitive paper on the physiology of delirium.
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  So, and so in the CL world, that's, that's, uh, you know, rather well known though, not universally known.
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  So what, what that's about, of course, is integrating the various elements of the patient's illness and experience into a sort of a.
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  If you will holistic, uh, care model so that all these elements are taken care of because, know, I don't know what others experience was is, but I will say that the vast majority of
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  discharge problems are not clinical at all.
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  are social patients, homeless patients do not, they, maybe they have a place to live, but they don't have the ins home supports because now they're, they're hemiplegic and can't
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  get around it.
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  And I could go on and on about that.
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  Whereas the, the acute, uh,
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  care hospital operates in a dichotomous way.
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  Do you need to be in the hospital or do you not?
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  Which doesn't take into account the frequent inadequacy of post-hospital systems, be it rehab units, be it home with assistance, be it somebody to call them, all those things.
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  And the discharge planners are often have to kind of after the fact kind of put that together.
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  And the other point you sort of made perhaps inadvertently is
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  When you apply the biosoccal social model that very quickly identifies what we call the complex patients.
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  These are patients who are the uh top one or 2 % in medical utilization, multiple, uh probably unnecessary trips to emergency room, admissions to hospital, longer length of
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  stay and all that.
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  When that has been studied, those patients have a hundred percent risk of psychiatric illness.
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  be it substance abuse, chronic schizophrenia, dementia, whatever it is.
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  So it's not much of a stretch to say that psychiatry should be involved in every complex patient, even if for no other reason than just to sort it out and try to direct what kind
• 16:28
  of services the patient needs, as opposed to try to expediently discharge them for the inevitable recurrent return to repeat the same process.
• 16:38
  Yeah.
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  How do we, and this, you know, again, like ideally, if I'm hearing you correctly, we have some psychiatric worker, case worker or social worker who's triaging every case that comes
• 16:55
  into the hospital to some extent.
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  How do we scale that when we know that we have such a huge, huge shortage um in healthcare work, psychiatric?
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  you know, mental health workers.
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  You know, I will share with people that I'm, you know, like I'm married to a nurse.
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  She is a director of neurosurgery at the hospital.
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  Their hospital system is like a thousand plus bed hospital.
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  You know, I oftentimes get to hear their meetings while she's working from home, overhear them and they, you know, we invariably hear about like the patients with psychiatric
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  conditions and how they're a challenge to cutting.
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  get it in and out and, you know, after getting prepped for back, you know, these big massive back surgeries or neurosurgery that are there, but like, how do we scale it so
• 17:46
  that everybody's getting some eyes on them?
• 17:49
  Reasonably, yeah.
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  Well, of course, that's a great rhetorical question, right?
• 17:53
  Yeah.
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  Well, I think there's some I never know if I should be optimistic about this or not, but there's some there's some room for optimism.
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  And the way the reason I'm saying it that way is that.
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  Now, the EMRs are.
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  Universal and.
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  People love to complain about EMRs, except you can't live without them, so EMRs are.
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  we should embrace them fully.
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  And the real advantage of EMRs beyond the interval patient care is macro data management.
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  You know, if you are skilled at this or have uh colleagues who can do this for you, you can almost immediately identify the uh ultra high utilizers.
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  So when I was at UCSF for five years, we did just that.
• 18:45
  So we would flag ultra high utilizers.
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  I can't remember how we defined it, but it was unequivocal.
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  was like, you know, four emergency room presentations in a month or something like that.
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  And even if the patient was not acutely hospitalized right then, we would meet in the multidisciplinary team, including uh senior geriatric physician, myself, clinical
• 19:09
  pharmacist, I think three social workers and
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  nurses and people who were sort of not professionally trained, but we train them up and define them as care navigators.
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  So they would be given a cohort of patients to sort of look after and keep track of how they're doing and provide logistical support.
• 19:32
  Basically we want what we want them to do, which, which is a soup.
• 19:37
  Sounds a little paradoxical, but it's very successful.
• 19:39
  What you want is you want these patients using a whole lot of primary care.
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  Way more than typical.
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  Because if they're doing that, they're not in the hospital.
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  And we were able to show um with this intervention quite routinely within three months of this teams coming online, the patients stopped the ultra utilizing behavior.
• 20:03
  We were then open to the new court of ultra, ultra, hyper utilizers.
• 20:08
  So to receive this, what you need is what I would call.
• 20:11
  oh
• 20:12
  empathically attuned and supported primary care.
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  So, so be that an internist, family medicine, a clinical nurse practitioner, it doesn't really matter that much, but someone who is attuned to the fact that the psychiatric
• 20:27
  comorbidity is part of the picture and have ready access to psychiatric consultation, outpatient as needed.
• 20:36
  And you try to take the inpatient multidisciplinary model and move it.
• 20:42
  to outpatient.
• 20:43
  I think that's the next step if we could universally apply that kind of thinking.
• 20:49
  So that's what I would hope other places could consider.
• 20:53
  Yeah, no, I might, again, like my wife was, I think part of her return was doing care navigation, right?
• 20:58
  And that was a lot of the coordination that's involved, especially for these, you know, again, overhearing the stuff is, you know, these patients are very complex in regards to,
• 21:08
  you know, if you're getting a massive surgery, like a back surgery or such, something like that, like is a massive, massive, it's not just you're in the hospital for a few days and
• 21:17
  you're all cured.
• 21:18
  Like, no, there's everything that comes along with it afterwards.
• 21:21
  And then of course, if you
• 21:23
  going to factor in things like depression, schizophrenia, bipolar disorder, that just complicates it further, further.
• 21:31
  I think your example is a good one because what we need to be the uh modal uh care model is we need perhaps even extended PM and our inpatient units with active psychiatric
• 21:47
  co-management.
• 21:50
  That is not as common as one would think.
• 21:51
  the examples are legion.
• 21:54
  You know, the great epidemic that no one ever talks about is traumatic brain injury.
• 21:59
  Yeah.
• 22:01
  The suffering and traumatic brain injury down the road is something like 90 % psychiatric.
• 22:09
  Care models, unfortunately, sort of define themselves out of that.
• 22:13
  The community mental health model doesn't consider TBI to be a psychiatric illness when it is 90 % of psychiatric illness.
• 22:21
  community mental health model doesn't want to own dementia, even though the vast majority of problems in dementia are behavioral.
• 22:30
  So I think the psychiatric sector needs to broaden its sense of what the patients are and be very actively
• 22:37
  involved in embracing and seeking those patients.
• 22:41
  Yeah.
• 22:42
  So that's a nice little segue to like CL psychiatry as a whole.
• 22:48
  What is it about CL psychiatry that how they see problems unique about them that maybe other teams may miss, whether that's inpatient psych teams, medical teams, what is unique
• 22:58
  about the field?
• 23:01
  Well, to me, there's a lot unique about it, which is why I find it attractive and why I've been doing it for nearly 30 years now.
• 23:12
  Um, it's a different role.
• 23:15
  And many of our colleagues, psychiatry colleagues don't embrace the role.
• 23:19
  And what I mean by that is your role, you're never the main leader.
• 23:24
  You're the consultant to the main leader.
• 23:26
  Right.
• 23:26
  And, and you have to kind of, you know, accept that and work within that.
• 23:31
  Uh, secondly, uh, the systemic medical surgical illness is always the number one problem, at least acutely.
• 23:41
  So your role is to ascertain the comorbid CNS illness that impacts the experience of the main illness.
• 23:49
  And, know, sort of, if you will chip away a bit and manage that as a separate component and weave that care into the overall management of the patient so that those, uh
• 24:01
  comorbidities are not, uh let's say, de-emphasized compared to what they should be.
• 24:07
  And then there's a presence at the discharge exercise, assuming the patient needs ongoing care.
• 24:14
  Not everyone does, most do, to somehow make your system work to be sure the psychiatric outpatient management is part of the plan.
• 24:26
  Now, in some cases, that can be
• 24:30
  effectively accomplished by primary care once they're directed what to do.
• 24:36
  So the other piece I would add here, someone, is the highly desirable model of embedded psychiatric care in primary care.
• 24:46
  There's the Collaborative Care Model, University of Washington.
• 24:49
  Many folks know about them.
• 24:51
  We at Davis are, we're not as...
• 24:54
  uh
• 24:57
  thorough as they are, but we do a similar thing here where we have, I don't know, a couple dozen primary care clinics with psychiatric assets in the primary care clinics.
• 25:06
  So that makes a very desirable handoff because the patient needs primary care anyway.
• 25:11
  So you say when you get to primary care, engage the psychiatric resources in primary care and, you know, pick it up from here.
• 25:20
  Now that works pretty well because we're all in the same EMR system.
• 25:24
  So they can look up any um
• 25:26
  any charting they need to get them started without patient care.
• 25:28
  Now, if that were to be done all the time, you can see the benefit of that.
• 25:34
  Yeah.
• 25:35
  We have, you know, again, over here in Virginia, and especially for pediatric patients, um, you know, again, like we know, psychiatrists, adult psychiatrists as a whole, there's
• 25:46
  a massive shortage.
• 25:47
  know that child and adolescent psychiatrists, there's even greater shortage.
• 25:51
  Um, and you know, again, that's part of the reason that I have pediatric residents with the hospital rotating with me as they do their rotation with me is to train them up.
• 26:00
  then one program we have here is something called V map.
• 26:03
  which is essentially a model of the embedded care, but more so in regards to like a warm line or a hotline where primary care docs can call in to be like, hey, here is a
• 26:16
  situation.
• 26:16
  I'm not super familiar with psychiatric stuff.
• 26:20
  What do I do?
• 26:21
  You know, which is a nice model if you don't have that, you know, the NPPA or a doc that's in the primary care clinic that's available to them.
• 26:31
  So.
• 26:32
  you see tremendous kind of benefits with that collaboration that's there.
• 26:37
  Yeah.
• 26:38
  Thanks for mentioning it in those terms.
• 26:39
  mean, yeah, often the colloquialism curb sighting is used for what you describe.
• 26:44
  And at UCSF, we actually did that and it was actually independent of the complex care theme I discussed.
• 26:52
  This was done exclusively between the psychiatry department, CNL group, numerous internal medicine outpatient clinics.
• 27:01
  the way it worked was the patient had to be enrolled with internal medicine as the PCP.
• 27:07
  And it had to be in our system.
• 27:09
  So if those criteria were both fulfilled, then the PCP could, um, or actually was encouraged to e-consult as meaning send a secure email describing the condition, identify
• 27:23
  the patient.
• 27:24
  And, um, can we offer sort of hands-off advice on what to do in such a circumstance?
• 27:30
  And, uh, the CL team would rotate.
• 27:33
  I think it was once a week, we would take this.
• 27:35
  as a side duty and watch these messages.
• 27:38
  And we found after, I don't know, relatively short amount of time, em 90 % of the questions could be handled by a chart review and direction.
• 27:49
  Meaning you're avoiding 90 % of the consultations to physically come to the clinic.
• 27:55
  So you can imagine if you scale that up to the appropriate size, that could make, that kind of approach could make a big difference too.
• 28:01
  huge difference.
• 28:02
  Yeah.
• 28:03
  So I mean, you know, I've, I've been helping them at times too, cause they, they operate out of our clinic as well, or at least for our region and creating like a handbook, you
• 28:13
  know, again, that's been like easily, you know, PDF searchable handbook.
• 28:17
  So really that education and they put on workshops kind of like, you know, basic psychiatry for like the primary care docs.
• 28:23
  So which are, which are wonderful, wonderful programs as like, you know, bringing that CL world to the outpatient world as well.
• 28:30
  If I can raise one other program, of course, I have a vested interest in this, I will disclose.
• 28:35
  uh At University of California Irvine, which is one of our partners, we have what's called the Train New Trainers program.
• 28:45
  This started 10 years ago at Davis.
• 28:49
  And the mission is to teach primary care clinicians, be it NPs, PAs, or physicians.
• 28:57
  There's an occasional specialty physician who participates, but it's primary care focused and it's a year long course.
• 29:05
  think the participants get 50 something CMEs for doing this.
• 29:09
  They have two trips to the, to somewhere in Southern California where we have two days intensive CME twice a year.
• 29:17
  Then we offer, um, curbsiding advice, group supervision, a series of noon time.
• 29:25
  standard presentations ago the whole year.
• 29:28
  And they are encouraged, basically what you want to do is make us a more psychiatrically uh knowledgeable and skilled primary care clinician.
• 29:39
  But we retain, once they finish the program, they can email us down the road indefinitely with questions.
• 29:47
  And this kind of program, of course, it's somewhat personnel intensive and all that, but you see the point of it.
• 29:52
  I mean,
• 29:53
  The solution is to make primary care work better.
• 29:56
  We can't treble the number of psychiatrists.
• 29:59
  Even if we could do that, we couldn't, that wouldn't work.
• 30:02
  You need to do it the other way.
• 30:04
  An interesting thought after I was reading this article was that the article is saying that post discharge failures are due to system issues.
• 30:15
  How do we balance system responsibility with patient agency autonomy without slipping into blame?
• 30:23
  Saying like, this is so and so's fault that something didn't work out.
• 30:27
  meaning presumably the patient doesn't avail themselves of the help and that's on them if you will.
• 30:33
  Yeah.
• 30:34
  Well, I mean, there, there is a bit of that, but that's not most of it.
• 30:39
  I mean, I think the solution in a constructed sort of way would involve a couple relatively straightforward ideas, some of which we're actually doing here in Sacramento.
• 30:54
  for instance, we have two
• 30:56
  medicine, psychiatry, and family medicine, psychiatry, combined training programs, and then clinics to support them.
• 31:05
  So the clinics populated by our group, what they take care of is folks with complex chronic medical illness and complex chronic psychiatric illness, sort of at a one
• 31:17
  location.
• 31:18
  Now not every place can do that, but that's part of what we do.
• 31:23
  The second thing would be a greater,
• 31:26
  intuitive alignment between psychiatry only outpatient models and primary care only outpatient models.
• 31:37
  Now some places, including here, the county mechanism might run a primary care program and run a psychiatry program.
• 31:47
  So those can be encouraged to be more collaborative with each other.
• 31:53
  Is it optimum?
• 31:54
  No, but it's oh
• 31:55
  could be optimized.
• 31:59
  I'm not convinced that the psychiatry outpatient clinics routinely want to know who the patient's primary care physician is, routinely collaborate to and fro.
• 32:11
  And I think that needs to be done better.
• 32:16
  Yeah.
• 32:17
  There is aspect, especially when we're talking about outpatient psychiatry and a lot of, you know, outpatient psychiatrists are doing, um, private practice, right?
• 32:27
  Or they kind of fall into siloing, isolating themselves and not reaching out as much as would be ideal.
• 32:35
  Like as, as much would be available in a, in a hospital system or a shared EMR kind of system where we're like, yeah, they are seeing other people as well.
• 32:43
  There are other other other people that are involved in.
• 32:45
  this patient's care.
• 32:46
  Yeah, so that's something we want to...
• 32:51
  that's, m agree with that and.
• 32:54
  oh
• 32:57
  I mean, what do we do with that?
• 32:58
  Well, one is what I would call more in, if you will, enlightened primary care, structural elements, including common EMR, including not labeling psychiatry notes as secret.
• 33:14
  Yes.
• 33:14
  Making them open like any other consultation.
• 33:17
  Cause I will tell you, and this may be controversial.
• 33:19
  I really don't care if it is excessive reliance on psychiatric secrecy.
• 33:26
  itself encourages stigma.
• 33:30
  Remember, primary care doctors, deal with sexual matters, existential matters, all kinds of things.
• 33:35
  So to imply that they cannot understand psychiatric material is in fact a little insulting.
• 33:42
  And as if what we do is so fundamentally different that we can't communicate it to others.
• 33:46
  I think we need to all actively question that and encourage collaboration at a sort of a parallel.
• 33:54
  Yeah.
• 33:56
  Tell me more about that.
• 33:57
  it seems like this is like a little, a kind of idea that's brewing a little bit or there's a little bit more under the surface to like, again, I joke about it that like there's the
• 34:07
  psychiatric magic or the wizardry that we have, the psychiatric superpower that we have that allows us to be, to do what we do.
• 34:15
  But that like you guys, you other doctors don't understand what we do, right?
• 34:20
  Well, yeah, there's a bit of that.
• 34:22
  Now, you know, you make the argument that certain kinds of psychotherapy models that that's justified?
• 34:28
  Yes, I think you could justify that.
• 34:30
  So I'm not I'm not having issue with that exactly.
• 34:34
  But I'm saying most of what is done in clinical management, um you know, includes uh medication monitoring and things like that.
• 34:44
  I mean, you can even argue you can even make a safety argument.
• 34:47
  Now, if.
• 34:48
  If a patient is being treated in a psychiatric clinic, let's with lithium and clozapine and things, and that note is made secret and the patient shows up in the ED delirious and
• 35:02
  someone tries to figure that out.
• 35:07
  I might even have difficulty accessing that chart.
• 35:10
  And if I knew that data, I would immediately know what to do.
• 35:13
  Right.
• 35:14
  So it's actually a safety concern and that's not trivial.
• 35:19
  Right.
• 35:20
  I've seen it even with like other psychiatrist notes, or again in the shared EMR system, where like, I'm not even able to access some of the notes at times.
• 35:30
  And I was like, we're in the same field, or, you know, this is a referral that you've sent over to me and I can't access your notes to look at what's going on.
• 35:37
  And it's like, this is little bit of a problem.
• 35:41
  Well, and I think our field needs to number one, confront that and number two, see themselves as part of a broader continuum of care involving team care at numerous levels.
• 35:55
  Yeah.
• 35:56
  Again, it's easy, obviously intuitive for a CNL person to say that because we do it all the time.
• 36:01
  But I think there's an element of that that is part of this.
• 36:05
  It's not the whole thing, but I can't ignore it either.
• 36:09
  Yeah.
• 36:10
  Speaking of like stigma, you know, and I think a stigma is, know, this big broad word and has a lot of kind of stigma around the word stigma.
• 36:23
  Um, but what do you feel or what kind of stigma have you maybe felt from peers in the field?
• 36:35
  I, I know
• 36:36
  maybe either towards patients or even towards yourself or within the field as a whole.
• 36:42
  Like I can remember stories and I think they give a nice case example in the article was back reminded me of something in training where I was training at the VA.
• 36:54
  I had a consult at like two in the morning from the surgery team, patient being called a difficult patient.
• 37:00
  Can you talk to them?
• 37:02
  And I go over there and
• 37:05
  I'm saying like, Hey, what's going on?
• 37:08
  And she's saying, you know, I don't want the surgeons touching me.
• 37:12
  Like I, and I was like, okay, could you tell me a little bit more about this?
• 37:16
  And what she's, what I ended up saying is like, you know, she had a history of, you know, military sex or sexual trauma.
• 37:24
  know, that was like in the chart, but again, not like highlighted as this something to what be watching out for.
• 37:32
  have med students coming in and like,
• 37:34
  four or five in the morning to like do physical exams unannounced.
• 37:39
  And, you know, she's telling them to get out and surgery is like, why are you doing this?
• 37:46
  Why are you yelling at our students and, you know, refusing physical exams.
• 37:49
  And now you're a difficult patient and you have this label on you that's, that gets slapped on the patients.
• 37:54
  And then I'm seeing them at two in the morning, going back to the surgical team to be like, please ask permission and identify yourself.
• 38:01
  And like,
• 38:02
  before, announce what you're doing before just randomly touching people in the middle of the night.
• 38:08
  Well, I mean, that's a nice example because, um, you know, use the term trauma informed care is becoming a little bit more, um, where, mean, uh, why isn't all care trauma
• 38:19
  informed care?
• 38:21
  I mean, it's really what you should be doing anyway.
• 38:24
  It's just some of the, would say accentuated in your example, but it's valid very broadly.
• 38:31
  So if we contribute to an appreciation of that more broadly, and that is happening.
• 38:37
  It's not always happening, you know, to a pleasing degree, but I see much um more awareness of such concerns among our physician colleagues than I would have 25 years ago.
• 38:48
  I will say that unequivocally.
• 38:51
  Is it where it should be?
• 38:52
  No, probably not.
• 38:53
  But is there favorable momentum?
• 38:55
  Yes, there is.
• 38:57
  Yeah.
• 38:58
  Do you come across any issues again, like with your medical colleagues or about whether it's hesitation with reaching out to you over reliance with reaching out to you?
• 39:09
  Things like saying, Oh, can you do capacity evaluations?
• 39:12
  Cause you know, other capacity evaluations are along those lines.
• 39:19
  Well, number one, we are the subject matter experts on decisional capacity.
• 39:24
  So like any other intervention, some are straightforward and, you know, really anyone can and should do them, but some are not.
• 39:31
  And that's the whole referral consultation threshold thing.
• 39:35
  So if patients, if other physicians truly need our help with that, I mean, we need to uh be uh forward and available and, you know, kind of seek that out.
• 39:47
  You know, my group wrote a...
• 39:49
  Decisional capacity review paper 2019, I believe it was, which is sort of a summary that a literature at the time and a, I thought was a very directive kind of how to approach if
• 40:02
  people, people told me they find that helpful.
• 40:07
  Um, so that's a significant part of a consultation liaison business.
• 40:10
  It's, something like a fifth to a sixth of all consultations are just that, but sometimes it's not just that sometimes you.
• 40:19
  encounter the decisional capacity question and in course of working it up, you ascertain the patient's gut dementia and delirium and that's a whole other problem.
• 40:30
  I must say those of our colleagues who I think very regrettably will focus on only the decisional capacity question, not the reason it's impaired.
• 40:40
  They're not doing everything they could do.
• 40:43
  So I would treat it like a chief complaint.
• 40:46
  Questionable decisional capacity.
• 40:48
  requires a certain evaluation.
• 40:50
  And, you know, many times, of course, uh intervention might improve the decision or capacity and then the patient is in a better place.
• 40:58
  So that's my statement on decision capacity.
• 41:02
  But it's important function.
• 41:04
  mean, we need to completely own it.
• 41:06
  And if others can't do it, we don't try to, we shouldn't try to say, you should do it.
• 41:10
  If you can't, you can't.
• 41:11
  Call us when you need it, but call us telling us what you have tried and what you have seen, because that's a starting point.
• 41:19
  kind of wrapping up a little bit, like, is one thing that psychiatry could learn from the rest of medicine and vice versa?
• 41:26
  One thing that medicine could learn from us.
• 41:29
  Hmm.
• 41:31
  Boy, how much time do have for that one?
• 41:36
  Well, taking your first condition first, I think we in our own learning and our own development, we need to try to be as medically current as, as, practical and be aware of
• 41:50
  what's out there, know what patients are experiencing.
• 41:53
  That doesn't mean you have to be the providers of those things, but you should know about them.
• 41:58
  uh There's Legion examples.
• 42:00
  could go on and on uh psychiatric side effects of immunomodulators.
• 42:06
  You know, in CNL, you see this all the time.
• 42:09
  So, you know, complex organ transplant cases, complex cancer, chem, all of that.
• 42:14
  And many of the side effects are purely psychiatric and they look a whole lot like schizophrenia.
• 42:19
  Well, who's going to figure that out?
• 42:21
  That is our job to figure that out.
• 42:25
  acceptance that psychiatric illness is on the spectrum of all medical illness.
• 42:30
  We should not use terminology like medical versus psychiatric illness.
• 42:34
  There is illness.
• 42:36
  There are different symptoms, but it's all illness.
• 42:38
  um What others could learn from us, so I hope they do learn from us, is take a more integrative approach, more, uh if you will, individual approach.
• 42:50
  Why does this particular patient have this particular difficulty right now?
• 42:54
  Well, that's because they have comorbid, whatever they have.
• 42:58
  And again, that's another illness the patient has that has to be understood in both the psychiatry and the
• 43:05
  and the general medical side.
• 43:09
  I mean, I would argue that's the role of C-AL is sort of to be the transduction object between those two areas.
• 43:14
  Yeah.
• 43:16
  It's, it's one of the things I always, when I have the residents, Peds residents and they're, they're kind of shocked that I'm not just talking about Prozac and Zoloft all day
• 43:25
  long.
• 43:26
  I, you know, I ask them or I tell them all the time is to like reflect and say, is this a medicine problem or is this a non-medicine problem?
• 43:33
  Like, what are the other things in the person's life that are going on and that are contributing to why they're here in my office today?
• 43:42
  And so I.
• 43:44
  You know, again, like I think it's a very, very, very interesting field.
• 43:48
  think it is a thing that we have to remember as psychiatrists too, is that like we're physicians first, right?
• 43:54
  And, know, again, like people talk about the DSM, they have criticisms, valid, invalid, whatever you want to say about it.
• 44:00
  But the one good thing is that it says, um, cannot be better explained by a medical condition and or a substance, right?
• 44:08
  And a lot of times we kind of overlook, forget that part of it.
• 44:11
  I I remember from my residency, one of my better residency instructors, the terminology is now a little anachronistic, but what he would say to us all the time was, your first three
• 44:23
  diagnostic questions are organic, organic and organic.
• 44:28
  If there's nothing there, well, then you move on, but you always start there.
• 44:32
  And certainly CNL people, I would say would do that as a core mission.
• 44:38
  Yeah.
• 44:40
  Last kind of question and then we'll kind of wrap up, but like, what are some things that you do for yourself, for your own self care?
• 44:47
  Because those are very, very important things for all of us in the field.
• 44:52
  I'm probably not the best model.
• 44:54
  um You know, I, people ask me what's, what's the work like say, well, I usually work half days, only six to six.
• 45:02
  uh What do I do?
• 45:04
  I was trying to maintain, I think it's helpful to maintain a sense of balance, such as having numerous activities.
• 45:14
  even though I love being in the hospital and I'm about to go over there, of course, I wouldn't want to do it every hour, every day.
• 45:22
  So I spend about um maybe a fifth of the time doing TMS procedures, doing ECT and things like that.
• 45:31
  um Consulting with outpatient systems, being very involved in teaching nursing students, PA students, medical students, residents and so on.
• 45:40
  So doing that in a very purposeful way to encourage a balance.
• 45:46
  It's an enduring challenge.
• 45:47
  The current environment is extremely difficult, but not just for us, for everybody.
• 45:53
  And I think if we just empathically resonate with that, um when I think about that very actively, I'm a lot less impatient with our ED colleagues.
• 46:01
  Because I think of what they're up against and it's, you have to be respectful of that.
• 46:06
  Yeah.
• 46:07
  Cool.
• 46:08
  Cool.
• 46:08
  Any kind of like parting words for listeners or anything you want to leave them with.
• 46:14
  Thank you for the interview, first of all.
• 46:16
  Second, coming back to this article, which again was unsolicited, I think they did a very good job of this in terms of active consideration of the handoff to outpatient care, what
• 46:27
  kind of things need to be accomplished, uh all in the spirit of the patient doing their best and not ending up needing hospitalization too much.
• 46:36
  I think we all need to try to do what we can to avoid that.
• 46:38
  So I thank them for the submission.
• 46:40
  I told them that when I approved it some months ago.
• 46:43
  Thank you for paying so much attention to this nice article too.
• 46:46
  I hope others read it as well.
• 46:48
  Yeah.
• 46:49
  Thank you so much, Dr.
• 46:50
  Prajara for being able to fill on in and your time with us this morning.
• 46:55
  Nice to meet you, thanks Michelle for helping.