JANUARY 19, 2024
Originally published by our sister publication General Surgery News
At a recent surgical morbidity and mortality conference, a case was presented of a female patient in her 70s whose course extended for weeks. Admission was for a chronic enterocutaneous fistula and failure to thrive. After unsuccessful conservative management, she underwent a series of operative
Originally published by our sister publication General Surgery News
At a recent surgical morbidity and mortality conference, a case was presented of a female patient in her 70s whose course extended for weeks. Admission was for a chronic enterocutaneous fistula and failure to thrive. After unsuccessful conservative management, she underwent a series of operative procedures.
Notable in the presentation was the context of the case, which included a history of bipolar disorder, poor and problematic social support at home, and a pattern of ambivalence or initial rejection of every clinical suggestion. Also of note was the fact that despite these factors and extended stay, no psychiatric or psychological consult was ever placed.
Post-conference, the presenting resident was casually and supportively asked whether, given the significant psychiatric history, poor support and behavioral management challenges, consideration was ever given to obtaining a psychiatric/psychological consult. The reply was “her mental capacity was fine.” On further discussion, the resident was readily able to recognize the aforementioned psychological factors, but was at a loss as to why a psychiatric consult to help with them was not requested.
This interaction raised a question of whether surgical training and practice has an excessively narrow view of the potential contributions of psychiatry and psychology to the comprehensive care of the surgical patient. Given the necessary emphasis on training technical skills and patient management, it may be that psychological training and understanding of patients, with or without a formal psychiatric diagnosis, is less than what allows surgeons to be comfortable with consultation for and management of these issues. It appeared the parts w ere there, but they did not sum up to a whole allowing benefit to both patient and surgeon.
While good contemporary data are somewhat scarce, the overall literature seems to reflect this, as the percentage of surgical patients receiving a psychiatric consult (excepting specialized services like bariatrics or transplantation) ranges from just under 1% to just over 10%.1-3 This is striking as psychological stress in surgical patients, especially anxiety, has been reported up to the range of 40% to 50%.4,5
Furthermore, the concordance rates of diagnoses between surgeons and psychiatric consultants generally fall in the 30% range.6 It appears that delirium and other organic brain disorders are the circumscribed focus and trigger for a psychiatric consult, as this is often the primary reason for a consult request.1,2 The imbalance in consult requests, and especially lack of agreement in diagnoses, is represented by concordance for delirium being in the 70% range, but agreement on an anxiety diagnosis is just below 7%.1,6
Finally, it appears that surgeons do not always follow the consultation recommendations provided. For example, and somewhat paradoxically, medication suggestions for delirium are adopted only 50% of the time compared with depression where they are accepted 100% of the time.7
The emphasis on diagnosing and treating delirium is not misplaced, as delirium is associated with mortality in hospitalized medical–surgical patients.8 However, there are multiple other situations in which consultation can facilitate care by helping to: manage chronic or acute preoperative anxiety; manage chronic or pre- and postoperative depression; diagnose and manage post-traumatic stress; clarify patient/family ambivalence; mitigate sign-out (against medical advice); promote surgeon and staff understanding the patient psychologically; guide substance abuse issues; assess and manage suicidal ideation; and arrange or provide postoperative/discharge psychological support.1,2
Consultation occurs to assist in alleviating potential problems before they become critical.
So, collaboration takes on even more importance in light of mounting research demonstrating that surgical patients with concurrent mental health diagnoses show poorer outcomes on postsurgical pain, length of stay, complications, readmissions, wound healing, quality of care and, possibly, mortality.9 Further, A 2021 review of surgical outcomes for patients with mental illnesses found that preoperatively, patients were 7.5% to 40% less likely to be deemed surgical candidates, were less likely to receive testing, were more likely to present at later stages of their disease or have delayed surgical care.10
There is certainly always a duty for consultants to meet surgeons’ expectations of timely and useful suggestions and care, lest they reify any surgeon’s doubts about their value. The minimum response that should be expected from a consultation is an evaluation of the patient with suggestions for management. Where there are more robust consultation services, ongoing visits with a patient, while in the hospital to integrate psychological care with surgical care, can also be part of the consultation service.
However, there are several suggestions when making a psychiatric consultation request, which if considered by the surgeon, are likely to provide the most effective and satisfying consultation experience. First, request the consult sooner rather than later, especially if there is a significant mental health history, or if anxiety or depression are obviously present. Earlier consults have a greater impact on outcomes.11
Second, specify the concern and the questions to be addressed. Writing for a “psych consult” gives little direction to the consultant and may lead to what the surgeon sees as excessive or irrelevant information. Historically, up to 40% of psychiatric consultation requests may be vague or unclear in the stated reason for the request.3 Most beneficial is specifying the concern, the questions to be addressed and what actions are desired of the consultant: evaluation and treatment or suggestions only.
The most productive consultation will result from an interaction between the surgeon and consultant. Being open to a brief phone call, text or discussion with the consultant will clarify the reason for the request. Being open to a brief discussion after the consultation will highlight nuances in the recommendations.
Finally, it is important to inform the surgical patient that the consult request is being made. Given the sadly ongoing stigma and hesitations around psychological care, it is crucial to advise the patient that it is a psychologist or psychiatrist who will be coming to see the patient.
Use of vague terms like “specialist,” “wellness doctor” or “stress expert” will lead to surprise, disappointment or even anger, when the patient asks the consultant about their specialty. It will create barriers to establishing a relationship for diagnostic and therapeutic effectiveness and may tarnish trust in the surgeon. However, beginning the discussion of a possible psychiatric consultation with the patient using the term “stress” and acknowledging the “stress of surgery” often helps allay any negative reactions, as most patients readily relate to stress of various types.
A surgical team wouldn’t hesitate to consult endocrine on a patient with refractory diabetes, or cardiology on a patient with a history of heart failure. So, although surgery and psychiatry are often seen as opposite ends of the medical specialty spectrum, they complement each other in optimal and comprehensive care for the surgical patient. A primary role may be in the context of delirium, but the potential integration of psychological and surgical care has broader opportunities to benefit the patient, surgeon and surgical team alike.
Dr. Asken is a psychologist and senior organizational performance consultant for the Department of Surgery; Dr. Childers is the director of the general surgery residency, Department of Surgery; Dr. Spence is a chief and a fifth-year general surgery resident; Dr. Joshi is a psychiatrist and the director of Provider Well-Being for Graduate Medical Education; all are from UPMC Pinnacle Health Hospitals, in Harrisburg, Pa.
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