As a private psychiatrist, I often receive referrals of the sort: 'Mr X is severely stressed and depressed. Please take over management,’ No medical background at all.
KwaZulu-Natal psychiatrist Dr Maria Dobreva writes:
As if the field of psychiatry is completely detached from any medical condition or treatments, write, which of course couldn't be further from the truth.
Practicing sound psychiatry involves a thorough assessment of the presenting symptoms in the context of the ‘bio- psycho-social’, model, drummed into our heads from our medical school years. Each patient is unique, with an individual constellation of medical conditions, genetic predispositions and vulnerabilities to stress. The starting point is to critically review their biological wellbeing, identifying underlying medical conditions or treatments, which may possibly account for some of the psychiatric symptoms they present with.
To give an example, it is common to come across patients treated with antihypertensive drugs, who complain of feeling nervous, nauseous, dizzy, lacking energy and motivation, weak, lightheaded… Sounds a bit like depression with anxiety? Well, yes…
Likewise statins, which are generously prescribed, can often cause insomnia, muscle weakness, dizziness, drowsiness, and headaches. These are rather vague symptoms, but also commonly attributed to psychiatric conditions.
Stress and burnout are the buzz words. Who isn't stressed or depressed at times at least in today's world? It's becoming increasingly the norm. It's much easier to blame the symptoms on these conditions, rather than painstakingly exhaust the possible side effects from prescribed medication.
So here is my frustration. I am looking at the patient, who has reasons to be anxious or depressed, but how do I tease out the symptoms that are purely in the psychiatric domain, not contaminated by the medical comorbidities or the drugs they are on?
In theory, it shouldn't be that hard, if the patients are mindful enough to pick up cause and effect, which uncovers the link to the start of a particular drug, which is unfortunately seldom the case. At that point, what the sound pracitioner should do is to stop or change the suspected pharmaceutical culprit.
But somehow a lot of GPs and physicians have a blind spot for this and just don’t do it. So, I have to do it, even though this is in a way to cross professional boundaries and is frowned upon.
Normally, I first communicate the plan of action with the patient and the referring doctor, keeping them in the loop. If, however, the depressive/anxiety symptoms are severe enough to warrant aggressive and immediate treatment, I do so, which is not ideal.
Another major challenge in private psychiatry is providing care for a hospitalised patient. This involves a complex interaction with the GP, other treating specialists, psychologists and the nursing staff, which often fails because of a basic failure to communicate.
It's all about being ethical and wise, utilising many possible ways of communication, by leaving a summary note in the patient file, dropping an SMS or relaying a message via the sister.
The sad reality is different: physicians are scarce and see dozens of patients every day; they simply have no time for it; they undermine the importance of sharing clinical information; they may feel it is of no relevance to the treating psychiatrist (an assumption that infuriates the psychiatrist); or, sadly, they just don't really care.
Not all are unwilling partners of course, but some are pathetic. Leaving me frustrated. There are many reasons why doctors may not communicate sufficient clinical information about the patient to their colleagues. These can include pressure of time, difficulty accessing colleagues or just a bad habit of not playing the role of a responsible team-player, which an integral part of the multi-disciplinary team.
So what happens is that I often assume the role of the collaborator, trying to gather relevant information from patients and families, which at time-scan be a futile exercise, or chase after the physician and the neurologist, apologetically asking for a few minutes of their precious time. That is if I am lucky and they answer their always ringing cell phones.
What are the consequences? Passing care between doctors is inadequate and fragmented. This often leads to omission of important investigation or duplications of such, lack of understanding of important comorbidities, which all results in suboptimal and inadequate patient care or even the risk of harm to the patient.
However busy physicians are, they can use their time and energy smartly. There is simply no excuse for poor communication with the colleagues involved.
We are all treating an individual patient with an unique combination of comorbidities. We shouldn't practice, ignoring the basic principle of good clinical communication and sound treatment ethics.