The Good Psychiatric Referral

Trastorno-bipolar

I love my job. I have always felt like this is what I am meant to do, ever since I was in med school. 

My job deals with stories. Getting the right timeline. Getting the right plot. Working for the right ending for my patients. I am a book lover and I love stories. And thus, I chose Psychiatry as my field of dedication and so far, I have not regretted the decision. 

The only part of my job that I don’t really fancy is the on-call part. And a lot of it has to do with the sort of referrals we sometimes have to entertain because…well, some of the referrals are plain ridiculous. 

“Sorry, my consultant asked to refer.” is the usual manner of apologetic referral we receive when the HOs themselves know that the referral is not indicated but have no choice other than obeying the consultant’s order. (The HOs are sometimes more reasonable than the consultant when it comes to indication for PSY referral, I must admit)

 Short of saying that “your consultant is not very bright for asking you to refer this patient to psychiatry”, what else can we PSY MOs do when we received such referrals? We can babble our annoyance to the HOs, (which is really not fair to them) but at last, we still go and see the case…

….Because “THE CONSULTANT asked to refer”. 

I hate that. 

But again, I suppose, it’s good PR. (I mean personal relation, here. Not per rectum. Haha)

Being an INTP with underdeveloped inter-personal skill, I really had to fight the urge to say “I reject that referral because bla bla bla. I know it is your consultant’s request that the patient be referred to me. But she/he is not a consultant in MY field and I am not obliged to follow what she/he said.”

Of course, the consultant might decide to pull rank and straightaway call MY consultant in MY field and requested MY consultant to make me go and see the referred case. And consultants and specialists always try to accommodate one another. It’s good PR, remember? 

So, I would feel upset that after I have so clearly rejected the case, I end up having to see it anyway because rank has been pulled. I would feel like my judgment and my reasoning have been undermined and second-guessed and I am honest enough to admit that I don’t like that. But I understand why maintaining good PR is just as important. (This has happened to me once. But my specialist understood why I rejected the case in the first place. It’s just that psychiatric specialists are nice and accommodating.)

***

Indication, Indication, Indication!

Indication is the main criteria that makes up a good referral. 

If your referral is indicated, we are more than happy to see the patient or give an early appointment, depending on the urgency of the case. (and the urgency is also a matter of great contention. The consultant might ask the HO to refer the case to be seen stat and AGAIN pull rank when we don’t oblige. Can we all stop pulling rank?)

We won’t even care that your history is a bit patchy because taking a good psychiatric history is our job, not yours. But your indication has got to be solid and at least, make sense. And therefore, you need to know basic psychiatric symptoms to know that the referral is indeed warranted. The main subjects you need to study are just psychosis and mood disorders. Just know MDD and Bipolar and Schizophrenia (refer DSM V) and delirium. That’s all. if you know those, you know the basic.

The PSY MO will settle the fine points and the real diagnosis. That is our job in PSY. You just need to know your basic in order to make a good referral. Good points to remember and look out for in your patient while referring to us are:

-psychosis (hallucination, delusions, disorganized speech)

-orientation (especially important for delirium)

-if you think that the patient might have mood disorders, mind the DURATION of the mood problem you think she/he has. Duration can make or break or alter a diagnosis, remember this! (and just google DSM V for the criteria. When you google it, you will come across other symptoms like elated mood, grandiosity, flight of ideas, energetic, etc etc that you can include in your referral if relevant. It increases the chance of your referral being accepted when you use proper words. So easy! Just google it!)

-Basic MSE: especially behaviour and speech! No need too much description.

I, personally, don’t require detailed history to accept a case. I am pretty relaxed about it because the history is my job! Your job is to take ‘just enough history’ to make me see the indication. When your referral is indicated, I will accept the case without pushing you for more detailed history because, I repeat, taking detailed history is my job! If any PSY MO gives you a hard time for not knowing detailed history, just tell him/her “But that’s your job!” hahah. Berani tak, adik-adik HO sekalian?

Below are many examples of poor psychiatric referral due to non-indication. Please, the respective department in my hospital should not be offended, because I am going to declare that these examples are not only from my own hospital but also from others all over Malaysia which I have collected based on our ventilation session among ourselves. You will not know which example belongs to which hospital. That way, no one can say for sure that this particular department in this particular hospital was the one making that poor judgement in asking for PSY referral. Haha. This is purely for learning purpose. If you are going to be offended, stop reading right now. 

Consider yourself warned. Proceed at your own risk. 

Example Number 1: Inappropriate Time and Indication – Example From O+G

HO : This patient is a 17 years old pregnant girl, currently in LATENT PHASE OF LABOR. She was raped by her boyfriend and the rape resulted in the current pregnancy. We would like to refer her for post-partum blues.

PSY MO: Sorry? Post-partum blues? I thought she is in latent phase of labor? Baby not yet delivered, so how can she develop post-partum blues?

HO: My consultant asked to refer because she might develop postpartum blues as this is a teenage pregnancy of a rape case. 

PSY MO: So you are referring for PREVENTION of post-partum blues? While she is in LATENT PHASE OF LABOR???

HO: (silent)

PSY MO: Ok, how is she now? Is she teary eyed? Depressed? How is her appetite? How is her sleep? Any suicidal thoughts? She has got 9 whole months to come to terms with her current pregnancy, why do you think she is depressed while she is IN LATENT PHASE OF LABOR? (obviously we are trying to be accommodating and ‘bersangka baik’ here. Maybe the referral was made because the patient REALLY seems depressed)

HO: No, she is not suicidal. (the HO did not elaborate on the other symptoms because the HO did not ask and did not know)

PSY MO: She is in latent phase of labor. Why do you refer her for postpartum blues while she is in latent phase of labor? Why is it urgent? Why can’t it wait until she delivers her baby, when she really IS postpartum, you know. I know it is your consultant who asked you to refer, but I want you to confirm with your MO or your consultant whether the patient REALLY is indicated for referral at this time and call me back. 

My comments:

-The referral just doesn’t make sense. Any PSY MO would have been upset when receiving such a referral. The time of referral (when the patient was in labor) is just not appropriate at all. There was no urgency to it. In fact,there was NO INDICATION at all. 

-How can you refer someone to psychiatry (at a tertiary centre) for PREVENTION purpose? Primary Prevention is  the job of Public Health Department. Hahah. Maybe the Public Health Department can PREVENT Post-Partum Blues by doing a “Be A Happy Mom Campaign”, promoting the expectant mothers to exercise more to release endogenous endorphins or to just eat chocolate, LOL. I mean, seriously?  

-In general, if the patient is undergoing acute treatment, or in labor, or tachypnoeic…. deal with the acute presentation first. Unless the patient is very aggressive or is actively struggling to jump out the window to kill herself while being in labor, don’t refer the patient to us. 

Example Number 2: Unclear Purpose of Referral – example From medical

HO: Hello doctor. I am a HO from medical department. I would like to refer one case for INCONSISTENT HISTORY.

PSY MO: *speechless*

My comments:

When I heard that story, I laughed out loud.

Please, please….have a clear idea why you are referring to us. What do you mean by inconsistent history? Is it irrelevant speech that you meant? So are you referring for thought disorder as evidenced by her disorganised speech, causing you to have difficulties taking history? Is that what you mean? 

Or is the patient has no abnormal speech but you just think that the patient is lying? (but again, even if the patient is lying, why refer psychiatry? Most psychiatric patients are very honest about what they have in their minds, and that’s how they get diagnosed. They honestly believe their bizarre delusions and did not lie about it. They are disinhibited, they act on their delusions. Honest to goodness transparent in their presentation! Or…. Are you referring for anti-social personality disorder, evidenced by the patient’s manipulative behaviour? I mean, what exactly?)

We don’t need you to really have a diagnosis in mind. We just need to understand what you want from us that you could not get by yourself.

Can you imagine if I refer to medical for “warm body”? Do I mean having fever? What is the temperature? What other associated symptoms? What sort of help do I really want from medical when I refer medical for ‘warm body”? Any Medical MOs would be downright ANGRY if they receive such referrals!

Imagine how they feel if I then rub salt in their wound by saying “My CONSULTANT asked me to refer this patient for warm body.” 

If you don’t remember anything else I wrote, please remember this: Pulling rank is an ungentlemanly and unladylike behaviour among doctors when they are dealing inter-departmentally. Instead of pulling rank when your HO fail to get me to see your patient, you as the MO or the specialist can call me yourself and explain your request or ask for a favour when the referral is not indicated but you still need me to see the patient, anyway. I can do a favour. I prefer doing a favour. But I resent losing to ranks rather than reasons! I am just not very conventional, when it comes to obeying based on ranks. 

Some MOs do not like it when a specialist/consultant call them after they have rejected a HO’s referral. But I actually welcome the opportunity to explain MY SIDE OF THE STORY about why I reject the referral. If the consultant gives a clearer reasoning for referral than that given by her HO, then I will go and see the case if I feel that it is indicated. If the consultant cannot give a better indication for referral but still request psychiatry input, I will do it as a favour. Either way, I am doing it in good will. But if the consultant simply call my consultant to insist that I go and see the case being referred, I take it as pulling rank.

So whenever I reject a case over the phone, I will ask the HO to write my dictation word-by-word, as preemptive measures to defend my rejection of the referral. “Okay adik. Write what I said in the BHT word by word. Spoken to Dr. Afiza. There is no indication for psychiatric referral because a, b, c, and d. If patient develops the symptoms of e, f, g and h, you may refer again to psychiatric department with this and that blood investigation and get a CT Brain as well. Thank you.” I paused. “Please write the ’thank you’ ya, adik.” (that’s just me being funny)

I give you the dignity of rejecting your referral with my reasoning. I hope, you will give me the courtesy of telling me why I need to accept your referral just because you are a consultant in YOUR field. 

Example No 3: Poor Basic Counselling – example from Surgical

HO: I would like to refer this patient for depression. Patient just diagnosed of rectal Ca 3 days ago. According to his wife, he seemed depressed and worried. Since then, he has not communicated much. 

PSY MO: When you see a patient newly diagnosed of Rectal Ca laughing out loud instead of being worried, that is the one you must refer. That is the one I am more worried about. 

My comments:

When you refer someone for depression, it has to fulfil DSM-V criteria for it. The minimum duration is at least 2 weeks. Not 3 days ago upon receiving bad news. The patient was probably undergoing grief reaction. 

You, yourself is qualified to assess stages of grief and give supportive counselling. When I was a medical student, one of the OSCE station in Newcastle medical school was on stages of grief and counselling. Each semester, there will be at least one OSCE station on COUNSELLING. Each semester! This semester it would be counselling on bad news. Next semester the question may be on counselling about diagnosis and treatment. Another semester, they designed a question on sexual counselling. And so on and so forth until our final year! I am sure Malaysian Medical Schools also train their graduates in basic professional practice skill. It’s like doing Rectal examination… all doctors know how to do it! Not only surgical doctors!

As a doctor in YOUR field, you knew best how to counsel patient about their diagnosis, their treatment options and their prognosis. To me, counselling is a basic professional practice skill that SHOULD NOT be seen as limited to psychiatry. In fact, referring Psychiatry for basic counselling of bad news feels almost like an abuse of PSY service. 

You also have the option of referring the patient to the hospital counsellor first rather than to psychiatry. But scratch that! I believe, every doctor in their respective field MUST take the time to counsel their patient after receiving bad news. (In a proper environment with minimal noise. Complete with brochures and charts and detailed explanation) You MUST end your counselling session by offering the patient the opportunity to ask for any knotty points that they don’t understand. You should offer to repeat the whole process another time should the patient requires it.

Basic Counselling 101!

If after 2 weeks upon receiving the news, patient fulfil DSM-V criteria for Major Depressive Disorder, by all means, refer the patient to us! We will gladly see the patient. But the bottom line is, the basic counselling upon receiving bad news is YOUR responsibility. 

Example No 4: Ruling Out Organic Cause 

This is very important! Please remember the two equations below.

1)Fever + abnormal behaviour + Acute First Presentation = CT-Brain (to rule out organic cause)

  • A patient with FIRST PRESENTATION of abnormal behaviour coupled with fever is meningoencephalitis until proven otherwise. Please refer to medical team before you refer to psychiatry. We will go and see the patient, but not as the primary team.

2)Known case of Schizophrenia + Psychotic + A new complaint = Clinical Examination Addressing The New Complaint. 

  • If the patient is a known case of Schizophrenia and she complained of a new physical symptom, it is not necessarily her newly developed delusion. Please examine and investigate the physical complaint! I repeat, please EXAMINE & INVESTIGATE  the physical complaint.

-For example, an emergency department in one hospital treated a PSY patient for Neuroleptic Malignant Syndrome when the patient was brought to red zone with altered conscious level. The patient was previously psychiatrically well and on regular follow up. A PSY MO who was oncall insisted for CT-Brain to be done —> massive intracranial haemorrhage. 

-Another example:  A PSY patient was only just discharged from medical ward and came for PSY TCA a few days later. She was still psychotic as her antipsychotic was withheld while she was treated for NMS in the medical ward. But she had been whining and crying about leg pain since she was still in medical ward. The ward staff took her crying as part of her psychotic behaviour. When she came to psychiatry clinic for follow up, she came on wheelchair. The PSY MO who knew the patient could not compute why a patient who previously could walk had to come via wheelchair. Yes, she was still psychotic and whining and generally disturbing. It was so easy and tempting to simplify matter and attribute it to her psychosis. But all it took for the PSY MO to see that she had DVT was just to lift up her kain batik, and see the unilateral leg swelling up to knee. 

Just because the patient is a known case of psychiatric illness, does not mean they don’t suffer from other chronic medical illness or other acute medical emergency. Please, just verify the complaint. If it’s nothing and just the patient being psychotic, then you have done your job of checking! 

***

I hope, this post is helpful. 

I, personally, am not fussy about proper history. Only proper indication. But of course, you need basic history in order to show me that it is indicated. And the basic that you need to know is psychosis and mood disorders and delirium. If patient is suicidal, you just mention the ’suicidal’ word without any other history, I will accept the referral easily enough without hammering you. All casualty referrals are generally accepted EXCEPT when it is a FIRST PSYCHOTIC PRESENTATION with fever. 

See? It is not hard at all to refer to psychiatry. Maybe that’s why people do it too much without its proper indication.

When do I become difficult and hammer you about proper history? When the referral is not indicated. That’s when I do the hammering. I have to. Not because I want to give you a difficult time. But because I want to give you the opportunity to justify why I should see this patient. Your answers to my hammering might enable me to see the indication that you do not know to mention, prior to my questioning. 

That’s all. 

Good luck for your next PSY referral to me. *evil laugh*. 

2 thoughts on “The Good Psychiatric Referral

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