Improving the Relationship Between ER Physicians and Psychiatrists

Physicians specializing in emergency medicine (EM) and psychiatrists both share the same goal of wanting do the best they can for their patients, but their interprofessional relationships may become strained at times, especially regarding highly acute psychiatric patients. And with the growing numbers of psychiatric crises presenting in emergency departments (ED), interactions between the 2 specialties are increasing in frequency, as an estimated 6% to 9% of all ED visits involve patients with primary mental health diagnoses.¹ Unfortunately, tempers can flare when these patients are held in the ED while waiting for a psychiatric evaluation or disposition; this is a dilemma that can last from 7 to 34 hours on average across the United States.²

Discussion with practitioners from either side elicits arguments about the shortcomings of the other. And yet, it might take just a little bit of understanding about the other person’s situation to mitigate some of these disputes. Let’s take a look at some of the more common misunderstandings that occur and consider some ways to smooth things over.

Scenario 1: ED physicians express frustration that psychiatrists request what appear to be unnecessary tests and procedures in a manner perceived to be nothing more than stalling. It is not uncommon for ED physicians, when contacting a psychiatrist to approve a disposition or come for a consultation, to witness the psychiatrist request a number of requirements before participating in the case. Perhaps the most frustrating example is waiting for a blood alcohol level to fall below 0.08 before the psychiatrist will evaluate the patient or consider a transfer of service.

Advice: When patients are otherwise medically cleared and stable, they are typically not receiving psychiatric care in the ED, which can be a frightening and confusing place and not conducive to healing. One survey of psychiatric consumers reported that a majority had unpleasant experiences in medical emergency facilities and wanted to get to a specialized psychiatric treatment setting as soon as possible.³ In consideration of this, psychiatrists should facilitate the transfer or evaluation of psychiatric patients as quickly as they reasonably can do so. Many patients with blood alcohol levels greater than 0.08 can be lucid and participate in a full psychiatric interview. Decisions on readiness of psychiatric patients should be based on their clinical picture, not blood alcohol levels.  A helpful guideline we often use for psychiatric receiving of acutely intoxicated patients: their blood level is not very important as long as they are “walking, talking, and able to eat a sandwich.”

Scenario 2: Psychiatrists complain that EM physicians minimize medical issues and dismiss most situations as a psychiatric issue.

Advice: Having a psychiatric illness does not exclude a patient from having other medical comorbidities; therefore, EM specialists should not make any assumptions that another medical condition does not exist. Despite having psychiatric symptoms, a patient can still be a good historian for their physical complaints, and simply because an individual has symptoms of psychosis does not mean their reports of pain or dizziness are delusions! When treating a patient with a psychiatric history, an EM physician should pay attention to the history and physical just as they would do with any other patient. The situation is similar to that seen with a nonpsychiatric patient who presents frequently with chest pain. He or she still requires a full workup each time because, as experienced EM physicians know, it is that one time when a patient isn’t taken seriously that the results will come back to haunt you.