Scenario 3: EM physicians often express frustration that psychiatrists request a complete array of blood tests for patients prior to accepting a transfer. This can often lead to long delays awaiting results of what appear to be unnecessary lab work in otherwise healthy individuals.

Advice: Far too often, requests are made for tests that are not indicated and that will unnecessarily delay the patient access to mental health services. Furthermore, patients who are paranoid or frightened may see an attempt to draw blood as an assault, which can lead to an exacerbation of their symptoms or aggressive or combative behavior as they try to defend themselves. Studies have shown that when a lab test is not felt to be indicated by an ED attending, the risk of the lab test showing an unexpected abnormality is extremely low.4 Thus, lab tests should be required only when there is clear indication.


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However, one could argue that a hospital’s policy of having a full battery of baseline admission lab data for newly arriving patients must be enforced. Indeed, many hospitals do have such policies in place. This is often due to a limited ability to obtain lab data at their own facility, and baseline lab data can be especially important for psychiatric patients given their risk of metabolic syndrome and other issues related to psychiatric medications.

The solution can be fairly simple, though. The psychiatrist can ask the EM physician to have the blood drawn for those tests, but can also accept the otherwise medically-clear patient for transfer at that time, with the lab results to be sent once available. Such practice would solve the timely throughput and potential crowding issue at the sending ED, and the necessary lab data will still be available for the hospital’s use. But what if one of those rare, unexpected, and aberrant lab results occurs? The chances are that the EM attending will want that patient to return anyway. However, to be sure, the psychiatrist can inform the EM physician that the patient can be accepted for psychiatric evaluation with the expectation that the ED will accept the patient back if a concerning lab value is discovered.

Scenario 4: Psychiatrists complain that EM physicians assume that psychiatrists will not understand anything about nonpsychiatric medical issues.

Advice: It is important to remember that psychiatrists attended the same medical schools as their nonpsychiatrist colleagues, and that psychiatrists have had at least the basic training required for medical licensure. Indeed, some psychiatrists even had careers in other medical specialties prior to converting to psychiatry. Therefore, psychiatrists should be able to understand a general discussion of medical issues and use the information to decide collegially with the EM physician whether a patient is appropriate for a psychiatric disposition. The trust and openness will pay dividends down the road. A psychiatrist who believes that he or she is getting the full story from an EM physician will likely develop confidence in that individual and be more accepting of patients in the future.

And indeed, that points to the best way to avoid most of these roadblocks to practice and patient success for both specialties: demonstrate respect and eagerness to listen to the other side. Don’t be afraid to try this; you may find you have a valued new colleague.

Editor’s Note: The advice section of Scenario 3 was updated on April 18, 2016 to clarify that psychiatrists can request that a patient’s blood be drawn, accept the patient for transfer before lab results are complete, and request that the lab results be sent once available.

References

1. Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med. 2008;11(2):193-195.

2. Zeller, SL, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014 Feb;15(1):1-6.

3. Allen MH, Carpenter D, Sheets JL, Miccio S, Ross R. What do consumers say they want and need during a psychiatric emergency? J Psychiatr Pract. 2003;9(1):39-58.

4. Janiak B, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866-870.