Primary care in psychiatry
“Prudent Prescribing” by Drs. Richard Rosse and Stephen Deutsch (Current Psychiatry, October 2004) offers valuable advice about when psychiatrists should start medical workups. I have some additional thoughts.
Indications for a medical workup. The authors illuminated the need for medical testing for patients with clozapine complications, long-term complications of atypical antipsychotics, and health problems secondary to substance abuse. Psychiatrists also might be called upon to initiate or arrange for a medical evaluation in other situations, such as when:
- the patient presents in compromised health and has no primary care doctor
- the patient presents with a seemingly acute medical condition or reports such a problem over the phone
- the patient is acutely medically ill and his or her primary care doctor cannot be reached
- an acutely ill patient has no health insurance
- the patient fears going to the emergency room.
Psychiatry is ‘primary care.’ The National Health Service Corps considers psychiatry a primary care specialty. At times, we perform a “physician extender” role when collaborating with medical colleagues. Whereas in large multispecialty groups our role may be more narrowly defined, we may need to employ a far broader range of medical skills in private practice and even more so in treating underserved populations.
We are fully licensed physicians with the same training in basic clinical diagnosis as our colleagues in other specialties. It is our duty to distinguish organic from functional causes of psychiatric presentations to move our patients toward definitive care.
Medical screening tests. The authors listed several medical tests psychiatrists might order. That list should also include:
- antinuclear antibody and erythrocyte sedimentation rate tests, because autoimmune conditions often have psychiatric presentations
- hormone level testing for women, as perimenopause and menopause can have an enormous emotional impact
- mononucleosis spot test/Epstein-Barr virus titers, because mononucleosis can present with depression.
‘Turf’ issues. Because we see many patients more frequently than do our medical colleagues, we might be the first to spot a medical problem. A psychiatrist might be the only clinician with whom the patient is willing to discuss fears about the symptom—or the only clinician a paranoid patient will agree to see, period.
We must retain the right to start basic diagnostic workup and convey findings promptly to our medical colleagues without “turf” issues or threats of peer review for “overstepping our bounds.”
Sara Epstein, MD
Los Angeles, CA