The most important thing you can do as a psychiatrist...

 

I won’t build the suspense.  The most important thing you can do as a psychiatrist is to be the medical doctor that you were trained to be.  The second-best thing is to be a good if not great psychiatrist.

I had those thoughts today after reading about a case of misdiagnosed panic disorder (1).  The patient was an athletic 30 yr old women who reported episodic panic attacks, palpitations, light headedness, and shortness of breath.  A Cardiology evaluation was negative.  That was not too surprising since she was asymptomatic during the testing, but given the final diagnosis I would have expected a subtle baseline ECG change.  She was treated with a selective serotonin reuptake inhibitor for presumed panic attacks by her primary care physician.  She is seen in the Emergency Department and an ECG shows an irregular, rapid, wide QRS complex, tachycardia and her usual symptoms. A shortened PR interval with a delta (preexcitation) wave is noted. The entire case description with the associated diagnostic reasoning can be located at this link (1). I am not sure that readers can access it without an account.

The case is an excellent example of the real task of being a psychiatrist. The usual dialogue about what psychiatrists do is typically restricted to criteria in the Diagnostic and Statistical Manual (DSM).  There is a lot of confusion about the importance of the DSM and what it means for psychiatric practice. For example, the popular stereotype is that psychiatrists just sit around and estimate whether people “meet criteria” for a DSM diagnosis and then prescribe an indicated medication.  Life as a psychiatrist is not that simple.  The unique problems of the person in front of you cannot be captured by a crude system of classification.

Using this case as a backdrop, I need to know as much medical detail about this young woman as possible.  More details about the onset of symptoms and associated symptoms. More details about her baseline physical health, associated symptoms, and any cardiology consultation and testing that has occurred.  If I am on the same electronic health record system, I am pulling all of that up including her vital signs over time, lab testing, and cardiac testing.  I am looking at each ECG tracing.  I need to know her detailed family history for cardiac disease, arrhythmias, and sudden cardiac death. How much alcohol, tobacco, and caffeine does she typically use?  Is she using any stimulants?  Does she have an intercurrent illness that could affect her heart rate?

In the next few minutes, I need to be checking her vital signs especially her heart rate and rhythm, respiratory rate, and doing a rapid cardiopulmonary exam. My first decision point is whether she is in a medical emergency or not. This is not always as clear cut as this case where the discussant points out that the patient is treated using the American Heart Association (AHA) Advanced Cardiac Life Support ( ACLS) algorithm and needs electrical or medical cardioversion.

That is where things get tough for a psychiatrist.  Setting is a significant issue.  If I am working in an acute care setting in a hospital – I typically have plenty of back up.  Hospitalists services generally run codes or even have a team for acute care that does not involve codes and I could get them there in a few minutes.  At the other end of the spectrum -  I have worked in a community mental health center with absolutely no access to ECGs and no equipment for cardioversion.  In that case – 911 needs to be called and all medical staff in the facility should be able to perform basic cardiopulmonary resuscitation. 

The main work in this situation is recognizing the medical emergency and getting the patient to the correct setting where she can be stabilized. It is not always black and white.  This patient was eventually diagnosed with atrial fibrillation and Wolf-Parkinson White (WPW) syndrome.  Atrial fibrillation was probably the most frequent cardiac diagnosis that I made as a psychiatrist.  Most people who had it were not aware of it. I happened to pick it up because I noticed an irregularly irregular pulse when checking their vital signs and a pulse deficit on physical exam. It was almost always in a range where the heart rate was not a big problem.  In some cases, it was partially treated by a rate controlling medication like a beta-blocker or calcium channel blocker.  I could typically call the patient’s primary care physician and get them in for a comprehensive evaluation of the problem.  I would have to send some patients to the emergency department or urgent care.     

The issue of cardiac related anxiety is a very interesting issue. Cardiac symptoms can be an associated symptom of anxiety, panic, and other affects like anger.  The symptoms can arise as a sensory phenomenon due to an awareness that the heart is “pounding” or “beating out of my chest”.  Both of those descriptions are very common in people with panic attacks. The sequence of events and what is causing the cardiac phenomenon are wide ranging from an intrinsic cardiac problem to an imbalance in the sympathetic and parasympathetic innervation of the heart. Some electrophysiological experts think that at least some atrial fibrillation is due to overactivity of both autonomic systems.  Even in the absence of a sustained arrhythmias – the autonomic effects can result in premature atrial contractions, premature ventricular contractions, and sustained sinus tachycardia.

There are many other cardiac emergencies that occur in psychiatric settings. I was asked to see an acutely manic woman who was 85 years old.  She was extremely agitated and shouting that her chest hurt.  I was able to get a stat ECG that showed she was having a myocardial infarction and got her transferred to the coronary care unit.  In another case – I was told that a 70-year-old woman was “delusional” about her abdomen.  She clearly had a belief that there were supernatural forces causing her abdominal discomfort.  At the same time, she had a pulsatile mass in her lower abdomen and an abdominal aortic aneurysm on ultrasound.  Both patients survived with timely intervention.

I was a quality reviewer for many years and that job involved reviewing potential quality problems associated with inpatient hospitalizations.  One of those reviews was a patient who was hyperventilating.  He was diagnosed with panic attacks and treated with behavior therapy that did not seem to be effective.  As his condition worsened, he was eventually diagnosed with an acute pulmonary embolism. Since that review, I have seen many ambulatory patients who were short of breath for days due to pulmonary emboli and are not seen in a setting where they can be diagnosed and treated.

There are many more medical problems that crop up in psychiatric outpatients and inpatients that cannot be missed.  They can present as a possible psychiatric disorder and the potentially fatal nature of many mean they cannot be missed.  Many settings are set up to give the appearance that an emergency room physician, hospitalist, primary care physician, or physician extender is medically clearing these patients and that is not the case.  Most frequently that is because the time course of the condition is erratic or communication with a psychiatrist at a more detailed level is necessary.  The only assurance that these patients have no acute problems is if they are acutely symptomatic when they are screened or seeing a psychiatrist who can communicate with them, has no biases against them, and who knows the difference between a medical and a psychiatric problem.

To be very clear, I am not suggesting that psychiatrists initiate care for life threatening medical problems.  They do need to know if there are undiagnosed acute or chronic medical problems and how fast they need to be addressed. They need to be able to recognize the medical causes of signs and symptoms that can be misinterpreted as psychiatric.  They also need to recognize and manage the associated systems problems that in my experience are primarily countertransference driven.  Let me provide a clear example of what I mean.  I was working in an acute care setting and came across a patient leaning against a pool table. He was acutely short of breath, somnolent, and had a history of valvular heart disease. On exam, he was in congestive heart failure. I placed a call to the medical consultant and was told that I should start an IV line and manage the patient myself on an acute care psychiatric unit.  When I suggested that he needed transfer to medicine – I was met with the comment: “Well you know how to start an IV don’t you?”

I most certainly have started hundreds of IVs, but that is not the issue.  My patient had an acute medical problem that needed both medical and nursing expertise to manage in a more medical acute care setting than a psychiatric unit.  I eventually contacted the Chief of Medicine and got the patient transferred where he was subsequently in an ICU setting.  Ideally acute care psychiatrists today can develop good relationships with hospitalists for these kinds of transitions.  The best way to do that is by letting them know you have made a medical assessment and have a good indication for transfer.

Being a good if not great psychiatrist is hard work. My most significant worry was missing a major medical problem and not getting adequate intervention.  That is just the first step. The next steps are a psychiatric formulation, diagnosis, and treatment plan that incorporates state of the art communication and relationship building with the patient.  Hopefully that is followed by a long period of seeing the patient, helping them meet their goals, and providing medical diagnosis and follow up as needed.  In today’s world that is often occurring in a rationed suboptimal environment, overburdened by businesses rationing of both care and medication for profit.

My hat is off to the psychiatrists who are doing this work and probably working way too hard in 2025.

Happy New Year!

 

George Dawson, MD, DFAPA

Supplementary 1:  There is no doubt that I have practiced in settings where there was a high level of concurrent medical and in some cases surgical illness.  There is also no doubt that it was a conscious decision on my part to practice in those settings.  That undoubtedly sharpened my focus on making sure that I had the skills necessary to provide adequate care to those populations. It may be possible to cleanly partition psychiatric work from the rest of medicine but I have not seen that happen for some of the reasons cited in the above essay.  The training of psychiatrists in the past has had a variable relationship with medicine - at one point going to the extreme that much of the medical internship was eliminated.  The best advice I got in medical school was not to use elective time for additional psychiatry rotations because I would be doing psychiatry the rest of my life. I took neurology, neurosurgery, nephrology, endocrinology, cardiology, allergy and immunology, and infectious disease rotations instead. That initial training worked well over my years of practice and I don't regret it.

Some may question the emphasis in this post on the importance of not missing concurrent medical diagnoses and I would offer these additional observations.  Many patients seeing psychiatrists consider them to be their primary care physicians. That should not deter a psychiatrist from clarifying their role, but the fact that psychiatrist is probably seeing the patient much more often than the primary care physician is often a useful reality.  I have called primary care physicians to report what I consider to be an exacerbation of the patient's underlying medical problem.  That collaboration can get more timely care for acute or chronic medical problems.  I have also had the experience hearing from a person that a psychiatrist diagnosed their medical problem when nobody else did.  Many of these scenarios degenerate into who is the better physician.  The focus needs to be on what the patient needs rather than what the physician needs.  Not ignoring or missing a patient's underlying medical problems is a large part of that personalized care. 

 

Reference:

 1:  Hemingway TJ.  An athletic patient who thinks she has panic attacks.  Medscape December 17, 2024 (accessed on December 31, 2024):  https://reference.medscape.com/viewarticle/858516_6