Consultation-Liaison Psychiatry - Impact on Medical Practice

Early in my career in consultation-liaison (C-L) psychiatry, the opportunity to attend the American Psychiatric Meeting's 2001 Distinguished Psychiatrist Lecture by Professor Donald Kornfeld was particularly timely.

As one the founders of C-L psychiatry, Dr. Kornfeld gave an inspiring and erudite account of the field's many contributions to medical practice. As it is based on research primarily published in medical and surgical journals, many psychiatrists are unaware of the important role psychiatry has played in shaping medical practice.

Below some of the early contributions of C-L psychiatry will be highlighted; further elaborated in the recent publication of Dr. Kornfeld's lecture in the American Journal of Psychiatry (ref. 1).

Policy changes

C-L psychiatry research has led to numerous policy changes in medical practice . "Black patch delirium" was first coined by Weissman and Hackett in 1958 (ref. 2), after their observation that delirium post-cataract surgery was related to the sensory deprivation of bilateral patching.

Postoperative techniques have since been revised and careful attention to adequate sensory stimulation is now requisite in the management of any delirium.

Importance of sleep

The architectural design of hospital wards was also influenced by a seminal 1965 report by Kornfeld et al. identifying delirium risk factors (ref. 3). For example, the now standard provision of bedroom windows and clocks followed recommendations from this report.This same study led to lasting changes in nursing procedures, which have since been restructured to promote uninterrupted sleep.

The importance of sleep for medical trainees was also apparent to psychiatrists, who were the first to formally document the impact of sleep deprivation on the performance and psychological state of interns (ref. 4). A swift and sustained change in the on-call requirements of most training programs ensued.

Culture of medical practice

The education of medical trainees and colleagues by C-L psychiatrists has also had a profound influence on the culture of medical practice. Bibring (ref. 5), and later Groves (ref. 6) with his seminal "Taking care of the hateful patient" paper, provided common-sense recommendations in the management of the "difficult patient", which have since been incorporated as tacit principles.

While free of jargon, they used their dynamic understanding of different personality styles to bring meaning to difficult behaviour. The "biopsychosocial model", introduced by Engel in his 1977 Science publication (ref. 7), now forms the foundation for clinical teaching in medical schools.

Bridging the gap

These pioneers of medical psychiatry clearly responded to the integration of general hospitals and psychiatric units, bridging the former gap between medicine and psychiatry, and laying the foundation for the exciting collaborations that have ensued.

Active areas of collaborative clinical care and research now include cardiovascular illness, neuropsychiatry, transplantation psychiatry, end of life care and clinical ethics, to name a few.
The unique training and skills of psychiatrists enable astute observations in medical-surgical settings, which are then communicated in our liaison role to our colleagues in clear and simple terms. In so forth, we are in an ideal position to act as ambassadors for psychiatry and advocate for the human experience and narrative of patients.

Established psychiatric specialty

C-L psychiatry has visibly become an established psychiatric specialty, as evidenced by the American Board of Psychiatry and Neurology recommending it for formal subspecialty status. While it was founded in the USA, the model is now well established throughout the western world.

Recent international developments include the European Consultation-Liaison Workgroup (ECLW) (ref. 8), and the establishment of an international C-L database (ref. 9), living up to our nature of collaborating!

References

1. Kornfeld DS. Consultation-Liaison Psychiatry: Contributions to Medical Practice. American Journal of Psychiatry 2002; 159:1964-1972

2. Weissman AD, Hackett TP. Psychosis after eye surgery – establishment of a specific doctor-patient relationship in prevention and treatment of black patch delirium. New England Journal of Medicine 1958; 258:1284-1289

3. Kornfeld DS, Zimberg S, Malm JR. Psychiatric complications of open-heart surgery. New England Journal of Medicine 1965; 273:287-292

4. Friedman RG, Bigger TJ, Kornfeld DS. The intern and sleep loss. New England Journal of Medicine 1971; 285:201-203

5. Bibring GL. Psychiatry and medical practice in a general hospital. New England Journal of Medicine 1956; 254:366-372

6. Groves JE. Taking care of the hateful patient. New England Journal of Medicine 1978; 298:883-887

7. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136

8. Huyse FJ, Herzog T, Malt UF, Lobo A. The European Consultation-Liaison Workgroup (ECLW) Collaborative Study. I. General outline. General Hospital Psychiatry 1996; 18(1):44-55

9. Strain JJ, Campos-Rodenas R, Carvalho S et al. Further evolution of a literature database: the international use of a common software structure and methodology for the establishment of national consultation-liaison databases. General Hospital Psychiatry 1999; 21(6): 402-407