In 2019, I accepted a position at the University of Rochester’s Strong Memorial Hospital in Rochester, N.Y. I knew this wouldn’t be bread-and-butter hospital medicine, but rather a unique hospitalist role in inpatient medicine in psychiatry; a medical-psychiatric unit where the majority of patients carry diagnoses of serious and persistent mental illness (SPMI). It’s a road less traveled, owing largely to the paucity of such units in U.S. hospitals.
The experience has been one of personal and professional growth. Like many internists, my primary exposure to patients with SPMI (major depression, bipolar disorders, schizophrenia, and borderline personality disorder) had occurred during the psychiatry clerkship in medical school, followed by sporadic encounters in residency, during which the mental-health diagnosis most often took a backseat to the acute medical problem.
Now, I spend my days surrounded by catatonia and clozapine; haloperidol and hallucinations; benztropine and benzodiazepines. The practice of providing medical care for people with psychiatric conditions simply wasn’t part of my prior medical training, and thus I learned it on the job. Having now developed a level of comfort, and a better understanding of the patients and the practice, I seek to share some of the pearls I’ve gathered along the way.
One fact I didn’t appreciate early in my training, but that has become much clearer as I’ve spent more time with psychiatrists, is the reality that people with psychotic disorders, even on optimal therapy and without positive symptoms of schizophrenia, are likely still to possess negative symptoms, often including a degree of paranoia and mistrust that can make providing medical care more challenging, even if they may not need acute psychiatric care.
It’s worth noting this mistrust may arise as much from historically unfavorable interactions with the health care system as from psychopathology. This means building trust and forging a therapeutic partnership tends to require more time and effort than in the general population. Therefore, one of the benefits of operating a medical-psychiatric unit that endeavors to care for SPMI inpatients whenever possible is a level of continuity that for some patients and clinicians approaches what’s found in primary care.
The approaches I’ve found most fruitful working with patients with psychotic disorders are those that I already strive for with other patients, but benefit from greater emphasis—listening, meeting someone “where they are,” respecting autonomy, and reducing unnecessary interventions. Understanding how, for instance, a schizophrenic patient sees and interacts with the world is very important if you are to reach them therapeutically. This requires patience and may not be accomplished in a single visit. Obtaining collateral information from family and other contacts is highly recommended.
Deftly setting the stage for interaction with the patient is beneficial; presenting as polite, respectful, and unhurried can put patients at ease. I usually knock or otherwise announce myself before entering the room (the response to this will often be your first clue as to how receptive a patient is likely to be), provide at least a warning if a light is to be switched on, and sit down if a chair is available.
The building of trust starts early in the interaction; it’s best to start open-ended and patient-centered (e.g., “How can I help you today?”) without a hint of agenda. While many patients have priorities that differ from those of their physician, you may find that phenomenon to be particularly pronounced in this population. Addressing their chief concern will increase the likelihood that you’ll be listened to later. You are likely to find that even if you’re as patient-centered as possible, your patient may still decline medications and other interventions. In these cases, it is first crucial to understand why, as explanation and clarification may be effective.
If you find an interaction isn’t productive, sometimes returning at another time is useful. Often, declining care can be a patient’s means of communicating they’re feeling overwhelmed and need more time to process. If so, being flexible and offering medications and interventions multiple times throughout the day can prove successful. Of course, this requires buy-in from nursing and other members of the team. I’ve found that flexibility and teamwork are assets. Can the timing of medication administration be relaxed? Is it feasible to reduce the pharmaceutical burden to discontinue that which is relatively less important? What is your Plan B? A secondary plan that can be adhered to is universally preferable to a primary plan that empirically cannot. Formulating this secondary plan, of course, may necessitate participation by consulting services and may benefit from direct physician-to-physician communication in higher-complexity cases.
While psychotic disorders often respond readily to medication, not all psychiatric disorders do the same; certainly, few diagnoses color our preconceptions quite as vividly as borderline personality disorder. Marked by emotional volatility and instability of relationships, such patients may have a history of difficult interactions with health care professionals.
It’s important to exercise insight into your own biases and emotional responses before you even set foot in the room; countertransference (transferring your emotions to the patient) will be the physician’s undoing. Clarity and consistency of communication and expectations are essential. This applies to patient interactions as well as to handoffs to other team members. Further, to mitigate the possibility of splitting (viewing individuals exclusively positively or negatively), rounding as a team is advisable (e.g., attending physician, advanced practice practitioner or resident, and bedside nurse) whenever practical.
The clinician needs to understand that while the behavior of a patient with borderline personality disorder may feel manipulative or vindictive, its motivation doesn’t generally rise to conscious awareness. Being aware that an observer’s perception of the patient’s actions is often not congruent with the patient’s intention can be a powerful tool in managing your emotional response to the interaction, and, indeed, a dispassionate approach will prove most efficacious and therapeutic for all parties.
All that being said, there will be times when a patient’s behavioral dysregulation will render an encounter unproductive or even counterproductive. In these instances, it’s necessary to set boundaries and terminate the encounter. The clinician can then return later when the patient is calm and amenable to continue the conversation.
In caring for patients with SPMI, it’s natural for the clinician to experience discomfort or disorientation. You may be tempted to attribute these sensations primarily to the patient. On the contrary, I’ve found these interactions have been ruthlessly revealing of growth opportunities in my own practice style; much of the discomfort is internally attributable. Bedside manner, patient-centeredness, and clear and consistent communication with patients, family, and other health care team members are less desirable than they are absolutely essential in this setting. I owe my patients a debt of gratitude for having shaped me into a better physician. I am privileged to have gained as much as I have given.
Dr. Bobeda is an assistant professor of psychiatry and medicine at the University of Rochester in Rochester, N.Y., and practices hospital medicine within the department of psychiatry, division of medicine in psychiatry services at Strong Memorial Hospital in Rochester, N.Y.