Hospitalists began branching out from traditional general medical wards into specialized fields such as cardiology and oncology many years ago. One of the latest evolutions in hospital medicine is the expansion into behavioral health. By providing medical care to individuals with mental health conditions, hospitalists help bridge the gap between physical and psychiatric services, fostering a more comprehensive approach to patient care.
Similar to their role on a general medical ward, a hospitalist in a behavioral health center is responsible for evaluating acute medical issues such as fevers and incidental lab abnormalities (e.g., abnormal thyroid and liver function testing), managing chronic conditions such as diabetes, and responding to emergencies, including rapid responses and codes when necessary. The essential distinction is that within a psychiatric unit, the hospitalist functions in a consultant role rather than as the primary managing practitioner.
Adapting to the behavioral health setting presents hospitalists with a unique set of challenges. Entering this “subspecialty,” if you will, may require some additional training and a mindful approach. To navigate this transition successfully, here are some fundamental considerations:
Training
Check with administration or human resources to see if your center offers safety training courses, especially those addressing workplace violence, crisis prevention, and de-escalation techniques.
Stay current with basic cardiac life support and advanced cardiac life support certifications, and whenever possible, take part in rapid response team workshops. As you may be the only medical professional on-site, you could be single-handedly responsible for managing emergencies, making thorough preparation essential. Familiarize yourself with the contents of the code cart, as the available medications may differ from those stocked on a general medical floor and could be much more limited.
Hospitalists should consider becoming proficient in procedures traditionally performed by nursing staff, such as administering intramuscular epinephrine and intranasal naloxone.
Preparing for the Patient Encounter
Review the patient’s chart to familiarize yourself with their medical history and also to understand their psychosocial background. For example, does the patient have a history of violence or intermittent explosive disorder? Having a complete patient overview may help you make an accurate medical diagnosis and help ensure a safe encounter.
Participating in daily interdisciplinary team rounds is highly beneficial. Here, hospitalists are often called upon to provide aftercare recommendations for discharge planning. Also, these huddles provide real-time updates on patient conditions, including changes in mood and any overnight incidents such as outbursts. Interdisciplinary team rounds additionally offer insight into broader institutional matters, such as staffing shortages, pest infestations, and outbreaks of infectious diseases, like COVID-19.
Be strategic with coordinating the timing of your patient visit, as patients have an active and structured day. Availability to see the patient may be limited, as patients are busy with group or individual therapy, art and music therapy, visitation hours, etc. To maximize the patient’s psychiatric treatment, it is preferable that one does not interrupt the flow of their set schedule.
Familiarize yourself with the medical resources available on-site. A psychiatric ward or hospital may have limited medical capabilities, so it’s crucial to understand what is accessible. Are blood draws offered, and if so, how frequently, and with what turnaround time for results? Are X-rays available, and if so, what types are available (e.g., a chest versus a joint X-ray)? Are intravenous fluids or medications possible, or are treatments limited to oral, intramuscular, and subcutaneous route options? Are physical therapists available? If consultants are available, are they on-site, and how often do they rotate through? Or is consultation provided strictly via telemedicine?
The Patient Encounter
Prepare to manage a younger patient demographic with a higher prevalence of primary care concerns. You may be called to evaluate conditions such as rashes, positive rapid plasma reagin and other possible sexually transmitted disease tests, skin and soft tissue infections, otitis media, essential hypertension, musculoskeletal pain, and migraines, often at a greater frequency than on a traditional medical ward.
Patients may require care due to infestations (e.g., bedbugs, scabies, lice), trauma, or injuries secondary to violence. Learning to manage basic wounds and suturing can help prevent emergency room visits for patients, which can interrupt their psychiatric care and be costly from an administrative perspective.
Encounters may be challenging as histories may be unreliable or incomplete. The patient may simply be unable to provide a full history due to factors such as psychosis, catatonia, depression, schizophrenia, or antisocial personality disorder. As verbal communication and engagement may be limited, a comprehensive physical exam becomes essential, provided the patient is calm and cooperative.
The Work-Up and Treatment Plan
Tease out the diagnosis by considering whether the etiology is primarily medical, psychiatric, related to substance abuse or withdrawal, due to neurological impairment, or the result of a traumatic brain injury. Prepare a broad differential diagnosis list that encompasses all these topics. For instance, when a patient presents with psychosis and transaminitis, consider whether these symptoms point to delirium tremens from alcohol withdrawal or if the psychosis is masking Wilson disease or porphyria. Some cases, such as unexplained weight loss, may be multifactorial, as diagnostic overlap is common; a patient might present with psychogenic nonepileptic seizures coexisting with epilepsy, for example.
Psychiatric medications are potent agents with the potential for significant side effects. Illnesses may be secondary to the psychiatric medications themselves, some examples being clozapine-induced constipation and myocarditis or olanzapine-related transaminitis (drug-induced liver injury, or DILI).
Be prepared for drug-drug interactions that could have substantial clinical implications. For example, rifampin may decrease the effectiveness of risperidone. Discussion surrounding this topic has recently intensified with the market introduction of Paxlovid for COVID-19 treatment, primarily due to its potential interactions with various psychiatric medications.
Recognize that non-adherence may complicate clinical decision-making. Being called for diabetic management is common. However, this may be challenging if the patient declines fingerstick checks and medications. Develop a lower threshold to offer medications via an oral route when feasible, rather than intravenous or subcutaneous routes, in the hopes of improving patient compliance. Gaining expertise in the oral management of diabetes is highly relevant.
Understand you may be called for some psychiatry-specific scenarios, such as optimizing a patient before electroconvulsive therapy, or ECT, or evaluating the risks and benefits of initiating antipsychotic medication in a patient with a preexisting prolonged QTc.
Appreciate that the patient is at a behavioral health facility for a reason. The hospitalist’s role is to evaluate a medical concern, determine its severity, and determine how urgently attention is needed. Can the patient’s issue be completely addressed at the psychiatric facility? If not, can the issue be handled safely down the line via an outpatient primary care practitioner visit? Or does the patient need an urgent transfer to a medical facility? The hospitalist’s role is to help minimize institutional transfers and admissions, with the principal goal being to preserve the continuity of the psychiatric treatment plan when possible.
Overall Systems Navigation
Become familiar with your center’s infection control policies. Does the facility have an isolation room if needed? Will the patient be allowed to remain at the center if they are unable to participate in group, art, or music therapy or eat in the communal dining hall due to the isolation? If a patient needs to be isolated, what is the plan if the patient is non-adherent to staying in their room? If a provider has to wear personal protective equipment, how is that equipment to be discarded, as disposable stethoscopes and such may be misused as weapons?
Serving the community, it is inevitable that you will encounter a patient who is an acquaintance, friend, or even a family member. Navigating this delicately and always being mindful of HIPAA regulations is a trickier path than on a general medical floor.
On the topic of HIPAA, maintain a heightened sensitivity to the confidentiality related to mental health. Even calling an outpatient provider in order to obtain prior medical records and saying you are calling from a behavioral health center may feel like a slippery slope of disclosure. Sharing our approach, we reference the broader names of our overseeing institutions, such as Mount Sinai and Cornell/NYP, respectively, rather than divulging the names of our psychiatric centers. This method promotes discretion.
Like past hospitalist innovations that have transformed realms such as cardiology and oncology, hospitalist integration into behavioral health promises to bring the same high-level interdisciplinary care now to psychiatric patients. Utilizing the toolbox outlined above, hospitalists can seamlessly transition into the behavioral health arena.
Dr. Grabscheid
Dr. Faour
Dr. Grabscheid is a senior academic hospitalist at Mount Sinai Behavioral Health Center and a professor of medicine at the Icahn School of Medicine at Mount Sinai, both in New York. Dr. Faour is a hospitalist at New York Presbyterian Medical Group and Gracie Square Hospital, both in New York.
