Thursday, March 29, 2007

Reason for consult: "This patient is driving me crazy"

I've just finished my last rotation of medical school. Half of it involved working on a psychiatry consult team, which was a new experience for me.

Consult teams are a big part of how big academic hospitals work; when your primary team calls in an expert to consult, your team is "calling a consult." And I found last month that a common reason to call a psychiatry consult can be summed up as "This patient is driving me crazy!"– expressed in more technical terms, of course. Some of the consult team wryly referred to these as "staff distress consults."

One version of the "this patient is driving me crazy" consult is often the question of capacity. Capacity is determined by doctors – mainly, psychiatrists. They decide whether you have the ability (and therefore the right) to make decisions about your own health care. This is one place where your right to autonomy can be taken from you: the law assumes that to be autonomous you need to have the cognitive capacity to make autonomous decisions. Reasonable enough, but obviously there's a lot of wiggle room in how you define that capacity, and who decides whether you have it.

Competence is the legal term; if you do not have capacity, a court can declare you to be not competent. If you're not competent, the court will require you to have a guardian to represent your interests – and if no one is immediately available or your family is arguing about who should do it, the court can appoint a guardian. If you google "capacity" and "competence" together, you'll get a set of instructions for residents from one institution about how to approach this issue. It rightly instructs doctors to evaluate capacity even when the patient agrees with their recommendations.

But I can't remember ever seeing a consult like that. In my limited experience, capacity most often gets evaluated when a patient disagrees with the doctor for what the doctor thinks are wacky reasons, and can't be budged: thus, the "this patient is driving me crazy!" undertone. A common variant: "The patient doesn't want surgery which I have told her she needs, and the fact that I can't just tell her what to do is driving me crazy."

When the patient agrees, even if they have completely cuckoo-for-cocoa-puffs reasons for agreeing, the doctor is more likely to feel that the patient has the capacity to make medical decisions, because the patient is making a good decision; that is, the patient is making the decision that the doctor has already decided.

Hospitals concerned about quality and patient dignity should evaluate the purpose of capacity consults, to establish the ratio of calls for a capacity evaluation of patients who disagree with their doctor, versus patients who agree. If capacity evaluations were being conducted appropriately, the ratio should be around 1:1. It doesn't take long working on a psychiatric consult service to think that a 1:1 ratio seems impossibly utopian. But it would be good to try.

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