OR WAIT null SECS
Psychiatrists specialize in mental phenomena, but this special expertise does not confer license to ignore the additional information that can be gathered from physical signs.
“Good psychiatry begins with a responsible Doctor undressing the patient and carrying out a proper physical examination.”
-Pediatrician and psychoanalyst Donald Winnicott (quoted by Issroff1)
In one of his inimitable essays, Richard Asher tells of a patient whose retinitis pigmentosa was diagnosed by an ophthalmologist. The ophthalmologist's report concluded that the findings suggested the Laurence-Moon-Biedl syndrome. Was there, the ophthalmologist asked, any evidence of polydactyly? Asher comments bitingly that surely this is specialization run amok--can an eye doctor not count the patient's fingers?
Asher-among whose accomplishments were the description and naming of Munchausen syndrome-was an internist who specialized in psychological medicine. Behind his complaint was the assumption that we are all physicians first, specialists only afterward: “A good doctor should be a jack-of-all-trades and master of one.”2 The evaluation of the mental patient, from his perspective, was first the job of a physician. Should a physical examination be part of that job description?
Psychiatrists specialize in mental phenomena, but this special expertise does not confer license to ignore the additional information that can be gathered from physical signs. For example, delirium is well characterized in its psychological dimensions by psychiatric diagnostic manuals3 and commonly used rating scales.4,5 Unmentioned in these references is the near-pathognomonic status of asterixis in identifying a toxicmetabolic encephalopathy. Why would one think that as a psychiatrist one has no need of the techniques that are useful, indeed necessary, for other specialists-or perhaps the question is, why would one attempt to make a diagnosis with one hand tied behind one's back?
Psychiatric patients commonly suffer from general medical conditions; often these conditions affect or even produce the mental disorder.6 In formulating the psychopathologic condition and identifying its cause, why would one want to forgo tools that generations of physicians have found useful in the diagnostic endeavor?
For several decades, commentators have pointed out that psychiatrists endorse physical examinations more often than they perform them.7 Those who omit performing a physical examination offer several reasons. Concern about the psychological impact of the physical contact or intrusion is prominent. Lack of appropriate facilities for physical examination and lack of sufficient skill are mentioned.
Of course, psychiatrists must be concerned about the meaning of the physical examination to the patient. Under certain circumstances, to refrain from performing a physical examination may be wise. For example, imagine a patient referred by a trusted oncologist colleague. The patient, with a recent diagnosis of cancer, has been through the mill of consultations, examinations, and invasive investigations. The referral letter from the oncologist indicates the lack of cerebral disease in the staging evaluation. The patient's mental state gives no hint of an organic mental disorder; rather, the patient seems to be worn out by the process of becoming a cancer patient and to want to talk with someone about it. Such a person might do best to talk with a psychotherapist, who is not doing any physical poking and prodding. At least this judgment is one a reasonable clinician might make.
It is hard to understand, however, why giving a prescription for psychiatric medicine is less intrusive than looking at the rash the medicine may have caused or measuring the blood pressure the medicine may have altered. Indeed, the psychological impact of the physical examination-especially when few encounters with a psychiatrist are for exploratory psychotherapy based on understanding of the transference-may help rather than interfere with treatment.
Establishing oneself as a physician in the eyes of the patient-with the skills, the prerogatives, and certainly the responsibilities and professional abstinence that being a physician entails-can facilitate rapport and move the treatment along. Looking at or touching the affected body parts in a physically ill patient can bring those aspects of the patient's experience into the conversation.
Obviously, lack of skill in performing the examination merits concern. Unfortunately, this reason for not performing the examination is a self-fulfilling prophecy; one's skills will not improve sitting on the shelf. No one can expect that the psychiatrist will be as expert a cardiac examiner as the cardiologist, as expert an examiner of peripheral nerves as the neurologist. However, the objection overstates the difficulty of the examination. To be sure, subtleties and rarities may escape the psychiatrist, but auscultation of the heart may disclose an irregular rhythm audible to any physician. Examination may discover that tendon jerks are absent in the lower extremities, a conspicuous clue.
Taking the process seriously and improving with practice may be part of the remedy for a self-perceived lack of skill. Further, the psychiatrist should have the advantage over other examiners of having hypotheses in mind as to the organic conditions needing consideration in the particular psychiatric setting. Nonetheless, competent psychiatrists will know the limits of their competence and continue, when indicated, to make referrals for general medical evaluation of their patients.
Unavailability of suitable facilities hamstrings many potential examiners; administrators of psychiatric clinics should be brought to task about this. However, a great deal can be done even with a fully dressed patient seated in a chair opposite an examiner equipped only with knowledge. For example, Table 1 suggests a few relevant steps to take if alcohol abuse is part of the clinical picture. Is this a comprehensive physical examination? No. Should one rest content after this screening assessment? No. But for what reason would one do nothing?
An ordered examination
In my view, an undeclared reason for clinicians' discomfort is the failure of teachers of psychiatry to shape the key elements of the physical examination into a tool sharpened for psychiatric purposes. Statements in psychiatric textbooks such as “All patients presenting with 'psychiatric' symptoms require a careful and complete physical examination” do not go far enough.8
No practical examination includes all possible elements; moreover, an examination should be undertaken with a set of hypotheses to be explored and confirmed or refuted. It goes without saying that any element of a comprehensive examination may, in a given patient, be informative or even crucial. However, just as other specialties home in on the elements of the comprehensive examination critical for diagnosis with their patients, so should psychiatrists be able to choose from among the tools in the toolbox those most relevant for psychiatric patients.
Psychiatrists may well use laboratory testing to screen for general medical illness, but ordering laboratory tests without guidance from the history and physical examination is widely and rightly deplored. Again, any element of the medical history is potentially pertinent in a given patient, but one cannot ask everyone about everything as a screening technique. In recent years, several clinicians have offered advice on focused history taking and psychiatric physical examinations. Sanders and Keshavan9 outlined an approach to the physical examination of the psychiatric patient, as did Garden.10 I also provided a review of physical diagnosis of the psychiatric patient.11
The use of the physical examination as a diagnostic tool for the recognition of organic factors in mental disorders is not the only reason to concern oneself with physical diagnosis. As psychiatrists, we often see patients who lack the social skills and material resources to obtain adequate general medical care. Such patients have a substantial rate of significant general medical disorders.12 We need to ensure their access to proper care, not only by advocacy and social work measures but also by functioning as physicians, even if the disorders in question are incidental to the psychiatric illness (in the sense that they are not causing organic psychopathology).
Furthermore, we may make our patients sick with the medicines we prescribe. The current, justified concern over the metabolic effects of psychotropic drugs in itself should force reconsideration of the appropriate general medical role of the psychiatrist. The metabolic syndrome has had several definitions; its elements are listed in Table 2. Consensus guidelines for management of patients taking atypical antipsychotic agents now call for frequent measurement of weight, blood pressure, and waist circumference.13 How the implementation of such recommendations will affect the process of care in general psychiatry deserves thought.14 A practice set up to meet these needs might feature the psychiatrist in a rather different position from what is now customary.
Dr Ovsiew is professor of psychiatry at the University of Chicago, medical director of adult inpatient psychiatry and chief of clinical neuropsychiatry at the University of Chicago Hospitals; he is also president-elect of the American Neuropsychiatric Association. He has no conflicts to report regarding the subject matter of this article.
1. Issroff J. Winnicott and Bowlby: personal reminiscences. In: Issroff J, ed. Winnicott and Bowlby: Personal and Professional Perspectives. London: H. Karnac Books; 2005:13-69.
2. Asher R. The seven sins of medicine . In: Avery Jones F, ed. Richard Asher Talking Sense. London: Pitman Books; 1972:70-76.
3. American Psychiatric Association Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington, DC: American Psychiatric Association; 1994.
4. Gonzalez M, de Pablo J, Fuente E, et al. Instrument for detection of delirium in general hospitals: adaptation of the confusion assessment method. Psychosomatics. 2004;45:426-431.
5. Trzepacz PT, Mittal D, Torres R, et al. Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci. 2001;13:229-242.
6. Yates BL, Koran LM. Epidemiology and recognition of neuropsychiatric disorders in mental health settings. In: Osview F, ed. Neuropsychiatry and Mental Health Services. Washington, DC: American Psychiatric Press; 1999:23-46.
7. McIntyre JS, Romano J. Is there a stethoscope in the house (and is it used)? Arch Gen Psychiatry. 1977;34:1147-1151.
8. Tasman A, Kay J, Lieberman JA. Psychiatry. Philadelphia: WB Saunders; 1997:540.
9. Sanders RD, Keshavan MS. Physical and neurologic examinations in neuropsychiatry. Semin Clin Neuropsychiatry. 2002;7:18-29.
10. Garden G. Physical examination in psychiatric practice. Adv Psychiatr Treat. 2005;11:142-149.
11. Ovsiew F. Neuropsychiatric physical diagnosis in context. In: Yudofsky SC, Kim HF, eds. Neuropsychiatric Assessment. Washington, DC: American Psychiatric Publishing; 2004:1-38.
12. Jones DR, Macias C, Barreira PJ, et al. Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatr Serv. 2004;55:1250-1257.
13. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004;27:596-601.
14. Marder SR, Essock SM, Miller AL, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry. 2004;161:1334-1349.
15. Reisin E, Alpert MA. Definition of the metabolic syndrome: current proposals and controversies. Am J Med Sci. 2005;330:269-272.