Mental Health Consult

Clinical Segment 4: You know more than you think about behavioral and mental health


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People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, an editorial board member for Clinical Psychiatry News, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Pickar: Let me just say one thing about that training issue and so forth. There is a common ground in primary care medicine and psychiatry and that is the patient. You guys in primary care, you know patients. We do not use – I use stethoscopes – to make me feel like an internist again.

However, we psychiatrists really do not have to.

Whitney: Is that like “I’m not a doctor but I play one on TV”?

Dr. Pickar: I do that one, too, but in fact the real first step of evidence-based medicine is the patient. You just described it beautifully. Sometimes, I feel badly if the primary physician does not give him or herself credit for that first line of clinical observation. It is huge. Affect is the feeling state. You observe the affect: “He looks down or agitated, anxious.” That is affect, whereas the symptoms are if he is feeling sad, feeling anxious. That is what you do for a living, you find out these things. You get that piece going. We know we psychiatrists are going to need help in that direction. The issue around reimbursement for psychiatry and so forth, I am going to take a deep breath on that one.

I have plenty of feelings about that, but I just want to make sure that the primary care physician that may be watching this understands that he or she is not just the first line but he or she has good skills at observing the first pass what is going on with a patient.

Dr. Norris: Not only are they the first line, but frequently, if you are the person the patient has the relationship with – Dr. Beard, Dr. Barbour – the patient is more inclined to listen to you than to just some random specialist you refer them to.

Dr. Pickar: On the other side of that, even when you have collaborated with a primary care doctor, and times are changing and the meds are tricky, I like to be able to talk to the primary care person and say “Look, I am thinking this way …” The primary doctor might say, “I saw them and they were not looking bad,” that is helpful to hear, or “Yeah, boy we need to ...” That is helpful.

Dr. Norris: Not just a digital note on a shared electronic medical records. Talk … dialogue. There is a difference. This is an important point, there is a difference between clinicians dialogue on a shared patient versus I am reading your notes and you are reading my notes. I do not consider that dialogue.

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