do you ever perform physical exams?

[EFesta77]

i'm a third year getting ready to apply for psych. i feel like the one thing i will miss is performing physical exams. the psychiatrists at my school's main hospital never perform exams, and i feel like this is a mistake. while i was on medicine we had a patient come down from the psych unit that was short of breath. the woman had a heart murmur that was so loud that you could here it in her abdomen. my 12 year old cousin could have recognized this was an abnormal heart sound. it turned out to be severe aortic stenosis. after the echo, cardio said this valve has to be replaced pronto. the CT surgeon went in the room and walked right out stating, "she is crazy, i told her what needs to be done, and that's all im gonna do." no one took the time to try to talk with this poor woman (she was schizophrenic). so my medicine attending was like, "send her back to psych"....where she dropped dead a week later at the age of 62. this was really troubling to me. i feel like this patient was basically an afterthought for most of the attendings.
the take home for me was: i'm going to do physical exams on my patients even if i am a psychiatrist. this woman didn't have to die this way. her AS could have been picked up long ago by psych since she was in and out of the hospital so many times over the years.

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[OldPsychDoc]

There are a couple of different aspects to your post that deserve comment.

First off, in this case the surgeon was fairly callous, and I'm amazed that no one asked for a psych consult for competency, tried to establish a proxy decision-maker, etc. But it illustrates vividly how vulnerable our patients are. Some studies indicate that having severe, persistent mental illness such as schizophrenia reduces life expectancy by as much as 25 years. That's a LOT of mortality and morbidity, and we as psychiatrists are often the first to see it.

So next--do I do physical exams? No. And I don't miss it. I can still be a doctor who makes sure that medical issues are attended to (by a consultant FP attached to our service, or calling a consult), or, for my outpatients, coordinating care with a PCP. But in the realm of personality disorders and psychosis, having a patient get gowned and touching them in places not normally visible--I think raises a lot of boundary confusion. I think that it's important to make it clear that I am here to examine and treat their mental status, not check out their groin rash. I do do some brief neuro exams myself, and I think that that is within the bounds. My nurses check weights and VSs, and I'm always asking patients, in- and out-, how their medical health is doing. Our inpatients always have a physical exam and labs, and I spend a lot of time chasing medical comorbidities, but it is not necessary that I personally reconfirm that exam, and frankly, I really got enough of that as an intern. So I haven't forgoten that I'm a "real doctor", but the days of doing a full PE are done for me for the time being at least.

 

[EFesta77]

There are a couple of different aspects to your post that deserve comment.

First off, in this case the surgeon was fairly callous, and I'm amazed that no one asked for a psych consult for competency, tried to establish a proxy decision-maker, etc. But it illustrates vividly how vulnerable our patients are. Some studies indicate that having severe, persistent mental illness such as schizophrenia reduces life expectancy by as much as 25 years. That's a LOT of mortality and morbidity, and we as psychiatrists are often the first to see it.

So next--do I do physical exams? No. And I don't miss it. I can still be a doctor who makes sure that medical issues are attended to (by a consultant FP attached to our service, or calling a consult), or, for my outpatients, coordinating care with a PCP. But in the realm of personality disorders and psychosis, having a patient get gowned and touching them in places not normally visible--I think raises a lot of boundary confusion. I think that it's important to make it clear that I am here to examine and treat their mental status, not check out their groin rash. I do do some brief neuro exams myself, and I think that that is within the bounds. My nurses check weights and VSs, and I'm always asking patients, in- and out-, how their medical health is doing. Our inpatients always have a physical exam and labs, and I spend a lot of time chasing medical comorbidities, but it is not necessary that I personally reconfirm that exam, and frankly, I really got enough of that as an intern. So I haven't forgoten that I'm a "real doctor", but the days of doing a full PE are done for me for the time being at least.

I agree with all of your points. I guess I was just venting my frustration over that patient's death. The promise I'll try to make to myself is that if I am going to consult medicine for something (i.e. CHF) on an inpatient service, I'll at least give a quick listen to the lungs and heart

 

[Solideliquid]

Several things, first of all even if the psychiatrists on the unit performed a PE on this lady every day that in itself wouldn't have gotten her into surgery, nor would it have persuaded the surgeons to treat her any different.

I think as OPD is saying, this lady probably didn't understand or grasp the severity of her condition nor did she likely understand the procedures involved. We don't know enough about the case, for instance did she refuse treatment or did she not have capacity to make a decision?

Lastly, we don't know if the aortic stenosis was the cause of death, it may have been something unrelated to this particular condition. Basically psych did the right thing in calling for a consult/transferring the patient for treatment of her SOB. I wouldn't have taken her back onto the psych floor before these concerns were addressed however, except in the rare case that the patient was found to have capacity and still did not agree to have treatment.