Liaison News
The newsletter of the Liaison Faculty
Summer 2006
Comment
Please accept my apologies for the somewhat belated arrival of
this newsletter. The only excuse is one of too many
commitments.
As mentioned in the previous newsletter, liaison psychiatry
continues to experience uncertain times. The advent of payment by
results (PBR) in the acute sector has brought additional threats to
some services. The Government intends to extend PBR to mental
health services. They acknowledge, in a recent briefing document,
that this has never been tried before anywhere in the world. It
appears that this is seen as a good reason to proceed as soon as
possible. Inspires confidence, doesn’t it? I understand, however,
that the timescale has recently been put back a year. The reason
that all this is relevant to liaison psychiatry is that the initial
work on PBR for mental health appears to have completely ignored
the type of work that we do in liaison psychiatry. Efforts are now
being made, by the faculty executive and others, to try to redress
this. We have been invited to prepare a document for the groups
doing the work on mental health PBR regarding liaison psychiatry
work. If any member has any information that would be useful,
please contact Else Guthrie (elspeth.a.guthrie@man.ac.uk) or Mel
Temple (melanie.temple@cddps.northy.nhs.uk).
College news
CCTs
Over the summer, and after heated debate, the College decided to
recommend that the number of CCTs in psychiatry should be changed.
Currently the number of CCTs in psychiatry is six, with the option
of one of three endorsements to a CCT in General Adult Psychiatry.
The current system is becoming increasingly anomalous, with the
growth of sub-specialities that could argue a reasonable case for
their own CCT or endorsement. The endorsement system is also
anomalous: liaison psychiatry is no more a branch of general adult
psychiatry than it is a branch of old age psychiatry or child
psychiatry. For these reasons and others, the College has
recommended that there should be one CCT, in Psychiatry, with
sub-speciality recognition. This is a system that is working well
in other branches of medicine. It is anticipated that someone
gaining a CCT under the new system will have a certificate that
will include their sub-speciality qualification in brackets eg:
“Psychiatry (Old Age and Liaison)”. It will apparently not be
possible to get a generic CCT: everyone will have to have the
brackets! Don’t expect this new system to be introduced quickly:
the change will require an alteration in European law.
Changes in psychiatric training
Most members will be aware of the changes that are taking place
in all medical training, including psychiatric training.
Responsibility for postgraduate medical education (curricula,
quality, approval of schemes, etc.) has passed from the Royal
Colleges to the PMETB. At roughly the same time, the structure of
medical education is undergoing swingeing change with the onset of
MMC. It is possible (or, more likely, probable) that some of the
political drive behind these changes was a wish to reduce the
perceived power of the Royal Colleges. In practice, both these new
bodies have required massive input from the colleges. All Royal
Colleges have been inundated with requests for help, advice,
information, and to do massive pieces of work (eg writing
curricula), very often with short deadlines. In response to all the
changes, our College has completely changed its structures dealing
with education. The committee with overall responsibility for
education will be the Education, Training and Standards Committee.
This committee will be responsible to the Central Executive
Committee of the College (I know that this sounds a bit Stalinist,
but that’s what it is called), and the ETSC will be chaired by the
Dean. There will be bodies reporting to that committee with
responsibilities for such fields as exams, CPD, the curriculum,
etc. Each faculty has been asked to form its own Faculty Education
Committee. This is a welcome development, as previously the
faculties had little direct influence on training, apart from on
quality of training schemes.
Faculty news
Having been invited to do so, the faculty has formed its own
education committee. The first meeting of this committee will be in
September, prior to the meeting of the faculty executive. We hope
to be hearing news about how this venture is progressing.
SAS doctors in liaison psychiatry
There has been some concern expressed that the faculty executive
has not sufficiently considered the needs of doctors in
non-training grades. This is an area that has probably been
neglected in the past, an error of omission rather than commission.
Dr Jagoo Jagdish has been a member of the faculty executive for
about a year, and we hope that, with his assistance, we can start
addressing the needs of this group of liaison psychiatrists. He has
contributed the following statement:
It is my privilege to be a member of the executive committee,
Faculty of Liaison Psychiatry (starting summer 2005). I have been
able to attend most of the meetings held in London and also the
recent annual meeting at Liverpool. It gave me opportunity to meet
some of the colleagues and the work and the working. After going to
the meetings I realised that all the planning, policies and
discussions, have been centered around present consultants and
trainees (future consultants). When I introduced myself to the
committee it seems that some of the colleagues didn’t know about
affiliates/SAS grade. Not every hospital has a liaison
psychiatrist. In the absence of a liaison consultant/team, work is
carried out/ service is provided by an affiliate/ SAS grade doctors
but his/her role is not recognised. I would do my best to raise
affiliates profile. First step is to meet as a group, discuss what
they think about their role and what future holds in NHS. If there
are any difficulties what one can do about it. There is annual
conference for the trainees and new consultants (TNC) but not for
the affiliates/SAS grade. In the most recent faculty executive
meeting on 13th June I expressed my interest to organise a
seminar/meeting for affiliates/SAS doctors. Faculty members have
been very supportive of the idea and proposed to discuss with the
TNC to find if they would invite affiliates/ SAS doctors to their
conference, and involve them in their other activities. Failing
that I intend to hold a seminar/conference in 2007.
Jagoo Jagdish
Conference reports
EUROPEAN ASSOCIATION FOR CONSULTATION LIAISON PSYCHIATRY AND
PSYCHOSOMATICS (EACLPP) ANNUAL MEETING, HELD IN LAUSANNE, 15-17TH
JUNE 2006
EACLPP has now been well established for more than seven years.
Originally developing from the ECLW project, the meeting continues
to grow and is an excellent opportunity for liaison psychiatrists
from all European countries (and further afield!) to meet to review
recent research and clinical developments. The annual meeting has a
lively format and includes lectures, debates, workshops,
round-table discussions, ‘Meet the Expert’ sessions, clinical case
reviews and research presentations. Perhaps the most entertaining
section of the programme is the annual update given by
representatives of all the member countries.
At the Lausanne meeting, there were a total of 176 delegates
from the following countries : Norway, Great Britain, Saudi Arabia,
Portugal, Italy, Belgium, Denmark, Russia, Switzerland, France, The
Netherlands, Hungary, USA, Australia, Germany, Singapore, Turkey,
Canada, Iran, Spain, Greece, Austria and Croatia.
Remarkably similar issues are faced by most of the member
countries of the EU. In Austria a new health plan is creating
challenges, but the ambition is to have a consultation-liaison team
in every hospital in the country. The Austrians are also running a
national training course. In Belgium there are very significant
problems with finance, in that consultation-liaison psychiatry
simply does not pay, and liaison psychiatrists have to ‘moonlight’
in other jobs. A bid is being put to the Belgium Government seeking
further support. In Denmark only around 35% of hospitals have a CL
service, but an additional 30% are seeking to extend their
services. At present the Danish organisation has no curriculum, no
guidelines and no compulsory training in liaison. In France,
liaison psychiatry is growing slowly but is not a recognised
sub-specialty. The German association is progressing well and had a
major meeting in May 06 in Nuremberg. The DRG approach to health
reimbursement is causing problems but a major project is being
undertaken on this. A curriculum for liaison psychiatry has been
accepted by the German Psychiatric Association and board
certification is now achieved. The Germans also have a new journal
entitled Psychosomatics and Consultation Liaison Psychiatry,
published by Springer.
In Italy the national liaison society are very active but have
identified weaknesses in funding for liaison. They remain keen to
improve standards, and will host the next meeting of EACLPP from
27th – 29th September 2007 in Milan. In the Netherlands the
Diagnostic Related Groups (DRG) reimbursement system now includes
consultation-liaison psychiatry codes, and this has led to an
increase in the number of Psych-Med units. The Dutch also have a
national CL course. In Spain the number of CL units is also growing
as is the number of referrals, but there is no equity in that only
around 50% of hospitals have a service. There is also controversy
within the Spanish Psychiatric Association about whether CL
psychiatry should be involved in the emergency room and in primary
care. The Swedish CL Association was formed in 1992 and has
approximately 35 members (the population of Sweden is 9 million).
In Sweden there has been a reduction in hospital-based psychiatry
with general movement to the community and this has created some
difficulties. Services lack strong organisational backup. The
Swedish group are active in research but have little in the way of
training programmes. The Swiss CL Society was recently formed and
is aiming to develop a structured curriculum. There is some growth
in CL staffing within Switzerland.
The report from Turkey highlighted that, following the
establishment of the first CL unit in Istanbul in 1989, liaison
psychiatry became a distinct academic branch of psychiatry in 1997
and is now awaiting recognition as a sub-specialty. There is
support from the Turkish Government for services in general
hospitals that have 50 beds or more, and acceptance that liaison
should be part of the psychiatry residency programme. The Turkish
Association has being having a national CL Congress since 1990 and
it is estimated that between a quarter and one third of all Turkish
psychiatrists work in the general hospital. The Association is
focusing on development work in primary care.
A final important piece of work completed by EACLPP recently is
the development of a report on training in liaison psychiatry
across Europe. The EACLPP Committee suggests that this would be a
useful guide for the College Liaison Faculty Education Committee to
base its recommendations on. Clearly it is important that the
distinctive UK voice of liaison psychiatry is heard within EACLPP
and there are opportunities for members to get involved in a
variety of ways. The EACLPP is very keen to obtain more members,
particularly from the UK. When the organisation was initially
established it was difficult to organise payment of subscriptions
across all the countries, but the establishment of a secretariat in
Manchester has now solved this difficulty, and anyone interested is
encouraged to look on the eaclp.org website.
Rob Peveler
Southampton
EACLPP 2006 meeting: an SpR’s perspective
The 9th annual meeting of the European Association of
Consultation Liaison Psychiatry and Psychosomatics was held in
Lausanne, Switzerland from 15th – 17th June, 2006. The seed of what
was to evolve into a plan to attend this conference was probably
sewn last winter (somewhere in Sheffield) when the prospect of
‘conferencing’ on the shores of Lake Geneva in mid-June had held
obvious appeal. We were mildly surprised, though, by the relatively
thin British representation at the conference. We certainly were
the only British SpRs among the delegates.
From every point of view, the decision to attend this conference
proved to be extremely well judged. Excellent speakers, from both
sides of the Atlantic, brought an impressive range of expertise.
Delegates attended from much further afield. The location really
could not have been improved upon and the timetable was sensitive
to those with special World Cup needs.
The scientific programme was varied, featuring broad conceptual
and organisational themes eg the future of CL services and DSM V
etc as well as practice-orientated research. We were reminded of CL
Psychiatry’s commitment to a ‘holism’, rarely emphasised in other
specialities, and the theme of a ‘non-dualistic’ approach to the
mind/body and to the biological/psychological domains very much
underpinned the conference. We were all left informed and humbled
after participating in a workshop on the conceptual status of
somatisation disorder in the context of forthcoming revisions to
DSM IV. After some initial anxiety that we might be the only
participants and that we had unwittingly signed up to be the next
‘Somatisation Task Force’ for DSM, we were joined by eminently more
qualified participants. A rich discussion followed in which there
was an acknowledgment of the gaps in our current understanding. A
local GP offered her memorably eloquent perspective on the
psychological management of somatising patients in primary care,
emphasising the importance not only of acknowledging the patient’s
suffering but also of the physician’s uncertainty.
The theme of uncertainty is one which British psychiatrists
involved with liaison psychiatry in the current climate will be
somewhat familiar, but the presentations describing the state of CL
Psychiatry across Europe had an oddly comforting effect. We learned
that service provision throughout Europe is patchy and inconsistent
and that many psychiatrists providing liaison services combine this
work with other clinical interests. Each of us was individually
left with our own highlights from the programme of lectures and
workshops. For one of us (TB) Professor Sollner’s accounts of the
early German psychosomatic movement and Professor Adler’s lecture
on George Engel were particularly inspirational. One of us (MB),
who has a particular interest in affective disorders, took special
note of emerging research findings on sub- syndromal depression in
the medically ill. Excruciating though it was to watch, JM managed
to make an impression at the workshop on research methodology,
where the obscurity and vagueness of his question bamboozled the
facilitators into a state of utter perplexity.
On Friday evening, in the interests of true ‘holism’, attention
turned from the ‘bio-psychosocial’ to the ‘social’. Chateau D’Oran
formed a stylish venue for the gala dinner. Missing the coach to
the venue (which meant we had to make our own way) was testament to
the ‘clockwork-like’ precision and smooth organisation marking all
aspects of the conference (including the departure time of the
coach) in spite of our influence. We apologise for keeping Dr
Fernandes waiting as a result of our rather ‘non-Swiss’ approach to
time-keeping, but it was the SHO’s fault !? Nonetheless, the 15 km
journey offered the opportunity to see some quintessentially Swiss
countryside complete with cow bells and cheese-making all set
against an Alpine backdrop. We managed to secure seats on the coach
for the return journey in which, according to one version of
events, there was no hint of any rowdy or boisterous behaviour
?!
We are grateful to the organisers of this conference which left
us with many lasting positive impressions, inspiration and a
reinforced interest in liaison psychiatry. We have already started
to plan next year’s trip to the conference due to be held in Milan
in September 2007, where it would be nice to see more colleagues
from the UK joining us in flying the flag.
Tony Benning Mark Broadhurst Justin Marley
Specialist registrars in general adult psychiatry with special
interest in liaison psychiatry
Longley Centre, Sheffield
For those interested in finding out more about EACLPP, Francis
Creed has provided the following information:
Mailing list for EACLPP
We would like to introduce you to our new mailing list of the
EACLPP.
By subscribing to this mailing list you will be informed about
EACLPP activities and other activities in the field of CL
psychiatry and psychosomatics. Subscription to this mailing list is
free and open to all who are interested. Although this list is an
initiative of the EACLPP, it is not associated with membership of
the EACLPP.
To subscribe to the mailing list and for more information on the
EACLPP and on how to become a member we would like to refer our
website: http://www.eaclpp.org
Membership of EACLPP
The current membership fee is £60 per year and includes the
following benefits:
- subscription to the Journal of Psychosomatic Research, which
is included in the membership (NB regular price is £212 per
year!)
- reduced conference fees for the annual scientific meeting
- a 50% reduction of the subscription rate for the journal
‘General Hospital Psychiatry’ as well as a discount on the online
version of ‘Psychosomatics’.
- the possibility of participating in EACLPP working groups
- the awareness that you will help to promote and develop CL
psychiatry and psychosomatics within Europe
Join the EACLPP by credit card
Joining the EACLPP couldn’t be easier – we now accept payment by
credit card. For more information please contact Gill Dunkerley,
EACLPP Secretariat at jpr@manchester.ac.uk. Full details are also
available on the website.
We look forward to your support of the EACLPP.
Albert Leentjens, President
Wolfgang Sollner, Secretary
Francis Creed, Treasurer
Gill Dunkerley, EACLPP Secretariat
First Annual Royal College of Nursing Mental Health Care in the
General Hospital Conference, 10th May 2006
Sixty-five delegates attended the first RCN conference on mental
health care in the general hospital, at the RCN Headquarters in
London on 10th May 2006. The conference was organised by the RCN in
collaboration with Anthony Harrison and Chris Hart, two consultant
nurses in liaison psychiatry, and was aimed at general hospital
staff. The overall aim was to support nurses and other health care
staff to meet the meet the mental health needs of patients in the
general hospital setting.
The conference was chaired by Neil Carr OBE, Nurse Director at
South Staffordshire Mental Health NHS Trust, and presentations
covered the whole range of common mental health conditions and
problems encountered in the general hospital. Afternoon workshops
focused on alcohol and drug misuse, older people, and mental health
care within the emergency department.
Feedback from the day was overwhelmingly positive and the
organisers were encouraged that despite the current NHS financial
constraints, so many nurses had managed to attend. We would like to
make this a yearly event, as there is a growing demand for
high-quality conferences and educational opportunities for general
hospital staff in relation to mental health care.
We would be pleased to hear from medical colleagues who are
interested in helping us organise a joint event next year, or
further in the future – joint initiatives between professional
groups have a lot of potential to address practice issues that
transcend traditional professional boundaries.
Anthony represents the RCN on the College’s liaison psychiatry
faculty executive committee.
Contact: anthony.harrison@uwe.ac.uk
General interest
BSPOGA
The British Society of Psychosomatic Obstetrics, Gynaecology and
Andrology (BSPOGA) runs an annual conference which focuses
primarily on psychosomatic presentations affecting particularly
gynaecology, reproductive medicine and andrology. The Society is an
excellent forum for members to meet a number of clinicians from
different professional backgrounds to share ideas around
psychotherapy techniques. Our conference in October 2006 will be
held jointly with the Section of Sexuality and Sexual Health at the
Royal Society of Medicine and will be exploring the topic Pregnancy
– all in the mind. Kevan Wylie is currently the Chairman of BSPOGA
and the President of the section of SSH at the RSM. We strongly
welcome liaison psychiatrists to either or both groups and if you
are interested please contact Kevan directly at
k.r.wylie@sheffield.ac.uk.
Forthcoming events
The Association for Psychoanalytic Psychotherapy in the NHS
(APP)
and St Mark’s Hospital
The Body in Mind
Psychological disturbance presenting through the body
Second Annual Meeting
Friday, 6th October, 2006
St Mark’s Hospital, Harrow, London
Metropolitan Line - Northwick Park
The conference will feature case presentations by physicians and
psychotherapists treating patients where emotional difficulties are
revealed initially through the body. Clinical material will be
responded to by a psychoanalyst with an interest in the body and
its relationship to mental disturbance.
Speakers include:
Dr Egle Laufer,
Psychoanalyst, Brent Adolescent Centre
Dr Catalina Bronstein,
Psychoanalyst, Senior Lecturer, UCL
Dr Marcus Johns,
Psychoanalyst
Professor Christine Norton,
Professor of Nursing,St Mark’s Hospital, Harrow
Dr Julian Stern,
Consultant Psychiatrist in Psychotherapy, St Mark's Hospital
Dr Belinda Hacking,
Consultant Clinical Psychologist,Western General Hospital,
Edinburgh
Further information contact Annabel Thomas on
Annabel@athomas99.freeserve.co.uk
Or the APP website www.app-nhs.org.uk
4th Annual Liaison Psychiatry Conference
Organised by
The Trainees and New Consultant’s Group
of the Faculty of Liaison Psychiatry
Marriot Hotel, Leicester Friday 3rd and Saturday 4th November
2006
Speakers include:
Alex Mitchell
John Potokar
Thirza Pieters
Bob Lewin
Khalida Ismail
Trevor Friedman
Richard Brown
Max Henderson
Amrit Sachar
Amit Malik
Markus Reuber
For enquiries and sending reservation forms contact:
Mary Grant,
Liaison Psychiatry, Brandon Unit,
Leicester General Hospital LE5 4PW
Tel: 0116 225 6218
Fax: 0116 2951951 Mary.grant @leicspart.nhs.uk
Managing Acute Behaviour Problems in Medicine
Joint conference with Liaison Psychiatry Faculty of the Royal
College of Psychiatrists and the Royal College of Physicians
Tuesday, 14th November 2006
Venue: Royal College of Physicians, London
Description
The aim of this conference is to provide a lively and educative
day about the management of acute behaviour disturbance in the
general hospital. The day will cover the detection and management
of alcohol problems in the general hospital setting and the
management of other common forms of behavioural disturbance
including delirium, violence and aggression, and self-harm and
suicide.
Audience: the conference would be of interest to physicians,
psychiatrists, liaison nurses and clinical psychologists.
To book, please use the link below:
https://www.rcplondon.ac.uk/booking/booking.aspx?e=241
2007 meetings
Liaison Faculty Residential Meeting: 14th-16th March 2007,
Amsterdam.
Royal College of Psychiatrists Annual Meeting: 19th-22nd June
2007, Edinburgh International Conference Centre.
Original article
Reluctance to disclose difficult diagnoses:
Do oncologists and psychiatrists have something in common?
Working in psycho-oncology, it always seems relevant to ask
newly referred patients if they know their diagnosis and prognosis.
In my experience, few have received sufficient explanation from
their referring teams, although paradoxically many patients do not
volunteer this as a problem. Rather late in the day I began
wondering if psychiatric patients have the same issues.
Additionally, I wanted to know if this is a failure of patient
recall or more a reflection of own habits concerning disclosure of
health-related information.
Guidance on diagnostic disclosure in medicine and psychiatry
Most patients expect health care professionals to be honest and
open[i] – but is this reflected in national guidance for health
professionals? NHS documents strongly suggest involving patients
and carers in the process of health care.[ii] In the context of
cancer care, The National Institute of Health and Clinical
Excellence (NICE) states: “3.9 Any significant news, such as a
diagnosis, should be communicated honestly to a patient with the
minimum of delay.” [iii] In the mental health field (outside of
dementia care[1]), it is more difficult to find guidance regarding
honest communication with patients. The pre-publication draft of
NICE’s Schizophrenia document contained a section on diagnosis as
follows.[iv] “It also imposes on professionals the duty to provide
good, clear and honest information regarding the illness, and about
the treatments and services available.” The 2003 BAP guidelines on
bipolar disorder offer some sensible guidance on breaking a
diagnosis.[v] “Take responsibility for diagnosis, physical
examination, investigations and explanation of the medical plan of
management (S). Communicate clearly and honestly what you think
(S). Take the time to listen to what is bothering the patient (S).”
Given these clear guidelines on honest and open diagnostic
disclosure, what is the actual practice in medicine and psychiatry?
Further, does this practice conform to the underlying wishes of
patients and carers? Let us briefly examine the literature on how
clinicians have chosen to reveal diagnoses in oncology, in
different cultures and across several decades (readers will find a
more comprehensive review here - Mystakidou et al, 2004).[vi]
Diagnostic disclosure practice in oncology
Large-scale studies show that approximately 90% of unselected
cancer patients want “as much information as possible whether its
good or bad”.[vii] In Leicester we found broadly similar results at
least among the Caucasian population. Amongst local Asian patients,
only three quarters wanted “as much information as possible” and a
greater proportion preferred to get this information from their own
GP.[viii] These cultural differences are important if we want to
handle sensitive situations in a way that is most acceptable and
least anxiety provoking for patients.
Attitudes to revealing a diagnosis of cancer have been changing
since the 1960s. In 1961, a survey showed that 90% of US doctors
indicated a preference for not telling a diagnosis of cancer.[ix]
Eighteen years later, 97% indicated a preference for revealing a
diagnosis of cancer.[x] The change was not due to a significant
change in patients’ wishes as early surveys showed that most
patients wanted to know the truth.[xi] By the beginning of the
1980s, whilst most doctors in northern Europe and in other
Anglo-Saxon countries were ready to reveal diagnoses both to
patients and relatives, practice in Southern and Eastern Europe
were less consistent.[xii] vi In a multinational survey conducted
in Africa, France, Hungary, Iran, Panama, Portugal and Spain in
1987, only 40% of the oncologists routinely revealed a diagnosis of
cancer to the patient, while almost all respondents disclosed the
truth to at least one member of the family.[xiii] [xiv] Similar
findings (clinicians preferring to tell the truth to the relatives
in preference to the patient) continued into the 1990s in Saudi
Arabia,[xv] Egypt,[xvi] Singapore,[xvii] Japan[xviii] and
China.[xix] Yet there is evidence practice continues to change. The
diagnosis of cancer was shared with 13% who reported such a policy
in Japan in 1991, 27% in 1993 and 40% to 71% in 1998.[xx] [xxi]
However, only 10% were also told they had a poor prognosis if this
happened to be true. xxi
What are the patient and clinician factors that influence
likelihood of diagnostic disclosure? Clinicians understandably have
difficulty when the information is grave and likely to provoke
distress.[xxii] Most health professionals want to preserve hope and
find it hard not to give false re-assurance.[xxiii] [xxiv] If one
compared those told vs not told a cancer diagnosis, those who are
informed tend to be younger with head & neck or gynaecological
cancers and either no accompanying relatives during the treatment
or relatives who wanted the information to be disclosed.[xxv]
Interestingly, depression in the context of cancer is associated
with never wanting to discuss expected survival (but this could be
confounded by stage of disease).
Diagnostic Disclosure Practice in Psychiatry
We often express surprise that cancer clinicians have been
reluctant to reveal such a significant diagnosis in about half of
cases.vi Yet do we perform better in psychiatry? The results of a
survey of 126 inpatients suggests otherwise. Across disease groups,
53% had not been told their diagnosis.[xxvi] Remember these are
patients who had been admitted and treated for a psychiatric
condition. There may of course be differences between conditions.
One study found that most but not all depressed patients wanted to
know their diagnosis. What is more, the diagnosis of depression,
anxiety and substances abuse is usually communicated by
psychiatrists while the diagnosis of schizophrenia and other
psychotic disorders appears to be frequently omitted.[xxvii] In the
case of schizophrenia, only one third (34%) had been formally told
their diagnosis by French psychiatrists.[xxviii] Similarly, in the
same study only a third of psychiatrists said they would routinely
reveal this diagnosis by name, most preferring pseudonyms. Common
examples are “psychosis” (70%), “major mental illness” (51%) and
“mental breakdown” (19%).[xxix] Predictors of disclosure are
younger psychiatrists and/or those with fewer years of
practice.xxviii xxix Consultants in post for more than 10 years
appear to be more uncomfortable about telling the diagnosis of
schizophrenia and were less likely to volunteer the diagnosis
without being asked (42% v. 60%).xxix
Figure: Factors influencing Japanese clinicians willingness to
disclose a diagnosis of cancer.
It is interesting to consider if reluctance to reveal a
diagnosis such as schizophrenia is by product of diagnostic
confidence. In other words revealing a diagnosis may be considered
by some to be an action of last resort only when the diagnosis is
irrefutable. For example, one study found that 89% of psychiatrists
disclose a diagnosis of schizophrenia if it is a recurrent episode,
compared to 59% for a first episode.xxix The issue of diagnostic
certainty is pertinent to liaison psychiatry (see below).[xxx]
Are There Valid Reasons for Missed or Delayed Diagnostic
Disclosure?
We cannot assume all cases of missed diagnosis are cases of
medical error.[xxxi] Indeed most cases appear to be intentional
attempts by clinicians to minimize patient distress.[xxxii]
Remarkably, Elwyn et al (1998) found that Japanese clinicians
weighed 10 or more factors when deciding to reveal a cancer
diagnosis.xx [xxxiii] Clinicians often collude[2] with relatives in
a well meaning attempt to encourage hope by concealing a
potentially painful piece of information.xxxiii [xxxiv] [xxxv] In a
comprehensive study of videotaped cancer consultations, clinicians’
performance was worse when palliation was being discussed than when
they discussed potentially curative treatment.[xxxvi] It is
probably not by chance that prognostic errors are usually made in
an overly optimistic direction, and tend to increase the better the
doctor knows the patient.[xxxvii] Of course, wishes from patients
and relatives may place health professionals in a difficult
position. Most patients want information but at the same time are
wishing for good not bad news. Thus in one study 100% of
participants wanted doctors to be honest, yet 91% also wanted them
to be optimistic.[xxxviii] It is also important to acknowledge that
attempts to minimize patient distress can also be attempts to
protect clinicians from the fallout of this disruption during
clinical encounters and could be interpreted as “an attempt to
protect their own emotional survival as much as to help protect the
patient”.xxii
A second reason for not wanting to raise the likely diagnosis is
feeling medically uncertain about either the diagnosis itself or
available treatment. For example, in a study of 1593 patients who
met ICD-10 criteria for depression, only one in five general
practioners were able to make a confident diagnosis of ‘definite’
depression but a third were able to say ‘probable’ depression and
half missed the diagnosis altogether.[xxxix] Another primary care
study showed that general practioners often defer providing
information because of unease about communicating a diagnosis when
they have few therapeutic options to offer.[xl] The mistakes in the
diagnosis of medically unexplained symptoms (both false positive
and negatives) are a reminder that not all presentations have a
definitive explanation given our current level of
understanding.[xli] In some instances admitting the diagnosis is
currently uncertain is the most honest option. On the other hand a
tendency for health professionals to avoid a diagnostic label (eg
chronic fatigue syndrome)[xlii] can lead to patient dissatisfaction
and/or diagnostic error.[xliii] [xliv] Patients may then attempt to
conform to a medical model in order to get help (which is of course
much more than a diagnosis alone).[xlv]
Conclusions
Much world literature supports the notion that most patients
want to know their diagnosis whether it is physical or
psychiatric.[xlvi] A smaller (but still substantial) proportion
want to know detailed prognostic information, but less so when it
not favourable. In our study in ethnically diverse cancer patients
in Leicester a third of those using denial appeared to do so
successfully (that is with no anxiety or depression).viii
Interestingly, on direct questioning, the proportion wanting full
disclosure of a diagnosis of cancer is very similar to those
wanting to know if its dementia.[xlvii] There may be very valid
reasons why a patient does not want to be labelled with a
potentially stigmatising diagnostic term but this has to be weighed
against benefits of greater insights into their symptoms, ability
to access NHS treatment and ability to plan for the future.
Interestingly, one study in chronic fatigue syndrome showed that
much stigma preceded the clinical diagnosis.[xlviii] Stigma may
apply equally to cancer as well as mental health conditions.[xlix]
Giving a diagnosis can allay patients’ fears of ‘going mad’
especially when the patient or family suspects something is
seriously wrong in any case.[l] [li] One observation here is that
67.9% who developed cancer suspected their diagnosis before the
formal label was applied. An important question is whether the
process of disclosure (and the quality of this) impacts on the
psychological state of the patient? Patient centred communication
rather than disease focussed communication actually appears to be
preferred by patients themselves.[lii] My interpretation of the
evidence to date is that clinician communication style certainly
modifies adjustment and that the content of the “bad-news” may
provoke early distress but this is not invariable or irreversible.
Patients who were aware of their own diagnosis frequently reported
higher levels of hope than those who have not been informed of
their own diagnosis.[liii]
It is important to acknowledge that the clinician may have a
dilemma when the diagnosis is uncertain and linked with stigma or
fear and particularly if relatives request “not to tell”.
Clinicians are naturally hesitant about revealing a difficult
(sometimes scientifically uncertain) diagnosis – to the point where
they may prefer not to mention a diagnosis at all. However, the
issue of medical uncertainty cannot be the predominant explanation
because clinicians will inform relatives and inexperienced
clinicians tend to inform more. The issue of wanting to avoid
offence and possibly stigma is important and this may influence our
choice of pseudonyms. However, an over-reliance on pseudonyms and
medical jargon will impair the amount a patient understands and
later recalls.
Psychiatrists are not immune from poor communication
practicesxxvii [liv] and the desire not to offend patients may lead
to over-protective practices regarding diagnostic disclosure.
Revealing usually helps long term adjustment albeit with the risk
of short term distress, provided the diagnosis is correct and
help/support is offered.[lv] Ultimately, one test of what to tell,
is to consider what you would want in the same situation. Hamadeh
& Adib (1998) found that 99% of those who usually withheld a
diagnosis of cancer would like to be told themselves.[lvi] All
things considered, assuming a diagnosis is robust, 9 out of 10
patients want to know their diagnosis. If doubt exists it is
usually possible to ask the patient themselves what amount of
information they would prefer.[lvii]
[1] I have chosen to exclude diagnostic disclosure in dementia
from this article for reasons of space; although many of the issues
apply
[2] Collude: to act together secretly to achieve a deceitful or
non-transparent purpose
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Alex Mitchell,
Consultant and Hon SnR Lecturer in Liaison Psychiatry
Leicester.
Edited by:
Paul Gill,
Sheffield
Paul.Gill@sct.nhs.uk