Transplant psychiatry

[Pershing]

I have an interest in transplant psychiatry. However, my institution is not a transplant center, so I am planning to do an external transplant psychiatry rotation my last year of residency. Reading about transplant in the surgery forums, the highest volume or big names in liver transplant include UPMC, UCSF, UCLA, Columbia, Baylor, and Minnesota. What are the major centers of academic transplant psychiatry and prominent leaders in this field?

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[nitemagi]

I have an interest in transplant psychiatry. However, my institution is not a transplant center, so I am planning to do an external transplant psychiatry rotation my last year of residency. Reading about transplant in the surgery forums, the highest volume or big names in liver transplant include UPMC, UCSF, UCLA, Columbia, Baylor, and Minnesota. What are the major centers of academic transplant psychiatry and prominent leaders in this field?

What aspects are you interested in? Evaluating transplant candidates for their psychological appropriateness for a transplant? There's also some basic science researchers who look at immune function in relation to mental health/illness, with obvious implications for transplant medicine.

 

[TexasPhysician]

I want to say that a graduate of my program is doing transplant psych at UT-Houston/MD Anderson. I'll try to verify that.

 

[whopper]

Transplant centers are a good way to go about this, after all several hospitals aren't set up for transplants. I do know that Mass. General, Vanderbilt, Cleveland Clinic and U. of Cincinnati have teams specifically for transplant psychiatry. I've read a few papers in this area from the Cleveland Clinic though it's certainly not something I specialize in.

I'd look into not only programs attached to hospital that provide transplants, but also ones with with a setup that accommodate transplant psychiatry and a good C & L program.

 

[BobA]

I remember Longwood talking about this on interview day.

I'd be surprised if any transplant center had enough need that you could make a full rotation out of it. Perhaps transplant could be done as part of a CL rotation.

 

[notdeadyet]

I'll echo nitemagi in wondering what your interest in transplant psychiatry is. I know nothing at all about the field…. I'm curious....

 

[whopper]

One aspect I've seen transplant psychiatry work on is predicting the patient's compliance with anti-rejection meds.

A problem here is that this is something where there is little science to back an opinion. I've often mentioned that people often expect too much of psychiatry. E.g. sometimes a doctor calls a consult to psychiatry to see if a patient is lying. We do not have training in that, and per studies, a psychiatrist's ability to tell if someone is lying is no better than a layman.

That said, since several are calling upon psychiatry to make this prediction, some hospitals with transplant psychiatry are have psychiatrists rising to that challenge are and doing studies to determine factors to predict these things. I've seen studies in that area.

But, IMHO this is really the domain of psychology, not psychiatry. We treat mental illness. We don't make predictions on things where mental illness is not involved, though yes, a psychiatrist would likely have more insight on the medical end of things with transplants because of our M.D.s though psychologists tend to have better backgrounds in statistical number crunching in predicting future behavior.

To me this is like asking me to predict if a guy is more likely or not to buy a car after seeing a flashy car commercial. Like I said, that's more psychology than psychiatry if psychiatry at all. I took classes on treating schizophrenia and depression, not in predicting if a guy will take his meds.

I'm open to someone thinking I'm wrong and writing why because I know so little of transplant psychiatry. I just know I get bugged with consults asking me to do something when they're not mentally ill (E.g. reason for consult: patient doesn't like his nurse. Please find out why.), and the APAs stance on issues like this is that psychiatrists should not be placed in this position when asked, in general, though I've never seen an opinion in regards to transplants (E.g. predict if a guy will rape a kid if released from prison).

 

[pingouin]

I remember Longwood talking about this on interview day.

I'd be surprised if any transplant center had enough need that you could make a full rotation out of it. Perhaps transplant could be done as part of a CL rotation.

C/L is what I was thinking for an away. A search in VSAS for "transplant" gets a lot of hits for surgery, and some for IM (esp for BMT), but no psych hits. Prior.to setting up your aways, I think it's reasonable to ask the course director about exposure to transplant patients (or donors in some cases?).

 

[ieatpizza]

What aspects are you interested in? Evaluating transplant candidates for their psychological appropriateness for a transplant? There's also some basic science researchers who look at immune function in relation to mental health/illness, with obvious implications for transplant medicine.

I remember Longwood talking about this on interview day.

I'd be surprised if any transplant center had enough need that you could make a full rotation out of it. Perhaps transplant could be done as part of a CL rotation.

I'm interested in gaining exposure to the full spectrum of psychiatric care pre-, peri-, and post-transplantation. This may include the psychosocial assessment for and the ethics of transplant candidacy selection as well as the psychopharmacotherapy and psychotherapy of comorbid psychiatric illness and neurobehavioral sequelae before and after transplantation including familiarity with the impact of end-stage organ failure and immunosuppressive therapy on psychiatric treatment. It might be a C-L rotation focused on transplant patients if the volume is not adequate (though some of the institutions I listed above perform in excess of 100-200 liver transplants and 200-300 kidney transplants per year). I'm not particularly looking for involvement in active research as it pertains to transplant psychiatry, though both immune function in mental illness and predictors of medication adherence sound interesting.

 

[BobA]

Taking the upper estimates that 500/year. There are 52 weeks a year. Assuming that every single transplant recipient has to see the psychiatrist, that's 9.6 patients per week. Perhaps one day of clinic. . .

That being said, transplant psychiatry is really cool for all the reasons you mentioned. You should definitely seek it out as you are, I just don't think there will be a full rotation. When I was interviewing Longwood, (and perhaps Penn?) mentioned transplant psychiatry as something residents could do. I imagine that's a part-time clinic and not a full rotation, but I don't know for sure.

 

[nitemagi]

Taking the upper estimates that 500/year. There are 52 weeks a year. Assuming that every single transplant recipient has to see the psychiatrist, that's 9.6 patients per week. Perhaps one day of clinic. . .

That being said, transplant psychiatry is really cool for all the reasons you mentioned. You should definitely seek it out as you are, I just don't think there will be a full rotation. When I was interviewing Longwood, (and perhaps Penn?) mentioned transplant psychiatry as something residents could do. I imagine that's a part-time clinic and not a full rotation, but I don't know for sure.

I'd consider putting together a hybrid rotation with C/L and maybe even rotating with an ethics team.

 

[ieatpizza]

.

 

[Pershing]

Thanks for the ideas. I'm getting progressively more excited delving into this. APM has a transplant psychiatry SIG (http://www.apm.org/sigs/transplant/index.shtml), associated archived Google group (http://groups.google.com/group/transplantpsychiatry/topics), and bibliography (http://www.apm.org/library/pm-biblio.shtml#transplantation) for others who are also curious.

 

[pre med 2014]

What aspects are you interested in? Evaluating transplant candidates for their psychological appropriateness for a transplant?

If someone is psychologically unfit to undergo a transplant surgery how come they would be allowed to go through any number of other surgical procedures that require an equal or greater amount of mental fitness such as an awake craniotomy?

 

[nitemagi]

If someone is psychologically unfit to undergo a transplant surgery how come they would be allowed to go through any number of other surgical procedures that require an equal or greater amount of mental fitness such as an awake craniotomy?

Careful.
:troll:

 

[splik]

I know he's a troll with an axe to grind, but it is nonetheless useful to explain that psychiatric assessment prior to transplantation is not an assessment for the procedure itself, but the complex aftercare (high risk of rejection, need for powerful immunosuppressants, need for behavior change i.e. no alcohol, no smoking etc). There is also the issue of resource allocation - other surgical procedures do not have number of available organs as the rate-limiting step - it becomes that much more important not to waste the organ on someone who cannot look after it, or who does not even want to. The assessment usually involves not just an assessment of the mental state, but asking about various behavioral and social aspects of the history that the surgeons should have asked about anyway but never do.

 

[pre med 2014]

I know he's a troll with an axe to grind, but it is nonetheless useful to explain that psychiatric assessment prior to transplantation is not an assessment for the procedure itself, but the complex aftercare (high risk of rejection, need for powerful immunosuppressants, need for behavior change i.e. no alcohol, no smoking etc). There is also the issue of resource allocation - other surgical procedures do not have number of available organs as the rate-limiting step - it becomes that much more important not to waste the organ on someone who cannot look after it, or who does not even want to. The assessment usually involves not just an assessment of the mental state, but asking about various behavioral and social aspects of the history that the surgeons should have asked about anyway but never do.

Although you may think I am troll, there is a real basis to my sarcastic comment. The fact is that society does not want felons to have the same access to organ transplants. People get upset when a criminal gets a transplant and their law-abiding loved one is made to wait in line.

It is not an easy problem, of course some people are more deserving than others, however, at the same time, everyone would agree it is morally repugnant to allocate organs based on social worth. Which is why we now have 'transplant psychiatrists' to diagnose criminals with personality disorders unfit for transplantation, it is still allocating organs based on social worth, but under the disguise of medicine so to avoid responsibility of doing what they are really doing which is assigning value to human life.

I think the real problem becomes when transplant psychiatrists evaluate past behaviors, and pick and choose who should be forgiven and who not to be forgiven, this leaves the door open to prejudice and bigotry where one persons ethnicity, cultural and social circumstances could be discriminated against.

 

[splik]

Obviously you are not interested in knowing what transplantation psychiatry is actually about, or having your fantasies challenged, but you raise a point about values which I will address in general. Anyone who thinks that the problems with psychiatry are unique to the field, and not problems with medicine as a whole doesn't know what they're talking about. It's not psychiatrists who assign value to who should have a transplant or not, it is physicians who might consider whether transplantation is indicated in the first place. Not everyone who might be a candidate for transplantation is considered, and thus few have a psychiatric assessment. It is the medical/surgical team looking after the patient that will make the call. If they deem that patient 'not deserving' then no transplant would ever be considered. Transplantation is a hot field in bioethics for the very reason that values, meanings and assumptions come to the heart of who should and should not, who does and does not have a transplant. In this way it is not psychiatrists who are the moral arbiters, but whoever decides on referral for transplantation in the first place.

Psychiatry is an easy target for criticism because of the nature of the problems which are treated and the lack of validity of diagnoses, but most of the criticisms for psychiatry are true for medicine in general. It's not just psychiatric RCTs which are flawed, in all specialties there are significant problems. It's not just psychiatrists who medicalize or where there is illness mongering, look at the concept of pre-diabetes, the expansion of the concept of hypertension, the overuse of bisphosphonates, the medicalization of the menopause, the statin market, the medicalization of aging, repetitive strain injury, the marketing of restless leg syndrome etc. It is not just psychiatry which has had an army of opponents, there is also a powerful anti-vaccination lobby, there are those who are anti-contraception, anti-abortion, anti-pharmaceuticals, and anti-obstetrics. If you think that only psychiatry involves coercion, you are in for a rude awakening, there are elements of coercion, which are more pernicious because they go unacknowledged in all areas of medicine. In short, it is not just psychiatry which generates opposition, nor is it just psychiatrists who are agents of social control, physicians in general are whether they like it or not (usually not). There is no way of getting around the values, meanings and assumptions of clinical practice, nor the difficult ethical waters we must tread. But it does a great disservice to everyone to pretend this is specific to psychiatry. The only way psychiatry is different is that it is one's subject experience that is regarded as disordered. There is no doubt this is a major point of contention. But most spleen against psychiatry has nothing to do with this and thus is misdirected when psychiatry actually does more to acknowledge the precarious moral waters we tread than do other physicians.

 

[whopper]

I'm repeating myself here but I question why psychiatry should be the field to do this. If a person does not have a mental illness why should we enter the field of psychology, do something that is typically psychology's domain and call it "transplant psychiatry?"

If a doctor had a diabetic patient and wanted to know if that patient would be compliant on their meds should they consult a psychiatrist and call it "diabetic psychiatry?" How about a sports medicine psychiatry now start predicting which team will win the Superbowl? I'm not trying to be sarcastic. If ever asked to do these things, I'd simply tell the treating doctor that this is not what psychiatry is about and we have no expertise in this area. We cannot offer anything with our training that they don't already possess.

If psychiatry is supposed to be the treatment of mental illness using a medical model, I don't see how psychiatry fits in the picture of prediction a patient's future behaviors with regards to their fitness for a transplant, even on the behavioral level unless that patient was mentally ill.

Several times in our history, the APA has told various entities such as the government to not ask us psychiatrists to do things such as predict future violence, or a sex offender's risk of causing a future sexual offense because we are not trained in this area, have no expertise in it, and there wasn't much science behind it (at the times it was asked). If transplant psychiatrists want to do this, and start establishing a science behind it so be it. It's needed and that'd be a good thing, but this IMHO is not psychiatry. If we want to expand upon the definition of psychiatry for us to start predicting future behaviors in all of medicine, then so be it, but then we're not practicing psychiatry as it is currently defined, nor are we trained in the statistical models used to predict future behaviors. I know a psychiatrist that does do that, but he's an exception and on his own mastered this area of statistics to a degree superior to that I've seen from several psychologists. (This guy is a true genius. Anyone mastering math to a degree you'd expect from a Ph.D. in the area on his own spare time as a hobby...WOW).

 

[splik]

actually diabetes psychiatry is a slow but growing field! where i went to med school they had a psychiatrist who worked full time in the diabetes clinic and did inpatient diabetes consults, and there was also a resident rotating through. The most common things were depression, anxiety, eating disorders, and also health behavior change with regards to diet or adherence to medication glycemic control and there were psychologists and nurses trained in motivational interviewing (motivational enhancement therapy) and CBT. Also some more weird and wonderful things like hypoglycemia unawareness, and they would assess appropriateness of suitability for pancreatic islet transplantation. Patients with >3 DKA admissions in 6 months also had an assessment, usually borderlines.

Transplantation psychiatry is far more than tea-leaf reading and trying to guess what will happen. That is a very small part of the assessment. There are lots of weird and wonderful neuropsychiatric complications due to immonosuppression, issues with coping, grief, abnormal illness behavior, living donors, adjustment disorders, mood disorder, personality pathology, capacity, family systems problems, health behavior change etc.

there are transplantation psychologists too who tend to do more of the therapy and psychological assessment stuff. The benefit of having psychiatric input is psychiatrists have the benefit of medical training and understanding of the complexity of transplantation and its complications. Very little of it has anything to do with predicting 'what will happen in the future', it is often fairly obvious a patient is completely inappropriate candidate for transplant and you have to wonder why referral for psych assessment was even made (I saw a pt referred for assessment for lung transplantation who was still smoking! not only that she lived in a car, had multiple psych hospitalizations in the past, zero social support, no understanding of the procedure, poor adherence to treatment etc!)

 

[Pershing]

This is not in line with the current discussion, but just in case anyone is interested, this website (http://www.srtr.org/csr/current/Centers/Default.aspx) allows you to search the volume, wait time, outcomes, etc. for each organ by transplant center.

 

[notdeadyet]

I'm repeating myself here but I question why psychiatry should be the field to do this. If a person does not have a mental illness why should we enter the field of psychology, do something that is typically psychology's domain and call it "transplant psychiatry?"

I agree with this big-time. For a field that likes to gripe about others making inroads into our forte, we sure seem to have no problem trying to make inroads into others. If a person isn't mentally ill, it really isn't our area.

 

[notdeadyet]

actually diabetes psychiatry is a slow but growing field! where i went to med school they had a psychiatrist who worked full time in the diabetes clinic and did inpatient diabetes consults, and there was also a resident rotating through. The most common things were depression, anxiety, eating disorders, and also health behavior change with regards to diet or adherence to medication glycemic control and there were psychologists and nurses trained in motivational interviewing (motivational enhancement therapy) and CBT.

I question how much of this is diabetes psychiatry as a growing field and how much of this is diabetes as a growing disease. Nothing I read here indicates anything that a decent generalist psychiatrist shouldn't be able to handle. We'll all be "diabetes psychiatrists" in a few years at the rate projections are going.

Transplantation psychiatry is far more than tea-leaf reading and trying to guess what will happen. That is a very small part of the assessment. There are lots of weird and wonderful neuropsychiatric complications due to immonosuppression, issues with coping, grief, abnormal illness behavior, living donors, adjustment disorders, mood disorder, personality pathology, capacity, family systems problems, health behavior change etc.

Again, all general psychiatry problems. The oddball immunosuppression feature could be handled by a shrink in conjunction with his primary team. The coping, grief, adjustment stuff should be bread and butter.

I'm just dubious by this desire of everyone to consider themselves a subspecialist. My prediction is that you'll have all sorts of oddball fellowships popping up to exploit the naive to get folks to devote a year of their life doing a psychiatrists job with some specialized didactics thrown in in exchange for a hospital getting a psychiatrist willing to work ridiculous hours for about $60K/year. Maybe I'm old and cynical.

 

[whopper]

actually diabetes psychiatry is a slow but growing field!

And if a psychiatrist decides to insert himself/herself into making future predictions with no real science behind it, that doctor is practicing quackery.

If an IM or endocrinologist asked me to give advice on a patient future compliance to insulin, I read over his history and gave advice, it'd be based simply on my own common sense. In several studies where psychiatrists have been asked to do things outside their field such as determine if someone is lying, they did not do better than a layman.

If psychiatrists want to play this faux role, they are not practicing psychiatry. If they want to actually research, learn, and understand the science of predicting future behavior and do consults asking them to predict the future, so be it because they actually then are using evidenced-based methods but they are not practicing psychiatry as it is currently defined. That is said with full deference that someone needs to do this and that would be something beneficial.

I don't see much difference between a psychiatrist trying to make predictions without any science to back him up and Madame Cleo. I suspect if their insurance carrier mandates they not practice outside their field, they'd be in violation of that, and thus not covered by insurance, and in many states to practice under those conditions is illegal.

Regarding diabetes, there actually is some psychiatric issues in that area, especially with mental state. Low blood sugar, for example, causes irritability. But that is a far cry from predicting future behavior.

Transplantation psychiatry is far more than tea-leaf reading and trying to guess what will happen. That is a very small part of the assessment. There are lots of weird and wonderful neuropsychiatric complications due to immonosuppression, issues with coping, grief, abnormal illness behavior, living donors, adjustment disorders, mood disorder, personality pathology, capacity, family systems problems, health behavior change etc.

Somewhat agree, and I have read evidenced-based papers on transplant psychiatry, but all the above minus the psychiatric disorders is stuff any doctor can handle and they do not necessarily need a psychiatrist for that. If someone has a personality pathology, or psychosis as a result of corticosteroids, yes we can provide assistance, but in dealing with families, any doctor should be able to handle that. If transplant doctors don't want to deal with it, my argument is that instead of expanding our field to do something outside our parameters, why not expand their role to do something they're supposed to do anyway.

When this has happened in the forensic psychiatric arena, the APA argued we shouldn't be doing things such as predicting future violence, and then the Supreme Court ruled something to the effect of -too bad, someone needs to do it, we can't think of anyone else so you're stuck with it.- At least in that situation there now is a legal mandate to perform outside our specialty even if we don't want to do it. Since then there have been evidenced-based advances, but for years psychiatrists were operating on no science when doing this type of stuff but they were forced by the court to do so.

 

[cleareyedguy]

It is difficult/impossible to predict behavior, but there is a strong rationale for specialists in different transplant areas. That does not mean there should be a fellowship for transplant, IMHO, but that it is reasonable for a CL fellowship to include transplant exposure. There are multiple, very interesting ethical dilemmas related to transplant psychiatry, and they don't begin and end at being part of the team that does the evaluation for "worthiness."

If I were looking to do an away elective, I probably wouldn't start with the roster of which places do the most transplants but instead consider where I wanted to train as a resident and then see which of those appears to have a good elective in CL/Transplant/Ethics. At least where I am, we have a couple of pertinent electives, but if someone came up with a more precise version of those electives, we'd be open to adaptation; as long as you are tactful about it, I assume most places would give you some leeway.

 

[MrJiggles]

actually diabetes psychiatry is a slow but growing field! where i went to med school they had a psychiatrist who worked full time in the diabetes clinic and did inpatient diabetes consults, and there was also a resident rotating through.

Yeah the Joslin diabetes centers typically have a psychiatrist on board, and theres tons of research about the interesting physiology and bidirectional etiology of DM in depression, anxiety, etc. I do some research into these matters myself actually. I didn't know this was its own specific field, but I guess it would make sense.

In the same vein, Psycho-Oncology has its own fellowships and such too, theres tons of oddly specific branches of medicine I never knew about until digging a bit! I never knew transplant psychiatry existed until this thread actually.

I agree with Whopper, it seems like psychiatrists are sometimes treated as wizened sages who have some strange intuition about the human soul that other physicians do not. I'm an MS4 and the residents who know about my career interest in Psych already send me in to "diffuse" tense situation and see if theres "something fishy" going on with patients...I find it very amusing.

 

[Ceke2002]

Although you may think I am troll, there is a real basis to my sarcastic comment. The fact is that society does not want felons to have the same access to organ transplants. People get upset when a criminal gets a transplant and their law-abiding loved one is made to wait in line.

It is not an easy problem, of course some people are more deserving than others, however, at the same time, everyone would agree it is morally repugnant to allocate organs based on social worth. Which is why we now have 'transplant psychiatrists' to diagnose criminals with personality disorders unfit for transplantation, it is still allocating organs based on social worth, but under the disguise of medicine so to avoid responsibility of doing what they are really doing which is assigning value to human life.

I think the real problem becomes when transplant psychiatrists evaluate past behaviors, and pick and choose who should be forgiven and who not to be forgiven, this leaves the door open to prejudice and bigotry where one persons ethnicity, cultural and social circumstances could be discriminated against.

I am the administrator of a group that works to support organ donation & transplant awareness as well as organisations like Donate Life. One of the biggest stumbling blocks we've found in actually getting people to register as organ donors is those who say "why should I give away my organs when some scumbag criminal, drug addict, lunatic, insert whatever other 'undesirable' might be the one who gets them. It's amazing how quickly they back down when they find out I used to be one of those scumbag criminal drug addicts they're so loathe to help, because clearly no one can change and become a better person.

We've also had to write articles imploring people not to take their names of the donor registration list just because a certain politician had received a transplant. Not to mention the occasional idiotic extreme pro lifer who insists that transplant Doctors either kill people, or take their organs when they're still alive.

 

[whopper]

I've been told that in Spain, if someone dies, their organs are automatically taken away unless the person did action to prevent this while in life (e.g. sign a waiver). In the US it's the opposite. As a result there's ambulances to take people's organs away upon death because most people do the default action.

I was asked to do transplant psychiatry in my current place of employment and I flatly said no. A colleague of mine did tell me that other doctors asked him to predict things that I felt were inappropriate. I later found out that a doctor that took over in the transplant psychiatry position in the hospital is of the same opinion as mine--that we do not predict behavior and made it clear to the other doctors she will not do it. We'll see how this pans out for her.

 

[pre med 2014]

I've been told that in Spain, if someone dies, their organs are automatically taken away unless the person did action to prevent this while in life (e.g. sign a waiver). In the US it's the opposite. As a result there's ambulances to take people's organs away upon death because most people do the default action.

I was asked to do transplant psychiatry in my current place of employment and I flatly said no. A colleague of mine did tell me that other doctors asked him to predict things that I felt were inappropriate. I later found out that a doctor that took over in the transplant psychiatry position in the hospital is of the same opinion as mine--that we do not predict behavior and made it clear to the other doctors she will not do it. We'll see how this pans out for her.

If she won't predict future behaviors will she at least be able to determine if alcoholics are medically fit to undergo the mental rigors of a liver transplant? Otherwise I don't see how she could fulfill any of her job duties???