physical exams

[MDhasbeen]

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i know i must perform them thoroughly when called for. but more often than not, i get this weird boundary violation feeling inside. i guess the best i can explain it away is by saying that, by being a psych, i feel as though my domain of work should be the brain/behaviors/mood of the patient, not so much their physical body. and while i consciously know the mind and body are completely interconnected, i still feel odd about the whole physical exam thing sometimes, more so for certain parts of the body than others. like when any sort of genital/rectal issues arise, i outright say "no" and pass to my medicine/peds colleagues on consult in house.

thoughts?

 

[Solideliquid]

i know i must perform them thoroughly when called for. but more often than not, i get this weird boundary violation feeling inside. i guess the best i can explain it away is by saying that, by being a psych, i feel as though my domain of work should be the brain/behaviors/mood of the patient, not so much their physical body. and while i consciously know the mind and body are completely interconnected, i still feel odd about the whole physical exam thing sometimes, more so for certain parts of the body than others. like when any sort of genital/rectal issues arise, i outright say "no" and pass to my medicine/peds colleagues on consult in house.

thoughts?

During PGY I, I constantly felt the same way when admitting a pt to our unit directly. I'm pretty much over that, I think it was (for me anyway) mostly an unconscious method for sort of wanting to ignore medical issues so I wouldn't have to deal with them.

I don't mind getting my hands dirty now-a-days, as I'm more relaxed and confident. However a few points: On rectal/genital exams, I typically will defer these exams to the consult team if there is a need to call for a consult. I don't really feel comfortable doing PAP and pelvic exams simply because I haven't done them since 3rd year and I'm sure if something is there I will miss it.

Mostly my motivation for doing a thorough exam now-a-days is in case I do find something, I can explain in detail to the medical/or whoever consult service to ensure they actually come and see the patient. I don't have any patience for consult services who specialize in lame attempts and excuses to block a consult. So the more info I have, the better chance they will agree to see the patient, and I don't have to explain to the attending the next AM why the consult service refused to come.

 

[jjbmsiv]

Ugh. Which rotation is it that will make us do PEs ourselves, so I know better to brace myself next year?

 

[whopper]

Most standards of care & hospital policies will allow psychiatrists to not have to do certain physical examinations such as a genital or rectal exam so long as the other things are examined. Heck in fact when I was doing IM you didn't have to do a genital or rectal exam unless there was specific symptoms in the systems of those areas that warranted investigation.

At least where I am, you want to do a good PE. ER docs several times clear patients that truly aren't clear or write down everything on the PE is normal when it is not. Several of those sx they say are normal that aren't are psychiatrically relevant such as self mutilation, scratch marks, or signs of trauma.

 

[Solideliquid]

Most standards of care & hospital policies will allow psychiatrists to not have to do certain physical examinations such as a genital or rectal exam so long as the other things are examined. Heck in fact when I was doing IM you didn't have to do a genital or rectal exam unless there was specific symptoms in the systems of those areas that warranted investigation.

At least where I am, you want to do a good PE. ER docs several times clear patients that truly aren't clear or write down everything on the PE is normal when it is not. Several of those sx they say are normal that aren't are psychiatrically relevant such as self mutilation, scratch marks, or signs of trauma.

True dat. They let us admit a woman who had a two inch laceration on the back of the head. The chief resident of the ED had to come up and staple her closed himself.

 

[MDhasbeen]

Ugh. Which rotation is it that will make us do PEs ourselves, so I know better to brace myself next year?

for one thing, everyone through the door at psych emergency services unless they've been seen by the adult er. but if a patient gets directly admitted from an outside hospital, you're it. and lemme tell ya, as mentioned above, there are tons of things that slip by with our patients that are downright scary. there was this female geri patient i admitted through the psych er one night. she was dead in a week. why? she was minimally cooperative, no one bothered to listen to her lungs, and she developed a raging pneumonia during her hospitalization. bleh.

 

[Venko]

As a psychiatrist you are not immune from physical contact with your patient! In fact, you carry an obligation to ensure that they are adequately treated as organic illnesses amidst a psychiatric backdrop can present with very odd cheif complaints. Never forget that the moment the patient has been labeled as having a psychiatric illness, other physicians sometimes overlook what are common, serious, or obvious medical problems. Not to mention that your differential for mood disturbances and other psychiatric behaviors must first look to r/o organic causes. Consider hypoxia, TBI, syphillis, seizures, MI, illicit substance abuse, and a myriad of other conditions can cause symptoms that lead to psychiatric hospitalization if not carefully investigated.

If you didn't want to have to touch the patient you should have specialized in the theory of psychology rather than the practice of psychiatric medicine. Every patient needs a thorough neurologic examination, examination for side effects, differential specific physical exams, check their vitals daily. Be a physician; thats why you went ot medical school.

 

[Hurricane]

True dat. They let us admit a woman who had a two inch laceration on the back of the head. The chief resident of the ED had to come up and staple her closed himself.

Double true dat. Neurosurgery sent us a lady who had gotten agitated on their service and ripped out some of her stitches and had a CSF leak when she got to our floor, with nothing in the chart but illegible haiku-length notes that mentioned nothing about wound care.

 

[luft]

with nothing in the chart but illegible haiku-length notes that mentioned nothing about wound care.

😀 Man, that made me laugh. That exactly describes the neurosurge notes I've seen in my own hospital. Where do you think that comes from? It makes me want to strangle the lazy dears when I have to try to figure out what the heck they are trying to communicate.

 

[Solideliquid]

😀 Man, that made me laugh. That exactly describes the neurosurge notes I've seen in my own hospital. Where do you think that comes from? It makes me want to strangle the lazy dears when I have to try to figure out what the heck they are trying to communicate.

Their orientation at the start of residency?

 

[zenman]

Every psych hospital I've worked at has had a contract with a FP doc to do the initial PE

 

[Puffle]

I agree that we are physicians first and foremost, and that we are obligated to treat the whole patient. But as psychiatrists, we do have different boundaries that can't be crossed. The APA has specific guideline barring psychiatrists from performing breast, pelvic, genital, and rectal exams on patients. If I see a patient that is in need of any of these, I consult a primary. Just because I can't do it myself, doesn't mean that it can't get done. And remember, that especially with our homeless and working-poor patients, we are often the only physician they come in contact with, so it's sometimes even more important that we treat the "whole" patient.

 

[Hurricane]

The APA has specific guideline barring psychiatrists from performing breast, pelvic, genital, and rectal exams on patients.

Do you know where I can find that? (A quick survey of the practice guidelines section of the apa website was unfruitful.) We have an attending that insists that we must do rectals on every male over 40. I don't mind doing them if I'm on the medicine service or whatever, but I think having your psychiatrist stick their finger up your butt crosses a boundary.

 

[Puffle]

Do you know where I can find that? (A quick survey of the practice guidelines section of the apa website was unfruitful.) We have an attending that insists that we must do rectals on every male over 40. I don't mind doing them if I'm on the medicine service or whatever, but I think having your psychiatrist stick their finger up your butt crosses a boundary.

I'll have to dig around for it; no pun intended. The VA we were working at had the same asinine (again, no pun intendend 🙂) policy, but one of the more senior residents did his homework, brought in a ton of documentation, and lo and behold, he got it shut down. This little index finger hasn't been "up the bum" since med school.

P.S. I have a feeling there might be something under the AMA code of ethics, as well.

 

[phd2b]

How do these apply to those who are dual boarded in FP/Psych or IM/Psych? Are you saying that we can't do our own PE???? The patient might actually expect that, right? Educate me.