Today patients recovering from open-heart surgery are not likely to be disoriented or psychotic. When they arrive in the intensive care unit, they now might have a window view and see a clock to get their bearings. If they still have trouble coping, a psychiatrist can be called in immediately.
But 40 years ago, surgeons observed that post-cardiotomy delirium was common. Research by two Columbia psychiatrists, Dr. Donald S. Kornfeld, professor of psychiatry at P&S, and associate dean of the faculty of medicine, and Dr. Sheldon Zimberg, clinical professor of psychiatry at P&S, and a cardiac surgeon, Dr. James Malm, professor emeritus of surgery at P&S, showed the problem was related not only to pre- and intra-operative factors, which could not be modified, but also to the environment of the cardiac surgery recovery room. Their 1965 paper in the New England Journal of Medicine led to changes in intensive care unit design and in nursing procedures. The delirium phenomenon later came to be known as ICU psychosis.
In 1971, Dr. Kornfeld, Dr. Richard Friedman, lecturer in psychiatry at P&S, and Dr. Thomas Bigger, professor of medicine and pharmacology at P&S, demonstrated the deleterious effects of sleep deprivation on intern effectivenessand patient healthin the New England Journal of Medicine. These findings led to a change in house officer on-call schedules from every other night to every third night.
These are only two examples of the many ways bedside psychiatry, or consultation-liaison psychiatry, has changed the way medicine is practiced at Columbia and at other major academic medical centers. In the December 2002 American Journal of Psychiatry, Dr. Kornfeld recounted the contributions of the field to medical care in a review of more than 75 research papers, many of which came from the Consultation Liaison Service at Columbia Presbyterian Medical Center.
The review is timely as consultation-liaison psychiatry is expected to receive subspecialty status from the American Board of Medical Specialties in the spring. As a recognized subspecialty, under the name psychosomatic medicine, federal funding will become available for fellowship training programs in the field.
At Columbia, consultation-liaison psychiatry is a division of the Department of Psychiatry that responds to consultation requests throughout the hospital and provides consultation between psychiatrists and other clinicians. Liaison psychiatrists help colleagues in neurology, dermatology, HIV/AIDS, oncology, primary care, rehabilitation, and organ transplantation. For example, the psychiatrists evaluate all patients and donors involved in kidney, heart, liver, and lung transplants and provide assistance after the operation.
Dr. Peter Shapiro, associate professor of clinical psychiatry at P&S and associate director of the Consultation Liaison Service, has published research papers on the evaluation of patients awaiting heart transplant that say that a psychiatric diagnosis is not necessarily a contraindication for transplantation, but should be viewed as a medical complication, and, therefore, as a therapeutic challenge.
Dr. Shapiro also has collaborated with Dr. Alexander Glassman, professor of clinical psychiatry, on a recent preliminary study that suggests treating depressed myocardial infarct patients with an SSRI anti-depressant may reduce mortality rates. Dr. Shapiro hopes such research is just the beginning of a shift beyond treating the psychiatric problems of patients with medical illness to an understanding of how psychiatric problems may affect medical outcomes.
End-of-life care is another key area for the service. Dr. Philip Muskin, professor of clinical psychiatry and director of the Consultation Liaison Service, described the complexity in any patient's request for "assisted suicide" in a 1998 Journal of the American Medical Association paper. Dr. Muskin said a psychiatrist's responsibility is not merely to attest to a patient's mental ability to make such a request, but also to delve into the variety of motives that can underlie it.
The subspecialty's new name has a special significance for Columbia as the late Dr. Helen Flanders Dunbar, director of Columbia's psychosomatic research program from 1932 to 1949, was among the founders of the American Psychosomatic Society and its journal. When Dr. Lawrence Kolb became chairman of psychiatry in 1955, he shifted the focus of what is now the consultation-liaison service from the study of how psychological factors contribute to the etiology of specific disorders to psychiatric care at the bedside of medical and surgical patients.
The consultation-liaison service, an integral part of psychiatric residency and medical student training ever since, trains approximately 12 residents and one fellow per year. Attending psychiatrists have served as psychiatric preceptors to third-year medical students on internal medicine rotations since the 1930s and an elective for fourth-year students also is offered.
"There is a need to infuse medical education from medical school through residency training with such bedside teaching in which physicians learn to better understand their patients and themselves," Dr. Kornfeld says. "Consultation-liaison psychiatrists are particularly well equipped to play an important role in that task."