Psychiatrist: My Medicine Raised Our Patient’s Blood Sugar, Can You Help? PCP: That’s a Dump!

If my hypertensive patient develops orthostatism and falls and breaks her hip, I fully expect the orthopedic surgeon on call to treat her. I may kick myself that this happened but I’m not qualified to treat a broken hip.

If my anticoagulated patient hits his head and suffers a subdural hematoma, I expect the local neurosurgeon to graciously treat him even though it was my decision and not his to start the patient on his blood thinner. After all, brain surgery is tricky stuff.

Why is it then that primary care docs, sometimes myself included, feel a little annoyed when we have to deal with the consequences of psychiatric medication prescribing?

My psychiatry colleagues diligently order the blood work that is more or less required when prescribing atypical antipsychotics, for example. But when the results are abnormal I get a fax with a scribble indicating that the PCP needs to handle this.

We need to just deal with that and appreciate that there has been communication between treating providers. Because that doesn’t always happen. Particularly with medication prescribing, we don’t always get a notification from our psychiatry colleagues when a patient is started on something new because their records are so much more secret than ours.

The other day I sat in my monthly conference with staff from the Behavioral Health Home that I serve as the medical director for. I consult on clinical and policy matters.

I heard of a couple of examples like the one in the headline and thought that we need to have a Clinical Collaboration Contract in place between providers who see these patients.

This would require notification when medications are started or changed and an expressed understanding that the participating clinician who is best qualified to treat a complication of either a psychiatric or somatic medication should do so.

If a prescribing provider notices that their prescription has a side effect, but the medicine is clearly the best choice for the patient, I can’t just expect them to stop what may be a major therapeutic breakthrough for the patient.

Here are some ideas for what a Clinical Collaboration Contract might include:

I will tell my colleagues if I start, stop or change any medication.

I will share lab work I have done in order to avoid duplication.

I will update my colleagues on major changes in the patient’s health or circumstances.

I will collaborate with my colleagues for the benefit of the patient even if it’s inconvenient.

I will not criticize my colleagues in front of my patient but raise my concerns provider-to-provider in a professional and open-minded manner.

Maybe this is too obvious and self evident to formalize, but judging from the stories I heard the other day, it probably isn’t.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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