Medical Assessment in the

Psychiatric Emergency Service

The evolution of emergency medicine from general medicine is
relatively recent. As is the current case in the PES, until the past
few decades practitioners in emergency “rooms” often were moonlighters
whose main professional duties were elsewhere. As the
field of emergency medicine evolved into a distinct medical specialty,
striking changes occurred in the philosophy of practice.
Emergency medicine physicians began to see their task as isolation
and treatment of the presenting condition. Patients who
present with a broken bone may get a focused assessment appropriate
to that body part, but a more extensive physical examination
and medical history may be deferred to the primary care
office, assuming there is one.
As of this writing, the ACGME requires that most psychiatry
residency programs offer a scant 4 months of general medicine
and 2 months of neurology in the internship year. As a result,
many psychiatrists are poorly equipped to handle even routine
medical problems.
Psychiatrists in emergency settings are thus faced with a dilemma.
As emergency medicine has evolved, the tradition of
relying on colleagues in the medical ED for “medical clearance”
of psychiatric patients is inconsistent with their practice philosophy.
Emergency physicians do not conceptualize their role as
something as diffuse as “clearance,” with no index symptoms to
explore. As will be discussed in more detail elsewhere in this
chapter, patients receiving care in the PES are increasingly being
found to be medically ill, and many of the serious medical comorbidities
encountered in people with psychiatric illness may
actually be caused by psychiatric treatment (e.g., dystonia). Psychiatrists
often are in a better position to recognize and treat these
problems.
Medical, Psychiatric, and Cognitive Assessment in the PES 37
The PES demands medically competent psychiatrists. To
that end, the American Association for Emergency Psychiatry
(AAEP) and others have begun to devise structured residency
and fellowship curricula to fill the gaps common in general psychiatry
residency programs. Grounded in the biopsychosocial
model, these curricula stress an integrated approach to mindbody
health.