December 4, 1998

Thou shalt not try to convert pediatricians into psychiatrists was one of the 10 commandments passed on to consultation-liaison psychiatrists by Gregory Fritz, M.D.

Fritz spoke last month at the annual meeting of the American Academy of Child and Adolescent Psychiatry in Anaheim, Calif. He was the winner of the Simon Wile Award, which honors a renowned pediatrician and lifelong supporter of child and adolescent psychiatry. The recipient is recognized for outstanding leadership and continuous contributions in the field of consultation-liaison child and adolescent psychiatry.

Fritz is director of child and family psychiatry at Hasbro Children's Hospital and Bradley Hospital and a professor of psychiatry at Brown University in Providence, R.I. He advised C-L psychiatrists in children's hospitals to follow these commandments:

1. Talk often and avoid jargon. "Our pediatric colleagues' most frequent complaint is that child psychiatrists don't communicate easily and frequently enough. To keep the referrals coming, we must follow the example of our oncology and orthopedic colleagues who dictate a letter to the patient's pediatrician after seeing the patient, which serves as the progress note."



2. Don't try to convert pediatricians into psychiatrists. "C-L psychiatrists sometimes view ourselves as missionaries, taking our message to the heathen. In general, heathens don't want to be converted, and it doesn't wear well for the missionary either."



3. Recognize inherent professional differences. Pediatricians tend to be practical, reassuring, optimistic in their view of childhood, interested in normal development, and oriented toward public patient advocacy. In contrast, psychiatrists tend to be reflective, tolerant about anxiety, more pessimistic in their view of childhood, interested in psychopathology, and oriented to helping individual patients improve.



4. Don't be fooled by articulations of the biopsychosocial model. "Given that most medical students and residents have been taught this model in the last decade, it is remarkable how few physicians practice it despite the evidence that psychological interventions can reduce medical utilization."



5. Fight important battles. Advocate against mental health carveouts and reductions in mental health benefits and space for psychiatric staff and research in hospitals. Don't fight intrahospital turf wars, symbolic points, and specialty status for behavioral pediatricians.



6. Be an activist. "Don't wait for every-one's blessing, including managed care authorization, before acting. It's better to do something good and ask for forgiveness later than become paralyzed while waiting on the bureaucracy to grant permission."



7. Think big in terms of a C-L service. "We need to have a large staff, including psychiatrists, psychologists, and nurses, who can manage pain medication, biofeedback, psychopharmacology, and behavioral techniques and understand the intricacies of hospital politics and systems."



8. When a case becomes confusing, disorganized, and hopeless, call a meeting. A case conference with all the relevant staff, including attending physicians, trainees, and consultants, allows them to pool their expertise, stimulate discussion of ideas, and share solutions.



9. Research is the best therapy for C-L psychiatrists. "Research allows us to focus on an area of interest and is good for the field, patients, and physicians. It is also a good antidote to the frustrations and lack of control experienced in C-L psychiatry."



10. Be persistent. "C-L is not a popular subspecialty in psychiatry because there is no set schedule, it is poorly paid, and it can be isolating. However, C-L psychiatry is also fun and interesting, taps all of one's medical skills, and offers the opportunity to influence a case in a short amount of time."