Sarah Chauvin is a medical student in the Class of 2018 at the University of Toronto
Collateral. Collateral. Collateral. Three weeks in a psychiatric Emergency Department, and I have more than a mere appreciation for collateral: I’ve come to understand it as a key diagnostic investigation.
Toward the end of my weekend call shift, my young patient with severe alcohol use disorder and borderline personality disorder — who had been discharged the week prior with an addictions referral — was back in the ED for alcohol intoxication. Though I had been cautioned that the patient would likely return, I was disappointed to see her name back on the patient-tracking list.
As I entered the waiting room, I saw her sprawled across two seats with mascara streaming down her cheeks, picking at the scabs on her forearms. She remembered me and looked momentarily relieved. When I began the interview she started sobbing, telling me she had left AMA from a community hospital where they had the audacity to put her on a “Geriatrics” floor. She told me she had not seen a physician in the last 48 hours, and that even though she had requested more Valium for her withdrawal symptoms, a nurse was never available. As her emotions escalated, I tried to get her to slow down by having her take a few deep breaths with me. I then switched into validation mode to work with, rather than against, her borderline traits.
Once she had calmed down, she was able to tell me that she had returned home shortly after discharge and continued to drink until her family brought her to their local hospital. That morning, she called her friend to drive her to our hospital because she had met with the addictions physician from our referral and was on a waitlist for inpatient treatment. I gently told her that we had no record of her meeting with that physician, and wondered if what she was telling me was the truth. She insisted she had, but that she was confused about the happenings of last week. She then gave me consent to call her friend, her mother, and her family physician.
I went back to my resident and told him what little I could, then started my phone calls. First, I called the local hospital to have them fax over her records, confirming she had left against medical advice. Next, her friend confirmed that he had driven her to the ED. I then called her mother, who confirmed she had gone to the clinic appointment with her daughter. Lastly, I called her family physician, who faxed over his exchanges with the clinic and filled in some of the gaps from the past week. By the end of my phone calls, after having effectively “interviewed” four people, we made the decision to admit her overnight with a transfer to an inpatient unit when a bed became available.
Prior to starting my psychiatry rotation, I had been on paediatrics. There, it was easy to obtain a logical timeline of events from concerned parents who were almost always the most reliable historians. I didn’t usually feel the need to double-check facts with other sources prior to presenting a case to my staff. In retrospect, I had been gathering collateral for my patients for the entire rotation without truly appreciating it. It really wasn’t until my psychiatry rotation that I recognized the meaning of collateral, and how important it is to not accept everything at face value — to dig deeper and appreciate the components of the history that were not adding up.
I admittedly felt a bit betrayed when I discovered through collateral that my patient with antisocial personality disorder was seeking admission for secondary gain, or that my patient with substance use disorder had a history of seeking Valium in emergency departments. I also found obtaining collateral to be extremely frustrating, sometimes finishing a 40-minute history only to have to call an additional two or three people for more information. Yet it was also very gratifying to use that collateral to develop a plan that better served the patient’s needs and improved the allocation of health resources.
Through collateral, I also gained a better appreciation for how to conduct an interview over the phone. It was initially a bit awkward not being able to read facial expressions or knowing when to pause. There were also moments of intimidation, being the lowly third year clerk calling up prominent psychiatrists in the community to inquire about their patients. I could sense when I was interrupting someone’s busy day, or when I didn’t cut to the chase fast enough for some physicians. I learned from these negative phone interactions to always have the ED fax number jotted down in front of me, and to always have the chart open so that I could answer questions in a timely fashion. I also learned the types of information that could not be communicated over the phone without consent.
I opted to reflect on collateral because I believe that it is an important extension of patient-physician communication — one that I didn’t necessarily realize existed prior to my time in psychiatry. Regardless of which field of medicine I choose to specialize in, there will be instances in my career when I will need to communicate with other sources to make the right decision. Furthermore, obtaining collateral is a form of communication that requires treading the line between maintaining confidentiality and eliciting the information needed to make decisions. Collateral can also take many forms, including in person and over the phone, and can involve different professionals and non-professionals. I strongly believe that this experience has made me into a more effective communicator: one that will critically analyze what my patients tell me, and one that will seek out collateral when it is needed.
Note: All characters in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
This is an important lesson and I recall my own passage of learning to obtain information about my patients from various outside stories.
I sense that mistrust has grown over the years, and I wonder if that’s not the fault of the system rather than the patients we serve and treat.
This sounds like yet another patient bounced around from one setting to another, desperately trying (and good for her!) to receive meaningful treatment, and instead finding herself assessed and re-assessed over and over again.
Borderline personality disorder is a treatable condition, although admittedly the treatment is complex and expensive.
Still, in a better world and a better system, this patient would be in a “real” DBT program (a virtual impossibility in my city of Toronto) and some kind of trauma-informed therapy, since almost every borderline patient has a history of severe developmental trauma and neglect.
Someone recently said to me that mental health patients in the Ontario medical system spend 80% of their time receiving assessments and only 20% receiving any kind of therapy (despite the fact we know each assessment is to some degree re-traumatizing and that often the therapy received is inappropriate for the specific condition, e.g. CBT for borderline personality disorder).
Our newly graduated physicians deserve to work in a system where mental health patients receive mental health care, rather than wander through series of revolving doors.