A survey of Midwest physicians' experiences with patients in psychiatric distress in the emergency department

Context: Emergency medicine (EM) physicians commonly stabilize patients with acute psychiatric distress, such as suicidal ideation. Research has shown that suicidal ideation is difficult to manage in emergency department (ED) settings and that patients in psychiatric distress are often "boarded" in the ED while awaiting more definitive care. Objectives: To examine the attitudes and experiences of emergency physicians regarding the care of patients in psychiatric distress. Special attention is given to suicidal ideation due to its prevalence in the United States. Methods: A 19 question anonymous survey was sent via email to 55 emergency medicine residency directors throughout Michigan, Ohio, Indiana, and Illinois, who were identified using an Internet search of residency programs in the region. The program directors were asked to distribute the survey to their colleagues and residents. The intent of this procedure was to generate as many survey responses as possible, while obscuring the identities of the respondents. Responses were gathered from October 29, 2019 until January 16, 2020. The survey was designed to assess respondents' self-reported demographic data as well as their experiences with the boarding process, initial examination, final disposition, reevaluation of the patient, physician training and resources, and follow up care. Statistical analysis was performed using a Mann-Whitney U test, significance was set at p<0.01. Results: In total, 47 EM physicians responded to the survey; however, not all of the respondents completed all 19 questions. Ten of 44 respondents (22.7%) reported that they do not perform the initial psychiatric examination themselves and instead defer to a nurse or social worker. Twenty-two of 44 respondents (50.0%) reported that they defer to a social worker when determining the final disposition of psychiatric patients. Respondents reevaluated patients in psychiatric distress statistically significantly less often (p=0.01) compared with patients with cardiac pathology. Additionally, 15 of 38 respondents (39.5%) reported that they did not feel adequately trained to handle psychiatric emergencies, and 36 of 39 respondents (92.3%) of physicians felt that their facility would benefit from additional mental health resources. Thirty five of 39 respondents (89.7%) reported that their facility did not have a system in place to follow up with suicidal patients upon discharge. Conclusions: Caring for patients who are acutely suicidal or in psychiatric distress is complex and more research is needed to optimize treatment strategies. The results of this study indicate that EM physicians may regularly defer to nonphysician providers when evaluating and treating patients in psychiatric distress. A perceived lack of training in psychiatry may contribute to this practice. The results of this study are in accord with previous research that indicated a need for additional psychiatry training in EM residencies.