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Public and community psychiatrists who care for patients with serious mental illnesses regularly face ethical challenges. This article summarizes key ethical considerations in the care of a population that can be difficult to engage and may reject treatment, sometimes necessitating coercive care. The digital revolution in medicine, with its promises and perils and accelerated by coronavirus disease 2019 (COVID-19), has added ethical complexity regarding privacy and access to care. Shared decision-making, a process to resolve ethical dilemmas, and commitments to professionalism and reflective practice are emphasized as three ways to practice ethically in public and community psychiatrists' daily work. Additionally, COVID-19 has highlighted that engagement in social justice is a critical element of ethical practice for physicians today. [ Psychiatr Ann . 2021;51(6):272–277.]

Schizoaffective disorder, which straddles schizophrenia and mood disorders, is a problem for our diagnostic classification system. Its validity as a unique disorder independent from schizophrenia and affective illnesses has not been established, and its reliability in routine clinical care is poor. However, it clearly fills a gap in our nomenclature, particularly for good-prognosis schizophrenia-like cases that remit like mood disorders do. In this article, we provide some historical and conceptual background to help clinicians understand the epistemological challenges of the diagnosis of schizoaffective disorder. [ Psychiatr Ann . 2020;50(5):186–189.]

For several decades, a protection standard has prevailed in determining the conditions under which a mental health provider, in concert with state authority, might intrude upon the civil rights of a person with serious mental illness. This approach contrasts with a treatment standard that guides consideration and assessment of incapacity in all other branches of medicine. This Open Forum examines the rationale, goals, and limits associated with involuntary intervention in serious mental illness compared with the rest of medicine. The authors believe that reviving a treatment standard that focuses on capacity among persons with serious mental illness would help build bridges between psychiatry and general medicine, between patients and providers, and between illness and recovery.

Polypharmacy is common clinical practice in the United States for many psychiatric conditions and for many reasons. In this article we encourage clinicians to use the familiar practice of differential diagnosis to systematically identify etiological factors contributing to polypharmacy. We offer a clinical approach based on (1) reviewing the four main factors responsible for polypharmacy (the disease, the patient, the physician, and society) and (2) answering two questions about optimizing medication regimens (What can I do without explicit permission from the patient or others? What can I do with permission from them?). We contend that all physicians share a professional responsibility for prescribing medications judiciously because unnecessary prescribing exposes patients to unwarranted risks and squanders valuable and scarce resources. Psychiatrists can ask themselves a Kantian question: would my way of prescribing lead to good, socially acceptable outcomes if followed by all physicians treating similar patients?

Learning about the scope of psychiatric practice in the general hospital is essential for trainees and their patients. Consultation-liaison (C-L) psychiatry (officially named psychosomatic medicine), the subspecialty of psychiatry that deals with the care of patients with comorbid psychiatric and medical/surgical illness, is taught through formal didactics, teaching and bedside rounds, and demonstration of specific skills (eg, critical thinking, autognosis [self-knowledge]). Both the process and the content f these educational forums are equally important. In this article, we discuss the heory, place, techniques, and challenges of teaching the craft of consultation sychiatry.

Ms. A is a 36-year-old, married woman, referred by her gynecologist to psychiatry because the patient was having a difficult time accepting her diagnosis of uterine agenesis. When Ms. A was initially seen by the consulting psychiatrist in the Women’s Health Center, she was working full time at a local retail chain and was married, though she and her husband had always lived separately with their families of origin. She had graduated from high school and had held her current job for 15 years. She reported that she and her husband had been married for 4 years, with no children. The patient described a childhood full of medical tests attempting to explain her constellation of symptoms, which included low body weight, alopecia, and precocious breast development. Ms. A was unable to explain her medical diagnosis and stated that she had undergone an extensive workup at Children’s Hospital, though “they could never figure out what was wrong.” Ms. A has two brothers born with congenital problems—one with severe cognitive impairment and one with abnormal brain vasculature.

Background The commonly-accepted “biopsychosocial model” does not always lend itself to the kind of pragmatic decisions that many clinical situations demand of physicians. Objective The authors attempt to identify and close gaps in the biopsychosocial model that hinder its application in certain real-life clinical situations. Method The authors review some of the current and historical literature on the development and application of the biopsychosocial model, and argue the shortcomings of this modality in various clinical situations. Results The authors present three dicta to guide clinicians toward relevant areas of inquiry: 1) Think neuroanatomically; 2) Think existentially; and 3) Think “dirty;” that is, understand that patients and physicians sometimes work toward different goals. Discussion These dicta form an addendum to the biopsychosocial model, identifying and filling three specific, commonly-encountered gaps in that paradigm, which, ironically, is usually considered all-inclusive.

Delirium is a neuropsychiatric syndrome of disordered consciousness and cognition whose hallmark is a gross deficit of attention. A frequent complication in critically ill medical and surgical patients in the general hospital, especially those in the intensive care unit, delirium should be considered a state of acute brain failure, alongside other types of organ failure. It is caused not by geographic assignment to the intensive care unit but by diverse medical and surgical conditions and their treatments. As such, its definitive treatment is reversal of these underlying medical and surgical problems, and minimization or outright discontinuation of offending therapies.

The two fundamental tasks of the consultation psychiatrist, diagnosis and treatment, can sometimes seem at odds with the consultee's desired plan or outcome. While implicitly recognized, this fact is rarely explicitly taught to residents or addressed in the literature. The authors proffer three principles of inpatient consultation psychiatry aimed at dealing with tensions that can arise over issues of; 1) diagnosis (Principle I: Do not be afraid to refute notions of psychopathology); 2) medication (Principle II: Do not be afraid to discontinue unnecessary psychotropics); and 3) responsibility (Principle III: Do not be afraid to "sign off" when necessary). These principles emphasize the medical model, the status of the psychiatrist as a medical expert, and the importance of defining one's professional limits.

Background The 4-abilities model of decision-making capacity is vulnerable to constricted application and teaching. Objective The authors attempt to assert the fundamentally clinical nature of capacity evaluations, while acknowledging that the concept of decision-making capacity must be legally grounded. Methods Relevant aspects of clinical care are examined and emphasized as they apply to the evaluation of capacity for medical decision making. Results Accessing patients' maximal abilities, attending to noncognitive aspects of choice, and identifying diagnostic explanations for patients' difficulties are important components of these assessments. Discussion The evaluation of medical decision-making capacity is not a purely forensic task; it is enhanced by an approach that bridges the clinical-forensic divide.

In their Viewpoint about discharges against medical advice, Drs Alfandre and Schumann1 asked, “Why would you discharge a patient against medical advice?” Until this question is answered, they argued, “continued use of the practice does not seem justified.” We believe the authors conflated 3 different scenarios, a clarification of which may help to answer their question.

Background Psychiatric consultations involving the evaluation of patients' medical decision-making capacity often seem to have little to do with truly compromised patient autonomy. Objective The authors seek to examine hidden ethical dilemmas that lead to capacity evaluation requests. Method The authors utilize the "principlism" approach to biomedical ethics to illustrate some common moral issues in patient care that are poorly captured by the "autonomy-versus-paternalism" paradigm. Results Patient autonomy sometimes comes into conflict with ethical imperatives to do "good," to avoid harm, and to deliver care fairly, as well as with the autonomy of others. Consultation psychiatrists are well positioned to unearth these dilemmas and begin to address them. Discussion Effective engagement of everyday ethics in clinical medicine is hindered by reflexive resort to capacity evaluations when moral problems arise. Greater attention to matters of values, aggressive urges, and obligations to others can enhance the negotiation of routine ethical dilemmas.

All physicians can find themselves feeling compromised by patients who are behaviorally inflexible, temperamentally difficult, or inappropriately demanding. While empathic negotiation, education, and persuasion rightly rule the day with such patients, we notice a general reluctance to confront those who are unresponsive to these measures. When confrontations do occur, they are sometimes mishandled. Our choice of the word confrontation is deliberate and incorporates 3 definitional elements to capture the essence of clinical interactions that (1) are interpersonally “face-to-face,” (2) carry the potential for emotional “clashing,” and (3) force a “comparison” between 2 points of view on medical care.1 Confrontation stands in contrast to criticism by connoting a communication tool informed by “doctors' sense of patients' best interests” and by a view of patient centeredness that relies heavily on shared responsibility.2 We propose a rationale for the judicious use of confrontation in patient care. Case vignettes are used to frame discussion. As the focus is on confrontation, readers are asked to assume that other interpersonal and social interventions have already been attempted with these patients. Our goal is to stimulate dialogue on an important subject that could reduce therapeutic misadventures, physician frustration, and resource misallocation.

The commonly-accepted "biopsychosocial model" does not always lend itself to the kind of pragmatic decisions that many clinical situations demand of physicians.The authors attempt to identify and close gaps in the biopsychosocial model that hinder its application in certain real-life clinical situations.The authors review some of the current and historical literature on the development and application of the biopsychosocial model, and argue the shortcomings of this modality in various clinical situations.The authors present three dicta to guide clinicians toward relevant areas of inquiry: 1) Think neuroanatomically; 2) Think existentially; and 3) Think "dirty;" that is, understand that patients and physicians sometimes work toward different goals.These dicta form an addendum to the biopsychosocial model, identifying and filling three specific, commonly-encountered gaps in that paradigm, which, ironically, is usually considered all-inclusive.

With anesthesiology increasingly practiced outside the operating room (OR) environment, it is important that anesthesiologists begin to identify and to teach the communication skills required for practice in non-OR general hospital settings. The "one back" position of the consultant, and the associated diminished sense of immediate control, can generate discomfort for many clinicians. This article discusses the literature regarding practice as a consultant and the navigation of conflict with an emphasis on how anesthesiologists might apply the findings to out-of-OR practice.

Objective To identify scenarios in which consultation psychiatrists encounter difficulty reconciling their clinical role with consultees' expectations and to suggest concepts that help navigate these situations. Methods The authors' clinical experiences are used to generate and discuss three major categories of situations that require psychiatric consultants to thoughtfully adjust the breadth and depth of their obligation to patients and consultees. Results "Occam's razor ‘dulled," "Conflation of the psychosocial with the psychiatric" and "Disposition preoccupation" are proposed as the major categories leading to conflicting patient management views between consultant and consultee. Each has, at its core, a compromise of patient ownership that blurs the boundaries of the consulting psychiatrist's responsibility . Conclusions Understanding and channeling ownership back to the consultee, while appropriately gauging and embracing one's responsibility, form a two-pronged approach to clarifying one's role in consultations.

The psychopharmacologist designation currently pervades and heavily influences the practice, perception, and teaching of clinical psychiatry. The authors hope to make a case and provide the raw material for informed discussion of this role during psychiatric residency training.A definition for the psychopharmacologist is sought. Historical trends in psychiatry which contributed most to its evolution are explored. Problems of the psychopharmacologist role are delineated. Extant solutions to psychiatry's problematic adaptation to an increasingly biological clinical role are critiqued, and a more effective one is pursued.The term psychopharmacologist seems linked to presumed scientific and medical approaches, a goal of symptom relief through medication, and often other providers who are considered patients' "primary" treaters. The role derives largely from economic and remedicalization trends. Aspects of disengagement are determined to form the core problem of the psychopharmacologist. The authors propose that psychiatry is defined by its practice of the medical model and call attention to three areas where the psychopharmacologist role and the medical model collide.Engaging psychiatric residents in a new dialogue about their role as physician will challenge the previously unquestioned psychopharmacologist categorization, begin to address its problems, and bring a vital element to trainees' professional identity development.

The term institutionalisation describes dehumanising processes by which people with mental illness were assimilated into the workings of large, long-term psychiatric hospitals. Patients were pushed further into deviance by role expectations imposed on them by the asylums’ operational needs

The invocation of exceptionalism can be beneficial, but it can also exact a cost. Employed nationalistically – for example, ‘American exceptionalism’ – it can inspire the citizenry or rally a mob. ‘HIV exceptionalism’ protects vulnerable patients but may compromise public health.