Saturday, July 07, 2007

An Open Letter to Hospital Physicians Requesting Psychiatric Consultations


I saw Rob's excellent An Open Letter to Consultants over on Musings of a Distractible Mind (please go over there and read his letter first... my letter attempts to match his "tone" so don't get all offended if it comes off as testy), so I thought it would make sense to write a similar letter, aimed at medical and surgical attendings who request an inpatient consult from the Consultation-Liaison service. I have also rolled into this my thoughts from Intueri's recent post about delirium in surgical patients.



Dear Requesting Physician:

Thank you for asking me to see your patient in the hospital.

While I understand that you had a few extra years of medical or surgical training above me, and certainly have extensive knowledge in your clinical area, I would like to share with you a few important points about our relationship. Understanding these things will help me better care for your patients and will greatly help me get what I need so that I can do a better job with the consultations I receive from you.
  • You are not a moron. You went to medical school and probably did a psychiatry rotation. When you request a consult, please -- at a minimum -- tell me what your concern is. "Depression." "Confusion." "Overdose." "Suicidal." Even "acting weird" will do. But "psych consult" is not a reason for a psych consult. Please be more specific.

  • Your patients are not morons. If they are in the hospital for chest pain and you ask me to see them because you think these are panic attacks, tell your patient I am coming. I've gotten really good at smoothing this over with them, but they are usually shocked, surprised, and sometimes even insulted, that a psych consult has been requested without their knowledge. Having to explain why to them (especially if you haven't given me the reason) can make it harder for me to establish a trusting relationship with them, which really helps if they are going to give me useful information. Be straight with them and tell them you want a second opinion or that you want to "cover all the bases."

  • Contact me. Call me on the phone and speak to me personally about what is going on with your patient. This is immensely helpful as you have clues in your head that do not get written down on paper. You probably won't write down "I think patient's wife and job is stressing him out to the point that he is probably faking this 'abdominal pain' and making himself vomit, because I can't find anything wrong with him so he must not be truly sick," in the chart, but it would really help me to know that is what you are thinking before I spend an hour addressing some other aspect of this patient.

  • The "Mental Status Exam" section of the H&P is not restricted to only psychiatrists. Anyone can do one. If you expect your patient has a psychiatric problem, it is customary (though, unfortunately, more rare) to perform a mental status exam, however limited. If your patient had respiratory difficulty, I am certain your exam would be more than simply "Lung: resp 24 and labored."

  • Here's the most important one. Just because your patient has a history of psychiatric illness or is on a psychiatric medication, don't automatically assume that the presenting symptom is due to one of these. Don't stop looking for the cause of their sudden-onset left-sided weakness just because there is a history of schizophrenia.

I promise to do what I can to make your job easier. Please help me in my quest to do what is best for your patients.

Sincerely,
Dr. Roy