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.
Excellent! Can identify. Like the request for a psych consult for an 'upset' patient. Failed to mention the multiple suicide attempts, the OCD and other psychological history.
I completely agree..this happens All the time. And like you said, these are not morons..these are decent physicians who do care for their patients. I suspect this has something to do with the dogma associated with psych..as soon as there is a whiff of mental disorder, most doctors dissociate. Its ridiculous, and the only good way of dealing with it is giving continuous feedback. Every time.
Good job, Roy. I take back all of the bad things I have said about you.
Oh no! who will prevail when Dr. Rob wants Dr. Roy to ask himself "What question does Dr. Rob want me to answer?" and Dr. Roy wants Dr. Rob to say "Here is the question I'd like you to answer"?
(Ask not what your consultant can do for you, but what you can do for your consultant?)
As to your last point, about assuming that any patient on a psychiatric medication has a psychiatric illness, does this typically occur with all psychiatric drugs (eg very commonly prescribed drugs such as SSRI's) or only with less commonly prescribed psychiatric medications?
Not to rain on your parade but how can I talk to you if you won't even return my page. I have come to the sad conclusion that psych (and derm) are fields that are of the opinion that returning pages are optional.
Terrific letter! I especially like the last point, as I've seen medical doctors and nurses who treat anyone with a psych history really crappy because they must be "crazy," and blow off serious symptoms because of it.
It's been a long time since I was in this role. My "can you believe" story that still sticks vividly in my head: 74 year old with no psych history who started hallucinating post-op. I suggested that this was not a primary psychiatric disorder (meaning the patient didn't just happen to become schizophrenic in the hospital) and that it had something to do with that white count of 20,000. The patient was discharged that day. Ugh.. Long ago and far away, I don't know what happened.
I think docs are intimidated by psychiatric disorders and psychiatric patients. I think it's getting better as more and more people are treated with SSRI's, it's more openly discussed, and all you have to do is ask to find a friend or family member on psychotropics. The one way that pharm advertising has helped (I think).
Just rambling. So what's new.
Nicely put. Isn't this just the tiresome mind-body split coming up again? A psychiatrist would probably be comfortable checking to see whether a patient has a pulse, after all, so a surgeon could check to see whether a patient is oriented X3. And it's turf, too, isn't it? Got to protect that! Now that I think of it, maybe we can throw in managed care, too, and its contribution to doctors' feelings of "this is the most I can do right now."
Lynn, MSW, who's spent many swell hours in the ER and psych ward with Seriously & Persistently Mentally Ill patients.
That's an excellent letter. Bravo!
its important to remember that those with a psychiatric history arent made immune to physical illnesses
my cronic fatigue was said to be depression for years until I managed to get a sleep study which diagnoses severe sleep apnea
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