After being paged by the CL service receptionist that there was a consultation request for evaluation of suicidality and psychosis for Melinda Smith in 3W Room 302, the psychiatric consultant rushed into the four-bed room. Around the third bed, the curtains were drawn, and there seemed to be a procedure being performed. Another patient was snoring. Another patient seemed to be in the middle of her lunch but looked at the consultant curiously. The fourth patient with a nasogastric tube was surrounded by several visitors. The consultant looked around the room, and asked in a loud voice, “Which one of you is Melinda Smith?” One of the visitors of the fourth patient pointed to the woman with the nasogastric tube. The consultant approached the bed, and said, “I am doctor Jones, the psychiatrist. Your doctor tells me that you have hallucinations and delusions and want to kill yourself. Is that correct?”

(What is wrong with this scene?)

The psychiatric consultation interview that occurs in a medical setting often requires special techniques which distinguish it from interviews in other psychiatric settings. The referring physician, or sometimes a nurse, is more likely to recognize a psychiatric issue, and seek help, than the patient. As the consultation request comes from someone other than the patient, the consultant must first establish rapport with the patient, who might not have been aware of the need for psychiatric evaluation, then, assess the psychopathology if present in the context of the medical situation, and answer the particular referral question being asked or solve the underlying problem which may not be clearly stated or even recognized.

The psychiatric consultation interview generally consists of six phases: (1) Preparation Phase, (2) Introductory Phase, (3) History, (4) Mental Status Examination, (5) Discussion of findings and Recommendations, (6) Follow-up visits.

This chapter will focus primarily on phase 1, 2, 5, and 6, as well as the process rather than the content of phases 4, and 5, which are covered in detail in Chaps. 3 and 4.

It is a mistake to think that there is an advantage to interviewing the patient without any prior knowledge about the patient, ostensibly to avoid being biased. The consultation liaison psychiatrist needs to perform an assessment and make recommendations in a timely manner, keeping up with the fast pace of contemporary hospital care. In order to do this, the consultant must work as efficiently as possible, and this requires being well prepared going into the interview. Much of the work of the consultation, in fact, is done prior to seeing the patient.

The information that has been gathered from the referring physician, the nursing staff, the medical records, and sometimes from old records and family members or other interested parties should prepare the consultation liaison psychiatrist for what she/he is likely to encounter in the patient interview. The consultant should also plan the probable duration of the interview. The initial interview for the cognitively intact patient is usually allocated between 20 and 50 min. Before interviewing the patient, the consultant should obtain as much privacy as possible, such as drawing the curtains in a multi-bed room. The consultant should also plan for contingencies, such as what if the patient seems grossly confused or agitated? If there are visitors in the room, should the visitors be asked to leave? What if the patient is in the middle of a meal? What if the patient is asleep?

The rule of thumb for such contingencies to ask the question, “What would the primary responsible physician do under the circumstances?” When the consultant interrupts a meal or awakens the patient from sleep, he/she should apologize for doing so. “Ms. Jones, I am sorry to wake you up, but your doctor wanted me to speak with you in order to help in your care…” We discuss the visitor issue later in this chapter.

We will discuss the introductory phase separately for cognitively intact and cognitive impaired patients, and then discuss the issue of whether or not to include significant others in the interview.