© Hoyle Leigh & Jon Streltzer 2015
Hoyle Leigh and Jon Streltzer (eds.)Handbook of Consultation-Liaison Psychiatry10.1007/978-3-319-11005-9_22. The Function of Consultation-Liaison Psychiatry
(1)
Department of Psychiatry, University of California, San Francisco, CA, USA
(2)
Psychosomatic Medicine Program & Psychiatric Consultation-Liaison Service, UCSF-Fresno, 155N. Fresno St., Fresno, CA 93701, USA
2.1 Introduction: The Dual Roles of the Consultation-Liaison Psychiatrist
There are two sets of dual interrelated roles that a consultation-liaison psychiatrist plays—consultation and liaison, and consultant and psychiatrist.
2.1.1 Consultation and Liaison
The term, consultation-liaison psychiatry, consists of the two primary functions—that of a psychiatric specialist providing expert advice on the consultee’s patient and that of a liaison or link. Historically, the liaison function indicated that the psychiatrist was stationed in, and worked as a member of the medical team. Currently, the term has been expanded to indicate the educational, and facilitative function of the consulting psychiatrist, i.e., the linkage the psychiatrist provides the consultee between medical and psychiatric knowledge and skills on the one hand, and the facilitation of communication and understanding that the psychiatrist provides between the patient and the health care personnel. Thus, the liaison function is inherent in the comprehensive approach utilized by the psychiatric consultant to the patient and the health care system. Furthermore, increasingly, the liaison function includes administrative/legal services required of the consultant such as determination of decision making capacity, conservatorship, and involuntary hospitalization.
2.1.2 Consultant and Psychiatrist
The CL psychiatrist is both a consultant and a psychiatrist, i.e., he or she has two masters, the requesting physician (consultee) and the patient. The obligation to the requesting physician often extends to serving the interests of the health care facility, and of society at large. Sometimes this duality leads to an internal conflict, such as in situations when the perceived interest of the patient conflicts with the desires of the consultee, the needs of the hospital, or of society (See Sect. 2.4, below).
CL psychiatry developed mainly in teaching hospitals with psychiatric residency training programs. There is usually a psychiatric consultation-liaison service in major teaching hospitals consisting of one or more full or part-time faculty, one or more psychiatry residents rotating to it, and, perhaps other staff and trainees, e.g., resident rotating from another specialty (most commonly internal medicine or family practice), medical student, psychiatric nurse, social worker, psychologist. Such CL services generally serve several explicit and implicit functions, i.e., clinical, educational, administrative, and research. In medical settings without a formal CL service, one or more full or part-time psychiatrists may be hired or designated to be a consultant for defined times. Such CL psychiatrists’ function may be limited to the clinical and administrative functions.
2.2 Clinical Function: Consultation vs. Referral
The consultant’s primary clinical function in an acute general hospital is to facilitate the medical treatment of the patient since that is the primary reason why the patient is in the hospital. In this sense, consultation should be distinguished from referral, usually seen in outpatient settings and chronic care facilities. In referral, the psychiatrist is asked to take over the psychiatric care of the patient if indicated, while in consultation, the psychiatrist renders an opinion or advice to the requesting physician. In addition to such advice and opinion, the requesting physician usually, and implicitly, requests collaborative care of the patient if indicated, which forms the basis of the direct rendering of treatment by the CL psychiatrist. Except in emergencies and psychotherapy inherent in diagnostic interview and facilitation of communication through meetings and phone calls with members of family and staff, direct treatment of patients including ordering medications should be with the explicit acknowledgement and cooperation of the consultee so as to prevent a diffusion of responsibility for direct care.
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