© Hoyle Leigh & Jon Streltzer 2015
Hoyle Leigh and Jon Streltzer (eds.)Handbook of Consultation-Liaison Psychiatry10.1007/978-3-319-11005-9_33. The Why and How of Psychiatric Consultation
(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
3.1 Vignette
The reason for the psychiatric consultation simply stated, “Behavioral problem. Please evaluate.”
When the consultant called the requesting physician, she said, “I don’t really know what the problem is, but the nurses seem to be upset about the patient. The patient just had an MI but is doing OK. I think he may be a little depressed though because he is so quiet.” When the consultant spoke with the nursing staff, the night nurse had written that the patient was observed crying in the middle of the night. Upon interview, the consultant was able to diagnose a recurrent major depression.
3.2 The Nature of a Psychiatric Consultation
Why is a psychiatric consultation generated? Specialty consultations are requested to obtain expert opinion in diagnosing and treating conditions that fall in the specialty area. As psychiatry deals with a vast area of human experience including cognition, emotion, and behavior, it is often difficult to know the exact reason for referral as the Vignette illustrates. Psychiatric consultation, like any other consultation, is not the primary reason for the patient’s hospitalization or contact with the health care system, and not a few patients may be surprised that a psychiatric consultation has been requested. Primary physicians may also be reluctant to request a psychiatric consultation because of the perceived stigma. Therefore, requesting a psychiatric consultation on a patient requires a certain amount of motivation on the part of the referring physician. This motivation is often generated by a strain in the health care unit consisting of the doctors, the nursing staff, and allied professionals around the patient. Common causes of such strain are anxiety, communication difficulties, behavioral problems, and administrative/legal requirements.
While some consultations are generated at the patient’s request, most psychiatric consultations arise out of discomfort on the part of one or more health care personnel, and recognizing this discomfort or strain is an essential part of a successful consultation. It is the consultant’s job to ameliorate the strain so that the health care personnel can proceed to provide medical care without impediment.
As discussed in Chap. 2, the consultant serves two masters—the requesting physician/health care system (consultee) and the patient. The primary role of the consultant is to provide expert advice to the consultee so that medical/surgical treatment can be successfully rendered. A secondary role may be to provide direct psychiatric care for the patient with the consultee’s agreement. In a collaborative care model, such as in medical homes, the consultant may supervise the ongoing mental health care provided by either the mental health care manager or the primary care physician (Croft and Parish 2013; Huang et al. 2013)
The psychiatric consultant is often the face of psychiatry in the health care facility. It is through her/him that the nonpsychiatric physicians form an impression about psychiatry, and, hopefully, learn psychiatric approaches and techniques. The educational function of the consultant psychiatrist, as discussed in the previous chapter, is an integral part of the practice of CL psychiatry.
3.3 How to Do a Consultation
3.3.1 Receive a Consultation Request
Most health care institutions have formal mechanisms for requesting a consultation—computerized request, written request, fax, e-mail, telephone, etc. Informal requests may also be made either by phone or by button-holing. While informal consultations, especially when urgent, are often attended to, it is a good idea to insist on a formal consultation request as well.
3.3.2 Talk to the Referring Physician and Clarify the Consultation Request
Consultation requests are often vague and sometimes misleading (as in the Vignette), usually because the consultee lacks the vocabulary of psychiatry. The consultee is aware of the discomfort of the strain mentioned above, but has difficulty putting it into words. Thus, it is critical that the consultant seeks out the consultee, usually by phone, and asks him/her to provide additional information about the consultation, particularly what the consultee would like from the consultant. It is a good idea to ask the referring physician to be sure to let the patient know to expect a psychiatric consultant, and, if possible, to introduce the consultant to the patient.
3.3.3 Determine the Scope of Consultation
The consultant should be able to determine the probable scope of the consultation after speaking with the referring physician, i.e., whether it is an emergency management of an agitated or acutely suicidal patient, a focused consultation about a specific question, i.e., the patient’s ability to sign out against medical advice, to consent to a surgical procedure, a comprehensive evaluation of the patient in assisting with diagnosis, etc.
Even though the question asked by the consultee may sound focused and simple, at times the consultant can facilitate the medical treatment through a comprehensive understanding of the patient and facilitation of communication, e.g., a patient may decide to stay rather than sign out against medical advice after a question and answer period between the patient and her responsible physician, which was arranged by the consultant.
In general, the narrower the scope of consultation, the quicker should the consultant respond to the referring physician.
3.3.4 Review the Chart
The chart of the patient should be reviewed prior to seeing the patient. Most recent progress notes and nurses’ notes should provide information about the patient’s recent and current status. Medication orders, and more specifically, medications actually administered, should be reviewed, especially for any recent additions or changes that might contribute to the patient’s changed mood or mental status. Laboratory and imaging findings should be reviewed for possible metabolic/structural causes of the psychiatric syndrome, as well as to determine which additional lab tests may be indicated. Reviewing chart notes from prior admissions, if available, may provide a perspective by which to put the patient’s current medical and mental status in perspective. Old records may even have previous psychiatric consultation notes that can be very informative.
Talking with the nurse who is directly taking care of the patient can yield important information not only about the patient but also about visitors and patient’s interactions with the staff. Furthermore, talking with the nursing staff allows them to discuss their impressions of the patient, and any difficulties they may be having in management. Nurses appreciate a doctor who is interested in their input. Their tolerance for deviant behavior will increase when the consulting psychiatrist shows interest. This alone may improve patient–nurse interactions.
3.3.5 Interview the Patient
The consultant should have a reasonable idea about the strain that resulted in the consultation, and the areas to focus in evaluating patient by the time she/he interviews the patient. Before interviewing the patient, privacy should be sought as much as possible—in many cases this may be drawing the curtains around the patient, or, in a private room, closing the door. If there are visitors with the patient, it is in general a good idea to ask them who they are, and then ask them to wait outside for a few minutes while the consultant talks with the patient. The consultant should not identify herself/himself as a psychiatrist until the visitors have left. An exception to this is when the patient’s cognitive function is known to be impaired. Under those conditions, the visitors may remain with the patient’s permission, and can provide valuable history and additional information.
Once some semblance of privacy has been obtained, the consultant should introduce self as a psychiatrist, and ask the patient whether he/she was expecting one. If not, the consultant should explain that the patient’s primary doctor asked a psychiatrist to consult for a comprehensive evaluation—which may be for anxiety, depression, mood changes, memory problems, hallucinations, etc. The consultant should reassure the patient that many medical conditions and medications, as well as the stress of being in the hospital, can cause such problems and they can be managed effectively.
The initial interview should ordinarily take not more than 30 min, and should identify the patient’s current concerns, the presence of major or minor psychiatric syndrome and its history, past history of psychiatric problems, family history, the family and occupational situation of the patient, and current mental status. In general, if the patient is obviously confused or delirious, a mental status exam (cognitive exam) may be performed in lieu of history, which may have to rely on collateral sources. When a patient is not obviously confused, the mental status exam may be performed for 5 min or less at the end of the interview, which can be prefaced by first asking the question, “How is your memory lately?”, followed by, “ I’d now like to ask you some questions to assess your current memory and concentration.”
3.3.5.1 The Mental Status Examination
The mental status consists of the following components: (1) appearance, (2) levels of consciousness and orientation, (3) status of the communicative facilities (speech and movement), (4) content of thought, (5) affect and mood, (6) cognitive processes (attention, concentration, comprehension, memory, perception, thinking logical thoughts, abstraction, judgment). Mental status examination usually refers to cognitive examination, and should be distinguished from mental status, of which cognitive status is a subset. For patients with cognitive deficits, cognitive tests such as the Mini-Mental Status Examination (MMSE) is useful in quantitatively determining the extent of cognitive deficit, and when used serially, in documenting changes in cognitive function (see Chap. 4 for MMSE).
Appearance. Appearance is an excellent indicator of the sum total of a patient’s mental status at a given point. Body build should be first noted, i.e., medium, slender, emaciated, moderately obese, morbidly obese, etc. Sloppy, disheveled appearance often signifies self-neglect or preoccupation and distraction. Flushed appearance and the smell of alcohol on the breath, combined with characteristic drunken behavior, point to the diagnosis of alcoholic intoxication. Pale, emaciated appearance accompanied by malodorous and sloppy dress may indicate the presence of depression or cachexia. Some patients with a lesion in the nondominant hemisphere of the brain may dress only one side of the body, completely oblivious to the presence of the other side (hemineglect, hemiagnosia). Such patients may pay attention only to one half of the visual field. Notations on appearance should include observations on the general impression made by the patient (e.g., sloppy, neat), including any unusual features (e.g., completely shaved scalp, unusual bodily habitus, dress).
Levels of Consciousness and Orientation. Awareness of self and environment constitutes consciousness in the mental-status examination. Consciousness may be subdivided into content of consciousness and arousal. The sum total of mental functions, including the ability to remember and to think, comprises the content of the consciousness, while the appearance of wakefulness and response to stimuli form the bases of inference concerning arousal. The content of consciousness is largely a function of the cerebral hemispheres, while the state of arousal is largely a function of the reticular activating system in the brain stem (Boly et al. 2008; Boveroux et al. 2008; Lapitskaya et al. 2013)
Arousal: Levels of consciousness may be classified as follows:
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