Psychiatric
Consultation-Liaison Service
UCSF-Fresno
Medical Student Orientation
Hoyle Leigh, M.D.
Director
Professor of Psychiatry, UCSF
Beena Nair, M.D.
Associate Director
Associate Clinical Professor of
Psychiatry, UCSF
Revised June 24, 2014
Psychiatric Consultation-Liaison Curriculum
Community Regional Medical Center,
UCSF-Fresno
This orientation is primarily
for psychiatric residents taking a 3 month rotation in CL psychiatry, but is equally relevant to the medical student, though the expectation
of learning is, of course, graduated on the level of
training and the length of rotation. Nevertheless, many students can, and have learned and functioned at a level comparable to psychiatric residents during their rotation to our service.
No matter what specialty you might
enter eventually, you are likely to encounter the kinds of patients and problems you encounter in the consultation-liaison
setting, and your experience
in this service will prove to be extremely
valuable. In addition, it
is our hope
that you will learn to understand
patients in any setting as human
beings adapting to various life situations including
that of disease and the health care system.
After you have observed or performed a
consultation with a resident
or attending, you will be authorized
to do initial consultations on your own. At this
point, all the information and procedures below intended for the resident apply to you as well.
All notes written by a medical
student MUST be co-signed by an attending or a resident.
The students are expected to :
1. present all the cases seen at the daily
rounds according to format below.
2. complete write-ups thoroughly and in a timely manner.
3. make a Biopsychosocial presentation according to format below usually during
the last week of rotation (Regular
Clerkship Students Only).
4. complete assignments
that may include reviews of literature or other questions asked at rounds or during supervision.
5. attend seminars and courses as requested and appropriate including CL Psychiatry Seminar with Dr. Leigh or Dr. Nair.
General Introduction
Welcome to Consultation-liaison psychiatry. It is through
contact with consultation-liaison psychiatrists that most patients and
physicians learn and form impressions about psychiatry. Indeed, one might
call it the face of psychiatry.
Consultation-liaison work is fun albeit sometimes stressful. It is fun
because it is never boring, and often full of surprises. Most patients
present with both psychiatric and medical/surgical problems, both have to be
taken into account in developing diagnoses and formulating a management
plans. Very often, interactions among the patient's personality, family,
the ward milieu, and the treatment team must be taken into account.
Consultation-liaison psychiatry is truly the practice of bio-psycho-social
approach.
Consultation-liaison psychiatry has a number of facets that are important
in training. First, it is an academic endeavor. Psychosomatic
medicine, or the study of the interface between psychiatry and medicine, is an important
component of this. Studying the role of hospital milieu on course of
illness, the role of health care systems, e.g., managed care, and the role of
political/legal systems in health care (e.g., emergency certificates) is
another important component. In the liaison function, the trainees have
an opportunity to educate nonpsychiatric
professionals (referring doctors, nurses, social workers, etc.) and medical
students. Secondly, consultation-liaison is an important clinical
training for the general psychiatrist as a significant portion of their
patients will have co-morbid medical/surgical conditions. An
understanding of the hospital system that the trainee learns in the
consultation-liaison setting may play an important role in any future administrative
roles he/she may assume. Thirdly, the consultation setting is an
important venue for obtaining referrals for the practicing psychiatrist.
Thus, many successful private practice of psychiatry includes consultation
activity both in inpatient and outpatient settings.
Consultation-liaison is an exciting rotation for the trainees to integrate
their psychiatric and medical skills, to teach and learn, and, often, to
provide the human dimension in the care of medical patients.
Objectives
It is assumed that trainees who start this rotation have already obtained the
basic skills of interviewing patients, developing a differential diagnostic
approach and making a tentative psychiatric diagnosis, formulating a strategy
for further evaluation and developing a management plan. It is further
assumed that trainees have sufficient medical knowledge and skills to review
the medical records of patients and communicate effectively with the
medical/surgical colleagues.
By the end of this rotation, each trainee is expected to be able
to consult on a medical/surgical patient independently and competently:
Each trainee must be able to describe the
function and role of psychiatric consultation-liaison service in a general hospital/health
care facility, and be able to explain the basic concepts related to
consultation-liaison psychiatry and psychosomatic medicine.
Each trainee must be able to
interview/assess patients in varying degrees of distress and/or with
communication problems, such as delirium, stupor, physical pain, dementia,
aphasias, catatonia, agitation, and mutism.
He/she must have learned flexible interviewing techniques taking into account
the patient's current mental and physical state.
She/he must be able to differentially
diagnose and evaluate a patient taking into account possible contributions of
medical disease to psychiatric problems as well as possible contributions of
psychiatric problems to medical problems including non-adherence.
He/she must be able to recommend
appropriate laboratory tests and imaging studies in further evaluating delirium
and/or dementia.
Each trainee must be able to obtain and
make effective use of collateral information in evaluating and managing a
patient.
Each trainee must be able to understand
and describe possible contributions of personality needs of patient and staff,
and the influences of social systems issues that might contribute to a
therapeutic impasse or tension, and suggest rational resolutions.
She/he must be able to understand and
describe the role of stress, social support, and the environment, including
hospital milieu, in the pathogenesis, course, treatment, and recovery from
illness.
Each trainee must have familiarity in the
use of psychotropic drugs in patients who have medical illness (and thus have
compromised organ function), and be familiar with psychotropic drug
interactions with other drugs.
He/she must be able to manage acutely
agitated psychotic or delirious patients.
Each trainee must be aware of community
resources, and be able to make effective referrals/transfers to psychiatric
facilities when indicated.
It is also strongly encouraged that
trainees take opportunities to view brain images (CT and MRI) and correlate the
structural and behavioral abnormalities.
Each trainee is expected to be
up-to-date through reading and conferences where new knowledge and skills can
be absorbed.
Requirements
1. Each patient must be presented in the CL
rounds according to format below.
2. Each resident must do a Biopsychosocial presentation on a patient during the last 2
weeks of his/her rotation
3. Each resident is required to participate in
Journal club every Tuesday when they will be presenting articles/topics related
to the cases they have seen during the week.
4. All patients must be entered into the CL
database appropriately.
5. Each note should indicate that the
resident had supervision by a named attending, e.g. "Discussed
with Dr. X"
6. Teaching and communication with other trainees and allied professionals as
indicated.
Clinical
Procedures
Consultation
1. Definition: A consultation begins when
our service receives a consultation request. Usually, a physician on medical/surgical
service fills out a consultation request in Epic, which results in a page, an
email to the Service, and a printout in the fax machine. Consultation
requests may also be made by a physician (attending or resident) by telephoning
our service, or phoning/paging one of the psychiatry residents, in which case
the physician should be asked to fill out the form as well. A
consultation is completed only when 1) the consultation was discussed at
rounds or with an attending, and 2) a consultation note has been placed in
Epic, 3) the consultant discussed the initial consultation with the
requesting physician in person or on the phone, and 4) at least one follow-up
has been made (unless the patient is discharged or transferred before follow-up
can be made). It is the responsibility of each resident to complete any
consultation received.
2. When to do
a consultation: The urgency of a consultation is in the
mind of the requesting physician. Therefore, call the referring physician
as soon as the consult is received (see above) to 1) clarify the
consultation request, and 2) determine the time of consultation. Usually,
the initial consultation should be done within the same day the request has
been received. There are, of course, stat consultations that must be done stat. When you speak with
the referring physician, however, you may find that he/she wouldn't mind your
seeing the patient in 2-3 hrs even though the request said stat. The first phase of
a consultation, then, is a phone call to the referring physician.
Remember, a non-responsive consultant raises anxiety levels in everyone
concerned.
3. How to do a
consultation:
1) Call the requesting physician (as
above) to clarify the
consultation. Quite often, the consultation request form offers few
clues about the true nature of the consultation. When speaking with the
requesting physician, ask about the medical/surgical condition of the patient,
why psychiatric consultation was requested, and how urgent the consultation is.
You might also ask if the patient was told that a psychiatrist would be coming,
and if not, encourage the referring doctor to do so. You could also
negotiate the time of your consult depending on your assessed urgency, and tell
the referring physician when, e.g., "I'll probably see the patient in 2
hrs", or "Looking at my schedule, it would be best if I saw the
patient first thing in the morning, would that be OK?"
2) Gather existing information about the patient from 1) medical records,
2) nursing staff, and, if available, 3) family, friends, co-workers, or other
collateral sources (this may have to be done after seeing the patient).
Determine from nursing staff whether an interpreter would be needed.
In reviewing the current chart, pay particular attention to lab
values that may explain an altered mental status, and any medications that
might contribute to psychiatric symptomatology.
Concerning California emergency certificate (5150), any 5150 executed by
police or EMT becomes inoperative once a patient is admitted to the
hospital for a medical reason according to the new Hospital Policy of
2005. Once the patient is medically stabilized and the patient is in need
of emergency psychiatric hospitalization, a new 5150 may be executed if
necessary (refer to the CMC Patient Care Manual-5150s and 5250s-Involuntary
Hold)
3) Interview the patient:
a. For the first
2-3 consults, interview the patient with an attending present if at all
possible.
b. The initial
interview should be approximately 30 minutes, and should include a mental
status examination on most patients. The interview should be flexible
depending on the state of the patient and the nature of the consultation.
c. Interview
should be conducted as privately as possible, e.g., draw the curtains around
the bed, if the patient is ambulatory, find a private room or area if possible.
If visitor(s) are at bedside, ask
them to step outside during the interview. If the patient insists on having
visitor at bedside document that.
d. In an acutely agitated, suicidal, or
homicidal patient, a California emergency certificate may be needed (5150).
It is available at the CL office.
4) Present the consultation at rounds or with an attending if
urgent.
5) Fill out the Psychiatric Consultation Template in Epic
and copy the relevant sections into the CL Database Patient Form (CL secretary,
Resident, or Attending will show you how to do this).
6) Please note that the two computers in
CL Service have desktop icons for the forms. The database can also be
accessed in any computer in the hospital as long as your id has been given to
CL secretary and you follow the procedures for log-on that is available with CL
secretary. If you input into the database, one can access it from anywhere in
the hospital
7) After presentation in rounds,
edit/revise your Consultation Report.
Call/page the requesting
physician (preferably the
person you spoke with initially, but any member of the team may suffice) and
discuss what you found and what you are recommending.
8) If the patient is a patient/client of
a mental health professional,
obtain patient’s permission to speak with the mental health professional if
possible, and call him/her to inform him/her of the patient’s hospitalization
status, and obtain more information and discuss treatment plans. Under HIPAA,
you may speak with a co-treating physician even without the patient’s consent.
9) Do at least one follow-up within 2-3 days. More follow-ups
may be needed depending on the situation. Be sure to enter the date of
follow-up in the computerized Follow-up form.
10) If a transfer to a psychiatric facility is needed,
call the psychiatric social worker or the case manager on the floor who will be
most helpful in effectuating it.
11) Outpatient referrals may be made when
indicated as follows:
A) Private psychiatrist/mental health professional referral if
patient has insurance or can otherwise afford it.
B) University Psychiatry Associates (UPA) Clinic referral if
patient meets criteria and is a
potential psychotherapy case.
C) County Outpatient referral to the Metro (County Outpatient
Clinic)
D) County Wellness Center
4. Off-Hour and
Weekend Consultations
The resident-on-call is paged for off hour and weekend
consultations directly by the referring physician/unit. All new
consultations during off-hour and weekends must be discussed with the Attending on
Call. All off-hour and weekend consultations must be reported to the Psychiatric
Consultation service by the resident who performed the consultation.
Anytime a resident changes
on-call schedule, he/she must
inform the hospital operator and the attending on call for the day/weekend the
change will be effective.
Computerized Reports: All normal consultation reports should be
Consultation Notes in Epic using the Psychiatry Consultation (.Psychcl)
template.
Exceptions are:
Progress Notes: Brief note may be
made if consultation could not be performed normally, e.g., patient was
comatose. You may indicate that a full consultation will be performed
when patient is able to communicate.
Follow-Ups are to be written
in Progress Notes.
When a resident is out, he/she should
inform the attending, and also ask another resident/medical student/attending
to cover for his/her patients who require follow-up with sufficient
information. The full-time resident is expected to be always informed
about all patients who are evaluated/treated by trainees on the service.
CL resident must
plan vacation at the beginning of the rotation, and obtain approval from the
director. The director will indicate the times when the resident may take
vacation, and may assign vacation time at times. Generally, a
vacation request will not be approved if it leaves the service without a
trainee.
Liaison
Liaison is literally a bridging function, and has two aspects. In one
aspect, the psychiatrist becomes a member of a medical/surgical team and
provides education and expertise, in the other, the psychiatrist teaches
members of the medical/surgical in course of performing the consultation.
ONE LAST ITEM: A CONSULTANT DOES NOT OWN THE PATIENT, BUT
ONLY RENDERS AN OPINION FOR THE RESPONSIBLE PHYSICIAN, WHO IS RESPONSIBLE FOR
IMPLEMENTING/NOT IMPLEMENTING THE RECOMMENDATIONS. THE CONSULTANT’S RESPONSIBILITY ENDS WITH THE
RENDERING OF THE OPINION.
Appendices
1. CL
Rounds Presentation Format (See below)
2. Appendix
2. Biopsychosocial Presentation Format and Examples for Regular Clerkship Students
Appendix I. CL
Rounds Presentation Format
A major
educational activity during your rotation to Psychiatric Consultation Liaison
rotation occurs in the daily attending rounds. Each trainee is expected to
present each case formally during the rounds unless otherwise instructed.
Presenting at CL
rounds demonstrates, in a nutshell, how you collect data about a patient, how
you transform the data into information, and how you use the information in
understanding and helping the patient. You should, above all, show how
you THINK about a patient, from what is important in history and mental status
to how you go about doing a differential diagnosis.
An important
aspect of the educational endeavor is the process of differential diagnosis,
which is not included in the written consultation report for the sake of
brevity. Differential diagnosis should not be a mere collection of
possible diagnoses (though this, too, is important) but rather how you think systematically in arriving at diagnoses and rule
outs. Once you have the multiaxial diagnoses,
then you must show how the current diagnoses interact with the person who is
the patient (who has a personal history, predispositions, strengths, and stresses)
in the mini-formulation called Summary Opinion.
Each formal
presentation should follow the following format:
1.
Identifying
data of patient: Name, Age, Ethnic background, gender, marital/SO status,
occupation.
2.
Reason
for hospitalization
3.
Reason
for consultation
4.
Present
Illness: You may combine medical and psychiatric history here if
indicated, e.g.,
“Pt came in for surgery, and
postoperatively, he developed visual hallucinations of bugs crawling all over
him.”
5.
Past
Medical & Psychiatric History
6.
Psychosocial
and developmental history (personal history). This may be integrated with
above if appropriate.
7.
Family
history, especially of psychiatric disorders
8.
Substances/medications
9.
Relevant
Labs and Imaging studies (This may be integrated with present illness if
indicated)
10.
Mental
Status Examination
This always begins with appearance, e.g., A 45 year old African
American female, moderately obese, dressed in hospital attire, with unkempt
braided hair, lying in bed with a cast on right leg, appearing somnolent…
Follow the format of the consultation report for the rest
11.
One
paragraph summary of relevant history and mental status:
This should summarize only the relevant findings that you will use
in formulating the differential diagnosis. Example: 25 yo Caucasian female with a long history of depression and
multiple suicide attempts admitted with Tylenol overdose with elevated liver
enzymes. Mental status reveals mild disorientation, labile affect,
depressed mood, but no current active suicidal intent.
12.
Differential
Diagnosis
This mental exercise is the most important part of presentation at
rounds. The differential should be based on the summary in item 10.
For example, the salient features of this patient are: hx of
depression, multiple suicide attempts, current suicide attempt, and depressed
mood on MS that lead to the ruling in of the diagnoses comprising the
depressive spectrum disorders and suicidal behavior; mild disorientation and
labile affect that lead to the ddx of
cognitive disorders and mood disorders. In the differential diagnosis of
any psychiatric/behavioral syndrome, secondary contributing factors should
always be considered first, i.e., medical diseases and substances (legal,
including prescribed by MD, or illegal) .
Note that these are not rule out or rule in, the contributing factors
often co-exist with a primary psychiatric diagnosis and may have precipitated
or exacerbated it. Having identified any such contributing factors, you should
proceed to the primary psychiatric diagnoses. The ddx for
depressive spectrum disorders include: major depression, bipolar disorder,
schizoaffective disorder, schizophrenia, PTSD (the SLE of psychiatry),
borderline personality disorder, and the minor depressions - dysthymia, cyclothymia, and
adjustment disorder. If none of these
can be diagnosed, the secondary contributing factors, if present, may become
the main diagnoses, e.g., depression
secondary to general medical condition and/or secondary to
substances. The ddx for suicidal
behavior is similar to that of depression per se though borderline personality
disorder becomes a prominent consideration if multiple. Situational
factors should also be considered.
The ddx for cognitive disorder
should include delirium (including intoxication, withdrawal, any medical
condition causing an encephalopathy including electrolyte imbalance, uremia,
etc), dementia (both reversible and irreversible). Think in categories,
and give reasons for including and ruling out ddx.
13.
Working
diagnoses
Psychiatric diagnoses, such as major depression,
schizophrenia, somatic symptom disorder, etc. There may be rule outs
and by history dx, such as r/o bipolar disorder,
schizophrenia by hx.
DSM-5 does not use the multi-axial system of DSM
III-IV. Nevertheless, we ask that you also consider, and list, as
indicated, Relevant Medical Diagnoses and Stressors/Assets.
14.
Summary
Opinion
This is a mini-formulation, i.e., your understanding of the
patient as a person with the current problem. This should logically lead
to informed recommendations in the three dimensions of the patient.
Example: This is a young woman with very limited coping skills, with multiple
episodes of depression and suicide attempt associated with interpersonal
rejection. The patient currently has no therapist, and the environmental
stressor has not been resolved with the suicide attempt. Therefore, the
patient would need inpatient hospitalization and antidepressant therapy.
15.
Recommendations
This should be considered in the following manner:
a) Immediate:
Further
Evaluation, e.g., interview family, phone calls to therapist, etc.
Immediate
Treatment
Pharmacological
Psychosocial, including restraints, sitter, 5150
b) Discharge Planning
c) Longer Term Rx --- We may not be doing this, but
the presenter should consider the eventual treatment modality for the
patient, if any. E.g. types of psychotherapy
16.
References
(Optional)
If you found any interesting publications that helped you in
evaluating this patient, you should mention it here.