How to write a request for consultation to a psychiatrist?

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Ypo.

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Hello. I was wondering if anyone can recommend some pointers or an article describing how to write a request for psychiatric consultation. Specifically, what information does the psychiatrist want, and is there a typical format?

Thanks. :)
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Thanks.

Edit-actually that article explains how to do the opposite of what I am asking.

I want to know what information to include when I (as a GP) request a consult from a psychiatrist.
 
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Oh, I see what you're saying.

How to REQUEST a consultation.

It's refreshing to see a GP so interested in this topic. Know that it's certainly appreciated on our end.

I'd say that a request for a psychiatric consult would be no too much different than that for any other medical subspecialty consult you might requst i.e. a cardiology or rheumatology consult.

To make it simple, I'd say that no psychiatrist, other than an annoying narcissist, would require more than this:

1. Name, age and brief demographics of patient, along with brief description of current medical issues and medications. Briefly describe the psychiatric complaint, and mention that you're sending the patient for continued treatment:

"I have a 36 year old single, employed female of Polish decent who presented to my office for followup of her newly diagnosed hypertension, which I have been managing for 3 months. She relates that she is 3 months pregnant and is having disabling panic attacks in the context of taking public transportation only. She has no suicidal ideation, and no obvious symptoms of depression. She requested Xanax from me, which she took in the past with good success, but am deferring this decision to psychiatry in order to best manage her at this time."

....something like that would be fine I would think. Most of the time, we get a fraction of that info.
 
I think this thread could also go down the route of:
how to place a psychiatric consult in the hospital.

Common psych consults I've gotten:

"I don't know, they're just acting weird"
"We want a psychiatric workup"
"I heard from a nurse they were crying a little."
 
nitemagi said:
I think this thread could also go down the route of:
how to place a psychiatric consult in the hospital.

Common psych consults I've gotten:

"I don't know, they're just acting weird"
"We want a psychiatric workup"
"I heard from a nurse they were crying a little."
Click to expand...

My all time favorite was this one:

Location: head
Reason for consult: Issues
 
sunlioness said:
My all time favorite was this one:

Location: head
Reason for consult: Issues
Click to expand...

Hopefully you refused that consult...and that your attendings backed you up when you did. No chance in hell I'm touching that one until I get that wise*** on the phone to explain him/herself properly.
 
I'm on the psych consult service at our local hospital and most of the information we get is 1 sentence. "Patient combative, h/o BPD."

So today the attending tells me to go up and see this combative patient with BPD and I spend about 20 minutes going through the chart, pulling up values and filling out what part of the consult note I can from the patient's chart. I am about to go find the nurse when the CCU doc comes up to me as tells me the patient is intubated and all they wanted to know is if they could give her some haldol or something.

LOL. It would have been nice to know that to begin with. I should have walked into the room first, but the resident taught me to get everything ready before going in there, especially with delirious/demented patients.
I literally wrote MSE-->"pt intubated." :laugh:

Anywho, I'm just a third year medical student, but today I got my first taste of how frustrating it can be when you are consulted but have little idea what for and know next to nothing about the pt.
 
I estimate that 12 minutes of each day on unit rounds this month has been spent listening to ICU docs say absurd things about psychopharmacology. So maybe you should thank that CCU attending.


My favorite from the month:

Attending: Well, if we have to intubate this patient again, she'll never get off the vent. If she'd just stop smoking...

ICU fellow: We talked to her yesterday about possibly starting Chantix, and she seemed...

Attending: OH MY GOD NOT CHANTIX SHE'LL KILL HERSELF!!! SHE'LL BECOME MANIC!!!

Seriously, I'm exaggerating like 5%.


And I tried to tell my medicine resident that it really didn't matter how you dose the seroquel if you're giving 5mg IM Haldol everytime the nurse sneezes. But the crickets, they burn!:eek:

I shouldn't complain too much, since this is the same unit where I actually got to see an NMS case as an M3.
 
My new favorite consult request: "the patient asked to see a psychiatrist." Do you think they would consult cardiology if the patient asked to see a cardiologist? Ha! I can imagine what the cards fellow would say! The saddest thing is, I didn't even see how silly this was until it was pointed out to me.

OP: When talking to the consulting team, have them clarify the question. If you get bad sign out from whoever it was who talked to the team (as it sounds like you did), call them back to clarify. Sometimes they stick with "they just seem weird" and then you ask them what they want you to do. They usually have something in mind (often it's "please tell me you should take them to psych"). I've found that a lot of times the patient's DO seem weird.
 
While working as a practicum student at a neuropsychology service last year, we received a referral from an internist with a presumptive patient diagnosis of "dementia due to normal aging?" :rolleyes:
 
Wednesday said:
My new favorite consult request: "the patient asked to see a psychiatrist." Do you think they would consult cardiology if the patient asked to see a cardiologist? Ha! I can imagine what the cards fellow would say! The saddest thing is, I didn't even see how silly this was until it was pointed out to me.
Click to expand...

Yup. I've noted the same thing. I also once had a c/s in the ED because a patient who had come in for something legitimately medical "could use someone to talk to." Fortunately I wasn't busy that night and I got them to not make it a formal consult so I didn't have to do a huge eval and I did chat with her for a few minutes and she was nice, but no, you would never expect a cardiologist to do that. :)

My other all time favorite was being asked to do substance abuse consults on patients intubated in the ICU. There's nothing like trying to talk to someone about his alcohol problem when he's sedated with a tube down his throat.
 
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Wednesday said:
My new favorite consult request: "the patient asked to see a psychiatrist." Do you think they would consult cardiology if the patient asked to see a cardiologist?
Click to expand...

Yes I do - if the patient had a cardiac history and was insistent enough.
 
It's extremely rare for a patient to request a consult to begin with. But usually if the patient wants to see a certain type of specialist there's a good reason and the consult is done. I am talking inpatient. I know little about outpatient consults.

While I haven't experienced it to be more common with psychiatry it makes sense that it would be more common, given that while there are external measures of cardiac distress, for psych the patient would be the main source of reporting of internal distress (perhaps accompanying such reports with the consult request) unless they are exhibiting some kind of externalizing behaviors. We have health psychology though at our hospital which is liberally consulted to help patients with psychological coping with illness/hospitalization.
 
Today I got a consult. So I show up and the patient is in process of being discharged. What the heck?
 
Ypo. said:
Today I got a consult. So I show up and the patient is in process of being discharged. What the heck?
Click to expand...

I can't comment about that specific situation of course ... but sometimes while on C/L as a student, we were consulted to help set the patient up with outpatient drug/alcohol treatment or to refer for counseling or psychotherapy after discharge.

I'd say it's more likely, given human nature, that there was just a lack of organization and the psych consult was ordered too late to be helpful, or discharge was made possible earlier than anticipated but the consult was already ordered.
 
Ypo. said:
Today I got a consult. So I show up and the patient is in process of being discharged. What the heck?
Click to expand...

Ah yes, the day of discharge consult.

Otherwise known as, the "oops..we forgot to call psychiatry on this case. Write that we consulted them in the chart to cover our ***** in case he commits suicide or kills someone else after he gets home, and tell the intern to page the psych service to make it legit."
 
Ah yes, I know it well. It's especially fun when it occurs in the evening while you're on call and have things to take care of on the floor and a bunch of patients to see in the ED. I always enjoy being paged by some medicine/surgical/whatever intern on his or her way home about a patient who needs to be "cleared by psychiatry" before he can go home. "Oh and can you please come soon? Because he's getting kinda impatient to leave." :laugh:
 
sunlioness said:
Ah yes, I know it well. It's especially fun when it occurs in the evening while you're on call and have things to take care of on the floor and a bunch of patients to see in the ED. I always enjoy being paged by some medicine/surgical/whatever intern on his or her way home about a patient who needs to be "cleared by psychiatry" before he can go home. "Oh and can you please come soon? Because he's getting kinda impatient to leave." :laugh:
Click to expand...

If I had a nickel...
 
sunlioness said:
My all time favorite was this one:

Location: head
Reason for consult: Issues
Click to expand...

:laugh: :laugh: I'm glad we have a consult nurse who really works hard to ferret out the question before passing the consults on to the residents. Although sometimes it's a little hard for her to fit the whole story into a 255 character text page. Once I got as part of the txt: "no psych hx but disheveled."

Most frustrating is when the consulting service is totally dismissive of your recs. Like my intubated SICU guy who was on a 7 mg/hr Ativan drip for 3 weeks, and they just shut it off abruptly, and then they call us because he's agitated and can we please write for some Risperdal because it's restricted to the psychiatry service. When we suggested perhaps some valium would be better since he's probably in withdrawal, they're like, no, we don't like benzos because it takes longer to wean them off the vent. Yeah, because DTs make that process go oh so much faster.
 
I'm glad I'm not the only one mentioning BS consults.

IF someone does a consult if they could write down why they wanted the consult. E.g. if I get a consult and all it says is reason:"depression" and the patient is denying any sx of depression, the staff denies seeing any sx and in fact the attending who ordered didn't see any, then why the heck was it ordered?

Attending: "well the staff asked me to order it because they were worried. I just gave the order because they asked me to do it. I don't know why the patient's supposedly depressed and she didn't seem that way to me"
Staff: "well it was a nurse on another shift and I don't know why she thought the patient was depressed. I didn't see anything wrong"
patient: "I don't know why you're here, frankly I find it very rude that the hospital thinks I'm crazy. I feel fine, I sleep fine and my energy level's fine."

From point A to B, I have to talk to the staff, go through the entire chart, beep the attending, wait for him/her to call back and interview the patient, all of which can take between 1/2 to 2 hrs and it turns out the consult was just completely BS to begin with. Sometimes I even called the family because none of the collateral info is getting me anywhere and then the family's all upset "she's depressed? Oh no!" (Turns out she's not depressed).

If the staff member who requested the attending order the consult could've actually documented why she thought the patient was depressed, that could've been something I could've addressed, but that staff person by the time I get to the consult is now off duty, & will not answer her phone when called by the hospital.

I have sometimes tracked the original nurse down on later days & asked them why the consult just to satisfy my curiosity. They usually give an answer like, "well when I saw her, she said she wanted an extra pillow, there's something going on there", or "she keeps on asking me to change her channels like she's a little kid. Isn't that something in psychiatry called regression? She must be depressed or schizophrenic or something like that"

Had I known this, it would've made the consult much easier. Yes I still would've done the consult, and yes its really not a reason for a psyche consult, but at least I know why the staff has its reason & I could actually adress that reason, instead of having to fish for hours for the REAL reason for the consult. That would've been better for everyone involved-including the patient.

I don't mind the occasional BS consult but when over 50% of them are BS, everyday, and its an all day thing, that's annoying.

The LESSON I LEARNED: when I'm an attending, if I do consults, get paid per consult, that way I at least get paid for this BS
 
Hey, so here is an example letter I wrote requesting consult from a psychiatrist. If any of you have input regarding what additional information I should include (or not include) I'd appreciate it.

Dear Dr. ____________

I would be grateful if you could see this 66-year-old man.

History: I initially saw Mr. ______ in the ER for a history of chest pain and shortness of breath. After ruling out a pulmonary and/or cardiac cause for the dyspnea and chest pain, further query revealed that he has a long standing history of anxiety and depression with what are likely panic attacks.
On physical exam he was noted to have numerous sores and linear excoriations in various stages of healing over his back, legs and arms. When asked about these he stated they were from him “scratching.” He states this started approximately ten years ago and occurs mostly at night when he is feeling nervous. He states it bothers him but he has been unable to stop. He thinks his chest pain and SOB is related to stress and anxiety. When asked in more detail about the sores on his arms, legs and back, he replies they are from him being “messed up in the head.”

Relevant Past History: He was recently divorced after a 20 year marriage. He is retired and used to own and run a bar which he sold last year. He now lives with his 92 year old mother. Per his daughter, since the divorce he has show a decline in mood, with an increase in anxiety and scratching behavior. He does have a diagnosis of depression for the past five years. He denies alcohol or substance use now or in the past. He does have a 40 pack year history of tobacco. There is no past psychiatric family history. Other medical conditions include HTN and hyperlipidemia.

Reason for referral: I believe this gentleman warrants a psychiatric evaluation. The scratches on his body are quite severe and are at risk for secondary infection. In addition, though he is being treated with fluoxetine 20 mg qd, it does not appear to be controlling his anxiety symptoms and I believe he needs some medication adjustment. His daughter, in particular, is worried about him.

Sincerely,
Ypo. Third year medical student.
 
ypo,

that's a great letter.

Is the patient currently an inpatient or an outpatient? If he is an outpt, then I think getting an outpt consult on this pt is a great idea.

If he is an inpatient, you may want to reconsider getting an inpt consult and just have the pt see a psychiatrist as an outpt. I used to run a University hospital C+L service, and it really irritated me to get consults on things that could wait until after discharge. A "psychiatric evaluation" isn't a magical cure. A simple change in meds isn't going to suddenly fix most patients. Think twice before ordering an inpt psych consult, in some cases it would be more appropriate to have a social worker arrange (hopefully longterm) outpt psych f/u
 
michaelrack said:
ypo,

that's a great letter.

Is the patient currently an inpatient or an outpatient? If he is an outpt, then I think getting an outpt consult on this pt is a great idea.

If he is an inpatient, you may want to reconsider getting an inpt consult and just have the pt see a psychiatrist as an outpt. I used to run a University hospital C+L service, and it really irritated me to get consults on things that could wait until after discharge. A "psychiatric evaluation" isn't a magical cure. A simple change in meds isn't going to suddenly fix most patients. Think twice before ordering an inpt psych consult, in some cases it would be more appropriate to have a social worker arrange (hopefully longterm) outpt psych f/u
Click to expand...
I actually saw this patient several months ago on my IM rotation. At the time he was getting a work up for aortic dissection and multiple myeloma! (gotta love those IM docs. :)).

That's a good point about the in patient versus outpatient. I was actually pushing at the time for a psych consult on the guy, because I thought his issues were more psychological than anything. However, I was shot down by the attending for the reasons you mentioned, and which I now fully understand after being on the psychiatric consult team for the past week.

Writing the letter was actually a school assignment that I had. I used him as an example. I specifically left the letter ambiguous so that it could be addressed to either an outpatient or inpatient psychiatrist. I do hope he got follow up care with a psychiatrist (i encouraged him to do so). He was a really nice guy.
 
Anasazi23 said:
Very nice consult request. It might even be longer than the consult itself.
:laugh:
Click to expand...


I had the same thought. May be as a learning experience when you are medical student but beyond that, no one is going to have the time or inclination to write such long requests. Good luck in getting more than 1-2 line consult requests. Usually, it's just a couple of words as other posters have mentioned. On top of that, nothing is mentioned in the chart itself. They like to send you on a fishing expedition, I guess:D.
 
TheWowEffect said:
They like to send you on a fishing expedition, I guess:D.
Click to expand...

Yes! I've been learning that.

First, have to find the chart. Then have to read the chart and hopefully find the real reason for consult. Then, talk to the nurse. Then if patient is out of it (90% chance on that lately) need to get permission to talk to family, then track family down. Hopefully track down consulting resident/physician and find out just what the heck they want out of the consult. Last step, page attending and report. Whew.
 
that's a great letter.
Click to expand...

It is.

All I'd want is the real reason for the consult. Much of the stuff written could be found elsewhere in the chart. The REAL reason is better than...

"depression" (real reason, patient's favorite football team lost)
"psychosis" (real reason-pt kept asking to not have any unnecessary procedures for fear of a big medical bill)
"competency" (they really mean capacity)
 
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