Calling collateral - what information to ask?

[snoopydawg]

I'm starting my psych rotation in a few weeks. When residents ask you to call collateral, what information are they looking for from family members or providers (especially for psychotic patients and emergency psych patients, but also for other patients in general)? A list of questions would be greatly appreciated.

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[SilverHawk]

Different providers will have differing expectations for questions. Some questions that I would be concerned about (assuming patient is very psychotic and poor information provider).......

How long has this episode been going on (i.e drastic change from normal baseline or slow progression)? If it has been going on for a long time, why bring him to hospital now? Any recent life stressors? Any recent medication changes? Any other weird neurologic signs noted by family members i.e. weakness, vision changes, smells, gait problems, shaking/seizures? (hopefully gets screened well in the ER but unfortunately doesn't always happen). If he's a patient with chronic psychosis, has he been compliant with medications? Has the patient been combative in the setting they were at previously? Any fever, discharge, travel to new locations, changes in diet?

Those would be some good questions to start

 

[FlowRate]

It doesn't hurt to ask your resident. This is something I would expect a med student on their first psychiatry rotation to be clueless about. And, as mentioned, sometimes the goal of the interaction differs. When I'm calling collateral overnight, it's usually one of two situations: 1. to get the family member/loved one to tell me if they think the patient will harm themselves and if they'll be able to keep an eye on them 2. to find out wtf actually happened because the patient isn't giving me much / seems unreliable.

When I'm calling from the inpatient unit, it's usually more aimed at baseline level of function, strategies that have helped in the past, concerned parties' expectations of hospitalization and aftercare.

 

[whopper]

Psychiatry On Call probably has a good guideline, but I haven't picked up that book in years. Reason why I mention it is more than half the questions any new resident will need answered is in that book.

 

[thoffen]

Well this is really the most critical skill in medicine. Not calling collateral information specifically, but generating an appropriate differential, set of hypothesis, and finding out how to test them. There could be a good generic answer, but really it depends. I think where you should start is by asking what do you need to know to successfully diagnose and treat the patient in the near term and to develop a more longitudinal treatment plan. Then to think about some possible answers to that missing information. Then to try and narrow down the highest value questions that provide those answers. This is just for the information gathering part.

Some important considerations:
1. Safety first -- need to understand risks they have (SI, past attempts, access to means, violence, threats, risky behavior e.g. sex/substance/etc.) and to put them in context of the environment they are coming from which leads to whether they need a different environment when they leave
2. Diagnostically, most important is course of present and past illness rather than acute symptomatology
3. Therapeutically, want to determine prior treatments and response and barriers, but in particular whether it seems there were adequate trials or not

This is like ordering imaging study. Patient presents to ED with psychosis -- get a CT scan (controversial)! Well, what is your differential diagnosis, what is the pre-test probability of those, and what is the sensitivity/specificity of CT for those diagnosis? I've had students and even residents advocating for studies like this without even being able to list a single pathology they would be looking to find.

FYI, I'm glad you are asking this. It shows an appreciation that how you do things is as or more important than what you do.

 

[snoopydawg]

Wow. Thank you all!

 

[DD214_DOC]

As mentioned a couple posts above, collateral shouldn't be a compulsory thing one does every time. I only do it if I actually need to. If I can make a decision on disposition/treatment/whatever without it, then what's the point? There should be something specific you're needing from the collateral that would aid in diagnosing, treating, developing a safety plan, etc.

I'd get collateral if the actual patient was too impaired to provide any meaningful history, the patient isn't providing a useful history, the history being given is suspect for various reasons, or the patient is a minor. Since I'm CAPS, I get collateral all the time but it is always done with a purpose.

I see many of the therapists in my clinic obtain collateral out of habit more than anything, which ends up just wasting their time listening to useless information with zero clinical value. I'm not going to call a kid's teacher just to get their side of the story if I think I've been able to get enough from the patient and parents. I will speak with a child's teacher if nothing the patient and parents are reporting makes any damn sense.

It's a bit amusing to me the number of clinicians who do things without really asking themselves why they're doing it and what value it actually has. This way of thinking is how we end up forcing patients at every single psych or therapy appointment to fill out of a bunch of meaningless symptom screening checklists that are really only for the primary care environment and which have absolutely no place in a specialty or subspecialty clinic.

 

[st2205]

It's a bit amusing to me the number of clinicians who do things without really asking themselves why they're doing it and what value it actually has. This way of thinking is how we end up forcing patients at every single psych or therapy appointment to fill out of a bunch of meaningless symptom screening checklists that are really only for the primary care environment and which have absolutely no place in a specialty or subspecialty clinic.

Try suggesting not doing that and watch everyone’s head explode as you become perceived as the heretic. “OMG how could we neglect to obtain _____? We’ve always obtained _____! Isn’t more information always better?!”

 

[thoffen]

Try suggesting not doing that and watch everyone’s head explode as you become perceived as the heretic. “OMG how could we neglect to obtain _____? We’ve always obtained _____! Isn’t more information always better?!”

Haha. These are good points, although I think most often psych rotations are inpatient where collateral holds a lot more value. I would always want it even if I have no immediate questions about diagnosis and treatment plan. There is big benefit to simply seeing the dynamics at play in someone's life and understanding better their outpatient situation for making decisions on how best to bridge them from the hospital. In almost all cases, that's the most important part of the hospitalization.

But...yeah. Doing something because that's the way everyone does it is the absolute worst reason to do something. Really it should be unacceptable in medical care.

 

[DD214_DOC]

Try suggesting not doing that and watch everyone’s head explode as you become perceived as the heretic. “OMG how could we neglect to obtain _____? We’ve always obtained _____! Isn’t more information always better?!”

Oh yeah, most certainly. If not for the PHQ-9 results giving me the suggestion as a reminder, I'd completely forget that I should screen my patients for depression.

 

[st2205]

Oh yeah, most certainly. If not for the PHQ-9 results giving me the suggestion as a reminder, I'd completely forget that I should screen my patients for depression.

Our system is trying to implement the OQ on everyone. People show up 5 minutes late for an appointment, take 5 minutes to check in, then get vitals, then I get them and they’re in the middle of the OQ. Most of the time I tell them to forget it, but the push is how important the OQ is and how “even just administering it improves outcomes!” So they say go through the questions one by one with the patient. My favorite is when someone comes to me acutely psychotic and they’re filling out the OQ like it’s going to be valid.

Anyway, it’s funny that we’re bemoaning the direction of society by replacing real interaction with social media and robbing people of real life experiences, then they come into the clinic and it’s “hey, we’ve only got a few minutes together, but by all means bury your nose in that tablet and complete those questions so I can reduce your symptoms to a number and then with the remaining 5 minutes we’ll talk about what meds to use to get those numbers down.”

We’re a terrible model for real human interaction. Apparently it’s passé to get a subjective history of what’s going on with the patient when we can just opt for the further nuance of the likert scale.

 

[FlowRate]

As mentioned a couple posts above, collateral shouldn't be a compulsory thing one does every time. I only do it if I actually need to. If I can make a decision on disposition/treatment/whatever without it, then what's the point? There should be something specific you're needing from the collateral that would aid in diagnosing, treating, developing a safety plan, etc.

I'd get collateral if the actual patient was too impaired to provide any meaningful history, the patient isn't providing a useful history, the history being given is suspect for various reasons, or the patient is a minor. Since I'm CAPS, I get collateral all the time but it is always done with a purpose.

I see many of the therapists in my clinic obtain collateral out of habit more than anything, which ends up just wasting their time listening to useless information with zero clinical value. I'm not going to call a kid's teacher just to get their side of the story if I think I've been able to get enough from the patient and parents. I will speak with a child's teacher if nothing the patient and parents are reporting makes any damn sense.

It's a bit amusing to me the number of clinicians who do things without really asking themselves why they're doing it and what value it actually has. This way of thinking is how we end up forcing patients at every single psych or therapy appointment to fill out of a bunch of meaningless symptom screening checklists that are really only for the primary care environment and which have absolutely no place in a specialty or subspecialty clinic.

Try suggesting not doing that and watch everyone’s head explode as you become perceived as the heretic. “OMG how could we neglect to obtain _____? We’ve always obtained _____! Isn’t more information always better?!”

Exactly this, some of our attendings pretty much require us to get collateral not only to back up that they think a patient is safe but also usually want someone to keep an eye on the patient for a day. All of that could fall through including the patient not following up and we should be comfortable letting them go even if that's what happens. Others who, despite already getting reassuring and reliable-seeming collateral, still want us to call all of the available collateral contacts. Too conservative and huge time sink, especially when the collateral includes gathering discharge summaries from year-old hospitalizations...

 

[clausewitz2]

Exactly this, some of our attendings pretty much require us to get collateral not only to back up that they think a patient is safe but also usually want someone to keep an eye on the patient for a day. All of that could fall through including the patient not following up and we should be comfortable letting them go even if that's what happens. Others who, despite already getting reassuring and reliable-seeming collateral, still want us to call all of the available collateral contacts. Too conservative and huge time sink, especially when the collateral includes gathering discharge summaries from year-old hospitalizations...

Year old discharge summaries, if well-written, have been enormously helpful to me on inpatient rotations when I get someone whose case doesn't make much sense and I am trying to figure out what the course of their illness has been like and how they tend to behave when hospitalized. Of course many are just haphazardly regurgitated stretches of previous notes and boilerplate risk assessments that list every possible risk and protective factor with no evidence that anyone put any thought into how they balance each other out.

There is one attending in our system who is mostly a high level administrator who occasionally covers inpatient units and I am always thrilled when he has had a patient of mine in the past. This is because he he dictates his notes and just talks for a while about his impression of the case and what he thinks is going on. Even a paragraph of this is incredibly useful for a longitudinal perspective and I aspire to doing this consistently in my own notes.

Agreed about the idiocy of requiring that someone be watched for a day as a condition of discharge. Had a situation a while back where a friend of a patient was badgering into saying they would let the patient stay with them. This friend kicked then out of the house roughly three hours after they were discharged.

 

[FlowRate]

Year old discharge summaries, if well-written, have been enormously helpful to me on inpatient rotations when I get someone whose case doesn't make much sense and I am trying to figure out what the course of their illness has been like and how they tend to behave when hospitalized.

This is because he he dictates his notes and just talks for a while about his impression of the case and what he thinks is going on. Even a paragraph of this is incredibly useful for a longitudinal perspective and I aspire to doing this consistently in my own notes.

I should have specified, this is all in the ED and often I'm asked to do that even after we've pretty much decided on a dispo (mostly a certain attending.) I don't mind getting collateral on inpt unit like that as you pointed out.

 

[Orange2black]

What do people do when the patient specifically states that you cant talk to their family?

 

[splik]

What do people do when the patient specifically states that you cant talk to their family?

If the patient is in the ER I don’t need the patients consent and if I think it’s necessary and I have the contact details I will contact the family. There is an exception to HIPAA in emergency situations. Otherwise you must respect the patients wishes and have a good rationale for breaching confidentiality when you do.

 

[deleted736562]

I think collateral is critical for diagnosis. Maybe not in the ER setting, but I think collateral on inpatient units is pretty much a requirement for every patient, imo. History is the only thing we have and we know how reliable our patients are (families not much better, but still). Even if they do seem reliable, there's a high likelihood that they are omitting critical information.

 

[thoffen]

If the patient is in the ER I don’t need the patients consent and if I think it’s necessary and I have the contact details I will contact the family. There is an exception to HIPAA in emergency situations. Otherwise you must respect the patients wishes and have a good rationale for breaching confidentiality when you do.

HIPAA is Federal and concerns the information you provide not receive. States may have tighter statutes than it, though. In mine the fact that someone is your patient is not considered confidential, thus it is legal for me to call anyone to receive information. However, whether it is a good idea if someone doesn't want me to is an ethical decision. Is the beneficence of the collateral to their care more compelling than their autonomy?

 

[NickNaylor]

Really depends on the presenting situation. As mentioned above, collateral isn't always necessary. If someone's acutely psychotic and you have no known meaningful history on them, I'd want to get a general picture of their usual functioning at home. For someone that may be imminently dangerous, I'd want to get more information about past suicide attempts, violent behavior, etc. etc.. If someone called the police on the patient (thus necessitating their visit), I'd want to know the particular concerns that caused them to call the police since that isn't always obvious.

It's a difficult to question to answer in a general sense. I think @thoffen's first response really gets at it; that is, what are you worried about or what do you need to know more about in order to formulate your treatment plan? That will guide the information that you want to get from your collateral.

In pragmatic terms, asking the resident and/or attending what they'd like more specific information about isn't a bad approach if you're unsure.