Diplomatic advice for dealing with stupid consults?

[HockeyPsyGuy]

Our program is somewhat CL heavy (from what I’ve heard), with 4-5 months on the service at a busy academic hospital. With no incentive to see more pts as a Resident, I have been finding it harder and harder to cope with/deal with getting called for non-acute psych issues when we continue to get overwhelmingly bombarded with new consults day to day. Lately I’ve been feeling like I want to throw the pager at a wall when it goes off for: “Chart says pt has history of schizophrenia” | “General Capacity of Pt for future reference in case something comes up” | “Pt is participating fully in his care but we think he has been slightly depressed for the past several decades” | “yesteray pt seemed very anxious for the surgery he is currently undergoing”...

The culture of our service is to push back a bit but ultimately “We are happy to see every pt.” I feel this is contributing to my burnout. Curious to see different perspectives on this matter. Any more positive ways to look at this other than “job security?” Any other approaches in different hospitals? If not, thanks for allowing me to vent.

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[siliso]

See the consults but educate the teams on the limits of what you have to offer inpatient vs what can and should be deferred to outpatient for resource management purposes. Let them know that you need to triage and may not get to their non-acute problem so quickly. Consider offering an educational session on your health system resources for outpatient care, when to consider outpatient referrals and what acute problems do merit an inpatient consult?

 

[WisNeuro]

Well, for the "General capacity for future reference" you can just tell them that it's kind of illegal. I've gotten that consult before, after some terse conversations with referring providers, they usually stop.

 

[clausewitz2]

Our program is somewhat CL heavy (from what I’ve heard), with 4-5 months on the service at a busy academic hospital. With no incentive to see more pts as a Resident, I have been finding it harder and harder to cope with/deal with getting called for non-acute psych issues when we continue to get overwhelmingly bombarded with new consults day to day. Lately I’ve been feeling like I want to throw the pager at a wall when it goes off for: “Chart says pt has history of schizophrenia” | “General Capacity of Pt for future reference in case something comes up” | “Pt is participating fully in his care but we think he has been slightly depressed for the past several decades” | “yesteray pt seemed very anxious for the surgery he is currently undergoing”...

The culture of our service is to push back a bit but ultimately “We are happy to see every pt.” I feel this is contributing to my burnout. Curious to see different perspectives on this matter. Any more positive ways to look at this other than “job security?” Any other approaches in different hospitals? If not, thanks for allowing me to vent.

The way it was explained to me by a consult attending that helped me stopped resenting this sort of thing nearly so much was this: by consulting you, the primary team is saying that something is wrong and they don't know what to do. Even if what is actually happening is not the official consult reason, something is going on.

Most of my most interesting C&L cases were for the stupidest sounding reasons.

 

[smalltownpsych]

The way it was explained to me by a consult attending that helped me stopped resenting this sort of thing nearly so much was this: by consulting you, the primary team is saying that something is wrong and they don't know what to do. Even if what is actually happening is not the official consult reason, something is going on.

Most of my most interesting C&L cases were for the stupidest sounding reasons.

That is a helpful perspective and one I try to adopt, as well. On the other hand, if it really is a stupid consult, it is also a good opportunity to improve your ability to educate the consulting doc either politely or sarcastically, whichever the case might warrant. I tend to be on the polite side of things, but occasionally we all have to channel our inner Dr. House. I just have to temper that a bit with remembering that I can be wrong too.

 

[SpinDktr]

I think consults in our program probably tended to do too much as well. But remember, many different specialties really get no psychiatric training, and I also think the liaison part is very important.

I have realized this more and more as I have worked into the attending role. I am doing primarily outpatient with occasional consults from the 50 bed hospital associated with us. At first, I was getting all kinds of stupid consults, but then I didn't have much of an outpatient clinic presence, so it helped with RVU's and I had the time.

Now, I only get consults every other week or so, and they are usually, but not always more appropriate. I even find that they sometimes anticipate what I would recommend, but like to get the "icing on the cake" so to speak, and a lot of times the consults are pretty short and straightforward. Which helps because my outpatient clinic is very full now.

Try to be patient and get through it. I did not like C&L much when I did it, but looking back it was a very useful opportunity to fine tune your skills at interacting with other medical professionals.

 

[Merovinge]

The way it was explained to me by a consult attending that helped me stopped resenting this sort of thing nearly so much was this: by consulting you, the primary team is saying that something is wrong and they don't know what to do. Even if what is actually happening is not the official consult reason, something is going on.

Most of my most interesting C&L cases were for the stupidest sounding reasons.

I had the exact same frustrations as OP and then the exact same experience with you, having some incredibly stupid sounding consults that turned out to be either extremely meaningful, directly life changing, or diagnostically incredible. There's nothing wrong about pushing back on inappropriate consults (I had one asking me to call the pharmacy to clarify the patient's outpatient medications), but I would almost always see and staff the case first and then try educating the primary team.

 

[Armadillos]

I would say just try to focus on how you can help the patient your being consulted on, even if it’s a dumb consult, if you can find a way to help the patient you’ve done something worthwhile.

Also I would say 99.99% of the time you can’t tell a consult is pointless until you’ve seen it. Have had several where I was shaking my head and ended finding a floridly psychotic or acutely suicidal patient.

 

[FlowRate]

The way it was explained to me by a consult attending that helped me stopped resenting this sort of thing nearly so much was this: by consulting you, the primary team is saying that something is wrong and they don't know what to do. Even if what is actually happening is not the official consult reason, something is going on.

Most of my most interesting C&L cases were for the stupidest sounding reasons.

Completely agree. I'd recommend OP take note of "stupid" ED consults that end up going to inpatient psychiatry as a way to get their confirmation bias going in the opposite direction. That was the easiest evidence for me to access when I was having a moment of "wtf with dumb consults" after being on a neuro service that had itself become burned out on consults. N.B. there are actually stupid neuro consults.

The main class of consults that I think might be pushed back on or turfed are "can you set this patient up with outpatient resources?" or "can you confirm these meds?" The first one is a referral to social work, the second one is "Please confirm their medications and I will be happy to help if there are psychiatric medications that you are concerned about."

There are definitely times in which I wish I could just help the team and not have to write a long negative-findings consult note to go with it.

 

[Shikima]

"Hey *******"

 

[Liquid8]

I just used to laugh a lot on my CL terms.

I can remember another one request enquiring about a possible change in diagnosis from "anorexia nervosa" to "anorexia" because the patient was no longer anxious.

There was one for an 80-year-old with a “first episode psychosis.” Usually these turn out to be a delirium, but this one just didn’t have her hearing aid in when the physicians saw her in the morning.

And then there are the ones who never get referred. On another occasion my CL nurse was looking through the file of a patient admitted following alcohol withdrawal. He was prescribed diazepam 20mg 4 hourly for a week (120mg/day), this was reduced to 20mg daily for 3 days, and then it was ceased. Unfortunately this patient went from an alcohol delirium to a benzo withdrawal delirium. A week later I was asked by a med reg to wean a patient off benzodiazepenes, because they didn't know how to do it. I believed them!

Generally agree with above comments about what it means when hospital teams consult you - most of the time they don't know what is going on. However, sometimes there are good surprises. The best referral I ever got had a full Maudsley style history, thorough mental state, formulation and treatment plan. All I had to really do was endorse the plan, so I ended up going out of my way to find and thank the referrer. They’d wanted to do psychiatry initially, but their partner thought it was too dangerous and convinced them to go into another field instead.

 

[michaelrack]

And then there are the ones who never get referred. On another occasion my CL nurse was looking through the file of a patient admitted following alcohol withdrawal. He was prescribed diazepam 20mg 4 hourly for a week (120mg/day), this was reduced to 20mg daily for 3 days, and then it was ceased. Unfortunately this patient went from an alcohol delirium to a benzo withdrawal delirium. .

due to the long half life of valium, this regime may work in some people (however the half life is variable)

 

[Liquid8]

due to the long half life of valium, this regime may work in some people (however the half life is variable)

Perhaps from a theoretical perspective, although in practice I feel it would be a nonstandard regime and hard to justify a rapid taper given the potential consequences.

I think the problem in that case was notes suggested that the dose was only reduced from 120mg in response to the patient becoming too sedated after a number of days; i.e. as a reactive change as opposed to being a planned reduction. For managing alcohol withdrawal I would regularly prescribe a total of 120mg/day that would include regular and PRN doses based on AWS (Eg. a combination like 20mg TDS + PRN up to 60mg), but I can only recall one patient that has maxed out the full amount and that was more due to them being very demanding with inexperienced nursing staff.

 

[thoffen]

We had a busy C/L service but a lot of bodies. Some of the better consults I found seemed like the worst, mostly because the consulting team just didn't know how to describe what they wanted but knew they needed help. But mostly those sound like bad consults. They should have a specific question for you (like med management of schizohprenia instead of "chart has history of schizophrenia listed" and "is a medication indicated for treatment of pt's depression", etc.). If something is inappropriate absolutely like the general capacity one, you can try to understand their hope and why it's not something you could provide even if you wanted to.

Mostly, though, try to work with your program to find out the scope of your work. Many times my co-residents would be miserable because they would do a full psych assessment on everyone (same deal for ED assessments). But your program might expect you to do a lot for everyone.

For example, “Chart says pt has history of schizophrenia”
- could be a 10-minute interview to recommend restarting medications and outpatient follow-up or not and a safety assessment. If you get enough detail to establish the diagnosis and whether the patient is safe, you don't need to explore everything or even elaborate the psychotic symptoms or past drug trials, etc.

“yesteray pt seemed very anxious for the surgery he is currently undergoing”
- could be a brief interview to elicit whether criteria is met for an anxiety disorder or a safety concern exists and end up with "recommend no psychotropic medications or outpatient psych follow-up; patient seems to have inadequate understanding of current medical illness and necessity of surgery, please provide further counseling; recommend consult pastoral care; recommend family meeting with son; etc."

 

[splik]

There's no such a thing as a stupid consult. only stupid people behind the consult. As a resident you really should not be blocking consults but helping the primary team formulate a good consult question and explaining what you cannot do. I get really annoyed if my residents block consults, however if I think a consult is weak I might go lay eyes on the patient and make sure there is nothing obvious that they had been missing. From a risk management perspective if you block a consult and there is a bad outcome that it going to be a successful lawsuit. We recently had a patient we didn’t see commit suicide. The consult question was poorly phrased by a resident who didn’t know the patient. We recently got a consult to start an antisdepressant on a patient who was crying. On evaluation the patient had steroid induced mania. I recently blocked a consult for “chart dx of bipolar but no symptoms” but went to lay eyes on pt who was hearing voices that were distressing and urging suicide.

1. Never block a consult - that is an attending level decision. It’s my license if something bad happens because you took it upon yourself to decide a patient didn’t need to be seen without evaluating them.
2. Always make sure the person you’re talking to has actually spoken to the patient themselves. “RN said pt endorsed SI” is not appropriate they need to ask themselves.
3. Always make sure they have told the patient they have consulted psych. Saves lots of anguish and sometimes they cancel the consult. Obviously in an emergency pt cannot refuse to see you but otherwise they can.
4. Try to get the team to make their own assessment first.
5. Remember, it is only a curbside if you do not know the patients name and is phrased as a general question - for example “can I prescribe an SSRI to a patient on elavil for pain or should we put them on Effexor?” Is a good curbside question. If it’s just a psychopharm question you may not need to see the patient.
6. If they don’t follow your recs sign off.
7. If you think it’s a bs consult do a brief eval and if it turns out your hunch is correct try to get your attendings permission to not write a full note. I don’t make my residents write a note if it’s truly a dud consult and we realize that after 5 mins.
8. It is usually better to just see the patient because you know it’s gonna bite you in the ass if you leave it til the end of the day, if they really want you to see them then you’ll end up doing so.
9. The fun bit of CL is the liaison part - have conversations with the team and explain what is and isn’t an appropriate consult and where we might cause more problems (eg might hurt placement if psych is involved or they make a big deal about SI in someone who could not actually hurt themselves).
10. You can create written guidelines for psych consultsfor education of other services.
11. The non urgent consults are usually the most interesting. I never understand why the residents don’t want these somatization, functional or factitious disorder consults - much more fun than these SI and capacity to leave AMA type consults.

 

[deleted736562]

I cancel crappy ED consults all the time. By "cancel" I mean somehow manage to convince the ED attending to drop the consult. The key is to always give a coherent rational, be firm and polite. Phrases like "we don't usually see patients for [x]" seem to be quite effective. Of course if they remain insistent then there's nothing you can do. It would be obviously inappropriate not to see the consult if the service provider still wants you to see the patient. It's also always a good idea to document the interaction in a small note. Also, if psych randomly sees 10 patients on medicine or in the ED, it's almost always certain that there will be something that is worthwhile commenting on and may alter the management. Does not mean that a consult is appropriate.

 

[Onions]

While I do understand where the "liason" part of C/L comes from (the reality that behavioral sciences are underemphasized in medical education so we have to be liasons with other specialties), I disagree with it. I simply don't believe that it is my responsibility to teach other doctors, who went to medical school just like I did, what question they want to ask. Nobody is expected to have all the answers, but we should all know how to formulate specific questions based on clinical information that we are ALL educated and trained to gather.

I am not blind to the fact that consults, no matter how poorly articulated, may simply be an expression of the primary team's need for help with something. Unfortunately, in my experience (and this may be a reflection of my particular institutional culture), more often than not, these poorly articulated consults are an expression of the primary team's production and reproduction of the stigma of all this psychiatric: the patient is crazy, psych needs to come deal with it. A medicine resident once asked me to see her patient for suicidality (a reasonable thing to consult psychiatry for) but when I asked her why the patient is suicidal she told me she hadn't asked him, saying "I'm not comfortable asking that." Oh you're not? Maybe I should ask you to come listen to my patients' breath sounds because I'm not comfortable touching their backs with a stethoscope. If you place a consult without taking your own history and doing your own exam (be it physical or mental status), then you are asking the consultant to do your job for you. That is laziness pure and simple and I'm not going to hold your hand through it and spoon feed you the question you don't even know you're asking because you couldn't be bothered to examine the patient's mind to the best of your own ability before concluding that you're in too deep and need help. Just like you don't need to be a surgeon to be comfortable with the sight of blood, you shouldn't have to be a psychiatrist to be comfortable with mental illness. We are all doctors.

That said, I can't block or cancel consults. The attendings on our C/L service would never do that. They don't care what the consult is, they just see it pop up in the computer and we have to go do it. If the primary team happens to remove the consult, they make us call and find out why. There have been times that my attendings have had me call other services and basically tell them to place psych consults on their patients. I find it all inappropriate and somewhat fishy, but who am I but a tiny cog in the machine? I get frustrated, sure, but ultimately, it's so much less work to just go see the case than it is to try to get out of it.

 

[splik]

That said, I can't block or cancel consults. The attendings on our C/L service would never do that. They don't care what the consult is, they just see it pop up in the computer and we have to go do it. If the primary team happens to remove the consult, they make us call and find out why. There have been times that my attendings have had me call other services and basically tell them to place psych consults on their patients. I find it all inappropriate and somewhat fishy, but who am I but a tiny cog in the machine? I get frustrated, sure, but ultimately, it's so much less work to just go see the case than it is to try to get out of it.

your attendings are probably productivity based and given how unproductive C/L is, they probably want you to see as many consults as possible so they get paid and meet their baseline targets.

 

[NickNaylor]

While I do understand where the "liason" part of C/L comes from (the reality that behavioral sciences are underemphasized in medical education so we have to be liasons with other specialties), I disagree with it. I simply don't believe that it is my responsibility to teach other doctors, who went to medical school just like I did, what question they want to ask. Nobody is expected to have all the answers, but we should all know how to formulate specific questions based on clinical information that we are ALL educated and trained to gather.

I am not blind to the fact that consults, no matter how poorly articulated, may simply be an expression of the primary team's need for help with something. Unfortunately, in my experience (and this may be a reflection of my particular institutional culture), more often than not, these poorly articulated consults are an expression of the primary team's production and reproduction of the stigma of all this psychiatric: the patient is crazy, psych needs to come deal with it. A medicine resident once asked me to see her patient for suicidality (a reasonable thing to consult psychiatry for) but when I asked her why the patient is suicidal she told me she hadn't asked him, saying "I'm not comfortable asking that." Oh you're not? Maybe I should ask you to come listen to my patients' breath sounds because I'm not comfortable touching their backs with a stethoscope. If you place a consult without taking your own history and doing your own exam (be it physical or mental status), then you are asking the consultant to do your job for you. That is laziness pure and simple and I'm not going to hold your hand through it and spoon feed you the question you don't even know you're asking because you couldn't be bothered to examine the patient's mind to the best of your own ability before concluding that you're in too deep and need help. Just like you don't need to be a surgeon to be comfortable with the sight of blood, you shouldn't have to be a psychiatrist to be comfortable with mental illness. We are all doctors.

That said, I can't block or cancel consults. The attendings on our C/L service would never do that. They don't care what the consult is, they just see it pop up in the computer and we have to go do it. If the primary team happens to remove the consult, they make us call and find out why. There have been times that my attendings have had me call other services and basically tell them to place psych consults on their patients. I find it all inappropriate and somewhat fishy, but who am I but a tiny cog in the machine? I get frustrated, sure, but ultimately, it's so much less work to just go see the case than it is to try to get out of it.

I think your frustration is reasonable, but just on a pragmatic level, what do you get out of taking a relatively hardline stance with respect to having teams formulate a reasonable question? All that’s likely to do is make the primary teams frustrated, not improve the quality of the consults you receive, and subsequently make you even more frustrated.

 

[Onions]

your attendings are probably productivity based and given how unproductive C/L is, they probably want you to see as many consults as possible so they get paid and meet their baseline targets.

That is exactly correct. And honestly, it's fine. But why does it have to be my problem? I'm not the one showing up to work because of the fat paycheck. Alas, these are the realities of residency training.

I think your frustration is reasonable, but just on a pragmatic level, what do you get out of taking a relatively hardline stance with respect to having teams formulate a reasonable question? All that’s likely to do is make the primary teams frustrated, not improve the quality of the consults you receive, and subsequently make you even more frustrated.

I'll give you an example. A young woman was in the hospital for endocarditis. She had a long and complicated history of developmental trauma, foster placement as a child, and over the past decade or so, severe IV heroin abuse. Naturally, she was not the most pleasant person to talk to and would basically yell and curse at anyone who came in her room. The primary team ended up bargaining with her: doses of Dilaudid in exchange for tests like echos, etc. They paged us "to assess capacity." Now, we all know that this woman, psychiatrically, is a mess. And it was obvious to me that the medical team taking care of her did not feel as though they "signed up for this." Their job, after all, is to make sure she doesn't become septic or go into heart failure, right? But "the patient is a mental case" (not their words, but my interpretation of their take on their patient) is clearly not formulated consult, so I asked the resident what intervention they were offering that the patient was refusing. I got her to narrow it down to "assess capacity to refuse cefazolin."

My point here is that while I knew full well that the primary team was implying to me that they wanted psychiatry to come and be the "heroin addict whisperer" and communicate with the patient because it was too hard for them to do it, I was not about to cut any slack in this regard. That's your patient, and you owe it to her to stick with her and advocate for her regardless of how mean she is. Part of being a doctor is communicating with your patient. That's not a consultant's place.

 

[splik]

That is exactly correct. And honestly, it's fine. But why does it have to be my problem? I'm not the one showing up to work because of the fat paycheck. Alas, these are the realities of residency training.

It's your problem because you are on your C/L rotation and this is how consults work (regardless of specialty) in the real world, which is that you see the damn consult no matter how stupid you think it is. If you think you are seeing too many consults that it is interfering with your learning or ability to provide good care that is something you should discuss with the chief resident, site director, or training director. If my residents are feeling overwhelmed with consults, I will see consults without the residents too. I also often see the complex patients the residents don't seem very interested in seeing by myself (e.g. factitious disorder, somatization, conversion, neuropsych) though the residents are missing out on a learning opportunity in how to approach such patients.

and your case example sounds like a great consult. obviously it was not a capacity question, but about how to manage a difficult patient that was so obviously being mismanaged by the primary team to felt held to ransom by a patient they were ill-equipped to deal with. part of our role is to help the team acknowledge their hateful counter transference and its enactments by saying the unsayable. whether the primary team should be able to manage this themselves is irrelevant, because they were not able to do so and wanted your help.

 

[Candidate2017]

That is exactly correct. And honestly, it's fine. But why does it have to be my problem? I'm not the one showing up to work because of the fat paycheck. Alas, these are the realities of residency training.


I'll give you an example. A young woman was in the hospital for endocarditis. She had a long and complicated history of developmental trauma, foster placement as a child, and over the past decade or so, severe IV heroin abuse. Naturally, she was not the most pleasant person to talk to and would basically yell and curse at anyone who came in her room. The primary team ended up bargaining with her: doses of Dilaudid in exchange for tests like echos, etc. They paged us "to assess capacity." Now, we all know that this woman, psychiatrically, is a mess. And it was obvious to me that the medical team taking care of her did not feel as though they "signed up for this." Their job, after all, is to make sure she doesn't become septic or go into heart failure, right? But "the patient is a mental case" (not their words, but my interpretation of their take on their patient) is clearly not formulated consult, so I asked the resident what intervention they were offering that the patient was refusing. I got her to narrow it down to "assess capacity to refuse cefazolin."

My point here is that while I knew full well that the primary team was implying to me that they wanted psychiatry to come and be the "heroin addict whisperer" and communicate with the patient because it was too hard for them to do it, I was not about to cut any slack in this regard. That's your patient, and you owe it to her to stick with her and advocate for her regardless of how mean she is. Part of being a doctor is communicating with your patient. That's not a consultant's place.

Young IV drug user, opioid dependence, childhood trauma, verbally abusive, endocarditis? Hells yeah! This is what we DO in psych. It's a great opportunity to continue to practice and learn, made even sweeter because their disposition is ultimately up to the primary team. And you might even make a difference in their life.

Sound like you might be burned out?

 

[NickNaylor]

That is exactly correct. And honestly, it's fine. But why does it have to be my problem? I'm not the one showing up to work because of the fat paycheck. Alas, these are the realities of residency training.

I'll give you an example. A young woman was in the hospital for endocarditis. She had a long and complicated history of developmental trauma, foster placement as a child, and over the past decade or so, severe IV heroin abuse. Naturally, she was not the most pleasant person to talk to and would basically yell and curse at anyone who came in her room. The primary team ended up bargaining with her: doses of Dilaudid in exchange for tests like echos, etc. They paged us "to assess capacity." Now, we all know that this woman, psychiatrically, is a mess. And it was obvious to me that the medical team taking care of her did not feel as though they "signed up for this." Their job, after all, is to make sure she doesn't become septic or go into heart failure, right? But "the patient is a mental case" (not their words, but my interpretation of their take on their patient) is clearly not formulated consult, so I asked the resident what intervention they were offering that the patient was refusing. I got her to narrow it down to "assess capacity to refuse cefazolin."

My point here is that while I knew full well that the primary team was implying to me that they wanted psychiatry to come and be the "heroin addict whisperer" and communicate with the patient because it was too hard for them to do it, I was not about to cut any slack in this regard. That's your patient, and you owe it to her to stick with her and advocate for her regardless of how mean she is. Part of being a doctor is communicating with your patient. That's not a consultant's place.

Interesting. Then perhaps what might be helpful is a shift in expectations. Obviously you aren't going to cure this woman - you aren't going to correct what I imagine are maladaptive patterns of behavior, issues related to her trauma, or her substance use. Certainly there is very little to no psychopharmacology you can offer in this regard. However, that doesn't mean you have nothing to offer. As @splik mentioned, it's evident based on your description that interpersonal issues were getting in the way of the patient receiving the care necessary for her physical health. You're right, this may not be the most well-described consult, but I would still argue that this is very much in the wheelhouse of psychiatry and a difficult situation for which you can be useful.

I get it, these kinds of consults can be frustrating, but at their core they are psychiatric. No, you aren't going to "solve the problem," but that doesn't mean that you can't be useful. Don't let perfect be the enemy of the good and all that good stuff.

 

[hamstergang]

I'm a bit confused by some of these posts. As psychiatrists, we're experts in the diagnosis of and management of mental illness. I don't see why we should be better at talking to difficult people -- that's really part of the job of every doctor, and if they'd just be patient enough they can do it too. Thus just feels like a misconception that as psychiatrists we can read people's minds and make them do things.

 

[Onions]

this is very much in the wheelhouse of psychiatry

Oh absolutely, no argument there. I never meant to suggest that this patient had no psychopathology or even that there was nothing interesting about her case. Though she made for very quick interviews: completely refused any engagement from multiple folks on our team including attendings (a fact that is neither here nor there). The only way I could get any history was from past records, as she had had contact with our institution as a teenager. My frustration was not at all with having to go see this consult. After all, we all know that there is no such thing as a bad teaching case, and I do truly believe that. My frustration, rather, was in the primary team's unwillingness to show that they at least tried to think about the case enough to ask for help in a way that would make it practical for me to do so.

Look, as I've said before, I do understand why it's called consultation/liason psychiatry. I just disagree with that, fundamentally. I actually find it a bit presumptuous. If you're taking care of a patient, you own that case. The consultant's job is to help you with stuff you need help with. I don't agree that it's a consultant's place to tell you what you need help with. Heaven help me if I ask, say, GI to see a patient of mine and I'm not dead on with what I want. And frankly, I think that's as it should be.

I also often see the complex patients the residents don't seem very interested in seeing by myself (e.g. factitious disorder, somatization, conversion, neuropsych)

Not sure why residents you work with would not want to see cases such as the examples you mentioned. I actually find factitious illness and malingering to be dizzyingly fascinating from a formulative perspective. I've seen one case of what I am almost sure was as actual functional neurologic syndrome, and it was a welcome break from the white noise of "SI" and "aggressive behavior" and "anxiety." And like you said, the "dumbest" consults can become the most interesting cases, but this is almost a trivial statement: any human being becomes an interesting story when you dig deep enough. But that's not what they asked for. They asked for capacity to refuse cefazolin.

Sound like you might be burned out?

Haha. I don't really think I am, but who knows, maybe you're right. I think I sound more disgruntled than I really am. Glad to be done with my C/L rotations, honestly. It can often feel like thankless work. I spend a lot of time with the patients I am asked to see, and I think carefully about the cases. I don't actually think anyone is ever going to read my novel of a social history, but at least follow the recommendations if you're going to ask for them, you know?

 

[clausewitz2]

I'm a bit confused by some of these posts. As psychiatrists, we're experts in the diagnosis of and management of mental illness. I don't see why we should be better at talking to difficult people -- that's really part of the job of every doctor, and if they'd just be patient enough they can do it too. Thus just feels like a misconception that as psychiatrists we can read people's minds and make them do things.

Two things:

1) While our therapy training is not uniformly impressive, we still get a ton more of it than most physicians. Some of these skills are incredibly valuable in helping to contain affect and engage with the part of the patient that wants to change their situation.

2) Our training also involves a lot more of interviewing people who scream obscenities at us or accuse us of being part of a Zionist conspiracy to murder them, so we end up having a much higher threshold for being done with people than most other physicians. This is not ideal, but it is at present true.