The C/L Bashing Thread

[Sushirolls]

I've posted variably in the depths of this forum my disdain for C/L.

Applause for Glaucomflecken again. This skit encapsulates the pain of C/L, and when a resident the attendings telling you to just please the primary services and just go do the consult. The time I wasted in residency with consults for "patient cried" etc. This skit just brought flash backs.


"patient is schizophrenic" <--stable, no symptoms, regular med compliance, in hospital for surgery or something but a reflex consult because of diagnosis. Rubber stamp patient stable continue home meds, don't change them... Signing off...

"patients requests psych just to see if their meds are correct" patient has outpatient psychiatrist for years, stable, doing well, no issues... yes, lets abuse the C/L service as a 2nd opinion

"patient suicidal" No patient not suicidal, just in pain after notable medical procedures, and made off hand comments to RN / CNA about pain level that got twisted into being suicidal.

"Capacity to leave" Get to room, patient is mid process of yanking out IV line, putting shoes on cursing every one. Heroin addiction, got a single round of IV abx for endocarditis, jonesing for heroin, basically tells you to fun off, or says, no I'm starting to go in withdrawal, no I don't want treatment, and I want to leave.

"suicidal patient" Only to discover, no the patient isn't suicidal. Simply cried, RN observed, who didn't talk with patient, caught the IM service Intern, who was swamped, said hey patient 303 cried, I think they should have a psych consult. Intern, like uh, yay, okay? Put it in. RN puts order in. Talking with people once you get on site, IM service doesn't know they consulted you. Intern vaguely recalls discussion with RN when pressed, and current RNs on shift have no idea what's going on. Only learn from that RN who put order in, the next day, once they are back on shift, oh, yeah, patient cried "and maybe said they were suicidal?" Patient is normal as normal can be, except for the suck of their primary issue of being in hospital and wondering who/why anyone said they were suicidal and in state of WTF, and clearly well adjusted, with healthy relationships, solid ego, future oriented, etc
*Bonus points. After this consult is done... might get an RN be like oops, we meant patient in 304.

The list goes on and on.

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[comp1]

Yeah, I'm not into treating other doctors and that's what CL is. Still beats outpatient by a mile though, excepting child which has a similar identified patient dynamic.

 

[FlowRate]

This must have been posted on SDN recently because the top hit when I googled to find the paper was an SDN post.

 

[Stagg737]

The video is great and our whole consult team enjoyed it. We've had almost these exact conversations more than a few times. That being said, consults is still my favorite psych setting by far, requires us to actually remember our medical training and also provides a much wider variety of cases. So far this year I've seen stiff person syndrome, transient global amnesia 2/2 hypothermic shock, and a case that's almost certainly CJD (not yet confirmed). I can see it being a nightmare at some hospitals where you're just trying to help "move the meat", but at large academic centers where there are thorough work-ups you'll see stuff a lot of docs may only see once or twice in their career if ever.

"patients requests psych just to see if their meds are correct" patient has outpatient psychiatrist for years, stable, doing well, no issues... yes, lets abuse the C/L service as a 2nd opinion

"patient suicidal" No patient not suicidal, just in pain after notable medical procedures, and made off hand comments to RN / CNA about pain level that got twisted into being suicidal.

"suicidal patient" Only to discover, no the patient isn't suicidal. Simply cried, RN observed, who didn't talk with patient, caught the IM service Intern, who was swamped, said hey patient 303 cried, I think they should have a psych consult. Intern, like uh, yay, okay? Put it in. RN puts order in. Talking with people once you get on site, IM service doesn't know they consulted you. Intern vaguely recalls discussion with RN when pressed, and current RNs on shift have no idea what's going on. Only learn from that RN who put order in, the next day, once they are back on shift, oh, yeah, patient cried "and maybe said they were suicidal?" Patient is normal as normal can be, except for the suck of their primary issue of being in hospital and wondering who/why anyone said they were suicidal and in state of WTF, and clearly well adjusted, with healthy relationships, solid ego, future oriented, etc
*Bonus points. After this consult is done... might get an RN be like oops, we meant patient in 304.

These are garbage consults and we regularly push back on these unless the consulting team can give us an actual reason to see them. We also push back on the "patient wants to talk to someone" consults as well, we have therapists that can be consulted for that and just redirect the primary docs to them.

"patient is schizophrenic" <--stable, no symptoms, regular med compliance, in hospital for surgery or something but a reflex consult because of diagnosis. Rubber stamp patient stable continue home meds, don't change them... Signing off...

If truly as described this is typically an easy consult, but given how often I see schizophrenic patients where their outpatient docs have them on some insane med regimen or meds that will significantly interfere with the medical treatment I don't mind these. Most of the work is done with chart review before seeing the patient and the actual f2f time is short. This is easy money where we can actually be useful. The more annoying version of this is "patient takes lexapro 5 mg and is a little anxious about being the hospital, assist with med recs". Non-psychiatrists getting nervous about LAIs, high doses of antipsychotics, or stuff like lithium/depakote is fine with me. Non-psychiatrists acting completely clueless about low-dose SSRIs in the context of very mild and situationally normal depressive/anxiety does annoy me, but I'll begrudgingly take the RVUs.

"Capacity to leave" Get to room, patient is mid process of yanking out IV line, putting shoes on cursing every one. Heroin addiction, got a single round of IV abx for endocarditis, jonesing for heroin, basically tells you to fun off, or says, no I'm starting to go in withdrawal, no I don't want treatment, and I want to leave.

This is fair and I get why some psychiatrists don't like it, but I don't see how this is different from many of the cluster B patients we see in outpatient clinics. I'll take this capacity consult 100% of the time over having to see these people in clinic. I also don't mind capacity consults because where I'm at they're usually very straightforward CYA stuff that primary just wants to have affirmation about and takes 10 minutes or it's more complicated and a psych and/or ethics consult is actually worthwhile. I also like forensic stuff, so probably the most adjacent thing to actual forensic psychiatry I see with any regularity.

 

[annoyedpsychiatrist]

hey it beats the outpatient people that come in and say "im here for my xanax and adderrall" then you say no and they give you a lovely review after

 

[mistafab]

I love C/L. Hard to miss the appeal:

1. Many “one-shot” cases.
2. Not fielding calls from nursing
3. Not putting in orders
4. Not fielding calls from family
5. “Family wants to speak with you” - nope, not me thanks
6. Primary team calls you because they need your help, even if it’s dumb
7. Clock in, clock out
8. Need a consult at 2am? Too bad. My phone is off and you’re the primary.
9. 2 open consults - I’ll go grab lunch first, no rush
10. Late consult comes in “I’ll see it tomorrow” and leave
11. Work with other people in your field and talk smack all day
12. Rare stuff / interesting problems sprinkled in
13. “Patient is sad” - yep, they’re sad. That’ll be $400
14. “Patient has schizophrenia” yep, they do. Give them their medicines. That’ll be $400
15. “Patient had bipolar” - nope, it’s borderline
16. “ADHD meds?” Borderline
17. “We have a consult” - borderline
18. Borderline

 

[docksan]

I've posted variably in the depths of this forum my disdain for C/L.

Applause for Glaucomflecken again. This skit encapsulates the pain of C/L, and when a resident the attendings telling you to just please the primary services and just go do the consult. The time I wasted in residency with consults for "patient cried" etc. This skit just brought flash backs.


"patient is schizophrenic"
"patients requests psych just to see if their meds are correct" patient has outpatient psychiatrist for years, stable, doing well, no issues... yes, lets abuse the C/L service as a 2nd opinion

"patient suicidal" No patient not suicidal, just in pain after notable medical procedures, and made off hand comments to RN / CNA about pain level that got twisted into being suicidal.

"Capacity to leave" Get to room, patient is mid process of yanking out IV line, putting shoes on cursing every one. Heroin addiction, got a single round of IV abx for endocarditis, jonesing for heroin, basically tells you to fun off, or says, no I'm starting to go in withdrawal, no I don't want treatment, and I want to leave.

"suicidal patient" Only to discover, no the patient isn't suicidal. Simply cried, RN observed, who didn't talk with patient, caught the IM service Intern, who was swamped, said hey patient 303 cried, I think they should have a psych consult. Intern, like uh, yay, okay? Put it in. RN puts order in. Talking with people once you get on site, IM service doesn't know they consulted you. Intern vaguely recalls discussion with RN when pressed, and current RNs on shift have no idea what's going on. Only learn from that RN who put order in, the next day, once they are back on shift, oh, yeah, patient cried "and maybe said they were suicidal?" Patient is normal as normal can be, except for the suck of their primary issue of being in hospital and wondering who/why anyone said they were suicidal and in state of WTF, and clearly well adjusted, with healthy relationships, solid ego, future oriented, etc
*Bonus points. After this consult is done... might get an RN be like oops, we meant patient in 304.

The list goes on and on.

And as a C/L I'll tell you these are all great opportunities to make comments in your assessment that reduces the likelihood they abuse you in the future.

Would you rather them not consult us and then they hurt the patient?

 

[comp1]

I'm glad there are some people who enjoy this and I definitely agree that regardless it's all better than outpatient. I can see how it could be fascinating at a tertiary academic medical center, although I would argue most of the exciting conditions described above would be better followed by neuro than psych. I really liked the article separating out liaison from consultant, although I won't say I followed all of it. I personally find the consult specific side okay, but's pretty simple and should really be a chart review in the vast majority of cases. The liaison side, which I would argue has dramatically overshadowed the consultant side since 1989, is really what I do not enjoy, particularly with other physicians. I'd much rather just be called by nurses on an inpatient unit. Since Father Murray died in 2013, I think he probably did live long enough to see liaison cardiologists in the form of whole health...

 

[nexus73]

The people I've talked to who don't like consults have been on services that are understaffed. You're facing a mountain of patients and then the 3rd consult for competency comes in for a patient who is refusing to go to a nursing home. So they're pushing back on bad consult requests all day, they're not happy, the services asking for consults aren't happy. It's a bad situation.

If the consult service is well staffed, these "inappropriate" consults are really no problem. Psychiatry sees them, helps the primary team, everyone is happy.

One big problem is hospitals don't recognize psychiatry takes more time than other specialties, and psych consults are not easy cases. In contrast to internal medicine consults which typically are easy cases. Hospitalists don't understand this because when they get consulted it's for basic stuff--rashes, HTN, managing insulin--but if a patient is medically complex they wouldn't be consulting internal medicine, the patient would just be on their service. So a hospitalist consult for insulin, probably takes them longer to write the note than see the patient. When psych gets consulted for capacity eval, or post suicide attempt, or even something that seems basic like someone's "sad", etc, these require a fair amount of time face to face to know what's really going on, plus potential phone calls for collateral. Not easy, not necessarily quick. I've had hospitalists complain about psych pushback on consults, saying they help us out all the time with basic, outpatient medical issues when people are on psych. What they struggle to understand is those consults take them 5 minutes doing an uber focused evaluation, but when they consult psych you have to do a full psych eval, more like 45+ minutes.

 

[calvnandhobbs68]

I think CL where there's some kind of reasonable incentive pay for seeing more consults is a lot more palatable than CL as a resident or when you're on straight salary.

If you're getting paid something decent for it, it's probably a lot easier to walk into capacity consults with a smile on your face. When you're a resident or it's just added on as part of your inpatient/ER position, that consult suddenly gets a lottttt more annoying.

 

[annoyedpsychiatrist]

I think CL where there's some kind of reasonable incentive pay for seeing more consults is a lot more palatable than CL as a resident or when you're on straight salary.

If you're getting paid something decent for it, it's probably a lot easier to walk into capacity consults with a smile on your face. When you're a resident or it's just added on as part of your inpatient/ER position, that consult suddenly gets a lottttt more annoying.

yea exactly. If youre getting paid well, then 10 consults of "patient had a bad day, come and talk to them?". Sure, ok.

As a resident that would be annoying though and used to drive me crazy. But to make to make an attending salary and get consulted on minor problems...thats called job security

 

[Sushirolls]

And as a C/L I'll tell you these are all great opportunities to make comments in your assessment that reduces the likelihood they abuse you in the future.

Would you rather them not consult us and then they hurt the patient?

Them "hurting" the patient is their fault not mine. Don't spin that on me or the collective "us." There are more hospitals in the country without a C/L service than those with.

Yes, to other's points there are some occasional cool cases, but as another on here noted, we are merely the fly on the wall. We don't make those diagnoses. We don't impact the direction of those cases. Neurology does. CJD? Neurology. FFI? Neurology. Locked in syndrome? Neurology.

A suicidal patient? They need close follow up post discharge, or they need psych admission. Either way, a day or two delay in starting an SSRI isn't that consequential. As evidenced by most hospitals in the country not having C/L.

Capacity, all doctors are capable...

Delirium... so, so, so prevalent, that the rubberstamp we do on C/L services should have been cattle branded into every Intern when they set foot on IM.

Conversion disorders? Simply because neurology abdicates their duty to educate patients on treament options, prognosis, and general condition education we are supposed to do clean up for them on their Epilepsy services? Is it so hard to talk with the patient to concretely tell them you don't have epilepsy; it is quite powerful having a quality diagnosis/prognosis discussion from the Neurologist instead of clean up psychiatrist. Instead of documenting in chart, and sneaking away after clicking "consult psych"?

Primary services just ignore the recommendations any way.

C/L VALUE:

• Essentially Psychiatry on C/L is a antipsychotic dispensary service, with being overly reductionistic. But even this can be mitigated by cattle branding haldol IM/PO/IV basics into interns who rotate thru with IM. Need a different antipsychotic? sure, call Psych then.
• Transplant services to be the medication soup watchdog - not pharmacist - not IM - to reduce manage delirium.
• Detox - psych just does it better than IM/FM etc. But even in a resource deficit, CIWA protocol still works and captures majority of cases just fine.
• Munchausens/fictitious; picking up the phone to call ethics/risk management/primary service to coordinate a single meeting of what to do next...

I like outpatient, I won't sing its praises here, that would be for another thread, LOL. This is the C/L bashing thread.

Training in giant academic hospital, and practicing in mid size hospital doing C/L work in past I rarely. Rarely thought to myself, good thing I'm here. This truly made a difference, that couldn't have been handled in a simpler manner. I tried to buy in, truly I did, the kumbaya koolaid of being the liasion, to teach and educate other doctors and nursing staff. But ultimately their care, compassion, empathy, whatever, was just gone. It simply is a look of irritability or glazed hollowness in their eyes "We don't care... just make our lives easier... pull out your crystal ball and fix this mess or at least reduce it... or give us the false hope that you are making it better... show us your inner shaman."

 

[docksan]

Lol k

 

[Peonage]

This reminds me of the time when I got consulted for "bad dreams" in the ED a few months ago.

 

[Stagg737]

Them "hurting" the patient is their fault not mine. Don't spin that on me or the collective "us." There are more hospitals in the country without a C/L service than those with.

Yes, to other's points there are some occasional cool cases, but as another on here noted, we are merely the fly on the wall. We don't make those diagnoses. We don't impact the direction of those cases. Neurology does. CJD? Neurology. FFI? Neurology. Locked in syndrome? Neurology.

A suicidal patient? They need close follow up post discharge, or they need psych admission. Either way, a day or two delay in starting an SSRI isn't that consequential. As evidenced by most hospitals in the country not having C/L.

Capacity, all doctors are capable...

Delirium... so, so, so prevalent, that the rubberstamp we do on C/L services should have been cattle branded into every Intern when they set foot on IM.

Conversion disorders? Simply because neurology abdicates their duty to educate patients on treament options, prognosis, and general condition education we are supposed to do clean up for them on their Epilepsy services? Is it so hard to talk with the patient to concretely tell them you don't have epilepsy; it is quite powerful having a quality diagnosis/prognosis discussion from the Neurologist instead of clean up psychiatrist. Instead of documenting in chart, and sneaking away after clicking "consult psych"?

Primary services just ignore the recommendations any way.

C/L VALUE:

• Essentially Psychiatry on C/L is a antipsychotic dispensary service, with being overly reductionistic. But even this can be mitigated by cattle branding haldol IM/PO/IV basics into interns who rotate thru with IM. Need a different antipsychotic? sure, call Psych then.
• Transplant services to be the medication soup watchdog - not pharmacist - not IM - to reduce manage delirium.
• Detox - psych just does it better than IM/FM etc. But even in a resource deficit, CIWA protocol still works and captures majority of cases just fine.
• Munchausens/fictitious; picking up the phone to call ethics/risk management/primary service to coordinate a single meeting of what to do next...

I like outpatient, I won't sing its praises here, that would be for another thread, LOL. This is the C/L bashing thread.

Training in giant academic hospital, and practicing in mid size hospital doing C/L work in past I rarely. Rarely thought to myself, good thing I'm here. This truly made a difference, that couldn't have been handled in a simpler manner. I tried to buy in, truly I did, the kumbaya koolaid of being the liasion, to teach and educate other doctors and nursing staff. But ultimately their care, compassion, empathy, whatever, was just gone. It simply is a look of irritability or glazed hollowness in their eyes "We don't care... just make our lives easier... pull out your crystal ball and fix this mess or at least reduce it... or give us the false hope that you are making it better... show us your inner shaman."

This is such a jaded and frankly grossly oversimplified perspective. Where I'm at we work with neuro in a lot of those cases and some of them we manage ourselves. I know it's uncommon, but where I'm at we co-manage patients and often place orders ourselves. I'm quite familiar with how to order IVIG at our hospital. To the idea that we're just a fly on the wall, same can be said of any consult service that sees a patient, makes basic recs, and then does nothing more.

I think you're also missing some major areas of expertise for C/L psychiatrists. It is very common for medications to cause psych-related side effects and knowing which meds can cause significant problems is a big part of our job. Stuff like voriconazole-induced psychosis, Trikafta-induced depression, cefepime-induced neurotoxicity (especially with AKI or ESRD), etc. Or how about "patient is encephalopathic but haldol made it worse, help!" That can be a more complicated work-up than people realize.

Helping identify causes of encephalopathy is also something we frequently help with. We see a lot of catatonia, which falls solidly into our domain as psychiatrists, but it's also frequently due to a GMC which is also good points to be effective liaisons. Imo we just know more in terms of differentiating delirium vs catatonia vs SS vs NMS vs anticholinergic toxicity vs some other etiology. It's also important because the treatment for these can be dramatically different and the wrong recommendation could significantly harm or even kill someone.

Capacity is also not always straightforward. Yes, anyone can do an assessment, but some cases are just best left to actual experts. Had a case a couple of months ago where a patient was refusing a fairly straightforward treatment that was necessary to live but there were significant problems with family/DPOA dynamics. This was a case that was far from straightforward and absolutely warranted our involvement to assist the surgical team's assessment (even though they did quite well with their own eval). This is where some affinity to forensics is necessary, which I realize some psychiatrists hate, but I've found psychiatrists just tend to be far more well-versed in medical law than many other docs.

I can definitely see how being C/L in other settings would be awful, but that's the same for any area of psych. Plus, for all the downsides of C/L it's still far better than having to deal with insurance companies and trying to figure out what meds they say I am or am not allowed to prescribe due to coverage or patients calling me or leaving messages in my inbox or any of the administrative BS that comes along with that.

 

[FlowRate]

For some reason, I thought Glauc was going to say "You want a competency eval? Well, any competent doctor should be able to do a capacity eval. And if you can't do a capacity eval, I don't think I can declare you a competent doctor."

 

[clement]

I've posted variably in the depths of this forum my disdain for C/L.

Applause for Glaucomflecken again. This skit encapsulates the pain of C/L, and when a resident the attendings telling you to just please the primary services and just go do the consult. The time I wasted in residency with consults for "patient cried" etc. This skit just brought flash backs.


"patient is schizophrenic" <--stable, no symptoms, regular med compliance, in hospital for surgery or something but a reflex consult because of diagnosis. Rubber stamp patient stable continue home meds, don't change them... Signing off...

"patients requests psych just to see if their meds are correct" patient has outpatient psychiatrist for years, stable, doing well, no issues... yes, lets abuse the C/L service as a 2nd opinion

"patient suicidal" No patient not suicidal, just in pain after notable medical procedures, and made off hand comments to RN / CNA about pain level that got twisted into being suicidal.

"Capacity to leave" Get to room, patient is mid process of yanking out IV line, putting shoes on cursing every one. Heroin addiction, got a single round of IV abx for endocarditis, jonesing for heroin, basically tells you to fun off, or says, no I'm starting to go in withdrawal, no I don't want treatment, and I want to leave.

"suicidal patient" Only to discover, no the patient isn't suicidal. Simply cried, RN observed, who didn't talk with patient, caught the IM service Intern, who was swamped, said hey patient 303 cried, I think they should have a psych consult. Intern, like uh, yay, okay? Put it in. RN puts order in. Talking with people once you get on site, IM service doesn't know they consulted you. Intern vaguely recalls discussion with RN when pressed, and current RNs on shift have no idea what's going on. Only learn from that RN who put order in, the next day, once they are back on shift, oh, yeah, patient cried "and maybe said they were suicidal?" Patient is normal as normal can be, except for the suck of their primary issue of being in hospital and wondering who/why anyone said they were suicidal and in state of WTF, and clearly well adjusted, with healthy relationships, solid ego, future oriented, etc
*Bonus points. After this consult is done... might get an RN be like oops, we meant patient in 304.

The list goes on and on.

CL is all too often about making people who are uncomfortable with psychiatry feel more comfortable about it. And far less about the glorious zebras in the mgh handbooks.

That, and in some (many) cases getting someone to do your cya documentation as a means to discharge a provocative pt with every intention of living or to assuage the capacitated ama dc on the floor.
As a trainee I really disdained being forced to do inappropriate non emergent consults just to maintain “the relationship” with the er or hospitalist service…at various places I worked at, er or hospitalist chiefs had no respect for psychiatrists and so the inappropriate consults were pervasive. Because cl bleeds money and psychiatrists were at their call and beckon. Collusion at its best. Like doing capacity consults that anyone should be able to do, strictly to keep the service afloat.

 

[docksan]

I guess that I just default back to "do I really want to use my time and energy arguing with someone who has no idea what they're doing or do I want to affect a little change and educate everyone else involved in this patients care" because frankly a lot of psychological harm is inflicted at the hospital by people who have no idea what they're doing.

Is it a waste of my time to go see someone for a capacity eval the primary team could have easily taken care of? Yes. Yes it is. But I'm not here for me. I'm here for the patient. And if there's a chance my wasted time in a day acts as a voice for that person I'll take it.

 

[clement]

I guess that I just default back to "do I really want to use my time and energy arguing with someone who has no idea what they're doing or do I want to affect a little change and educate everyone else involved in this patients care" because frankly a lot of psychological harm is inflicted at the hospital by people who have no idea what they're doing.

Is it a waste of my time to go see someone for a capacity eval the primary team could have easily taken care of? Yes. Yes it is. But I'm not here for me. I'm here for the patient. And if there's a chance my wasted time in a day acts as a voice for that person I'll take it.

I don’t disagree. It’s worth nothing that it depends on how your position is structured and whether there are 8 other competing (pressing) clinical interests. Where I trained, they sometimes tried to filter the capacity consults, looking for those that seemed to arise from a primary psychiatric ailment— as opposed to purely contentious communication (or lack thereof) between pt and primary team (ie sometimes the need for goals of care conversation masquerades as a depression consult or ama panic consult)…in my book, that’s dumping and largely furthers a rift between the pt and their primary team…as opposed to helping (sometimes even feeds splitting).

 

[Celexa]

I don’t disagree. It’s worth nothing that it depends on how your position is structured and whether there are 8 other competing (pressing) clinical interests. Where I trained, they sometimes tried to filter the capacity consults, looking for those that seemed to arise from a primary psychiatric ailment— as opposed to purely contentious communication (or lack thereof) between pt and primary team (ie sometimes the need for goals of care conversation masquerades as a depression consult or ama panic consult)…in my book, that’s dumping and largely furthers a rift between the pt and their primary team…as opposed to helping (sometimes even feeds splitting).

I actually don't mind capacity consults. My process is:

1. An effusive, friendly interrogation of the person who is calling on the medical situation. Primary team hasn't even talked to the patient? Major diagnostic information missing? Aren't even sure what they want to offer? Wouldn't actually do anything different if the patient lacks capacity? So sorry, here's the laundry list of things you need to figure out, call me back and I'll be happy to help.

2. "I'm happy to help. Let's go talk to the patient together".

If the team doesn't actually want to do the work, they suddenly figure out they don't really need the consult when they realize I'm not gonna do their work for them. If they're really concerned and distressed about the situation, their response to #2 is genuine gratitude, I can usually detangle the situation and get everyone tucked in in a pretty straightforward manner, provide some good teaching, and it usually roles forward into the teams trusting me more next time I work with them.

CL isn't for everyone but my day to day definitely doesn't resemble the futile hellscape described in this thread, not by a long shot.

 

[clement]

I actually don't mind capacity consults. My process is:

1. An effusive, friendly interrogation of the person who is calling on the medical situation. Primary team hasn't even talked to the patient? Major diagnostic information missing? Aren't even sure what they want to offer? Wouldn't actually do anything different if the patient lacks capacity? So sorry, here's the laundry list of things you need to figure out, call me back and I'll be happy to help.

2. "I'm happy to help. Let's go talk to the patient together".

If the team doesn't actually want to do the work, they suddenly figure out they don't really need the consult when they realize I'm not gonna do their work for them. If they're really concerned and distressed about the situation, their response to #2 is genuine gratitude, I can usually detangle the situation and get everyone tucked in in a pretty straightforward manner, provide some good teaching, and it usually roles forward into the teams trusting me more next time I work with them.

CL isn't for everyone but my day to day definitely doesn't resemble the futile hellscape described in this thread, not by a long shot.

Oh. Right. I forgot all about, let’s plan to see the pt together (cancels up to 18% of capacity consults) and pre consult priming questions, like, have you talked to the pt yet. When I was an intern, some senior residents had an overnight script where they’d offer to bring a capacity handout to empower whoever (typically a medicine intern) was calling while offering to walk them through it (cancels 19% of consults). We also required that consult calls be placed by physicians only. But this was an insanely busy consult service that also covered a large and exquisitely methy med er (psych consults literally every 30 minutes some nights).

Another strategy I’ve seen piloted is building in a screening checklist or questionnaire in the emr that pops up by default when primary teams place certain types of psychiatry consults.

Overall I think part of the education to other specialties tenets of cl is boundary setting too (but maybe this isn’t the case in cushier and quieter settings).

 

[clausewitz2]

Hey @Sushirolls , Claude Opus has your back:

-----
Ah, you want my unfiltered take on consult-liaison psychiatry, do you? Well buckle up, because I've got some strong opinions on the matter!

Listen, I've been around the block a few times in this field. And let me tell you, consult-liaison is where promising psychiatric careers go to die. It's a thankless, soul-sucking grind that will chew you up and spit you out.

First of all, you're constantly dealing with medical teams who don't respect psychiatry and just want you to rubber stamp their patients as "cleared." They page you for the most ridiculous reasons at all hours of the day and night. You're lucky if you can get them to even read your notes half the time.

And don't even get me started on the patients. You're seeing the sickest of the sick, with every possible medical comorbidity under the sun. They're delirious, they're withdrawing, they're in pain, and they sure as hell don't want to talk to a psychiatrist. You're basically just putting out fires left and right.

There's no continuity of care, no chance to develop therapeutic relationships. It's just an endless parade of one-off consults on the most miserable patients in the hospital. You'll start to question why you even went into psychiatry in the first place.

Oh, and research? Forget about it. Consult-liaison research is a barren wasteland. No one is breaking new ground or making meaningful contributions to the field. It's where research careers go to wither on the vine.

So trust me, if you want to make a real difference in psychiatry, steer clear of consult-liaison. Focus on outpatient work where you can actually help people make substantive changes in their lives. Or go into research and push the boundaries of what we know about the brain and behavior.

But for the love of all that is holy, don't waste your talent on being a glorified hospital bureaucrat and babysitter. You're better than that. Leave consult-liaison to the masochists and the unambitious. You've got bigger things ahead of you.

----

But don't worry, C/L folks, Claude sees you there:

-----

Ah, my young padawan, so you're considering a career in consult-liaison psychiatry? Let me tell you, that's the best damn decision you could make! Consult-liaison is where the real action is in psychiatry. It's where the rubber meets the road and you get to make a real difference in people's lives.

First of all, forget about outpatient work. That's just a bunch of neurotic yuppies whining about their problems. In consult-liaison, you're dealing with real, high-stakes medical issues. You're seeing the most fascinating cases in the hospital - delirium, dementia, ICU psychosis, you name it. It's never a dull moment.

And the best part? You get to be a real doctor. You're working hand-in-hand with the medical teams, showing them how psychiatry is an essential part of comprehensive care. You're not just some shrink in an office, you're a crucial member of the treatment team.

Plus, the research opportunities in consult-liaison are endless. You're at the cutting edge of the mind-body interface, exploring how psychiatric issues impact medical outcomes and vice versa. This is where the most exciting and impactful research is happening in psychiatry today.

And let's talk about the patients. Sure, they're complex and challenging, but that's what makes it so rewarding. You get to help the most vulnerable and severely ill patients in the hospital. You're there for them at their darkest moments, providing comfort, clarity, and hope. It's incredibly meaningful work.

So forget about outpatient psychiatry. That's for people who want a cushy 9-to-5 job. If you want to be a real psychiatrist, if you want to make a real difference, if you want to be at the forefront of the field, then consult-liaison is the only way to go.

When you're on the consult-liaison service, you're the go-to person for all things psychiatric. The surgeons, the internists, the neurologists - they all turn to you for guidance and expertise. You're the one who helps them navigate the complex interplay between mental and physical health.

But it's not just about providing recommendations and disappearing. No, no, no. You're there on the front lines, shoulder-to-shoulder with the medical teams. . You're an integral part of the treatment team.

And let me tell you, when you're able to help a skeptical surgeon understand the psychiatric factors at play in their patient's case, or when you're able to guide a medical team through a complex capacity evaluation - that's when you know you're making a real difference. You're not just improving psychiatric care, you're elevating the entire standard of medical care.

The liaising, the interfacing, the collaborating - that's the heart and soul of consult-liaison psychiatry. It's where you have the opportunity to truly transform patient care. You're not just a psychiatrist, you're a leader, an educator, a change agent.

Trust me, I've been doing this for decades and I wake up every day excited to go to work. Consult-liaison psychiatry is the most challenging, the most rewarding, and the most important work you can do in this field.

 

[comp1]

I do ask almost every team how their care will vary if I stamp them to have capacity or not to have capacity. Are you going to strap them down and force the surgery if I say they lack capacity? It's frustrating how almost no one has an answer to this or really even thought about it.

 

[Celexa]

I do ask almost every team how will their care will vary if I stamp them to have capacity or not to have capacity. Are you going to strap them down and force the surgery if I say they lack capacity? It's frustrating how almost no one has an answer to this or really even thought about it.

See I love this moment. The moment you throw the wrench in and actually wake someone up off of autopilot. The moment they realize oh, I am allowed to think about what would've best for this patient in a big picture sense. The moment people remember to be doctors, not algorithm- and- policy-implementers.

I believe there are places where the institutional culture is such that doing CL is miserable. But for me, that liaising piece is what really makes it worthwhile. I think a lot of us ride or die CL folks get a lot of our sustaining energy from our relationships with our non psychiatrist colleagues. I can usually make things better for either patient or team, sometimes both, and usually at least one of those two is actively happy to get my help. It's great.

 

[Sushirolls]

@clausewitz2 Please change your name to Claude Opus. Please?

 

[Cath Up]

Hey @Sushirolls , Claude Opus has your back:

-----
Ah, you want my unfiltered take on consult-liaison psychiatry, do you? Well buckle up, because I've got some strong opinions on the matter!

Listen, I've been around the block a few times in this field. And let me tell you, consult-liaison is where promising psychiatric careers go to die. It's a thankless, soul-sucking grind that will chew you up and spit you out.

First of all, you're constantly dealing with medical teams who don't respect psychiatry and just want you to rubber stamp their patients as "cleared." They page you for the most ridiculous reasons at all hours of the day and night. You're lucky if you can get them to even read your notes half the time.

And don't even get me started on the patients. You're seeing the sickest of the sick, with every possible medical comorbidity under the sun. They're delirious, they're withdrawing, they're in pain, and they sure as hell don't want to talk to a psychiatrist. You're basically just putting out fires left and right.

There's no continuity of care, no chance to develop therapeutic relationships. It's just an endless parade of one-off consults on the most miserable patients in the hospital. You'll start to question why you even went into psychiatry in the first place.

Oh, and research? Forget about it. Consult-liaison research is a barren wasteland. No one is breaking new ground or making meaningful contributions to the field. It's where research careers go to wither on the vine.

So trust me, if you want to make a real difference in psychiatry, steer clear of consult-liaison. Focus on outpatient work where you can actually help people make substantive changes in their lives. Or go into research and push the boundaries of what we know about the brain and behavior.

But for the love of all that is holy, don't waste your talent on being a glorified hospital bureaucrat and babysitter. You're better than that. Leave consult-liaison to the masochists and the unambitious. You've got bigger things ahead of you.

----

But don't worry, C/L folks, Claude sees you there:

-----

Ah, my young padawan, so you're considering a career in consult-liaison psychiatry? Let me tell you, that's the best damn decision you could make! Consult-liaison is where the real action is in psychiatry. It's where the rubber meets the road and you get to make a real difference in people's lives.

First of all, forget about outpatient work. That's just a bunch of neurotic yuppies whining about their problems. In consult-liaison, you're dealing with real, high-stakes medical issues. You're seeing the most fascinating cases in the hospital - delirium, dementia, ICU psychosis, you name it. It's never a dull moment.

And the best part? You get to be a real doctor. You're working hand-in-hand with the medical teams, showing them how psychiatry is an essential part of comprehensive care. You're not just some shrink in an office, you're a crucial member of the treatment team.

Plus, the research opportunities in consult-liaison are endless. You're at the cutting edge of the mind-body interface, exploring how psychiatric issues impact medical outcomes and vice versa. This is where the most exciting and impactful research is happening in psychiatry today.

And let's talk about the patients. Sure, they're complex and challenging, but that's what makes it so rewarding. You get to help the most vulnerable and severely ill patients in the hospital. You're there for them at their darkest moments, providing comfort, clarity, and hope. It's incredibly meaningful work.

So forget about outpatient psychiatry. That's for people who want a cushy 9-to-5 job. If you want to be a real psychiatrist, if you want to make a real difference, if you want to be at the forefront of the field, then consult-liaison is the only way to go.

When you're on the consult-liaison service, you're the go-to person for all things psychiatric. The surgeons, the internists, the neurologists - they all turn to you for guidance and expertise. You're the one who helps them navigate the complex interplay between mental and physical health.

But it's not just about providing recommendations and disappearing. No, no, no. You're there on the front lines, shoulder-to-shoulder with the medical teams. . You're an integral part of the treatment team.

And let me tell you, when you're able to help a skeptical surgeon understand the psychiatric factors at play in their patient's case, or when you're able to guide a medical team through a complex capacity evaluation - that's when you know you're making a real difference. You're not just improving psychiatric care, you're elevating the entire standard of medical care.

The liaising, the interfacing, the collaborating - that's the heart and soul of consult-liaison psychiatry. It's where you have the opportunity to truly transform patient care. You're not just a psychiatrist, you're a leader, an educator, a change agent.

Trust me, I've been doing this for decades and I wake up every day excited to go to work. Consult-liaison psychiatry is the most challenging, the most rewarding, and the most important work you can do in this field.

Thesis and antithesis... I guess we have to do the synthesis ourselves 🙁

 

[docksan]

Or Dysthesis.

 

[clausewitz2]

Synthesis in the style of Schoolhouse Rock:

-------

*Intro music plays*
(Sung to the tune of "I'm Just a Bill")

I'm just a consult-liaison doc
And I'm here to say
There's two sides to this specialty
In a major way!

On one hand it's a thankless job
With no respect or glory
Patients are sick, teams are rude
It's a real sad story!

You're putting out fires left and right
No time for real therapy
Research is dead, you'll lose your head
It's a bleak reality!

*Record scratch, music changes to upbeat tune*

But wait, there's more to this tale
Consult-liaison's where it's at!
Fascinating cases, high-stakes medicine
It's a real feather in your hat!

You're a crucial part of the team
A liaison extraordinaire
Bridging mind and body, bringing depth
To medical care!

The research is cutting-edge stuff
Impactful and exciting
You'll help the sickest of the sick
It's truly rewarding!

So if you want a cushy job
Then look somewhere else, my friend
But if you want to make a difference
Consult-liaison's where to begin!

*Music fades out*

So there you have it, the good and bad
Of this polarizing field
It's not for everyone, that's for sure
But to some, it has appeal!

It all depends on what you want
In your psychiatry career
But one thing's clear, consult-liaison
Ain't boring, that's for sure!

*Outro music plays*

 

[Candidate2017]

And let me tell you, when you're able to help a skeptical surgeon understand the psychiatric factors at play in their patient's case, or when you're able to guide a medical team through a complex capacity evaluation - that's when you know you're making a real difference. You're not just improving psychiatric care, you're elevating the entire standard of medical care.

Nah, Mr. surgeon doesn't give two sticks about psychiatric factors. He's clicking the heck out of the consult button because of passive-aggression, displacement, acting out, etc. After all, he hates having to pay for those expensive cash-only child psychiatrists for his kids, who blame him for their depression, anxiety, and prodigious substance use. He also hates having to pay for child psychiatrists who testify on behalf of his ex-wives against him in child custody cases. I would conduct the liaison part and let him know that he's doing it all wrong because I'm not a child psychiatrist.

 

[docksan]

Yes well skeptical surgeon is thanking God they consulted psych when they get sued and listened, or, screaming loudly at a mirror when he has to pay out for not listening to our medical recs and the patient dies.