So I'm doing my IM month now, and I'm sure we'll be calling some psych consults at some point. But I never rotated on psych consults as a med student, and I want to avoid annoying my colleagues with inappropriate consults. What are some of the most annoying consults?
What about depression? If a patient is depressed, but not psychotic or suicidal, is a psych consult necessary?
The most annoying consults for me are often capacity assessments.
Me: So, I'm Dr. X, and I'm from the psychiatry department.
Patient: Why did they call you? I'm not crazy.
Me: Well, it seems like they didn't tell you I was coming, like I asked them to.
Patient: No, they didn't. And I'm not crazy.
Me: Fair enough. I'm here because your regular docs wanted me to help them determine whether or not you understand the procedure that they've got planned for you.
Patient: What procedure?
Me: They must have mentioned the lumbar puncture to you. It's also called a spinal-tap. We use the procedure to help determine or rule-out the possibility of certain types of infections and other conditions.
Patient: Do I really need it?
Me: Well, my job is not really to convince you one way or the other. From reviewing your chart earlier, it does appear that it would help from a diagnostic standpoint. They mentioned nothing to you about this?
Patient: No, it sounds painful. Is it dangerous?
Me: Well, it does have some risks which should have been explained to you by your primary medical team (proceeds to explain the risk/benefit ratio).
Patient: It sounds important. I should do it probably. Ok. They'll come do it now?
😡
If you're going to call for a capacity consult, take the time to tell the patient what you want to do, why, and the risks and benefits of the procedure. If you still aren't sure, then call psychiatry.
I've taken recently to dragging the resident, intern or even attending in with me to have them explain the procedure or discuss the decision to determine if I'm needed.
About depression. This depends on the nature of your particular C/L service. Obvious signs such as (true stories) breaking the window and trying to jump out 15 stories down, trying to hang yourself from the toilet bown handle, or hoarding pills that are then found in the drawer, deserve psych consults. Expressd suicidal ideation deserves a psych consult. Some transient dysphoria when a patient is s/p fall and finds out they'll be in the hospital for 2 weeks, or a few tears because they missed their daughter's piano recital do not deserve psych consults.
Some C/L departments, depending on their orientation, do engage in bedside psychotherapy for benign cases. I hate doing this and find it quite awkward. Frankly, our psych c/L service is too busy to do 45-minute therapy sessions at the bedside. Others like it a great deal.
If someone is on Paxil, Seroquel, Lexapro, or some other psychotropic, and they are stable, express no symptoms, and express no desire to see a psychiatrist, a consult is generally not necessary.
One thing that really irks me is when (DS might disagree with me here) a consult is called because "the patient wants to see a psychiatrist." My feeling is that this is not a private wellness spa, and that patients do not dictate their treatment or get to see a psychiatrist because they have minor issues or are bored.
If a patient said to you on rounds..."I want to see a nephrologist." Would you leave the room and call one? Of course not. Why would you do it to psychiatry? You should ask them why they want to see one, ask if they're suicidal or have a psychiatric history, then make a determination whether or not psychiatry should be consulted to offer an opinion on the case.
Some of these thoughts are just my own view. Others might disagree.
