SIU School of Medicine

Division of Medicine - Psychiatry

Welcome to the Consultation-Liaison Service.  During your rotation you will learn or expand your knowledge of the basic principles of evaluation and treatment of psychiatric conditions in medical-surgical outpatients.  The information that follows should help you understand what you will be doing on this rotation and the expectations the faculty will have of you.  Please review it carefully.

 

Topics Related to Consultation-Liaison Rotation
Faculty Involved	Days Off	Format of Dictated Notes
Competencies to be Obtained	Moonlighting Policy	Consultations
Professional Behavior Expectations	Vacation Policy	Referring Physician Letter
Call Schedule	Evaluation and Feedback	Discharge Summaries
	References

Faculty:

Jeffrey Bennett, MD	Robert Pary, MD
Philipp Bornstein, MD	David Resch, MD
Kathy Bottum, MD, PhD	Conrad Swartz, MD, PhD
Karen Broquet, MD

Competencies to be Obtained:

Patient Care

• Complete a reproducible medical-psychiatric history that addresses the question or questions asked by patient or the referring/consulting physician – both actual and implied.
• Collect collateral data as relevant to competently assess patient.
• Perform a reproducible neurological examination to assess neurological dysfunction.
• Ability to assess the risk of suicide.
• Demonstrate an ability to assess medication effects and drug-drug interactions.
• Ability to know when to order and how to interpret psychological testing laboratory testing pertinent to the patient’s problem list.
• Recognize and manage hospital stressors as manifested by written and verbal communication with the patient and hospital personnel.
• Place the course of hospitalization and treatment in perspective.
• Prescribe and manage psychopharmacological agents based upon current evidence and patient’s problem list.
• Assess and manage agitation.
• Assess and manage pain.
• Administer drug detoxification protocols.
• Make medicolegal determinations.
• To apply ethical decisions.
• Safely and legally initiate transfers to a psychiatry service when indicated by the patient’s problem.
• Assist with disposition planning.

Medical Knowledge

• This working knowledge should include an understanding of the epidemiology, diagnostic criteria, natural history and treatment options for the following illnesses
• Acute delirium
• Acute stress reactions
• Aggression or impulsivity
• Agitation
• AIDS or HIV infection
• Alcohol and drug abuse (including withdrawal states)
• Anxiety or panic
• Burn sequelae
• Change of mental status
• Coping with illness
• Death, dying, and bereavement
• Dementia
• Depression
• Determination of capacity
• Eating disorders
• Factitious disorders
• Family problems
• Generalized anxiety disorder
• Geriatric abuse
• Major depressive disorder
• Malingering
• Pain
• Personality disorders
• Posttraumatic stress disorder
• Pregnancy-related illness
• Psycho-oncology
• Psychosis
• Schizophrenia
• Sexual abuse
• Sleep disorders
• Somatoform disorders
• Transplantation evaluation – Donor and recipients
• Know the epidemiology and risk factors for suicide, and be able to competently assess a patients’ potential for suicide or violence.
• Have an understanding of common psychosocial factors in acute and chronic illness, including when to refer for psychotherapy.
• Residents are expected to read about the cases that they see.  Recommended resources are at the end of this document.

Practice Based Learning

• Choose and utilize appropriate psychotherapeutic strategies in talking with medical patients. These include support, clarification, ventilation, confrontation, interpretation, and empathy.
• Interpersonal and Communication Skills
• Present a concise, reproducible case presentation of the evaluated patient including relative biological, psychological and social contributions.
• Write a tactful, clear succinct consultation report in clear, non-technical language that answers questions posed.

Professionalism

• Professional behavior is demonstrated by
• Promptly dictating all notes (within 24 hours of evaluation)
• Writing progress notes on all patients each day
• Behavior consistent with the AMA Standards of Ethical Behavior for Physicians
• Empathically and respectfully interacting with all patients and staff.
• Reliably participating each day  (unless an excused absence is obtained)

Systems Based Practice

• Organize and teach when necessary, various non-psychiatric personnel to deliver appropriate interventions (these include the referring physician, the ward staff, and patient’s family or social agencies).
• Recognize and therapeutically utilize emotional reactions (including countertransference feelings) that arise among ward staff, referring physicians, or the psychiatric consultant.

Professional Behavior:

• All residents are expected to be professionally dressed and adhere to the AMA Guidelines of Professional Behavior.  Failure to do so will result in warnings and communication with the Residency Director.

Call Schedule:

• You are responsible for consults requested between 0730 and 1700 Monday through Friday and 0730 to 1200 Saturday. Any consults that are received by the on-call resident and/or attending will become your responsibility on the following work day.  You are expected to checkout and check in with the on-call resident each working day.

Days Off:

• Typically Sunday is scheduled off.

Moonlighting:

• Permitted with the approval of the rotation supervisor and under the policy of the Department of Psychiatry.

Vacation Time:

• Up to 14 days of vacation or educational leave (inclusive of weekend days) may be taken off during this three-month rotation.

Format of Dictated Consult Notes: 

Patient Identification

Reason for Consultation

Impressions

Recommendations

History

 Present Illness

 Past History

 Family Medical History

 Social History

 Review of Systems

Physical Examination (Minimum to be done and documented)

 Vital Signs

 Mental Status Examination

 Neurological Examination

Review of Lab and X-ray Results

Brief Concluding Statement indicating that the consult was discussed with the attending and thanking the referring physician for the referral.

Format of Letters Dictated to Referring Physicians

 Date of Dictation

Patient Name

Patient Date of Birth

 Dear Dr. __________:

 I had the pleasure of participating in the care of your patient, (patient name) [on (date of outpatient evaluation) or while hospitalized at (hospital name) (dates of inpatient hospitalization)].  We were asked to see (Mr./Ms. Patient name) for (reason for assessment).  Our impressions were (list of diagnoses form highest priority to lowest priority). 

 (Mr./Ms. Patient name) presented with (brief presenting history – five to six sentences at most).  (His/her) physical examination at that time was significant for (significant exam findings).

 (If hospitalized – “Your patient’s hospital stay was (detail events of hospital stay – keep concise and succinct).)

 Delineated pertinent laboratory studies and radiological procedures.

 Mr./Ms. (Patient’s name) mediations were (list of medications with doses and dosing intervals.)

 Our recommendations for Mr./Ms/ (Patient name) are

 Thank you for the opportunity to assist in the care of your patient.  If you have any questions, please feel free to contact us at (217) 545-4234.

 Sincerely,

 

Resident’s Name                              Attending’s Name
PGY (Year)                                     Title

 Format of Discharge Summaries: 

Patient Identification

Date of Admission and Discharge

Discharge Diagnoses

Discharge Instructions

Follow Up Appointments (psychiatric and medical) including dates and times

Medications prescribed

Dietary restrictions, if any

Activity restrictions, if any

Durable medical goods to be used - dressing changes, CPAP/BiPAP machines, walkers, etc.

Lab tests or procedures to be performed, including dates and times

Lab results, pathology reports, imaging studies that require follow up

Reason for Admission

Brief Presenting History and Physical Findings

Hospital Course

 Mental Status Examination on the Day of Discharge

Send copies to all physicians with whom the patient has follow up appointments
  (make sure to write an order to have the patient sign a release of information to each individual or group).

Evaluation/Feedback:

Faculty will complete a resident performance evaluation form for each resident.  The Faculty is expected to meet face-to-face with the resident at the end of the rotation to review the evaluation.  The Department of Psychiatry’s uniform residency evaluation form is used.

Residents will be expected to complete a self assessment exam in the last month of their rotation.

Credit for the rotation will be based upon an overall satisfactory evaluation and the amount of time the resident is present for the rotation. 

Relative breakdowns of the rotation will be as follows

 Active participation in rounds and outpatient activities 60%

 (Will include the assessment and treatment of patients)

 Interpersonal interactions with patients and staff  20%

Completion of the Consult-Liaison Self Assessment Module 20%

Residents will complete evaluations on each of the attendings and the rotation as a whole per department policy.

References That May Be of Assistance to You:

Beyer, John L, Weiner, RD, and Glenn, MD, Electroconvulsive Therapy, A Programmed text, 2^nd Ed. 1998, American Psychiatric Press.

Cassem, Ned H, Stern, Theodore, and Rosenbaum, Jerold, eds.  Massachusetts General Hospital Handbook of General Hospital Psychiatry, 4th edition, 1997, Mosby Year Book Publishers.

Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, 2000, 1994, American Psychiatric Association, Washington, DC.

Kammerer, William S., Gross, Richard J.  Medical Consultation:  The Internist on Surgical, Obstetric, and Psychiatric Services, 3^rd edition, 1998, Williams & Wilkins.

Lipowski, Zbigniew J.  Delirium:  Acute Confusional States, 1990, Oxford University Press.

Mental Health: A Report of the Surgeon General. www.surgeongeneral.gov/library/mentalhealth/home.html

The Practice of Electroconvulsive Therapy; Recommendations for Treatment, Training, and Privilege, 2^nd Ed. A Task Force report of the American psychiatric Association, 2001.

Rundell, James R. and Wise, Michael. Essentials of Consultation-Liaison Psychiatry: Based on the American Psychiatric Press Textbook of Consultation-Liasion Psychiatry, 1999, American Psychiatric Press.

Rundell, James R. and Wise, Michael. Textbook of Consultation-Liasion Psychiatry, 1996, American Psychiatric Press.

SIU School of Medicine Algorithm for Pharmacological Management of Delirium.

Stoudemire, Alan, ed.  Human Behavior:  An Introduction for Medical Students, 1998, Lippincott, Williams & Wilkins Publishers.

Stoudemire, Alan and Fogel, Barry, eds.  Medical-Psychiatric Practice, Volume 1, 1991.  American Psychiatric Press.

Stoudemire, Alan and Fogel, Barry, eds.  Medical-Psychiatric Practice, Volume 2, 1993.  American Psychiatric Press.

Stoudemire, Alan and Fogel, Barry, eds.  Medical-Psychiatric Practice, Volume 3, 1995.  American Psychiatric Press.

Stoudemire, Alan, Fogel, Barry, and Greenberg, Donna, eds. Psychiatric Care of the Medical Patient, 2^nd edition, 2000, Oxford University Press.

Strain, J. et al.  Consultation-Liaison Psychiatry Database (2000 Update), 1999, General Hospital Psychiatry,  21(6):  401-502.

Journal Articles of Potential Benefit

Management of Depression, Primary Care Reports, Vol.8, No. 3, Feb 4, 2002

Practice Guideline for the Treatment of Patients with Delirium, 1999, The American Journal of Psychiatry, 156:5 (supplement)

Practice Guideline for the Treatment of Patients with Major Depressive Disorder (Revision), 2000, The American Journal of Psychiatry, 157, 4 (Supplement).

Practice Guideline for the Treatment of Patients with Nicotine Dependence, 1996,  The American Journal of Psychiatry, 153 (Supplement).

Practice Guideline for Psychiatric Evaluation of Adults, 1995, The American Journal of Psychiatry, 152 (Supplement):  63a-80a.

Practice Guideline for the Treatment of Patients with Substance Use Disorders: Alcohol, Cocaine, Opioids, 1995, The American Journal of Psychiatry, 152 (Supplement): 1a-59a.

Practice Guidelines for Psychiatric Consultations in the General Medical Setting, 1998, Psychosomatics, 39 (Supplement) 8-30.

September 1994
Revised: October 1995
Revised: February 1997
Revised: August 1997
Revised: September, 2000
Revised: July, 2002