Difficult Psychiatry Consult Questions: Go Ask Alice?

I wrote a blog post about unusual psychiatry consultation questions for Cambridge University Press way back in the fall of 2010 and I thought it was worth revisiting. As a psychiatric consultant, I sometimes get questions that I think might be better for Alice in Wonderland. I often wonder what somebody must have been smoking when they filled out the consultation request form. It’s important to every consultant in medicine and surgery to get a clear question from the physician requesting a consultation. A question that is difficult to decipher or is not a question at all is probably even more difficult to cope with than the curbside question in the stairwell (see the post at shortlink http://wp.me/p1glcu-1ft). It helps to have the overall treatment goal in mind when asking a consultant for help in how to help patients move forward and recover in the hospital. Further, the more specific a question is, the more likely it is that a consultant will have a helpful recommendation. In the spirit of helping doctors frame answerable questions that will yield practical advice, here’s a list of actual consultation questions received by our psychiatry service over the years:

1.  “EEG shows no brain activity”

2.  “The patient doesn’t like me”

3.  “We want to know if the patient who believes they are Sponge Bob and wants to leave the MICU to start filming a new movie—is competent.”

4.  “I’m a humanitarian but can you transfer this patient to Mexico?”

5.  “The patient looked at me funny”

6.  “We are wondering whether to discharge to their own apartment a patient who is oriented only to self, cannot perform activities of daily living, and is actively hallucinating?”

7.  “I prefer not to speak with my patients”

8.  “I prefer not to speak with families”

9.  “Patient gets irritable during “that time of the month”

10.  “We are wondering if the patient should be taken off sedation before getting a history from them?”

11.  “Patient swallowed their narcotic sobriety pin and is upset that morphine was discontinued”

12.  “The patient is eating their fingers off”

13.  “Cardiac arrest”

14.  “Consult for bilateral disorder or generalized panic disorder”

15.  “Anxiety and agitation 5 minutes before Code Blue”

16.  “Please evaluate for catatonia versus brain death on intubated patient”

17.  “Patient was fine yesterday but now unresponsive. Please rule out catatonia before we work up. If catatonia ruled out, we’ll then get a head CT and labs.”

18.  “We want the consult for our own safety”

19.  “We need psychiatry’s blessing before we can feel comfortable discharging the patient”

20.  “Patient admitted for renal failure after being gored by a bull at a rodeo, please evaluate if this was a suicide attempt”

So the key is to remember the short and long-term goals for patients so as to emphasize high quality medical and psychiatric care, and keep the questions keyed to the goals.



  1. dremwinocur says:

    Hi Jim, I think that I created your confusion. I, Emanuel M. Winocur, MD., was answering to Katherine’s message. Her invitation was to you. Sorry.


  2. dremwinocur says:

    Dear Dr. Amos, you wrote “I wrote a blog post about unusual psychiatry consultation questions”. Well, what did you expected? You got plenty of unusual questions!!!


    • My cup runneth over.



    • Could you guest blog on my Shrinks Think category. As the consultations show apparently even professionals are a bit confused about what to expect when entering the Shrinks’ domain and what constitutes normal behavior.

      I directed mental health crisis teams in the Bronx, NY;served as a mental health consusltant to many parenting groups. I also taught human behavior courses at Columbia University School of Social Work. I am licensed and have had a number of personal therapy experiences beginning with a traditional analysis, but including family therapy, hypnotherapy, and Alanon,

      For almost fourteen years, my husband and I were special need foster parents. An experience which taught me as much or more than my professional training.

      All this to say I’ve been there and done that.

      My retirement project is trying to make some money doing good with Emotional Fitness Training, Inc. I offer self-help materials. The good part is sharing and part of the sharing is trying to reduce the stigma attached to seeking mental health services. The Shrinks Think posts are new and the first ones shared my lecture notes on the question of normal and not normal, including a detailed look at the mental status examination.

      I think to have some other professionals talk about what to expect from a consultation would be helpful. Let me know if you are interested. kglevine@gmail.com


      • dremwinocur says:

        Dear Katherine, you wrote “An experience which taught me as much or more than my professional training.”
        Many of us in the psychiatric-psychological field have unique and common experiences that have a profound emotional impact and leave unforgettable memories. They teach “to” us and “for” us lessons for life. Regrettable (what a pity) we can not apply for credit toward a license to practice.
        Your “retirement project to make some money” is shared by all; To make money and to do good simultaneously is a rare virtue.


      • Hi Katherine,

        I’m still trying to figure out who is replying to who in the Comment section. That’s because I’m still a geezer at the blogging thing. So forgive me if I’m talking out of turn. I think your site is inspiring. I wish I had more time to visit it and to write a guest blog, if you’re asking me and dremwinocur. If your offer is for dremwinocur only, I apologize if I’ve stepped on any toes.

        Thanks so much for your insights.

        Very Best Wishes,

        Jim Amos, MD


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