I thought it would be interesting to offer part of a sample quick introduction to a psychiatry consultation (C-L) service. The one offered as an example here fits a small, lean, fast, hit-and-run service like ours. The Code Green service is how we protect patients and others in situations when personal safety might be compromised due to threats and violence.
Orientation to the C-L Psychiatry Service Keyed to Core Competencies
Patient Care and Medical Knowledge:
The UIHC Adult Psychiatry consultation service is largely devoted to inpatient consult requests in the general hospital and critical care units. Delirium evaluation and management is the most frequent issue along with transfers to inpatient psychiatry, followed by suicide risk assessment, assistance with decisional capacity evaluations, and management of a variety of complex, comorbid psychiatric and medical problems. The consult service also participates in the assessment and management of violent patients in the general hospital as part of crisis interventions by a Code Green team trained in non-violent methods through Crisis Prevention Institute (CPI). A team-based model is encouraged with respect for the knowledge base of colleagues and the collateral information provided by family and friends.
Professionalism and Interpersonal and Communication Skills:
Typically, the service answers 7-10 (or more) new consultation requests per day during the week, with the resident being the first contact with the consult requestor. On weekend mornings the cross-cover consultant and one resident generally round on fewer patients. During the remainder of the weekend day, the staff psychiatrist on call handles staffing emergency consults (as staff backup to the resident on call), e.g., suicide risk assessment of patients tentatively planned for discharge from general hospital units. The Psychiatry Nursing consultation service works in parallel with the Psychiatry Consultation service, though advanced practice nurses deliver psychotherapy while psychiatrists generally conduct diagnostic evaluations and pharmacological management. Diplomacy, a collaborative spirit, and keeping the patient at the center are key factors in this enterprise.
One psychiatrist staffs the service per month, usually supervising two or three junior residents, often two from Psychiatry, sometimes one from Family Medicine, joined by up to two medical students. Work flow models include the traditional “residents as scouts” who see patients first, then staff with faculty or “tag team” with faculty and trainees seeing patients as a group. Depending on inpatient consultation volume, non-emergent outpatient consults can be accommodated at the discretion of the consultant with one example being initial evaluation of indigent patients challenged in access to mental health care. However, because of the high volume and unpredictable timing of inpatient consult requests, we typically encourage limiting outpatient consults to emergency suicide risk assessments. Lecture attendance is typically not protected for residents rotating on the service. If there is a high number of consult requests, the residents should stay on the service. If the service is slow and the faculty member agrees, which is often the case, residents can attend lectures. Lecture attendance is encouraged, but neither mandatory nor always practical on the consult service. Experience in the field is frequently the best way to learn. Familiarizing yourself with the local and broader context of psychiatric and medical practice involves meaningful use of the electronic health record which entails respecting patient confidentiality, respecting other practice models in the community, and respecting the opportunity for iconoclasm when outmoded practices, culture, and systems hinder providing the best patient care possible.
Practice-based Learning and Improvement:
The Clinical Problems in Consultation Liaison Psychiatry is a weekly case conference at which residents and medical students can present an interesting case the team saw which raised a question about how the service could improve service delivery.
Clinical Problems in Consultation Psychiatry (CPCP):
A weekly case conference held Wednesdays from 8:00 a.m. to approximately 8:45 a.m. Each week, a case is selected from the Daily Review Rounds Records to illustrate a clinical problem for the next week’s meeting. The residents are assigned dates when they rotate. The medical students are welcome and even encouraged to participate as well.
This is a practical way to approach teaching the Practice-Based Learning & Improvement Core Competency. This helps develop the habit of reflecting on and analyzing one’s practice performance; locating and applying scientific evidence to the care of patients; critically appraising the medical literature; using the computer to support learning and patient care; facilitating the education of other health care professionals. This is applying principles of evidence-based medicine (EBM) to clinical practice.
- Evidence-based medicine is a systematic approach to use up to date information in the practice of medicine
- Skills are needed to integrate the available evidence with clinical experience and patient concerns
- Application and evaluation of EBM skills will provide a frame-work for life-long learning.
Self-evaluation is vital to the successful practice of EBM:
- Am I asking answerable clinical questions?
- Am I searching the literature?
- Am I becoming more efficient in my searches?
- Am I integrating my critical appraisals into my practice?