Being on the road to retirement sometimes makes me wonder about ways to improve how our psychiatry consult service works before I go. But then I just think, “Heck, it’s already perfect,” and have another doughnut.
Seriously, I think the one-man, reactive, hit-and-run consult routine probably ought to make room for a newer model. That might be the proactive hospital consultation. One description is in the tweet below, just to save words from me:
It sounds great. In fact, what Sledge and colleagues say in the Methods section of the original paper in Psychotherapy and Psychosomatics really got my attention, “Inappropriate and missed consultations were virtually eliminated by this process.”
However, screening new admissions can usually raise the consult request rate from around 2% to 20% or more. That’s too much like asking for trouble without manpower. One guy holding up the consult world in a large academic center works as long as you’re not overrun. And as I’ve said in a previous post, “busyness” is an important factor in a smokejumper model:
A similar paper extolling the virtues of the proactive consultation model by Desan and colleagues lists several hints for making it work, some of which are below:
- You should target the right population, specifically those who would benefit the most from psychiatric consultation. Not everyone does.
- You should have an efficient screening method and the psychiatrist should be embedded in the process on the medical unit along with the primary medical team including nurses.
- The informal consultation, often known as the “curbside consult” is considered valuable, even though it’s not billable. It can help build a collaborative working alliance and facilitate discharge planning.
- Close follow up is vital, and would be easier to achieve with added manpower.
“A consultation service is a rescue squad. At worst, consultation work is nothing more than a brief foray into the territory of another service…the actual intervention is left to the consultee. Like a volunteer firefighter, a consultant puts out the blaze and then returns home… (However), a liaison service requires manpower, money, and motivation. Sufficient personnel are necessary to allow the psychiatric consultant time to perform services other than simply interviewing troublesome patients in the area assigned to him.”—Dr. Thomas Hackett.
Sledge, W. H., et al. (2015). “Multidisciplinary Proactive Psychiatric Consultation Service: Impact on Length of Stay for Medical Inpatients.” Psychotherapy and Psychosomatics 84(4): 208-216.
Holmes, A., et al. (2011). “Service use in consultation-liaison psychiatry: guidelines for baseline staffing.” Australas Psychiatry 19(3): 254-258.Holmes, A., et al. (2011). “Service use in consultation-liaison psychiatry: guidelines for baseline staffing.” Australas Psychiatry 19(3): 254-258.
Desan P, Lee H, Zimbrean P, Sledge W. New Models of Psychiatric Consultation in the General Medical Hospital: Liaison Psychiatry Is Back. Psychiatr Ann. 2017; 47: 355-361.