CPCP: Improving Psychiatry Consultation Questions

Today we had an outstanding Clinical Problems in Consultation Psychiatry (CPCP) presentation by several trainees, including residents and medical students. This is the first one about improving the two way street of communication between the psychiatry consultation service and consultees and I don’t know why it took us so long to get to it.

The reason for this CPCP is that we get a lot of difficult to understand “questions” (frequently non-questions). This happens routinely to psychiatric consultants and in some cases to other medical specialty consultants. This common issue led to Dr. J.R. Zigun’s paper published in 1990, (The consultation checklist: A structured form to improve the clarity of psychiatric consultation requests. General Hospital Psychiatry, 12(1), 36-44). He was a resident at the time he wrote the paper, in which he outlined a structured checklist called The Psychiatric Consultation Checklist (PCC). The PCC was designed to:

  • “Assist in clarifying consultation in the clinical setting,
  • Provide teaching as an “expert” like questioning system,
  • Establish a database for research regarding consultation phenomena
  • Be user friendly (i.e., checklist oriented, and
  • Take less than 5 minutes to complete”

One of our stellar senior medicine residents, Dr. Keenan Laraway, was there and he was very open to the observations and suggestions. He presented an excellent CPCP in the past. He should be cloned. He’ll connect with the Chief of the Hospitalists. And our current Chief Resident, Dr. Emily Morse, also attended and will be a link toward connecting with our Epic electronic health record (EHR) experts in implementing any change in our system to accommodate a new consult request form. And we couldn’t have done this without the medical students, Ellie and Tyler as well as residents Joel and Cyndi. They put together the presentation and it counts as an historic major effort toward systems and communication improvement.

One of the papers they cited was by Lavakumar et al (Lavakumar, M., Gastelum, E. D., Choo, T., Gerkin, J. S., Kahn, D., Lee, S., . . . Shapiro, P. A. (2015). Parameters of Consultee Satisfaction With Inpatient Academic Psychiatric Consultation Services: A Multicenter Study. Psychosomatics, 56(3), 262-267). The irony is that one of the cornerstones of what consultees want from psychiatric consultants is an understanding of the core question! Another fascinating insight from the authors is this:

We note that we do not believe that consultee satisfaction is entirely adequate as a sole global metric of consultation service clinical quality and effectiveness. Other relevant indices include patient outcomes, patient satisfaction, costs, and preventing adverse events. It is also worth noting that there may be an optimal level of consultation that includes some consultee dissatisfaction. There are situations in which a well-done consultation may require some level of disagreement or disappointment for the consultee. For example, there may be instances when patient safety requires retention of the patient on the medical unit instead of transfer to an inpatient psychiatric unit, to the dismay of the consultee. A consultant should have the courage and integrity to say, when necessary, what a consultee does not want to hear.

I was also glad to hear their opinion about prospective screening models, which is that, although it might help with costs, “…accepting cost saving as an important criterion of consult service value not only risks the primacy of improved medical and psychiatric outcomes as appropriate goals but also may set an unattainable bar.” It’s also akin to looking for trouble for a small, reactive consult service. It’s worth pointing out that the Lavakumar et al study included just that–“…traditional reactive consultation services…”

This was a great group of trainees on both the medical and psychiatric side who put together not just a presentation, but a proposal for change.

In order to see the picture galleries of photos or powerpoint slides, click on one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view any annotations.

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