The Hackett Fire Brigade Quote Expanded

I learned a little about the Internet Archive today, which lets you borrow digitized books, music and other items. I’ve always wanted to read what I’ll call the fire brigade quote from Thomas P. Hackett, MD from the original 1st edition of the Massachusetts General Hospital: Handbook of general hospital psychiatry, edited by Hackett and Cassem and published in 1978 (see reference below). Hackett’s quote is on the right hand column of my blog along with his picture. You can learn more about this outstanding C-L Psychiatrist at the Academy of Consultation-Liaison Psychiatry web page.

The full quote from Hackett:

“A distinction must be made between a consultation service and a consultation liaison service. A consultation service is a rescue squad. It responds to requests from other services for help with the diagnosis, treatment, or disposition of perplexing patients. At worst, consultation work is nothing more than a brief foray into the territory of another service, usually ending with a note written in the chart outlining a plan of action. The actual intervention is left to the consultee. Like a volunteer firefighter, a consultant puts out the blaze and then returns home. Like a volunteer fire brigade, a consultation service seldom has the time or manpower to set up fire prevention programs or to educate the citizenry about fireproofing. A consultation service is the most common type of psychiatric-medical interface found in the departments of psychiatry around the United States today.

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. He must be able to attend rounds, discuss patients individually with house officers, and hold teaching sessions for nurses. Liaison work is further distinguished from consultation activity in that patients are seen at the discretion of the psychiatric consultant as well as referring physicians. Because the consultant attends social service rounds with house officers, he is able to spot potential psychiatric problems.”

Reading the full chapter is a treat and is well worth the effort of registering with the Internet Archive because Hackett has more to say that is worth repeating and remembering. Pearls follow:

“Once organized, a liaison service tends to expand. Most liaison services are appreciated, and their contribution is recognized. Sometimes this brings tangible benefits such as space and salary from the departments being serviced. However, even under the best of circumstances, the impact of a liaison effort seldom lingers after the effort is withdrawn. Lessons taught by the psychiatrist need constant reinforcement or they are forgotten by our medical colleagues. In a way, this is an advantage since it ensures a continuing need for our presence. Conversely, it disappoints the more pedagogical, because their students, while interested, fail to learn. I believe we must be philosophical. After all, our surgical colleagues do not insist that we learn to do laparotomies. They insist only that we be aware of the indication.”

Hackett didn’t care for the name “psychosomatic service.” He said it leaves a “bad taste” in the mouth of physicians and patients.

“Approaching a patient in a consultation liaison capacity is different from meeting a patient in the context of outpatient psychotherapy. The consultation patient has not necessarily asked to see a psychiatrist and may, in fact, actively resist the interview. The proper introduction of the consultant to the patient by the referring physician is crucial.”

“As the internist and surgeon employ the skills of the psychiatrist they recognize the limitations of our specialty as well as its many uses.”

“Unfortunately, we will have to define our role to the general public for some time to come. Our image has been variously blurred, magnified, shrunken, and distorted over the years. We must accept the task of clarifying our skills and surveying our domain with equanimity and fortitude.”

“I do my best to be friendly when I meet a patient for the first time—not effusive, not with glad hand, nonetheless, decidedly amiable and interested. I want to learn something about this individual in a short time, and to do so I need his help. A frozen professional manner is not apt to elicit anything but hostile reserve. I seldom explain why I have come. My assumption is that this has already been discussed by the referring physician.”

“I never take notes during the first interview and seldom in subsequent contacts unless the events of the case are complicated.”

“As a matter of courtesy I sit down when interviewing or visiting patients. Long accustomed to the ritual of making rounds, many physicians remain standing as a matter of course. Standing, physicians remind me of missiles about to be launched, poised to depart. Even if this is not necessarily true, they look the part. Patients sense this and it limits conversation. In addition, when standing, the physician necessarily looks down on the patient. This disparity in height is apt to encourage the attribution of arrogance. Looking down at a patient who is prone emphasizes the dependency of the position. Sitting at the bedside equalizes station. Sitting with a patient need not take longer than standing with him.”

“Most liaison psychiatrists believe that teaching psychiatry to medical and surgical house officers cannot be done on a formal basis. When teaching is formalized in weekly lectures or discussion groups, attendance invariably lags.”

“Teaching is best done at the bedside on a case-by-case basis.”

A little history is a valuable thing.



Hackett, T. P., MD (1978). Beginnings: liaison psychiatry in a general hospital. Massachusetts General Hospital: Handbook of general hospital psychiatry. T. P. Hackett, MD and N. H. Cassem, MD. St. Louis, Missouri, The C.V. Mosby Company: 1-14.

2 thoughts on “The Hackett Fire Brigade Quote Expanded

    1. Agree. Hackett clearly knew the difference between consultation and liaison, although sometimes he used the words interchangeably.

      Not much has changed, has it?


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