Handbook of Consultation-Liaison Psychiatry

2. The Functions of Consultation-Liaison Psychiatry

Hoyle Leigh

CONTENTS

2.1 The Dual Roles of the Consultation-Liaison Psychiatrist

2.1.1 Consultation and Liaison

2.1.2 Consultant and Psychiatrist

2.2 Clinical Function

2.3 Educational Function

2.4 Administrative Function

2.5 Research Function

2.1 The Dual Roles of the Consultation-Liaison Psychiatrist

There are two sets of dual interrelated roles that a consultation-liaison (CL) psychiatrist plays: consultation and liaison, and consultant and psychiatrist.

2.1.1 Consultation and Liaison

The term consultation-liaison psychiatry encompasses two primary functions that of a psychiatric specialist providing expert advice on the consultee's patient, and that of a liaison or link. Historically, the liaison function indicated that the psychiatrist was stationed in and worked as a member of the medical team. Currently, the term has been expanded to indicate the educational and facilitative function of the consulting psychiatrist, that is, the linkage the psychiatrist provides the consultee between medical and psychiatric knowledge and skills on one hand, and the facilitation of communication and understanding that the psychiatrist provides between the patient and the health care personnel. Thus, the liaison function is inherent in the comprehensive approach utilized by the psychiatric consultant to the patient and the health care system.

2.1.2 Consultant and Psychiatrist

The CL psychiatrist is both a consultant and a psychiatrist; that is, he or she has two masters the requesting physician (consultee) and the patient. The obligation to the requesting physician often extends to serving the interests of the health care facility and of society at large. Sometimes this duality leads to an internal conflict, such as in situations when the perceived interest of the patient conflicts with the desires of the consultee, the needs of the hospital, or of society (see Administrative Function, below).

Consultation-liaison psychiatry developed mainly in teaching hospitals with psychiatric residency training programs. There is usually a psychiatric CL service in major teaching hospitals consisting of one or more full- or part-time faculty position, one or more psychiatry residents rotating to the CL service, and perhaps other staff and trainees, for example, a resident rotating from another specialty (most commonly internal medicine or family practice), a medical student, a psychiatric nurse, a social worker, a psychologist, and so on. Such CL services generally serve several explicit and implicit functions, for example, clinical, educational, administrative, and research. In medical settings without a formal CL service, one or more full- or part-time psychiatrists may be hired or designated to be a consultant for specifically defined times. Such CL psychiatrists' function may be limited to the clinical and administrative functions.

2.2 Clinical Function

The consultant's primary clinical function in an acute general hospital is to facilitate the medical treatment of the patient, as the patient is in the hospital primarily for medical care. In this sense, consultation should be distinguished from referral, usually seen in outpatient settings and chronic care facilities. In a referral, the psychiatrist is asked to take over the psychiatric care of the patient if indicated, whereas in a consultation, the psychiatrist renders an opinion or advice to the requesting physician. In addition to such advice and opinion, the requesting physician usually, and implicitly, requests collaborative care of the patient if indicated, which forms the basis of the direct rendering of treatment by the CL psychiatrist. Except in emergencies and psychotherapy inherent in diagnostic interview, and facilitation of communication through meetings and phone calls with members of family and staff, direct treatment of patients including ordering medications should be done with the explicit knowledge and cooperation of the consultee so as to prevent a diffusion of responsibility for direct care.

2.3 Educational Function

The liaison part of CL psychiatry largely denotes its educational function. The education is for patients, requesting physicians, nursing staff, patients' families and friends, and the health care system. Examples of liaison education include teaching the psychological needs of patients based on their personality styles (see Chapter 15), the immediate management of psychiatric conditions (see Chapter 5), the use of psychotropic drugs, and the determination of capacity to consent to procedures (see Chapter 28).

The CL service in teaching hospitals has formal educational functions in addition to the liaison function. They include the teaching of various trainees including psychiatric residents, residents from other departments such as internal medicine and family practice, medical students, nursing and social work students, psychology interns, etc. The CL setting is particularly well suited to teach medical students and primary care residents the aspects of psychiatry that would be most relevant to any physician. Members of the CL team may also give lectures and seminars or participate in the grand rounds of other departments as a part of the formal teaching function. A recent survey showed that about 60% of psychiatry departments provide didactic courses, 36% participate in case conferences, and 15% participate in joint rounds with primary care training programs (Leigh et al., 2006).

2.4 Administrative Function

The administrative functions of the CL psychiatrist are often mandated by either the government or the institution and often involve coercive measures such as emergency hold and involuntary hospitalization of patients. Institutional rules usually mandate that an acutely suicidal or homicidal patient has to be evaluated by a psychiatrist, who will decide whether the patient should be placed on an emergency involuntary hold and be transferred to a psychiatric facility when medically stable. The CL psychiatrist may be required to evaluate a patient with suspected dementia and apply for a conservatorship.

The risk-management department of the health care institution relies on the CL psychiatrist to evaluate patients' capacity to sign out against medical advice or to refuse medical/surgical procedures, and for general behavioral problems that disrupt the facility's function.

At times, the mandated administrative function may interact or interfere with the clinical function of the consultant, such as an emergency hold disrupting the consultant's rapport with the patient. These conflicts can usually be resolved with skillful communication, but the CL psychiatrist must recognize and be comfortable with the multiple roles inherent in the function.

2.5 Research Function

The CL setting provides unique opportunities for research in the interface between psychiatry and medicine. Much of psychosomatic research in the 20th century was done by CL psychiatrists. The CL setting gave rise to such subspecialty fields as psychonephrology, psycho-oncology, and psycho-obstetrics, and gynecology.

The role of psychiatric intervention in medical utilization has also been a productive field of research, and has provided evidence that psychiatric intervention actually reduces the cost of health care (Katon et al., 2005; Wells et al., 2005).

As the gene-environment interaction becomes better understood, the CL setting may provide unique opportunities to study the role of genotype and environment in the selection or sequence of organ dysfunction (e.g., the subgenual cingulate cortex and the intestines; see Chapter 6).

References

Katon W7, Schoenbaum M, Fan M, et al. Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry 2005;62:1313-1320.

Leigh H, Stewart D, Mallios R. Mental health and psychiatry training in primary care residency programs. Part I. Who teaches, where, when and how satisfied? Gen Hosp Psychiatry 2006 May-Jun: 28(3):189-94.

Leigh H, Stewart D, Mallios R. Mental health and psychiatry training in primary care residency programs. Part II. What skills and diagnoses are taught, how adequate, and what affects training directors' satisfaction? Gen Hosp Psychiatry 2006 May-Jun: 28(3):195-204.

Wells K, Sherbourne C, Duan N, et al. Quality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run? Am J Psychiatry 2005;162:1149-1157.

Bibliography

Tilley DH, Silverman JJ. A survey of consultation-liaison psychiatry program characteristics and functions. Gen Hosp Psychiatry 1982;4(4):265-270.

Wasylenki D, Harrison MK. Consultation-liaison psychiatry in a chronic care hospital: the consultation function. Can J Psychiatry 1981:26(2):96-100.



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