“Inappropriate” Consults: Taxonomy and Strategy

Psychiatric Times, Vol 39, Issue 3,

A look at 7 common reasons for "inappropriate" consults, as well as strategies for addressing these calls for assistance.

Consultation-liaison psychiatrists wear 2 hats in the hospital setting. The consultation function, similar to consultants in other medical specialties, offers colleagues guidance on the diagnosis and management of medical or surgical patients with psychiatric comorbidities.1 In contrast, the liaison function—often less clearly defined and too often afforded short shrift—involves educating nonpsychiatric physicians and other clinicians about psychiatric illness, as well as serving as an intermediary between other medical teams and mental health providers.2

The subspecialty evolved from its psychoanalytically informed forebearer, psychosomatic medicine, starting in the 1930s and more rapidly in the 1960s and 1970s in conjunction with the widespread embrace of George Engel, MD’s biopsychosocial model, although the formal transition to the term consultation-liaison psychiatry dates only to 2018.3,4 Estimates are that up to 30% of patients in general medical units have psychiatric disorders.5 As a result, consultation-liaison psychiatrists and teams remain in high demand. In that context, consult requests that psychiatrists believe to be inappropriate—for a range of reasons—can prove burdensome and pose a challenge to interservice rapport. Filtering out inappropriate consults detracts from the time and energy that psychiatrists might devote to appropriate consultations.

As early as the 1970s, Anastasia Kucharski, MD, and James Groves, MD, described the challenge of consult requests that “superficially appear…to the consultant as covert, manipulative, illogical, [or] ill-timed” and seemed “to represent a dysfunction in the medical or surgical staff caused by arousal of conflicted aggressive, sexual, or depressive feelings.”6 Nearly 50 years later, a cursory review of social media sites (eg, Reddit, Student Doctor Network forums) reveals that gripes about inappropriate consults remain intense. Of course, one physician’s inappropriate consult may be another physician’s good-faith, legitimate effort to secure better care for a patient.7

As the medical profession becomes increasingly specialized, consultants may mistakenly consider their knowledge to be common sense and therefore resent physicians in other specialties who lack their expertise.8 For the psychiatric consultant, managing requests for consults that may be inappropriate—without offending colleagues in other specialties—is a crucial and underappreciated skill.

Unnecessary consultation calls may prove deleterious in multiple ways beyond the burden that they place upon already overtaxed consultants. For instance, summoning a psychiatrist might lead a patient to believe their credibility or sanity is being questioned, causing ruptures in the relationship with that patient’s primary care team. Because certain types of consults inherently may raise questions about a patient’s psychiatric stability or decisional capacity, this impact should be minimized by avoiding unnecessary consults. In particular, surplus decisional capacity consults that are conducted when no reasonable question exists regarding the patient’s ability to render decisions—because they are either grossly impaired or not impaired at all—implicate the autonomy of patients and may be perceived as threatening.

At the same time, exploring with the primary team the circumstances and motives behind a consultation request initially deemed inappropriate may reveal details that render the consult justified or even essential to patient welfare. Unfortunately, no effort to establish a taxonomy for inappropriate consults has occurred in nearly 50 years, whereas earlier classification schemes reflect largely outdated approaches to psychiatric pathology.6 What follows is a review of 7 common reasons for which consults may appear inappropriate, as well as strategies for addressing these calls for assistance.

Challenge: Premature Consult

Among the most common sources of frustration for consultation-liaison psychiatrists are consults that are called in prematurely. Often these requests will occur under the guise of “getting psychiatry on board early”—so early that it remains unclear whether a psychiatry consult would be indicated. In many cases, a medical work-up that should precede the psychiatric evaluation is incomplete. For instance, the psychiatry team may be asked to assess a patient for new-onset primary psychosis before head imaging or a urine toxicology screen has been obtained. At the extreme, a psychiatrist may be asked to address a functional disorder or suspected malingering before the primary team has ruled out other medical causes of illness.

Management Strategy: Whether a formal consult will eventually be required can be difficult to predict. When consultation appears premature, the psychiatrist may wish to thank the primary team for alerting them to the patient’s presence in the hospital. However, rather than consult immediately, the psychiatrist should lay out specifically what steps ought to be taken before a formal psychiatric consult is indicated—the more detail in this regard, the better. “Please call back when you have the results of the head CT and the urine toxicology. If these results are negative or if the patient’s symptoms persist, I will be happy to evaluate the patient” is liable to generate a far more positive response than the much less precise, “Can you call back when your work-up is done and the patient is medically cleared?”

Challenge: No Specific Question

When calling a consult, the physician seeking guidance should pose a focused question to the consultant.9 Unfortunately, many requests, at least initially, lack such a core inquiry. Rather, they are phrased as broad calls for assistance or, even more challenging, broad requests for assistance shrouded in vague, sometimes tangential questions. For example, a clinician might say, “We need help treating the patient, and they might be depressed or psychotic.” In essence, the primary team is asking the consultant to assume responsibility for the patient, rather than soliciting guidance with regard to specific aspects of their presentation. Needless to say, such broad management is generally not the role of the consultant in the hospital setting and is an abrogation of duty by the admitting service.

Management Strategy: The key to consultation requests where the requesting physician appears to lack a clear question is to investigate whether the request is for general management or whether the barrier is merely in how the core question is formulated. Often, the primary team does have legitimate questions but has not yet precisely honed them. In other words, the challenge is with interservice communication—not the need for a consult itself. An important part of the psychiatrist’s liaison function in such cases is to help the primary team formulate their question(s).

Challenge: No Active Question

In contrast to vague questions, sometimes no active question exists at all. These cases arise most frequently when the patient has a history of psychiatric illness or behavioral disturbance but no active symptomatology. The primary team may say, “When the patient was hospitalized last year, he was suicidal, so we want to make sure he is not now.” Sometimes this is referred to as a request to “treat the chart,” rather than the patient.

Management Strategy: Consultants should generally not evaluate patients without active or recent signs or symptoms of illness. In addition to a burden on resources, systematic billing for such consults may rise to the level of fraud. At the same time, declining such consults outright without offering any assistance does not build rapport. Rather, the psychiatrist might inquire whether the patient is in ongoing outpatient psychiatric care. If so, the psychiatrist should urge the primary team to contact the outpatient psychiatrist or other clinician to ascertain whether the patient is off their baseline, agreeing to see the patient if the primary team still believes such a consult is indicated after discussing the case with the patient’s outside provider.

Often, the primary team seeks reassurance from the ongoing treating clinician, rather than a formal consult, and a brief phone conversation with the patient’s psychiatrist or psychotherapist can meet this need. Such collateral information is a foundation of good medical care. If the patient is not already in outpatient care, the psychiatrist might offer “curbside” suggestions of potential referrals. Alternatively, outpatient services might be arranged by a discharge planning social worker. To build additional goodwill, consultation psychiatrists might make themselves available to offer “curbside” suggestions to the discharge planning team as well.

Challenge: Consultation Will Not Change Management

Consults should be thought of as interventions, not merely tools, with their own potential sets of adverse effects and negative consequences—exhausting patients, damaging therapeutic relationships between patients and primary teams, and increasing medical error as a result of chart clutter.10 Consultation should occur only when it serves a clinical purpose. For instance, a decisional capacity consult for a patient who refuses a medical intervention should take place only if the primary team is willing and able to force that intervention upon a nonconsenting patient who lacks capacity to refuse.

Of particular concern are potential biases in requests for so-called nonactionable consults—with the risk that they are more likely to be called on patients with less social capital or from historically marginalized communities.11 For example, physicians may be driven by unconscious, implicit biases to assume falsely that certain patients, such as those from low-income communities or communities of color, have less understanding of proposed interventions than these patients actually do—resulting in surplus decisional capacity consultations that would not be called upon white patients in similar medical circumstances.11

However, on rare occasions, such as direct patient request, the reassurance of having a psychiatrist on board may justify a nonactionable consult. The value of such assistance should be discussed with the primary team. It is important to emphasize to the primary team that consenting to such requests is not the norm or standard of care, but it might be justified in some instances where concrete evidence indicates that the patient’s adherence to care will improve with such a consultation. For instance, a patient with a long history of previous psychiatric hospitalizations might request reassurance from a psychiatrist that signing a consent form for medical care will not lead to another involuntary commitment. Needless to say, psychiatrists agreeing to see such cases run the risk of sliding down a slippery slope, so discretion is highly advised to manage future expectations.

Management Strategy: Nonactionable consults can usually be preempted if the psychiatrist clarifies the purpose of the consultation with the primary team. In consults related to decisional capacity, the refusal of care, or efforts to leave against medical advice, the potential consultant should routinely ask the question, “How will you change your treatment plan based upon my recommendations?” Frequently, explaining to the primary team that a consult will delay treatment or disposition without changing the outcome is sufficient advice for the primary team to retract a formal request for consultation.

Challenge: Wrong Specialty Consulted

In some cases, the primary team does require guidance, but the psychiatric team is the wrong source of expertise. Such requests may arise when the primary team does not require a clinical consultation but rather the support of nonmedical professionals such as patient representatives, an ethics committee, risk management officers, or even hospital attorneys. In other cases, the history and symptomology may strongly suggest a condition best managed by another medical service, such as neurology or pain medicine.

Management Strategy: The liaison function of the consult-liaison psychiatrist is valuable in cases where a psychiatrist is consulted for nonpsychiatric help. But steering the primary team elsewhere may be seen as an effort to wash one’s hands of a case. Rather, the psychiatrist should suggest that the primary team consult the appropriate specialist or authority first and may even assist them in doing so with the reassurance that, if psychiatric help is still required after that consultation, psychiatry will follow up with a consult of its own. In some cases, the psychiatrist might also emphasize that obtaining a different consult first will enable the psychiatric consultation to prove more helpful. For example, having the neurology consultant confirm a diagnosis of Parkinson disease prior to a psychiatric consultation might guide the latter in choice or medication and course of treatment.

Challenge: Issue Best Addressed as an Outpatient

Few consults frustrate the busy psychiatric consultant more than being called in to address a problem better suited for outpatient management. For instance, such requests might occur in cases of simple phobias, for help with smoking cessation, or for decisional capacity assessments to execute financial documents. On some services, when patients stay in the hospital for lengthy periods of time (eg, after an allogeneic stem cell transplant), these may take the form of the patient requesting psychiatric assistance under the guise of, “While I’m here anyway…”

Management Strategy: Many interventions are best offered in the outpatient setting for reasons of efficacy and logistics that transcend the mere inconvenience of providing them during hospitalization. For example, one might not wish to begin treatment with a time-limited, manualized psychotherapy (eg, interpersonal therapy) if the patient’s planned discharge from the hospital halfway through the course of treatment would disrupt continuity of care. Explaining to the primary team (and, when appropriate, the patient) why the patient is better served by commencing treatment in the outpatient setting and providing the name and contact information for a psychiatrist who can offer such treatment upon discharge will resolve the need for further inpatient management.

Challenge: Question Previously Answered

One of the situations that damages interservice rapport is when the consultant has answered a consult question, but the primary team continues to request guidance. Occasionally, this may prove to be a communication error, with the primary team overlooking guidance that has already been documented. At other times, the primary team may simply be unhappy with the suggestions offered and expect a change in opinion.

Management Strategy: The easiest path in such cases, although far from the most effective, is either to decline further consultation or to repeat the consult with a brief follow-up note affirming the original recommendations. Of course, if the recommendations proved insufficient or unwelcome initially and the primary team is still seeking assistance, reiterating the previous recommendations does not resolve the underlying challenge. Such cases are best discussed in a joint meeting between the primary team and the consultant—and with the patient or family present when appropriate—to consider alternatives to the original recommendations. Working together, the primary and consulting teams often find alternative options that address the concerns of all interested parties.

Conclusions

Occasionally, psychiatric consults are called for overtly nonclinical reasons, such as wanting a psychiatrist’s name in the chart to deflect or reduce potential liability. Far more often, consults perceived as inappropriate by consultation-liaison psychiatrists are well-intentioned efforts to secure care for patients. The effective consultant should always assume good faith on the part of the clinical service requesting the consult and work with that clinician to understand the motives underlying the request. Telling other clinicians that their request for consultation is inappropriate often engenders bad feelings and pushback. In contrast, having a taxonomy that delineates why a psychiatric consultation might not be beneficial in a specific case can help steer primary and consulting physicians toward productive understanding.

Dr Appel is director of ethics education in psychiatry and assistant director of the Academy for Medicine & the Humanities at the Icahn School of Medicine and an emergency department psychiatrist in the Mount Sinai Health System in New York, New York.

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