The written psychiatric consultation is the distillation, the official permanent record, and the one universal element of the consultation process. Both the document and process present a good and growing opportunity for service and teaching. The authors offer a conceptual and practical scheme to help potential consultants make decisions about the content, style, and wording of their written communications. Each of the components of the consultation document, including headings, openings, history, examination, and formulations, is considered in terms of its effects on the liaison with the consultee and the care of the patient. (Am J Psychiatry 139:849-855, 1982)
Psychiatrists have recently been under intense pressure both to prove themselves as members of a medical discipline distinct from nonmedical psychotherapists and to collaborate with other medical specialties in planning training and health care programs and caring for patients. The growth of consultation-liaison psychiatry as a subspecialty is evidence of these forces, and a consulting psychiatrist is in an ideal position to respond to these needs. The art and science of writing consultations, however, have not been adequately addressed in the training of most psychiatrists or in the literature. A written psychiatric consultation on a general hospital inpatient is a unique medical document. Like the usual medical record, it records the history, examination, and the physician's impression of the patient (1). But unlike the usual record, it is not written only to supplement the physician's memory or to provide a legal record. It includes a therapeutic plan yet does not constitute official orders for nursing and house staff to carry out. It involves not just the patient's concerns but also—and especially—the questions asked by the primary physician about the patient's diagnosis and care. It is an official doctor-to-doctor communication. The content and form of the written psychiatric consultation must serve the function of answering the expressed questions of the primary physician. There is some question in the literature as to who is the consultee—the patient, the doctor, or the staff (2). The consultation process benefits both the patient and the medical staff. It is an ideal vehicle for imparting useful psychiatric knowledge because the interest of the consultee has been awakened by the immediate need to address some obstacle in the care of the patient. The consultation process involves both verbal and written communication. This paper concerns the document, which is 1) formally addressed to the patient's primary physician, 2) available to the patient by law, 3) designed to be used by the entire treatment team, which variously may include nurses, social workers, and specialty therapists and their students, and 4) available to others such as insurance companies and hospital review committees. While there is considerable literature on the consultation process as a whole (3), little has been published on the subject of the consultation document. From our experience on the psychiatric consultation-liaison service in an urban university hospital, we have developed an appreciation of the complex and profound issues involved in writing consultations and a suggested outline.
This paper is organized into sections corresponding to the suggested sections for a written consultation and other medical documents: title, date, identifying statement, history, examination, formulations, and recommendations. We considered but rejected the idea of discussing a wide variety of consultation styles. Instead, we offer a scheme as well as the rationale underlying each suggestion. Certain issues come up again and again in the consideration of the written consultation, including the consultation audience, confidentiality, the indivisibility of mind and body, psychiatry as a bona fide, useful, and scientific specialty, the use of technical language, and the importance of the consultant-consultee and doctor-patient collaborative relationships. Mindful of these issues, we offer the following scheme, which contains the elements the consultant can use to facilitate his or her effective communication in the written consultation document. We attempt to capture a balance between an extensively detailed format and a skeletal
outline.
The written consultation should be given a title even when a printed general consultation form is used. The consultation is addressed to a staff bombarded by many sources of information, all vying for their attention. The title facilitates the location of specific desired and/or needed information among the usual welter of progress and nursing notes, laboratory reports, and other consultations. The title should include some form of the word "psychiatry," the rank or position of the author (resident, attending, intern), and the appropriate descriptive term ("consultation," "note," "preliminary note," "workup," and/or "follow-up"). Often there are several stages of written communication. The consultant may receive the consultation request, discuss it with the referring physician, review the chart, and then find that the patient is away from the ward or is sedated or otherwise indisposed. A titled preliminary note informs the service that the consultant is involved, interested, and available and has some preliminary data about the case. Similarly titled written notes are an integral part of the consultant's follow-up visits (contacts made) with the patient, the family, and the service.
Next to the title of each note are the date and time the note was written and a list of the sources of information used by the consultant. This serves three purposes: it conforms to the medical style; it informs the consultee of the old and new chart review and interviews performed by the consultant; and it records the data base for the consultant's conclusions and identifies resource persons, family, and other medical staff. Recording the length and number of visits underscores the time and effort expended, even when the written note is short. (This may also be relevant to billing and insurance transactions. We hope that these small notations will foster the current move to consideration of reimbursement for time and effort.)
The opening sentences of the note set the tone of the consultation. The psychiatrist must 1) distill all of the data about the patient into a succinctly worded summary of the patient's presenting condition and 2) clarify the often vague explicit and implicit demands of the referring service, thereby formulating a question that a consultant can reasonably address. The following is a consideration of each of these elements. One of the functions of a consultant is to bring a fresh perspective to a clinical question. A medical or surgical service may work with a patient for days or weeks, accumulating observational and laboratory data, performing procedures, and relating to the patient and family, who have both somatic and emotional needs. Data and demands accumulate; responsibility for the psychological observations and care of the patient is fragmented. The request for consultation arises from a psychiatric complication in the patient's hospital course. There are situations in which the primary physician has objectively noted signs and symptoms consistent with a specific psychiatric disorder such as depressed mood, vegetative signs, anesthesia inconsistent with nerve distributions, or cognitive deficits and simply calls in an expert on the subject.
More commonly, however, the request for consultation is a covert expression of the physician's frustration, guilt, and annoyance at his or her inability to diagnose (4), treat, and discharge the patient from the hospital. For example, the physician may be concerned that the patient does not comply with medical orders, behaves bizarrely and/or unpleasantly, persists in having symptoms after thorough studies have revealed no abnormalities, or is terminally ill. Behind the stated reasons for the consultation (5) is the desire that the psychiatrist will resolve the situation by arbitrating, counseling, or granting absolution for the patient. There is also the understandable fear that the consultant will judge, analyze, and increase the burden of the treating physician. The psychiatrist aims instead at removing impediments and increasing the mutual understanding and working relationship between primary doctor and patient so that they can together progress with the diagnostic and therapeutic tasks.
To write the consultation after assimilating all of this information, the consultant begins his or her remarks with a focus on those facts about the patient which are most relevant to the immediate problem. These include some of the facts that the intern enters at the beginning of a written history and are worded in the familiar medical style, but they are selected with a view to the formulations and recommendations to follow. For example, We are asked to see this socially isolated, needy 60-year-old woman with a history of unexplained multiple admissions for diabetic keto-acidosis," or "this 32-year-old man with a bleeding ulcer, whose mother recently died," or "this 45-year-old man with headaches, whose delinquent son was recently incarcerated," or "this 26-year-old woman, admitted for a hysterectomy because of pelvic adhesions and pain, who has a long history of surgical procedures in several institutions for various diagnoses, without relief of symptoms. . . ."
The next sentence or clause restates in a workable fashion the observations and diagnostic, therapeutic, and/or management problems that occasioned the request for a consultation. The wording of this request as received by the consultant is not uncommonly as vague as "R/O [rule out] schizophrenia." This reflects the psychologically unsophisticated and/or resistant (6, 7) state of the primary physician's thinking about the psychophysiological functioning of the patient and often engenders annoyance and sarcasm on the part of the consultant. There is no place, however, in the opening or any other part of the written consultation for expressing any feelings other than those due a professional colleague who has paid the consultant the respect of making a referral. It is useful to begin with a statement to the effect that a psychiatric evaluation has been requested and then to detail what seem to the psychiatrist to be the events or behaviors that precipitated the referral. Whether these observations, not interpretations, are offered explicitly in the referral or not, they are the formulation of the psychiatrist's approach to the consultee-consultant contract. Examples are, "Psychiatric evaluation is now requested because of a change in the patient's mood, alertness, and cognition occurring over the last week," or "The patient's daily crying spells since admission are of concern to the service."
At this point, the question of whether to use psychiatric technical language may arise (8-10). (The consultant's facility with biomedical language is generally not problematic and may even be beneficial.) A broad range of styles may be useful, depending on the circumstances, for example, the psychiatric sophistication of the consultees, the need for descriptive accuracy, the tendency to view psychiatric labels as pejorative, the potential for education, and clinical emergencies. Psychiatry, like other medical disciplines, has evolved a specialized terminology that reflects continuing efforts at descriptive and theoretical precision. The consultant's task is to strike a balance between oversimplification and technical ob-fuscation. In general, as in all writing, the aim is to be as clear, direct, and concise as possible. Technical terms should be used when necessary. A nonjudgmental definition of the term can be unobtrusively inserted. The consultee is seeking an expert opinion as well as one that he or she can understand and apply.
It is important to consider for whom (6) the consultation is written. The consultation formally exists as a doctor-to-doctor communication. It is seldom a personal letter, especially when written in a hospital record. The request for consultation itself may have been instigated by someone other than the attending physician—by someone else involved in the care of the patient, such as a nurse, another consultant, or a relative, who awaits the impressions of the psychiatric expert (11). The issue of responsibility and confidentiality in the consultation process has been thoughtfully considered by Kimball (12) and others (13). In any event, the written consultation is meant to be read, for clinical and educational purposes, by many people and is available, for currently unavoidable reasons, to many others, who may read it for insurance or review purposes, out of idle curiosity, or even out of maliciousness.
The ultimate clause or sentence is the consultant's formulation of the problem to which the rest of the document will be addressed. The consultant might note (to pursue some of the examples we have used), "For the purpose of differentiating an organic brain syndrome from a depression" and "Psychiatric evaluation is now requested to delineate the etiology, pathogenesis, and treatment options and recommendation of this possible depression." The consultee's appreciation for the clear reformulation of the patient's problem generally outweighs any passing annoyance at being paraphrased. The overriding necessity is to ask a question that is answerable, if only by a carefully explained, "I don't know." As we have already mentioned, the consultee's optimism and anxiety may be all-embracing and overwhelming. Dealing with these feelings tactfully and focusing requests are central goals both of ongoing psychiatric liaison and communications concerning an individual consultation. These issues are not part of this paper. The restatement and formulation of the consultee's request, once accepted, acknowledges the contract between consultee and consultant.
The psychiatric consultant's written history of the patient's present illness is a chronologically organized presentation of the interrelated life events—medical, social, and interpersonal—that bear directly on the current problem. The technique of psychiatric history taking and writing has been considered in depth in the literature relevant to the training of psychiatrists. Several considerations deserve specific attention in the writing of a consultation. We have addressed the issue of confidentiality in an earlier section of this article. In writing the history, the consultant must decide which of the sensitive communications of the patient or others are essential pieces of information for the treatment team so that they may pursue a more successful interaction with the patient. The issue is a complex one and is best handled in active collaboration with the informant in terms of what the consultant will and will not communicate to the consultee and/or others. This discussion may not absolve the psychiatrist from fulfilling his or her clinical responsibilities to the consultee, which may include divulging previous medical history about abortions, antisocial behaviors, and psychiatric illness. VIP patients and those personally as well as professionally known to primary or consulting physicians present delicate problems. The overriding consideration will be the welfare of the patient.
A 32-year-old woman was hospitalized for treatment of several vaguely described complaints of pain. She expressed massive hostility and anxiety to the whole staff and invoked in them a similar reaction. She had a highly developed ability to play on people's vulnerabilities and insecurities. She accused the staff of abandonment and malpractice and asserted that she was considering filing a lawsuit. The staff's enraged, helpless, and avoidant responses only fed into this vicious cycle. The consultant's history was an explication of the patient's lifetime of isolation, depression, and poor communication. Without further direction from the psychiatrist, the staff's annoyance turned to pity, their stance softened, and the working relationship improved so dramatically that an overlooked pneumonia and pleuritis were diagnosed and successfully treated.
The mental status examination tends to be ignored. Its skillful documentation by a psychiatric consultant underscores its necessity as a component of a medical workup (17). It educates the consultees in its performance and provides a baseline for future diagnosis and care of the patient, as well as the vital data base for correct management. It demonstrates that psychiatrists, like other medical specialists, base their conclusions on an orderly series of evaluations. Moreover, serial mental status examinations can often chart important signs along the course of an illness. Although other schemas are available, we find it useful to include the following aspects of the patient: appearance, verbal behavior, state of attention and cooperation, motor behavior, affect, thought flow and content, sensorium, intellectual capacity and function, insight, and judgment. Listing these categories serves to remind the consultant and educate the consultee about how to organize their thinking about a patient's mental status. The use and straightforward explanation of technical terms in this context also furthers these functions. Normal findings at the time of one examination may prove to be either an improvement on, or a deterioration of, the patient's usual functioning. In any case, they provide a vital baseline against which any changes in these findings can be identified.
In this context, it may be necessary to spell out the examinations that were performed and the details of the results. For example, in an 82-year-old patient with "altered mental status," we noted, "oriented to person, place, and time; unable to remember three objects at 5 minutes; could spell cat and hand forwards but not hand backwards; and a face-hand test positive, indicating diffuse cortical dysfunction." Many of the important elements of clinically valid mental status examinations have been discussed by Kahn and Miller (18). The examination's clinical validity is complicated by its exquisite sensitivity to the interviewer's tone and style and the patient's attitudes, expectations, and fears about both psychiatry and his or her cognitive functioning. The evaluation also identifies the patient's physical and emotional comfort, ability to attend to and cooperate with an interviewer called in by someone else, and the overall and immediate circumstances (including physiologic energy level and drug effects) of the patient. For example, a regressed, backward, severely disabled patient showed a dramatic improvement in mental status after being bathed, shaved, nicely dressed, and taken away from the ward for examination. Thus it is important for the consultant both to record the state of the patient at the time of the interview and to explicitly educate the consultee about its clinical influence.
When therapy, including pharmacotherapy, is to be instituted, a carefully documented mental status examination will inform physicians who see the patient in the future of the indications that led to the therapeutic decision. A patient successfully in treatment for a major psychiatric illness may appear so normal that the successful and necessary therapy might be prematurely and abruptly withdrawn.
This view of the mental status examination as a useful tool rather than a required exercise, and as a system for assessing the patient's functioning at a particular moment in time (similar to any other medical examination) rather than a fixed quality, makes for more reasoned, explicit, and accurate diagnostic formulations in general. For example, a consultant summoned by a gastroenterologist reviewed the chart of a 38-year-old woman admitted for treatment of irritable bowel syndrome. Review of the old chart revealed 8 psychiatric consultations in the past 8 years, each with a different diagnosis. These labels ranged from "hysterical character" and "obsessional character" to "schizophrenia." After careful review of the past mental status examinations to determine the criteria for each diagnosis, the consultant was able to explain to the treating service staff that the patient could most usefully be understood as having a borderline character disorder and as manifesting widely varying symptoms at various points in her unstable existence. A discussion of other issues in diagnosis follows.
The formulations pose the most delicate problems in writing the consultation. The choice of the term "formulations" rather than the more traditional medical "diagnosis" or even "differential diagnosis" highlights the issue. Offering a neat diagnostic label may provide a tidy ending not only to the document but also to careful consideration of the patient and to the human interaction of patient and medical care team. The situation is similar to that in other medical specialties, when a human being with a constellation of complaints and findings becomes "a diabetic" or "a missed abortion." Psychiatric labels are poorly understood and anxiety provoking and frequently put distance between consultant, consultee, and patient. However, diagnostic labels follow a medical tradition, help in structuring a set of observations or a differential diagnosis, and are sometimes required by insurance companies and regulatory agencies. In these cases the consultant can use a DSM-III formulation and number and explain it in the written consultation. (This is an opportunity to acquaint the consultee with DSM-III as a reference and as a demonstration of psychiatry's move toward greater diagnostic accuracy.)
Sometimes a final diagnosis cannot be made at the time of consultation because certain data are lacking. This situation needs to be specifically identified to the consultee. For example, additional criteria for schizophrenic and affective disorders may require further observation of the illness over a specified time span. The psychiatrist is frequently consulted to decide whether the patient's pain is organic or functional and can only conclude (19) after careful examination that it is neither—or both. The patient may have started out with an injury, but weeks or months of pain, spasm, anxiety, reactions in friends, relatives, and lawyers, and accommodations in life style obscure the clinical picture by the time the patient is admitted for a workup. The consultant's ability to appropriately say "I don't know" is evidence of professional maturity. It is a good example for physicians in general, and in cases such as those we have described, it serves two other functions. First, it helps the consultee to deal with the reality that all symptoms in such a patient require careful consideration. "Organic" patients may have "functional" complaints, and "depressed" patients may have appendicitis or cancer; and often, as in pseudodementia, one directly relates to the other. Second, the psychiatrist may offer welcome empathy to the primary physician's feelings of frustration, guilt, and annoyance by explicitly stating that these problems are frustrating, guilt provoking, and annoying. Occasionally the consultant may find it useful to explain how the patient's unexpressed affects tend to provoke similar feelings in the caretakers (15). "If the patient makes you feel helpless, he may be feeling helpless."
A discussion of the dynamics of the patient as an individual in the medical care situation is the most clinically useful summary of the consultant's findings. In the case of the patient with borderline character disorder described earlier, the psychiatrist wrote,
The patient desperately wants encouragement and support from others, but is unable to express her needs directly and successfully. At times she is driven to make human contact by dramatic complaints and seductive behavior; at other times she withdraws into rigidly controlled and controlling ritualistic behavior. When she fails and feels disliked, she may become so upset that she falls apart completely and is unable to function.Given this understanding (16), the primary service staff's behavior changed from avoidance to approach, and the patient's behavior, while erratic, no longer was such an obstacle to her care.
The recommendations (or suggestions or treatment) section is sometimes the only and often the first on that the consultee actually reads. In this section he or she hopes to find the answer to the problem, the fulfillment or embodiment of the implicit and explicit contracts between consultant and consultee. Like the contract, its tone is confident, informative, and respectful of the professionalism of the recipient. Its content is scientific, reasonable, and practical. The recommendations constitute a comprehensive approach to the clinical problem and a careful delineation of immediate and long-term management. For completeness, important components of the approach that have already been performed may be listed and checked off. The consultant may also indicate for which of those remaining to be performed he or she is assuming responsibility and when and how the consultee will be apprised of results.
Following is a suggested conceptual scheme for organizing the recommendations. First is the further workup to clarify the diagnosis, precipitating events, and/or resources. It may include laboratory tests for the diagnosis of abnormalities whether they are primary, such as serum alcohol level, or contributory, such as hematocrit. Workup also may require more history or history from other sources, such as old medical records, school files, employers, friends, and relatives. For example, a diagnosis of sleep apnea is often strongly suspected on the basis of the bed partner's report of loud snoring, apneic periods, and gross physical restlessness. The psychiatric consultant may also point out the need for consultation by other specialists.
The second category of recommendations is management by consultee. It may include pharmacologic, social, psychotherapeutic, situational, or legal management. The consultant may suggest the manipulation of drugs that are administered for the patient's primary conditions but produce side effects, such as impotence and drowsiness, that are relevant to the consultation problem. He or she may recommend administration or withdrawal of psychotropic medication. Specific detailed regimens should be suggested in the latter case, along with therapeutic and side effects to be anticipated. This is an effective way to communicate the medical relevance of psychiatry.
Examples of legal management recommendations include ways of explaining a procedure to a patient to obtain and document informed consent and ways of determining legal mental competence. It is important to help the consultee differentiate medical/psychiatric questions from medicolegal ones. This may involve calling and quoting the hospital's lawyer or suggesting that the consultee do so. Management of social and financial concerns is often crucial in designing an encompassing treatment plan. Recommendations for involving social workers, visiting nurses, public aid workers, and the chaplain or for assisting the patient in obtaining special equipment, such as wheelchairs, home dialysis equipment, or other special care devices, are often pivotal in ensuring successful aftercare. Such suggestions serve to guide the primary physician's attention toward holistic care (20) rather than just symptom relief.
The lines between situational, psychological, and psychotherapeutic interventions are sometimes difficult to draw (21). There is a conceptual continuum. At one end is structuring, ordering the environment and schedule of the disoriented patient with an organic brain syndrome, arranging for an interpreter for a frightened non-English-speaking patient, or obtaining permission for supporting relatives to remain with and care for the patient. In the middle of the continuum are recommendations for dealing with problems occasioned by the patient's character structure and response to the medical setting. A classic example is limit setting. An outline of the rationale and regimen for dealing with an abusive, constantly demanding, or engaging but draining patient and its implementation have a dramatically soothing effect on the service staff. The consultant thus channels (22) frustrated feelings provoked by the patient into constructive behavior by the patient and staff, such as setting up a schedule of frequent but structured patient contacts or instructions about how, when, and why to call in hospital guards or the police.
Next along the spectrum are recommendations for a general approach to the patient based on an understanding of character structure. For those patients who are acutely sensitive to power issues, the consultant may suggest that the primary physician explain and phrase all orders in terms of choices. With other patients, who are overwhelmed by ambivalences, the caretakers may make a contract to offer straightforward recommendations. The consultant may stress the need to reinforce the patient's desirable behaviors, downplaying preoccupations with symptoms and helplessness and underscoring attempts to assume responsibility. The consultant can use personal knowledge of the primary physician's personality style by taking this, too, into account in framing this kind of recommendation. The other end of the spectrum is the recommendation for formal psychotherapy. The consultant may recommend that the consultee encourage the patient to follow through on suggested psychotherapy or may suggest that a member of the primary medical team begin or continue a limited psychotherapeutic process. An experienced and sophisticated nonpsychiatric medical professional may wish and be able to do limited psychotherapy. Others on the medical team may use psychotherapeutic techniques for a patient who needs support and ventilation. These interventions may be on a one-to-one basis or may involve the patient's family. The psychiatric expert/consultant may offer advice as to the frequency, length, and duration of these sessions.
The third main category of recommendations is management by the consultant or care by a specialist in psychiatry. This category is largely self-explanatory. It includes recommendations for inpatient psychiatric hospitalization and outpatient psychotherapies and behavioral, psychodynamic, hypnotic, and/or somatic psychiatric therapy (ECT, pharmacotherapy, biofeedback). If a referral to another psychiatrist is advised, the precise mechanism must be specified. When the consultant will continue to evaluate the patient, this needs to be agreed upon and specified. If no psychiatric follow-up is indicated at the time, this may be stated, along with an invitation to contact the consultant or a suitable substitute when necessary. The consultation then ends with an expression of appreciation for the referral and the legible or retyped signature and phone number of the consultant. Making his or her availability manifest is tangible evidence of the physician's professional responsibility.