Involving a psychiatrist in a patient’s care for the first time

The psychiatrist knocks on the door of the patient’s hospital room.

Patient: “Come in.”

Psychiatrist: “Good afternoon, Mrs. Jones. I’m Dr. Moodbetter, one of the psychiatrists here. Your doctor asked me to see you. Did he say anything about this?”

Patient: “No, he didn’t! You know, I’m not nuts. I didn’t think he believed me. Great. Now he just thinks it’s all in my head.”

Psychiatrist: “Well, I don’t think he meant to imply that you were imagining anything. Since there’s a connection between the mind and the body, sometimes issues such as stress can affect our physical health. I do wish he had told you that he had asked me to come by, though. You should have been in the loop. I’m sorry you weren’t told about it. Anyway, would it be okay with you if we talk for a few minutes? Your medical situation sounds complicated, and maybe you and I can put some more of these puzzle pieces together. What do you think?”

Patient: (Hesitating, shrugs shoulders) “I guess. I’m still not happy about this. It’s nothing personal to you. Go ahead.”

Unfortunately, some variation of this conversation is often how psychiatric consultations begin in a hospital setting.

What’s troubling about this all-to-common scenario is that when consultations are requested of psychiatrists, two key ingredients are often missing. First, the reason for the consultation is often unclear. Second, the consultation is often requested either without the patient’s permission or knowledge, or, the patient is informed of the consultation but an inadequate or even inaccurate, potentially insulting explanation is given.

What are the consequences of all this?

  • The patient is angry with his or her referring physician.
  • The psychiatrist does not clearly understand what question(s) he is being asked to answer.
  • The psychiatrist must try to defuse the patient’s anger, apologize for how someone handled the consult request, and must work extra diligently to establish enough rapport with the patient to obtain an adequate history.
  • The patient often feels insulted and demoralized.
  • Bottom line: patient care is compromised

It doesn’t need to be this way.

I think the problem stems from a couple of different issues. One is the lack of understanding that many non-psychiatric physicians have about the seemingly mysterious field of psychiatry. The other is the stigma surrounding psychiatry, psychiatrists, and discussing emotional or mental issues. There is no doubt that involving a psychiatrist in a patient’s care, especially for the first time, is a delicate matter  that needs to be handled respectfully.

I never fault other doctors for not understanding enough about psychiatry to know exactly what question to ask a psychiatrist. But, as any consultant knows, in order to provide a useful consultation, one needs to know what the consult question is. If referring clinicians aren’t sure how to ask, but they know that a psychiatrist is likely needed, then calling the consultant and discussing the case or at least writing out a description of the concern in the progress notes or orders would greatly improve communication.

The second issue–the stigma–could be handled much better with very little effort.

I realize that many non-psychiatric physicians are uncomfortable discussing psychiatric issues with patients. But what I wish they would do is try to put themselves in the patient’s shoes. Not telling a patient that a psychiatric consultation has been requested is just plain disrespectful. So, at some level it needs to be discussed. It doesn’t need to be a lengthy conversation, but how it’s said is what matters. Very frequently, patients will understandably feel invalidated and self-conscious if a suggestion is made that they see a mental health professional.

How should it be handled?

The message that should be conveyed to the patient:

  1. Your symptoms are real; you are not imagining them. We know it’s not “all in your head.”
  2. Your medical situation is complicated, and we need more input to be sure we’re addressing all of your needs. A psychiatrist is a medical doctor who specializes in mental health conditions, and they may be able to help us with your care.
  3. All we’re asking is that you speak with the psychiatrist. You’re not obligating yourself to any ongoing psychiatric treatment or medication.

Not all patients will be satisfied with this explanation, but if it’s delivered respectfully, the therapeutic alliance between the referring doctor and the patient will likely be stronger, the patient’s pride will be less likely to be hurt, and patient care can be improved.

What do you think? Have you had any experience in this situation–either as a psychiatrist, referring doctor, other member of the medical team, or as a patient? Do you have anything to add?

Jeffrey Knuppel is a psychiatrist who blogs at The Positive Medical Blog.

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  • pacificpsych

    Typical consult sheet:
    [Pt sticker]

  • thedocsquawk

    Some of the patients who claim to be unaware of a psych consult weren’t listening when they were told about the consult. Some of them can’t even remember what I wrote down for them as instructions to lose weight, or their medications, or the names of the conditions they have. Being unable to remember a consult being made for them doesn’t surprise me.

    • I was not told

      I was in the hospital following an exacerbation of a neuromuscular disease following a car accident (that happened because I’d been driving when I was way too weak/tired to be so, double vision caused me to be less able to judge what was going on)
      My neuro called the consult, not because he felt I was faking it, but because he felt I was not dealing well with having a chronic illness. He did not tell me (and admitted to me that he’d not) because he was afraid I’d have left the hospital … I would have.
      It took me 10 years to understand that it was about how I was COPING not that he did not believe me and that his reasoning for not telling me was because I was a bit stubborn/resistant and would have not gotten the care I subsequently recieved.

  • Renske

    @thedocsquawk. Wow, CAN’T EVEN REMEMBER the instructions to lose weight, names of medications or names of conditions they have!!! Wow. That you qualify this in sentences as ‘can’t even remember’ unfortunately makes me immediately think that you must be a terrible communicator. Which makes you a worse doctor than you could be. Instructions, names et cetera are mostly new to people. When people are in pain, they can be in agony as well, which makes remembering stuff even worse.
    So maybe, just maybe, instead of writing down instructions and names of stuff you should also write down that you asked for a consult with a psychiatrist. And discuss it with them. Slowly. And listen. Listen yourself. Maybe then they don’t even need a psychiatrist. It won’t be the first time that a case of Wilson’s was by normal physicians made into a case of madness. Until the patient died.

  • heliox

    That sounds great, integrating the consult into a care team type strategy makes the whole thing sound more like thorough care than an intrusive slap in the face.

  • MomTFH

    Thanks for a great post. I am a medical student on an internal medicine rotation, and I am really surprised how many care decisions, especially consults, are done in the charting area and never end up being told or explained to the patients. I can see how this can be especially frustrating for a psych consult, when a lot of the success of the psych consult involves establishing rapport with the patient.

  • http://ShrinkRap Dinah
  • Tom

    I agree with the sentiment of this post. As a primary care physician I find that there has been an inherent bias by many allopathic physicians to look first for “medical” and “surgical” causes for conditions that are by nature complex in etiology, with a strong likelihood of at least some, if not a majority of symptomatology being related emotional or stress related factors. I can’t fault anyone for first looking for problems one can fix. Where I part company with some of my colleagues is when there is an inherent reluctance to involve colleagues to fully address the potential for mental health conditions that are contributing comorbidities. I think there are a number of reasons for this bias, that go beyond the individual belief systems of referring non mental health practioners and the sensitivities of patients who may see first view such a referral as “giving up” or disbelief in their symptoms as physiologic in origin.
    I am hopeful that federal mental health parity legislation, in effect now for about 1 year, will remove some of the contributing obstacles to patients having comparable access to mental health services (in comparison to medical & surgical care), and that referring to and involving mental health practitioners to manage complex individual cases comes to be seen as the right way to address the complexity in the same way it is routinely done across other medical and surgical subspecialties.

  • J.T. Wenting

    “Your symptoms are real; you are not imagining them. We know it’s not “all in your head.”
    Your medical situation is complicated, and we need more input to be sure we’re addressing all of your needs. A psychiatrist is a medical doctor who specializes in mental health conditions, and they may be able to help us with your care.
    All we’re asking is that you speak with the psychiatrist. You’re not obligating yourself to any ongoing psychiatric treatment or medication.”

    In other words, you lie.
    And if not, the patient WILL interpret your statements as such.
    Shrinks (yes, that’s how people think of mental health providers, like it or not) are called in when the patient is deemed deranged, insane, etc.
    IOW the patient WILL interpret your statement “no, we don’t think it’s between your ears” as “we think you’re making it all up and aren’t sick at all”.
    “a psychiatrist may be able to help us” => “we think you’re crazy and need to be put away in a mental ward”
    “you’ve no obligation” => people never believe this. They feel (correctly or not) that the moment a doctor walks into the room they’re obligated (and often their insurance and sometimes the law confirms this) to do whatever that doctor tells them to.

  • shrinkraproy

    Great post, Jeff! I use a different introduction when I go in to see a patient, many of whom have stereotyped images of psychiatrists. So, I don’t lead with the name of my specialty (it gets in the way). I lead with why I’m there.
    “Hi, I’m Dr Roy. Your attending asked me to see you about some problems with confusion. He told me you have a bladder infection and that you’ve been seeing things. Can you tell me more about it?”

    If they ask me my specialty, I tell them; and I’ll sometimes work it into the discussion, but by that time they see it coming. I wrote a post on this before called “An Open Letter to Hospital Physicians Requesting Psychiatric Consultations.” It’s at

  • gzuckier

    Standard hospital comedy plot point #17; nurse walks in, “Mr. Smith, how many times have we told you not to impersonate a psychiatrist! Now go back to your room.”

  • Jay E. Korman, LCSW

    As a clinical social worker, no MD after my name, I never rule out a physical cause for a patient’s condition until after they’ve seen an MD for a full physical. While it’s very true that some things are “purely” psychological, there’s plenty enough that isn’t and I’d be doing a disservice to my patient if I didn’t strongly urge a thorough physical exam and, if necessary, a follow-up with a specialist. I gladly explain this to patients and give them the example of the patient who came to see me because, in his first full-contact sexual relationship, he was experiencing “erectile dysfuntion.” I asked him if he’d seen a urologist. His exact words were, “No. Do you think it’s a good idea.” I explained to him that we should make sure the plumbing works before we check the control system.
    I would hope that MDs would treat calling in a consulting shrink (I include clinical social workers in that mix) in the same manner. Absolutely talk to the patient about doing this. Patients are going to think you think they’re crazy. It’s not important whether they do or they don’t. Any number of professionals stop by hospital rooms all the time without the patient knowing why except that he or she is a patient in a hospital.
    Writing it in the chart? Do the notes really get read. I work (part-time) in a community mental health clinic doing fee-for-service work. The psychiatrists don’t read our notes. We have to leave them separate notes about somebody if we have a specific concern. I hope it’s different in other clinics & hospitals but, given what many psychiatrists consider our input to be (little more than case-management,) I have my doubts.
    Always tell the patient what & who’s coming. It’s called “courtesy.”

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