Acad Psychiatry DOI 10.1007/s40596-014-0258-9
FEATURE: PERSPECTIVE
The Stages of Consultation-Liaison Psychiatry Jeanne M. Lackamp
Received: 11 September 2014 / Accepted: 11 November 2014 # Academic Psychiatry 2014
The process of learning, no matter how rewarding, can be daunting. It is important to recognize various stages, in order to identify stress (and its manifestations) on Psychiatry residents—and the patients and teams with whom they work. Humor can help residents cope and can bring levity to an admittedly exhausting training experience. The following tongue-in-cheek essay was informed by countless consultations and hours of resident supervision. It is written in the spirit of the New Yorker’s “Shouts and Murmurs” column, with inspiration from Elisabeth KüblerRoss’s “Stages of Grief.”
Anticipation You will find yourself tingling with Anticipation at the prospect of joining the Consultation-Liaison team. You have heard the stories, The consults. The patients. The pace. Residents Who Have Gone Before You will share helpful hints. You will know where the resident lounge is. You will know which cafeteria gives bigger portions after the lunch rush. You will know where the safest bathrooms are. Anticipation may be manifested by various symptoms (tachycardia, diaphoresis, GI disturbance) and may be indistinguishable from your feelings when starting other rotations. Or a pheochromocytoma. These feelings may prompt you to read up on medical topics, borrow your peers’ CL handbooks, or review flashcards from medical school. You may have insomnia in the days leading up to CL service. As though hypomanic, you will eagerly accept the CL challenge,
J. M. Lackamp (*) University Hospitals Case Medical Center, Cleveland, OH, USA e-mail: [email protected]
neglecting the warnings you have heard and the potential effects on your life. This is it—Your Big Chance.
Initiation Almost immediately on CL service, you will feel like you are Practicing Medicine. You will flex your knowledge base as you remember standard laboratory values. You will carry your Littmann Cardiology III Stethoscope and your penlight (and may even use them). You will excitedly practice the exam you learned as a Neurology rotator. You will find all of these both nerve-wracking and exhilarating. Your feelings may be coupled with newfound admiration for your CL attendings, as they both recall medical details and navigate the Real Hospital. You will realize it has been years since you followed electrolytes. You will shudder to think that you have not seen an EKG since your Internal Medicine rotation. You finally will use the medication app on your smart phone, as you realize how much interactions do matter. Early days on the CL service will feel like running a marathon through cement. You will feel slower and more plodding than ever before. Your mind will swim with medical details (what is diabetes insipidus again?), your feet will hurt (time for sensible shoes), and your GI system will rebel against your wayward lunchtime choices (note to self: No more chili.). Documentation, which you previously completed with ease, will be challenging to craft as you strive to include all pertinent medical and psychiatric details. Calling (and reaching) primary teams will seem more monumental than Match Day. Coping with patient death will become real…and will make you feel sad. You will wonder how you can possibly do multiple months of this. You will seek counsel from Residents Who Have Gone Before You in hopes of hearing that yes—it will get better soon.
Acad Psychiatry
Mastery Once you find your rhythm on CL service, you will attain Mastery. Mastery consists of Feeling Like You Know What You Are Doing. You will peacefully coexist with the electronic medical record. You will simultaneously look up labs and drink coffee during morning report. Impressively, you will “teach” medical students—imparting enough knowledge to seem engaged, while getting them to perform such onerous tasks as Calling Collateral Informants. Notes will be well-written, concise, and timely. You will rattle off recommendations for common clinical conditions with confidence. You will have a well-worn pocket card, with secret phone numbers for team rooms and outpatient clinics. You will manage malingering patients who would rather be in the hospital than go to jail. You will ferret out EKGs wherever they may hide. You will learn which social workers are most helpful with discharge planning. You will attend and contribute meaningfully to family meetings. As One Who Has Attained Mastery, you will have a sense of Knowing Things and Feeling Superior. You will cluck quietly when teams fail to recognize delirium. You will happily take chemical dependency resources to the patient you already saw twice this month. You will tolerate requests to “optimize medications”…on the day of discharge…with a smile on your face. The Mastery stage comes with its own dangers. Cockiness may backfire as One Who Has Attained Mastery finds that errors still occur. Forgot to check that medication interaction? Say hello to serotonin syndrome. Neglected to review that QTc? Perhaps a cardiology consultation is in order. However, during Mastery, even missteps will be handled with relative ease as you feel confident that No One Else could have done better given the circumstances. This feeling lasts; until it does not.
Anger The Anger stage will emerge when you conclude that the rest of the medical institution is not as clever as you are. Anger may be directed towards: &
& &
Primary teams, who call with such hard-hitting questions as, “Please evaluate patient for depression; he cried yesterday when told of his terminal diagnosis” and “Please evaluate this 80-year old for new-onset schizophrenia; she has a urinary tract infection and malnutrition;” Patients, who do not appreciate your valiant attempts to coordinate care and arrange follow-up appointments; Peers, including those (un)lucky enough to be post-call several times during the rotation;
&
&
Your attendings, whom you now realize are just regular psychiatrists, who happen to know lots of medical things, but who have stethoscope envy and annoyingly high expectations; Inanimate objects, such as the automated arm that will not let you into the parking garage, the vending machine that still is not working, and the elevators that seem to defy the laws of physics by moving slower—Every. Single. Day.
Anger will manifest in several ways, including but not limited to: snapping at colleagues (especially the hapless medical student who has the misfortune of calling for a non-urgent consultation at 1630), wandering away from nursing staff (as they attempt to fill you in on the patient’s bowel movement patterns when all you wanted was a new set of vitals), and “accidentally” dropping your pager into the toilet after being assigned your third new consult of the day. Around this time, it will be tempting to start secondguessing your life choice of going into medicine in general, and Psychiatry in specific. You may consider studying for the LSAT or entering the teacher training program at your local yoga studio. Sleep will be rare now too, largely related to your intake of caffeine. You will dream of working on inpatient units, outpatient clinics, community shelters…anywhere but CL service.
Acceptance This stage typically comes toward the end of your CL experience as you anticipate the end of your consulting days and the return to Life As You Once Knew It. You will walk into the hospital with a spring in your step knowing that it is Almost Over. No longer will you be an anxious “newbie” in the med/ psych arena. No longer will you be part of a tug-of-war between teams. No longer will you be a pawn in the game of medicine. This stage differs from Mastery. While in Mastery, you knew what you were doing; in Acceptance, you will know what you are doing—but more importantly, you will realize that what you know is not everything. Other variables in the hospital are beyond your control, and you will embrace that. Primary teams ignoring your insightful recommendations? No problem, they are busy. Patients refusing your well-considered interventions? That is ok; try again tomorrow. Psychiatry attendings placing unreasonable demands on your time? It is alright; there is nothing on TV tonight anyway. The line between acceptance and learned helplessness will start to blur—and you, floating in a state of Zen-like contentedness, will feel Fine With It.
Acad Psychiatry
You will be a different person after your CL months. Much like people who have survived a natural disaster, you will know that you endured something intense and were changed by it. As you walk the hospital hallways, you will remember teams who consulted you, patients who took swings at you, staff who helped you, and family members who cried with you. You may even find yourself Appreciating Life Differently—savoring your health and freedom to roam, untethered from IV poles, EEG leads, and heart monitors, through the world.
In upcoming rotations, your ability to identify medication interactions will impress your colleagues. Your time management skills will earn accolades from attendings and admiration from peers. Your talent for assessing (violent, angry, demoralized, confused, anxious) patients will be noted, and you will find yourself more confident in many clinical situations. All these things, and more, you will gain from your CL rotations. All these things, and more, you will grow to appreciate. All these things, and more, you will pass onto incoming residents…residents who, much like you, will be quaking in their shoes as they contemplate their first CL rotation.
FEATURE: PERSPECTIVE
The Stages of Consultation-Liaison Psychiatry Jeanne M. Lackamp
Received: 11 September 2014 / Accepted: 11 November 2014 # Academic Psychiatry 2014
The process of learning, no matter how rewarding, can be daunting. It is important to recognize various stages, in order to identify stress (and its manifestations) on Psychiatry residents—and the patients and teams with whom they work. Humor can help residents cope and can bring levity to an admittedly exhausting training experience. The following tongue-in-cheek essay was informed by countless consultations and hours of resident supervision. It is written in the spirit of the New Yorker’s “Shouts and Murmurs” column, with inspiration from Elisabeth KüblerRoss’s “Stages of Grief.”
Anticipation You will find yourself tingling with Anticipation at the prospect of joining the Consultation-Liaison team. You have heard the stories, The consults. The patients. The pace. Residents Who Have Gone Before You will share helpful hints. You will know where the resident lounge is. You will know which cafeteria gives bigger portions after the lunch rush. You will know where the safest bathrooms are. Anticipation may be manifested by various symptoms (tachycardia, diaphoresis, GI disturbance) and may be indistinguishable from your feelings when starting other rotations. Or a pheochromocytoma. These feelings may prompt you to read up on medical topics, borrow your peers’ CL handbooks, or review flashcards from medical school. You may have insomnia in the days leading up to CL service. As though hypomanic, you will eagerly accept the CL challenge,
J. M. Lackamp (*) University Hospitals Case Medical Center, Cleveland, OH, USA e-mail: [email protected]
neglecting the warnings you have heard and the potential effects on your life. This is it—Your Big Chance.
Initiation Almost immediately on CL service, you will feel like you are Practicing Medicine. You will flex your knowledge base as you remember standard laboratory values. You will carry your Littmann Cardiology III Stethoscope and your penlight (and may even use them). You will excitedly practice the exam you learned as a Neurology rotator. You will find all of these both nerve-wracking and exhilarating. Your feelings may be coupled with newfound admiration for your CL attendings, as they both recall medical details and navigate the Real Hospital. You will realize it has been years since you followed electrolytes. You will shudder to think that you have not seen an EKG since your Internal Medicine rotation. You finally will use the medication app on your smart phone, as you realize how much interactions do matter. Early days on the CL service will feel like running a marathon through cement. You will feel slower and more plodding than ever before. Your mind will swim with medical details (what is diabetes insipidus again?), your feet will hurt (time for sensible shoes), and your GI system will rebel against your wayward lunchtime choices (note to self: No more chili.). Documentation, which you previously completed with ease, will be challenging to craft as you strive to include all pertinent medical and psychiatric details. Calling (and reaching) primary teams will seem more monumental than Match Day. Coping with patient death will become real…and will make you feel sad. You will wonder how you can possibly do multiple months of this. You will seek counsel from Residents Who Have Gone Before You in hopes of hearing that yes—it will get better soon.
Acad Psychiatry
Mastery Once you find your rhythm on CL service, you will attain Mastery. Mastery consists of Feeling Like You Know What You Are Doing. You will peacefully coexist with the electronic medical record. You will simultaneously look up labs and drink coffee during morning report. Impressively, you will “teach” medical students—imparting enough knowledge to seem engaged, while getting them to perform such onerous tasks as Calling Collateral Informants. Notes will be well-written, concise, and timely. You will rattle off recommendations for common clinical conditions with confidence. You will have a well-worn pocket card, with secret phone numbers for team rooms and outpatient clinics. You will manage malingering patients who would rather be in the hospital than go to jail. You will ferret out EKGs wherever they may hide. You will learn which social workers are most helpful with discharge planning. You will attend and contribute meaningfully to family meetings. As One Who Has Attained Mastery, you will have a sense of Knowing Things and Feeling Superior. You will cluck quietly when teams fail to recognize delirium. You will happily take chemical dependency resources to the patient you already saw twice this month. You will tolerate requests to “optimize medications”…on the day of discharge…with a smile on your face. The Mastery stage comes with its own dangers. Cockiness may backfire as One Who Has Attained Mastery finds that errors still occur. Forgot to check that medication interaction? Say hello to serotonin syndrome. Neglected to review that QTc? Perhaps a cardiology consultation is in order. However, during Mastery, even missteps will be handled with relative ease as you feel confident that No One Else could have done better given the circumstances. This feeling lasts; until it does not.
Anger The Anger stage will emerge when you conclude that the rest of the medical institution is not as clever as you are. Anger may be directed towards: &
& &
Primary teams, who call with such hard-hitting questions as, “Please evaluate patient for depression; he cried yesterday when told of his terminal diagnosis” and “Please evaluate this 80-year old for new-onset schizophrenia; she has a urinary tract infection and malnutrition;” Patients, who do not appreciate your valiant attempts to coordinate care and arrange follow-up appointments; Peers, including those (un)lucky enough to be post-call several times during the rotation;
&
&
Your attendings, whom you now realize are just regular psychiatrists, who happen to know lots of medical things, but who have stethoscope envy and annoyingly high expectations; Inanimate objects, such as the automated arm that will not let you into the parking garage, the vending machine that still is not working, and the elevators that seem to defy the laws of physics by moving slower—Every. Single. Day.
Anger will manifest in several ways, including but not limited to: snapping at colleagues (especially the hapless medical student who has the misfortune of calling for a non-urgent consultation at 1630), wandering away from nursing staff (as they attempt to fill you in on the patient’s bowel movement patterns when all you wanted was a new set of vitals), and “accidentally” dropping your pager into the toilet after being assigned your third new consult of the day. Around this time, it will be tempting to start secondguessing your life choice of going into medicine in general, and Psychiatry in specific. You may consider studying for the LSAT or entering the teacher training program at your local yoga studio. Sleep will be rare now too, largely related to your intake of caffeine. You will dream of working on inpatient units, outpatient clinics, community shelters…anywhere but CL service.
Acceptance This stage typically comes toward the end of your CL experience as you anticipate the end of your consulting days and the return to Life As You Once Knew It. You will walk into the hospital with a spring in your step knowing that it is Almost Over. No longer will you be an anxious “newbie” in the med/ psych arena. No longer will you be part of a tug-of-war between teams. No longer will you be a pawn in the game of medicine. This stage differs from Mastery. While in Mastery, you knew what you were doing; in Acceptance, you will know what you are doing—but more importantly, you will realize that what you know is not everything. Other variables in the hospital are beyond your control, and you will embrace that. Primary teams ignoring your insightful recommendations? No problem, they are busy. Patients refusing your well-considered interventions? That is ok; try again tomorrow. Psychiatry attendings placing unreasonable demands on your time? It is alright; there is nothing on TV tonight anyway. The line between acceptance and learned helplessness will start to blur—and you, floating in a state of Zen-like contentedness, will feel Fine With It.
Acad Psychiatry
You will be a different person after your CL months. Much like people who have survived a natural disaster, you will know that you endured something intense and were changed by it. As you walk the hospital hallways, you will remember teams who consulted you, patients who took swings at you, staff who helped you, and family members who cried with you. You may even find yourself Appreciating Life Differently—savoring your health and freedom to roam, untethered from IV poles, EEG leads, and heart monitors, through the world.
In upcoming rotations, your ability to identify medication interactions will impress your colleagues. Your time management skills will earn accolades from attendings and admiration from peers. Your talent for assessing (violent, angry, demoralized, confused, anxious) patients will be noted, and you will find yourself more confident in many clinical situations. All these things, and more, you will gain from your CL rotations. All these things, and more, you will grow to appreciate. All these things, and more, you will pass onto incoming residents…residents who, much like you, will be quaking in their shoes as they contemplate their first CL rotation.
