Time for July Psychiatry Consults

It’s getting close to the busiest time of the academic year in a teaching hospital–July. The residents have a steep learning curve during that month. Some hospitals have a sort of boot camp to get the upcoming first year internal medicine residents prepared for July.

I’m looking at my retirement countdown timer and it’s showing I have 12 months to go. I’ll be back in the saddle July 1st.

July is usually the time for the most interesting psychiatry consultation questions. Many years ago, the psychiatry residents used to keep a list of the weirdest ones. At least that’s what they claimed. Actually, I think most of them were simply made up–maybe all of them. Even though there is no way to know for sure, there is very low probability that any item on the list below could identify any patient.

We used to call it the “wailing wall” of strange and difficult to answer psychiatry consultation questions sometimes asked by our non-psychiatry colleagues from internal medicine and surgery. Questions have been and still are sometimes ambiguous (worse in July) and often need to be reframed so that the psychiatric consultant can be helpful to both customers—the patient and the consult requester. Here are some “quotes” from probably fictitious consultation requests tacked to wailing wall in the distant past, certainly embellished in some cases by frustrated psychiatry residents:

1.  “EEG shows no brain activity.”

2.  “The patient doesn’t like me.”

3.  “We want to know if the patient who believes they are Sponge Bob and wants to leave the MICU to start filming a new movie—is competent.”

4.  “I’m a humanitarian but can you transfer this patient to Mexico?”

5.  “The patient looked at me funny.”

6.  “We are wondering whether to discharge to their own apartment a patient who is oriented only to self, cannot perform activities of daily living, and is actively hallucinating?”

7.  “I prefer not to speak with my patients.”

8.  “I prefer not to speak with families.”

9.  “Patient gets irritable during “that time of the month.”

10.  “We are wondering if the patient should be taken off sedation before getting a history from them?”

11.  “Patient swallowed their narcotic sobriety pin and is upset that morphine was discontinued.”

12.  “The patient is eating their fingers off.”

13.  “Cardiac arrest.”

14.  “Consult for bilateral disorder or generalized panic disorder.”

15.  “Anxiety and agitation 5 minutes before Code Blue.”

16.  “Please evaluate for catatonia versus brain death on intubated patient.”

17.  “Patient was fine yesterday but now unresponsive. Please rule out catatonia before we work up. If catatonia ruled out, we’ll then get a head CT and labs.”

18.  “We want the consult for our own safety.”

19.  “We need psychiatry’s blessing before we can feel comfortable discharging the patient.”

20.  “Patient admitted for renal failure after being gored by a bull at a rodeo, please evaluate if this was a suicide attempt.”

Some are humorous and a few are mind-boggling. What they all speak to is the omnipresent opportunity for the C-L psychiatrist to excel as an educator. Reframing the question is a skill that requires patience, diplomacy, and credibility as an expert in this field.

What’s the question again?

What this may also indicate is the necessity to include a bit more about psychiatry in medical school clerkship programs.

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