A day in the life of a consult-liaison psychiatrist

The senior residents were touring medical students around the inpatient psychiatric unit when they came upon my office.

“And this is Dr. LeFay, our CL psychiatrist,” one of the residents announced.

“A seal psychiatrist?” one of the students asked with wide eyes.

I couldn’t help but chuckle. Now four years out of fellowship, I’ve grown used to the confusion of laypeople, students and physician colleagues alike, many of whom have never heard of my subspecialty. This, however, was the first time I was assumed to be a psychiatrist for pinnipeds.

“It’s C-L psychiatry, short for consultation-liaison psychiatry,” I explained. “I work at the intersection of psychiatry and the rest of medicine. It’ll make more sense when you spend time on the service; it’s the best part of medicine, if you ask me.”

‘The most interesting part of medicine’

Even though my work is not so easily identified in casual conversation, I still genuinely believe that I work in the most interesting part of medicine. The business of CL is that of the brain-body connection, where complex neuropsychiatric and psychosocial conundrums lie, and we, the CL psychiatrists, are called to provide perspectives, diagnostic clarity and treatments when the answers aren’t always conveniently clear.

When applying for fellowship, I initially worried I would be disadvantaged as a DO among so many MDs in the field. In the end, being a DO did nothing to harm my odds in fellowship, and, if anything, the holistic view of human health and the structure-influences-function approach of the osteopathic philosophy is an ideal foundation for becoming a CL psychiatrist.

CL psychiatry: A brief history

American CL psychiatry, also known historically as psychosomatic medicine, has evolved over the decades from the slow integration of psychiatry departments into the general medical hospital in the late 1800s to early 1900s, to the rise of neuropsychiatry and the establishment of the Academy of Psychosomatic Medicine in the mid-1900s. In the 1980s, CL psychiatrists continued to explore new ways to support patients, including through the collaborative management of HIV (PPTX).

CL psychiatry officially gained subspecialty recognition by the ACGME in 2010, and today, there are approximately 1,700 board-certified CL psychiatrists in the United States. CL psychiatry roles are almost as varied as medicine itself, ranging from primary care consultation to subspecialty consultants in fields like oncology, cardiology and reproductive health. Many are generalists like me, the inpatient CL psychiatrists who answer consultations coming from all parts of the hospital.

Day-to-day duties

Follow me for a day, and you will experience the life of the inpatient CL generalist: unpredictable and ever-changing. My morning begins with looking through the list of consultations from admits the night before, which might include some of our bread-and-butter cases, like suicide risk assessments or advice on managing hyperactive delirium. Calls are made to discuss cases with the teams requesting consultation, where the first task is clarifying the question: How, exactly, can we be of help?

Some straightforward questions are answered in a phone call, but in most cases, we see the patient and gather information from collateral sources. We might have a medical mystery on the service: A patient is suddenly mute and not eating. Is this catatonia? Is the cause a primary psychiatric disorder, or are we looking at another neurologic cause? Our next patient is experiencing hallucinations and has an intracranial mass. Is this person unfortunate enough to have both a tumor and a primary mental health disorder, or could this symptom be a direct result of the mass, partial seizures or the steroids they were taking?

As much as we focus on pharmacology and neuroscience in this field, some of the cases I remember best required no imaging or fancy lab tests. We might uncover how a person’s “agitated behaviors” stem from medical trauma or find out that the “non-adherent” patient is just unable to read their after-visit instructions. I’ve spent hours attending ethics committee meetings regarding patients refusing life-saving treatments, where we ponder whether this is due to a treatable psychiatric condition or if it represents a person’s enduring personal values about medical care.

My day slows down for the “depression” consult, which turns out to be normative grief and fear when a person knows their life is ending. I have the privilege of being one of the last people to hear the patient’s life story before they pass away. I call on my experiences in palliative care to employ some techniques based on dignity therapy, but mostly, I’m just a human sitting with another human, taking the time to be a witness.

Collaboration, balance and vigilance

Working in CL can include managing conflicts, particularly when the consulting team disagrees with psychiatry’s assessment. In this field, it’s important to acknowledge when you are wrong and be willing to learn new things from colleagues. At the same time, you must also learn when to stand up for patients and what you know to be true. CL psychiatrists must remain vigilant for diagnostic overshadowing, the tendency for clinicians to assume a symptom is psychiatric in nature when it is attributed to another medical cause.

For example, a patient with bipolar disorder and a change in behavior could be called “manic” when, in fact, they have an infection or other illness causing delirium. When there is disagreement between our assessment and that of our nonpsychiatric colleagues, skill in managing difficult conversations and conflict becomes important.

Much of what we do, like sitting in on team meetings, taking part in ethics discussions and offering education to our colleagues, occurs behind the scenes. Whether in the hospital or in the clinic, we often serve not just the patient, but also the systems in which we work. There may be cases where we spend more time helping our colleagues understand a challenging situation than we spend in the diagnostic interview. Yet we always have the same goal: Ensuring the best possible care for our patients.

So go ahead, ask us a question. It’s what we’re here for.

Related reading:

A passion for psychiatry: How this DO is creating meaningful change in the medical world

We are not immune: Recognizing National Physician Suicide Awareness Day