How to Call a Consult

One of my jobs is to be the attending (really pre-tending) for the postpartum service for three months per year. This means that I act as a mentor for the residents taking care of the patients. The residents are told to call me if anybody gets "sick" and I meet with them twice a week to run through the list of patients and to do some teaching. (We"ve been talking about the care of cardiac disease in pregnancy).

At this point in the year, even the interns should know how to call a consult. However, I suspect that the level of professionalism that I was taught isn"t part of the culture here. So, in the hopes of not having to teach this lesson again and again, I"m going to post it here.

First, how to not call a consult. Putting an order in the computer that says, "Consult: Psychiatry; h/o depression, evaluate and manage" is not an acceptable way to obtain a consult.

You must take a history. Which means talking to the patient. Ask them about the history of their depression. How long? When? What meds are they on? Are they having any symptoms now? Any suicidality? Any history of postpartum depression? Who"s their doctor?

If a person has stable depression, well controlled on their meds and a relationship with a doctor who"s treating it, they don"t need a psych consult. They do need an early postpartum check to make sure they"re not having worsening of their depression or psychosis postpartum. And remember bipolar disorder is a HUGE risk factor for postpartum psychosis, which is very dangerous to mom and baby.

Then a consult always requires contact with the person you"re asking for the consult. Part of it is so that you can say "please" and "thank you". Part of the reason is so that you can give that person some sort of an idea of the urgency for the consult.

Next, the question is, who do you call? If the patient has a history of depression and is on, say, Zoloft, there"s a fair chance that someone, somewhere is prescribing her Zoloft. That person is treating her depression. There"s a fair chance that that person is either a primary care doc or an actual psychiatrist. If you have questions about the patient, that doc is the first person to call. If the patient doesn"t have a doc, and you have an actual question, you need to call the psych resident on call for consults. You can generally find this person through the operator. Or page whoever they give you as the psych resident on call, and that person will be able to help you find the right resident.

When you call that person, ask when they"ll be able to see the patient. Don"t nag them (and remember the please and thank yous), but if it"s important enough to ask someone else to spend their time on, it"s important enough to follow up quickly. Also, ask a specific question you"re looking for the answer for. It helps them give you a helpful consult. So, you could ask, "This patient has a previous diagnosis of depression, was on Zoloft, but ran out. She doesn"t remember the doctor who gave her the Zoloft. When she was admitted to L&D, she had a Blood Alcohol Level of 188 and extremely odd behavior. She"s sober now, no evidence of EtOH withdrawl. She states she was drinking because she ran out of Zoloft. Would you please come see her and make some recommendations for treatment?" Or, "This patient came in, seemed to have some odd behavior, and now she"s got an altered mental status, hallucinations, and delusions. Her creatinine is 2, she has a funny rash, and her platelets are 29. She has a psychiatric history that we"re unable to pin down. Would you please come help us figure out if this is delerium from TTP or if her behavior is due to a mental illness?"

Also, make sure the patient knows that a doctor from another service (especially psych, but it includes renal, derm, etc.) is going to come see them.

Read their entire note. You may learn something about the patient or about psychiatry (or any other specialty you consult) you didn"t know. If you can"t read it, page the consult resident and ask them to interpret their writing.

If the consult is an emergency, tell the service it"s an emergency or urgent or whatever, and call when you need it. If it"s not urgent, make sure that you call it in the morning, preferably by 10am, to allow the consulting service time to work it into their busy day. Remember, everybody"s busy, everybody"s time is valuable. Just because people don"t run around doing emergency c-sections and catching babies all day doesn"t mean that they"re not as busy as you are.

Thank you!