“He’s a 34 year old guy who jumped off of a high bridge, sustained a pelvic fracture, shattered his left femur, cracked a few of his left ribs, and fractured his left ulna. Can you see him for this suicide attempt?” the orthopedic surgeon asks.

“The ambulance service brought this 82 year old woman in because the nursing home was concerned about her behavior. She was apparently wandering the halls at night, eating toothpaste, and disrobing in front of the other residents. We’re working up her altered mental status; so far, we’ve found a urinary tract infection and a few ulcers on her rear end. She was up all last night, screaming at the nurses; she also won’t stop pulling at her IV and Foley catheter. Can you help us manage her agitation?” the internist asks.

“He’s a 54 year old guy—totally nice—who was diagnosed with acute myelogenous leukemia within the past few weeks; he’s here getting his bone marrow transplant. He’s upset and crying; can you give recommendations about how to treat his depression?” the oncologist asks.

“He’s a 49 year old man with hypertension and COPD (chronic obstructive pulmonary disease); no other major medical problems. I’ve been seeing him for about five years now and recently, he was telling me about people poisoning his coffee and cars following him. He’s otherwise pleasant. Can you tell me if he’s got schizophrenia?” the family practice doctor asks.

“She’s a 26 year old, G3P1 (three pregnancies, one delivery) woman who delivered yesterday; her birth was uncomplicated. She’s freaking out now, though; she refuses to let anyone else touch the baby. In fact, she won’t even let go of the baby—and she’s constantly screaming at the nurses to go away when they check in. Can you help us figure out what is going on?” the obstetrician asks.

“She’s a 37 year old woman with well-controlled diabetes and a history of kidney stones. She’s telling me that she’s been feeling depressed and unmotivated. She doesn’t want to kill herself and she’s still working, but she’s not feeling quite like herself. She just came into my practice about a year ago. Can you assess her depression and recommend a medication?” the internist asks.

“He’s a 32 year old man with HIV; we admitted him to work up his complaints of a severe headache. He’s causing problems for staff, though; he won’t stop insulting the night nurses, but he’s just fine with the day nurses. Hardly any of the night nurses are willing to work with him—and now the nurses are also starting to argue with each other. Can you help us?” the neurologist asks.

Consult-liaison psychiatry (also known as psychosomatic medicine) works at the interface of psychiatry and the rest of medicine. The above examples describe the “consultant” role of the consult-liaison (CL) psychiatrist; the “liaison” component is often less recognized, though can be more important. Although CL psychiatrists are frequently considered liaisons only between psychiatry and other medicine and surgical services for patients, they commonly provide liaison services for everyone else involved with the patient: Doctors. Nurses. Families. Other patients. Regardless if the belief is accurate, psychiatrists are considered the artisans of the interview and thus, skilled in diplomacy and managing difficult interpersonal interactions.

Because of frequent encounters with a diverse population, CL psychiatrists frequently engage in education. Not only can they teach patients about diagnoses (or lack thereof), medication options, and coping skills, they can also educate medical staff about the same topics—including how to appropriately manage their patients independently (e.g. how to exercise more care in diagnosing depression, versus prescribing a medication simply because the patient cries during the office visit). They can provide information about mental health and facilitate further engagement, if necessary, with psychiatric services. Knowledge of various medical conditions that may (or may not) adversely affect mental status falls under the purview of psychosomatic medicine. Other services can use this information to provide optimized care for patients, as not all psychotic behavior is schizophrenia: It could be a pneumonia, a urinary tract infection, overmedication with narcotics, a brain tumor, alcohol withdrawal….

The complexity that arises from the intertwining of medical and psychiatric conditions results in intellectual stimulation, creative problem solving, and flexible application of psychotherapy skills (though not the psychoanalytic kind—can you imagine a psychiatrist pushing a couch around the hospital?). The clinical experiences offer breadth and depth: The CL psychiatrist may see all of the above scenarios in the same day (though, admittedly, most patients that CL psychiatrists are asked to see are delirious—see example #2 above).

In the inpatient setting, CL psychiatrists also get to walk around a lot. This is a bonus for those of us who don’t like sitting down all day, every day (in contrast with private practice “talk” therapists).

Two of the major deficits of CL psychiatry (from my perspective) are (1) the absence of “continuity of care” and (2) the lack of longer-term psychotherapy. Behavior change does not occur overnight—nor necessarily in one week, one month, or one year. Helping people shift their thoughts and behaviors to result in improved moods and greater successes in reaching goals through psychotherapy is… fun.

Consult-liaison psychiatry is my fellowship interest. (I hope this exposition is sufficient for the inquisitive, persistent, and self-described intueri “devotee” Catherine.)