Am J Psychiatry 139:7, July 1982 849

THE AMERICAN JOURNAL OF PSYCHIATRY

How to Write a Psychiatric Consultation

BY THOMAS R. GARRICK, M.D., AND NADA L. STOTLAND, M.D.

The written psychiatric consultation is the distillation, the’official permanent record, and the one universal element of

the consultation process. Both the document and processpresent a good and growing opportunity for service and

teaching. The authors offer a conceptual and practical

scheme to help potential consultants make decisions about

the content, style, and wording oftheir written communica-

tions. Each of the components of the consultation docu-

ment, including headings, openings, history, examination,andformulations, is considered in terms ofits effects on theliaison with the consultee and the care ofthe patient. (Am JPsychiatry 139:849-855, 1982)

P sychiatrists have recently been under intense

pressure both to prove themselves as members of

a medical discipline distinct from nonmedical psycho-

therapists and to collaborate with other medical spe-

cialties in planning training and health care programsand caring for patients. The growth of consultation-liaison psychiatry as a subspecialty is evidence of

these forces, and a consulting psychiatrist is in an ideal

position to respond to these needs. The art and science

of writing consultations, however, have not been

adequately addressed in the training of most psychia-

trists or in the literature. A written psychiatric consul-tation on a general hospital inpatient is a uniquemedical document. Like the usual medical record, it

Received Sept. II, 1980; revised Feb. 2, 1981; accepted Feb. 25,1981.

From the Department of Psychiatry, Consultation-Liaison Pro-gram, University of Chicago. Address reprint requests to Dr.Garrick, Department of Psychiatry, 691/ll6A, Wadsworth VA Med-ical Center, Wilshire and Sawtelle Boulevards, Los Angeles, CA90073.

Supported in part by NIMH grant MH-07795.The authors thank the members of the consultation-liaison service

at the University of Chicago, who have fostered many of the ideasthat appear in this paper, and Dr. C.P. Kimball for his careful reviewof this manuscript.

Copyright c 1982 American Psychiatric Association 0002-953X/821

07/0849/07/$00.50.

records the history, examination, and the physician’simpression of the patient (1). But unlike the usual

r�cord, it is not written only to supplement the physi-clan’s memory or to provide a legal record. It includes

a therapeutic plan yet does not constitute officialorders for nursing and house staff to carry out. It

involves not just the patient’s concerns but also-and

especially-the questions asked by the primary physi-

clan about the patient’s diagnosis and care. It is an

official doctor-to-doctor communication.

The content and form of the written psychiatric

consultation must serve the function of answering theexpressed questions ofthe primary physician. There is

some question in the literature as to who is the

consultee-the patient, the doctor, or the staff (2). The

consultation process benefits both the patient and the

medical staff. It is an ideal vehicle for imparting useful

psychiatric knowledge because the interest of the

consultee has been awakened by the immediate need

to address some obstacle in the care of the patient.

The consultation process involves both verbal andwritten communication. This paper concerns the docu-

ment, which is 1) formally addressed to the patient’s

primary physician, 2) available to the patient by law, 3)

designed to be used by the entire treatment team,

which variously may include nurses, social workers,

and specialty therapists and their students, and 4)available to others such as insurance companies and

hospital review committees. While there is consider-able literature on the consultation process as a whole(3), little has been published on the subject of theconsultation document. From our experience on the

psychiatric consultation-liaison service in an urbanuniversity hospital, we have developed an apprecia-tion of the complex and profound issues involved inwriting consultations and a suggested outline.

This paper is organized into sections corresponding

to the suggested sections for a written consultation and

other medical documents: title, date, identifying state-

ment, history, examination, formulations, and recom-

mendations. We considered but rejected the idea of

850 HOW TO WRITE A PSYCHIATRIC CONSULTATION Am J Psychiatry 139:7, July 1982

discussing a wide variety of consultation styles. In-

stead, we offer a scheme as well as the rationale

underlying each suggestion. Certain issues come upagain and again in the consideration of the writtenconsultation, including the consultation audience, con-fidentiality, the indivisibility of mind and body, psy-chiatry as a bona fide, useful, and scientific specialty,the use of technical language, and the importance ofthe consultant-consultee and doctor-patient collabora-

tive relationships. Mindful of these issues, we offer thefollowing scheme, which contains the elements theconsultant can use to facilitate his or her effectivecommunication in the written consultation document.We attempt to capture a balance between an exten-sively detailed format and a skeletal outine.

TITLE

The written consultation should be given a title even

when a printed general consultation form is used. The

consultation is addressed to a staff bombarded bymany sources of information, all vying for their atten-tion. The title facilitates the location of specific desiredand/or needed information among the usual welter ofprogress and nursing notes, laboratory reports, andother consultations. The title should include someform of the word “psychiatry,” the rank or position ofthe author (resident, attending, intern), and the appro-

priate descriptive term (‘ ‘consultation,’ ‘ “note,”

“preliminary note,’ ‘ ‘ ‘workup, ‘ ‘ and/or “follow-up”).Often there are several stages of written communica-tion. The consultant may receive the consultationrequest, discuss it with the referring physician, review

the chart, and then find that the patient is away fromthe ward or is sedated or otherwise indisposed. Atitled preliminary note informs the service that theconsultant is involved, interested, and available andhas some preliminary data about the case. Similarlytitled written notes are an integral part of the consul-

tant’s follow-up visits (contacts made) with the pa-tient, the family, and the service.

DATE, TIME, AND SOURCES

Next to the title of each note are the date and timethe note was written and a list of the sources of

information used by the consultant. This serves threepurposes: it conforms to the medical style; it informs

the consultee of the old and new chart review andinterviews performed by the consultant; and it records

the data base for the consultant’s conclusions and

identifies resource persons, family, and other medicalstaff. Recording the length and number of visits under-scores the time and effort expended, even when thewritten note is short. (This may also be relevant tobilling and insurance transactions. We hope that these

small notations will foster the current move to consid-eration of reimbursement for time and effort.)

IDENTIFYING STATEMENT

The opening sentences ofthe note set the tone of the

consultation. The psychiatrist must 1) distill all of thedata about the patient into a succinctly worded sum-mary of the patient’s presenting condition and 2)

clarify the often vague explicit and implicit demands ofthe referring service, thereby formulating a questionthat a consultant can reasonably address. The follow-ing is a consideration of each of these elements.

One of the functions of a consultant is to bring afresh perspective to a clinical question. A medical orsurgical service may work with a patient for days or

weeks, accumulating observational and laboratorydata, performing procedures, and relating to the pa-tient and family, who have both somatic and emotional

needs. Data and demands accumulate; responsibilityfor the psychological observations and care of the

patient is fragmented. The request for consultationarises from a psychiatric complication in the patient’s

hospital course. There are situations in which the

primary physician has objectively noted signs andsymptoms consistent with a specific psychiatric disor-

der such as depressed mood, vegetative signs, anes-thesia inconsistent with nerve distributions, or cogni-

tive deficits and simply calls in an expert on thesubject.

More commonly, however, the request for consulta-

tion is a covert expression of the physician’s frustra-

tion, guilt, and annoyance at his or her inability to

diagnose (4), treat, and discharge the patient from the

hospital. For example, the physician may be con-

cerned that the patient does not comply with medical

orders, behaves bizarrely and/or unpleasantly, persistsin having symptoms after thorough studies have re-vealed no abnormalities, or is terminally ill. Behind the

stated reasons for the consultation (5) is the desire thatthe psychiatrist will resolve the situation by arbitrat-ing, counseling, or granting absolution for the patient.There is also the understandable fear that the consul-tant will judge, analyze, and increase the burden of thetreating physician. The psychiatrist aims instead at

removing impediments and increasing the mutual un-

derstanding and working relationship between primary

doctor and patient so that they can together progresswith the diagnostic and therapeutic tasks.

To write the consultation after assimilating all of thisinformation, the consultant begins his or her remarkswith a focus on those facts about the patient which are

most relevant to the immediate problem. These in-dude some of the facts that the intern enters at thebeginning of a written history and are worded in the

familiar medical style, but they are selected with aview to the formulations and recommendations to

Am J Psychiatry 139:7, July 1982 THOMAS R GARRICK AND NADA L. STOTLAND 851

follow. For example, “We are asked to see thissocially isolated, needy 60-year-old woman with a

history of unexplained multiple admissions for diabetic

keto-acidosis,” or “this 32-year-old man with a bleed-ing ulcer, whose mother recently died,” or “this 45-

year-old man with headaches, whose delinquent sonwas recently incarcerated,” or “this 26-year-old worn-

an, admitted for a hysterectomy because of pelvicadhesions and pain, who has a long history of surgicalprocedures in several institutions for various diag-noses, without relief of symptoms

The next sentence or clause restates in a workablefashion the observations and diagnostic, therapeutic,and/or management problems that occasioned the re-quest for a consultation. The wording ofthis request as

received by the consultant is not uncommonly asvague as “R/O [rule out] schizophrenia.” This reflectsthe psychologically unsophisticated and/or resistant

(6, 7) state of the primary physician’s thinking aboutthe psychophysiological functioning of the patient and

often engenders annoyance and sarcasm on the part ofthe consultant. There is no place, however, in theopening or any other part of the written consultation

for expressing any feelings other than those due aprofessional colleague who has paid the consultant the

respect of making a referral. It is useful to begin with astatement to the effect that a psychiatric evaluation

has been requested and then to detail what seem to thepsychiatrist to be the events or behaviors that precip-

itated the referral. Whether these observations, notinterpretations, are offered explicitly in the referral or

not, they are the formulation of the psychiatrist’sapproach to the consultee-consultant contract. Exam-

ples are, “Psychiatric evaluation is now requestedbecause of a change in the patient’s mood, alertness,

and cognition occurring over the last week,” or “Thepatient’s daily crying spells since admission are ofconcern to the service.”

At this point, the question of whether to use psychi-

atric technical language may arise (8-10). (The consul-tant’s facility with biomedical language is generally not

problematic and may even be beneficial.) A broad

range of styles may be useful, depending on the

circumstances, for example, the psychiatric sophisti-cation of the consultees, the need for descriptive

accuracy, the tendency to view psychiatric labels aspejorative, the potential for education, and clinicalemergencies. Psychiatry, like other medical disci-plines, has evolved a specialized terminology that

reflects continuing efforts at descriptive and theoreti-

cal precision. The consultant’s task is to strike abalance between oversimplification and technical ob-

fuscation. In general, as in all writing, the aim is to beas clear, direct, and concise as possible. Technicalterms should be used when necessary. A nonjudgmen-tal definition of the term can be unobtrusively insert-

ed. The consultee is seeking an expert opinion as wellas one that he or she can understand and apply.

It is important to consider for whom (6) the consul-tation is written. The consultation formally exists as a

doctor-to-doctor communication. It is seldom a per-sonal letter, especially when written in a hospitalrecord. The request for consultation itself may havebeen instigated by someone other than the attendingphysician-by someone else involved in the care of the

patient, such as a nurse, another consultant, or arelative, who awaits the impressions ofthe psychiatricexpert (11). The issue of responsibility and confidenti-ality in the consultation process has been thoughtfully

considered by Kimball (12) and others (13). In anyevent, the written consultation is meant to be read, forclinical and educational purposes, by many people and

is available, for currently unavoidable reasons, to

many others, who may read it for insurance or reviewpurposes, out of idle curiosity, or even out of mali-ciousness.

The ultimate clause or sentence is the consultant’sformulation of the problem to which the rest of thedocument will be addressed. The consultant mightnote (to pursue some of the examples we have used),“For the purpose of differentiating an organic brainsyndrome from a depression” and “Psychiatric evalu-ation is now requested to delineate the etiology, patho-genesis, and treatment options and recommendation ofthis possible depression.” The consultee’s apprecia-

tion for the clear reformulation of the patient’s prob-

lem generally outweighs any passing annoyance at

being paraphrased. The overriding necessity is to ask a

question that is answerable, if only by a carefullyexplained, “I don’t know.” As we have already men-tioned, the consultee’s optimism and anxiety may beall-embracing and overwhelming. Dealing with these

feelings tactfully and focusing requests are central

goals both of ongoing psychiatric liaison and commu-

nications concerning an individual consultation. Theseissues are not part of this paper. The restatement andformulation of the consultee’s request, once accepted,acknowledges the contract between consultee and

consultant.

HISTORY

The psychiatric consultant’s written history of thepatient’s present illness is a chronologically organizedpresentation of the interrelated life events-medical,social, and interpersonal-that bear directly on thecurrent problem. The technique of psychiatric historytaking and writing has been considered in depth in the

literature relevant to the training of psychiatrists.Several considerations deserve specific attention inthe writing of a consultation.

We have addressed the issue of confidentiality in anearlier section of this article. In writing the history, theconsultant must decide which of the sensitive commu-

nications of the patient or others are essential pieces of

852 HOW TO WRITE A PSYCHIATRIC CONSULTATION Am J Psychiatry 139:7, July 1982

information for the treatment team so that they maypursue a more successful interaction with the patient.The issue is a complex one and is best handled inactive collaboration with the informant in terms ofwhat the consultant will and will not communicate tothe consultee and/or others. This discussion may notabsolve the psychiatrist from fulfilling his or herclinical responsibilities to the consultee, which mayinclude divulging previous medical history about abor-tions, antisocial behaviors, and psychiatric illness.VIP patients and those personally as well as profes-sionally known to primary or consulting physicianspresent delicate problems. The overriding consider-ation will be the welfare of the patient.

Another issue is that of weighing completenessagainst immediate clinical relevance. Physicians aretrained to be highly invested in thorough documenta-tion. While this tradition is reasonable and oftenimportant, the consultee frequently perceives exten-sive consultations as peripheral to the patient’s care. Along, detailed report may simply leave the focus of thepsychiatric evaluation to the chance scanning of theconsultee.

Another special quality of the psychiatric consulta-tion history is that it aims both to teach other medicalprofessionals about psychosomatic aspects of illnessin general and to foster understanding of a particularpatient (14, 15). A formal psychiatric review of sys-tems can serve these simultaneous ends. This reviewincludes current medical conditions; ongoing pharma-cotherapy and other forms of therapy; recent stresses

and anniversaries of previous losses; the state ofsocial, family, and work satisfaction; and characteris-tic patterns of response to stress and their relationship

to past medical or psychiatric illnesses. It is frequentlyimportant to cite negative as well as positive findings.Viewing the patient’s present behaviors in the contextofhis or her psychosocial history, stressful life events,characteristic defenses, and behavioral styles helpsthe primary physician translate frustration into pur-poseful therapeutic activity (16). This understandingimproves the doctor-patient relationship and may pro-vide such a solid underpinning for the psychiatrist’sformulations and recommendations that their presen-tation seems almost superfluous. The following vi-gnette illustrates this point.

A 32-year-old woman was hospitalized for treatment ofseveral vaguely described complaints of pain. She expressedmassive hostility and anxiety to the whole staff and invokedin them a similar reaction. She had a highly developed abilityto play on people’s vulnerabilities and insecurities. Sheaccused the staff of abandonment and malpractice andasserted that she was considering filing a lawsuit. The staff’senraged, helpless, and avoidant responses only fed into thisvicious cycle. The consultant’s history was an explication ofthe patient’s lifetime of isolation, depression, and poorcommunication. Without further direction from the psychia-trist, the staff’s annoyance turned to pity, their stance

softened, and the working relationship improved so dramati-caily that an overlooked pneumonia and pleuritis werediagnosed and successfully treated.

MENTAL STATUS EXAMINATION

The mental status examination tends to be ignored.Its skillful documentation by a psychiatric consultantunderscores its necessity as a component of a medicalworkup (17). It educates the consultees in its perform-ance and provides a baseline for future diagnosis andcare of the patient, as well as the vital data base forcorrect management. It demonstrates that psychia-trists, like other medical specialists, base their conclu-

sions on an orderly series of evaluations. Moreover,serial mental status examinations can often chart im-portant signs along the course of an illness. Althoughother schemas are available, we find it useful toinclude the following aspects of the patient: appear-ance, verbal behavior, state of attention and cooper-ation, motor behavior, affect, thought flow and con-tent, sensorium, intellectual capacity and function,insight, and judgment. Listing these categories serves

to remind the consultant and educate the consulteeabout how to organize their thinking about a patient’smental status. The use and straightforward explana-tion of technical terms in this context also furthers

these functions. Normal findings at the time of oneexamination may prove to be either an improvementon, or a deterioration of, the patient’s usual function-ing. In any case, they provide a vital baseline against

which any changes in these findings can be identified.In this context, it may be necessary to spell out the

examinations that were performed and the details ofthe results. For example, in an 82-year-old patient with“altered mental status,” we noted, “oriented to per-son, place, and time; unable to remember three objectsat 5 minutes; could spell cat and hand forwards but nothand backwards; and a face-hand test positive, mdi-dating diffuse cortical dysfunction.” Many of the im-portant elements of clinically valid mental status ex-aminations have been discussed by Kahn and Miller(18). The examination’s clinical validity is complicatedby its exquisite sensitivity to the interviewer’s toneand style and the patient’s attitudes, expectations, andfears about both psychiatry and his or her cognitivefunctioning. The evaluation also identifies the pa-

tient’s physical and emotional comfort, ability to at-

tend to and cooperate with an interviewer called in by

someone else, and the overall and immediate circum-stances (including physiologic energy level and drugeffects) of the patient. For example, a regressed,backward, severely disabled patient showed a dramat-ic improvement in mental status after being bathed,shaved, nicely dressed, and taken away from the wardfor examination. Thus it is important for the consultantboth to record the state of the patient at the time of the

Am J Psychiatry 139:7, July 1982 THOMAS R. GARRICK AND NADA L. STOTLAND 853

interview and to explicitly educate the consultee aboutits clinical influence.

When therapy, including pharmacotherapy, is to beinstituted, a carefully documented mental status ex-

amination will inform physicians who see the patient inthe future of the indications that led to the therapeuticdecision. A patient successfully in treatment for a

major psychiatric illness may appear so normal thatthe successful and necessary therapy might be prema-turely and abruptly withdrawn.

This view of the mental status examination as a

useful tool rather than a required exercise, and as asystem for assessing the patient’s functioning at a

particular moment in time (similar to any other medi-cal examination) rather than a fixed quality, makes formore reasoned, explicit, and accurate diagnostic for-mulations in general. For example, a consultant sum-moned by a gastroenterologist reviewed the chart of a38-year-old woman admitted for treatment of irritablebowel syndrome. Review of the old chart revealed 8psychiatric consultations in the past 8 years, each witha different diagnosis. These labels ranged from “hys-tencal character” and “obsessional character” to“schizophrenia.” After careful review of the past

mental status examinations to determine the criteriafor each diagnosis, the consultant was able to explainto the treating service staff that the patient could mostusefully be understood as having a borderline charac-

ter disorder and as manifesting widely varying symp-toms at various points in her unstable existence. A

discussion of other issues in diagnosis follows.

FORMULATIONS

The formulations pose the most delicate problems inwriting the consultation. The choice of the term “for-mulations” rather than the more traditional medical“diagnosis” or even “differential diagnosis” high-

lights the issue. Offering a neat diagnostic label may

provide a tidy ending not only to the document butalso to careful consideration of the patient and to thehuman interaction of patient and medical care team.The situation is similar to that in other medical special-ties, when a human being with a constellation ofcomplaints and findings becomes “a diabetic” or “amissed abortion.” Psychiatric labels are poorly under-stood and anxiety provoking and frequently put dis-tance between consultant, consultee, and patient.However, diagnostic labels follow a medical tradition,

help in structuring a set of observations or a differen-

tial diagnosis, and are sometimes required by insur-ance companies and regulatory agencies. In thesecases the consultant can use a DSM-ll1 formulationand number and explain it in the written consultation.(This is an opportunity to acquaint the consultee withDSM-III as a reference and as a demonstration of psy-chiatry’s move toward greater diagnostic accuracy.)

Sometimes a final diagnosis cannot be made at thetime of consultation because certain data are lacking.This situation needs to be specifically identified to theconsultee. For example, additional criteria for schizo-phrenic and affective disorders may require furtherobservation of the illness over a specified time span.The psychiatrist is frequently consulted to decidewhether the patient’s pain is organic or functional andcan only conclude (19) after careful examination that itis neither-or both. The patient may have started outwith an injury, but weeks or months of pain, spasm,

anxiety, reactions in friends, relatives, and lawyers,and accommodations in life style obscure the clinicalpicture by the time the patient is admitted for aworkup.

The consultant’s ability to appropriately say “Idon’t know” is evidence ofprofessional maturity. It isa good example for physicians in general, and in casessuch as those we have described, it serves two otherfunctions. First, it helps the consultee to deal with thereality that all symptoms in such a patient requirecareful consideration. ‘ ‘Organic’ ‘ patients may have‘ ‘functional’ ‘ complaints, and ‘ ‘depressed’ ‘ patientsmay have appendicitis or cancer; and often, as inpseudodementia, one directly relates to the other.Second, the psychiatrist may offer welcome empathyto the primary physician’s feelings offrustration, guilt,and annoyance by explicitly stating that these prob-lems are frustrating, guilt provoking, and annoying.Occasionally the consultant may find it useful toexplain how the patient’s unexpressed affects tend toprovoke similar feelings in the caretakers (15). “If thepatient makes you feel helpless, he may be feelinghelpless.”

A discussion of the dynamics of the patient as anindividual in the medical care situation is the mostclinically useful summary of the consultant’s findings.In the case of the patient with borderline characterdisorder described earlier, the psychiatrist wrote,

The patient desperately wants encouragement and sup-port from others, but is unable to express her needsdirectly and successfully. At times she is driven to makehuman contact by dramatic complaints and seductivebehavior; at other times she withdraws into rigidly con-trolled and controlling ritualistic behavior. When she failsand feels disliked, she may become so upset that she fallsapart completely and is unable to function.

Given this understanding (16), the primary servicestaff�s behavior changed from avoidance to approach,and the patient’s behavior, while erratic, no longerwas such an obstacle to her care.

RECOMMENDATIONS

The recommendations (or suggestions or treatment)section is sometimes the only and often the first one

854 HOW TO WRITE A PSYCHIATRIC CONSULTATION Am J Psychiatry 139:7, July 1982

that the consultee actually reads. In this section he orshe hopes to find the answer to the problem, thefulfillment or embodiment of the implicit and explicitcontracts between consultant and consultee. Like thecontract, its tone is confident, informative, and re-spectful of the professionalism of the recipient. Its

content is scientific, reasonable, and practical. Therecommendations constitute a comprehensive ap-proach to the clinical problem and a careful delineationof immediate and long-term management. For com-pleteness, important components of the approach thathave already been performed may be listed andchecked off. The consultant may also indicate forwhich of those remaining to be performed he or she isassuming responsibility and when and how the consul-tee will be apprised of results.

Following is a suggested conceptual scheme fororganizing the recommendations.

First is the further workup to clarify the diagnosis,precipitating events, and/or resources. It may includelaboratory tests for the diagnosis of abnormalitieswhether they are primary, such as serum alcohol level,or contributory, such as hematocrit. Workup also mayrequire more history or history from other sources,such as old medical records, school files, employers,friends, and relatives. For example, a diagnosis ofsleep apnea is often strongly suspected on the basis ofthe bed partner’s report of loud snoring, apneic peri-ods, and gross physical restlessness. The psychiatricconsultant may also point out the need for consultationby other specialists.

The second category of recommendations is man-agement by consultee. It may include pharmacologic,social, psychotherapeutic, situational, or legal man-agement. The consultant may suggest the manipula-tion of drugs that are administered for the patient’sprimary conditions but produce side effects, such as

impotence and drowsiness, that are relevant to theconsultation problem. He or she may recommendadministration or withdrawal of psychotropic medica-tion. Specific detailed regimens should be suggested inthe latter case, along with therapeutic and side effectsto be anticipated. This is an effective way to communi-cate the medical relevance of psychiatry.

Examples of legal management recommendations

include ways of explaining a procedure to a patient toobtain and document informed consent and ways ofdetermining legal mental competence. It is important

to help the consultee differentiate medical/psychiatricquestions from medicolegal ones. This may involvecalling and quoting the hospital’s lawyer or suggestingthat the consultee do so. Management of social andfinancial concerns is often crucial in designing anencompassing treatment plan. Recommendations forinvolving social workers, visiting nurses, public aidworkers, and the chaplain or for assisting the patient inobtaining special equipment, such as wheelchairs,

home dialysis equipment, or other special care de-

vices, are often pivotal in ensuring successful after-

care. Such suggestions serve to guide the primaryphysician’s attention toward holistic care (20) rather

than just symptom relief.The lines between situational, psychological, and

psychotherapeutic interventions are sometimes diffi-cult to draw (21). There is a conceptual continuum. At

one end is structuring, ordering the environment andschedule of the disoriented patient with an organicbrain syndrome, arranging for an interpreter for afrightened non-English-speaking patient, or obtainingpermission for supporting relatives to remain with andcare for the patient. In the middle ofthe continuum arerecommendations for dealing with problems occa-sioned by the patient’s character structure and re-sponse to the medical setting. A classic example islimit setting. An outline of the rationale and regimenfor dealing with an abusive, constantly demanding, orengaging but draining patient and its implementation

have a dramatically soothing effect on the service staff.The consultant thus channels (22) frustrated feelingsprovoked by the patient into constructive behavior bythe patient and staff, such as setting up a schedule offrequent but structured patient contacts or instructionsabout how, when, and why to call in hospital guards orthe police.

Next along the spectrum are recommendations for a

general approach to the patient based on an under-standing of character structure. For those patients

who are acutely sensitive to power issues, the consul-tant may suggest that the primary physician explainand phrase all orders in terms of choices. With otherpatients, who are overwhelmed by ambivalences, thecaretakers may make a contract to offer straightfor-

ward recommendations. The consultant may stress theneed to reinforce the patient’s desirable behaviors,downplaying preoccupations with symptoms and help-

lessness and underscoring attempts to assume respon-

sibility. The consultant can use personal knowledge of

the primary physician’s personality style by takingthis, too, into account in framing this kind of recom-

mendation.The other end of the spectrum is the recommenda-

tion for formal psychotherapy. The consultant mayrecommend that the consultee encourage the patient tofollow through on suggested psychotherapy or maysuggest that a member of the primary medical teambegin or continue a limited psychotherapeutic process.

An experienced and sophisticated nonpsychiatricmedical professional may wish and be able to do

limited psychotherapy. Others on the medical team

may use psychotherapeutic techniques for a patientwho needs support and ventilation. These interven-

tions may be on a one-to-one basis or may involve the

patient’s family. The psychiatric expert/consultantmay offer advice as to the frequency, length, andduration of these sessions.

The third main category of recommendations is

Am J Psychiatry 139:7, July 1982 THOMAS R. GARRICK AND NADA L. STOTLAND 855

management by the consultant or care by a specialistin psychiatry. This category is largely self-explana-

tory. It includes recommendations for inpatient psy-chiatric hospitalization and outpatient psychothera-

pies and behavioral, psychodynamic, hypnotic, and/orsomatic psychiatric therapy (ECT, pharmacotherapy,biofeedback). If a referral to another psychiatrist is

advised, the precise mechanism must be specified.

When the consultant will continue to evaluate thepatient, this needs to be agreed upon and specified. Ifno psychiatric follow-up is indicated at the time, thismay be stated, along with an invitation to contact the

consultant or a suitable substitute when necessary.

The consultation then ends with an expression ofappreciation for the referral and the legible or retypedsignature and phone number ofthe consultant. Makinghis or her availability manifest is tangible evidence of

the physician’s professional responsibility.

THE LIMITED OR NONCOMPREHENSIVE

CONSULTATION

Situations arise in which the usual complete psychi-atric evaluation is not requested and/or indicated.These consultations are termed “limited.” The medi-cal or psychiatric picture may be emergent. The situa-

tion in which the time available for workup is limitedby the patient’s condition, treatments, or imminent

discharge is often a loaded situation and worthy of

fuller discussion elsewhere. It may be immediately

clear that the patient needs inpatient psychiatric care.The treating service may have a specific limited re-quest for advice or information, e.g., “Will treatment

with steroids pose a danger to this patient, who has a

history of a schizophrenic break in the distant past?”

In these cases, the consultant has a right and duty firstto decide as an independent physician whether a

limited consultation is appropriate and then to clearlyand accurately title the written document for medical

and legal clarity. Otherwise, the conceptual frame-work for deciding content, tone, and style is the sameas that for a comprehensive consultation.

CONCLUSIONS

We have tried in this detailed dissection of theanatomy of the consultation document to share ourgrowing awareness of the profundity and complexityof the issues involved in writing a consultation. Theseissues are often extensions of those faced by a liaison

psychiatrist verbally managing a consultation. Al-

though the array of delicate and demanding questions

may seem formidable, our aim is not to overwhelm butrather to impress the reader with the range of choices

and possibilities for having a constructive impact in

the written record as distinct from other liaison inter-actions. A psychiatric consultation is a rare opportuni-

ty not only to help a patient and doctor in distress butalso to communicate effective, lasting, implicit, andexplicit messages about psychiatric theory and prac-tide and about psychiatrists as experts, colleagues, andindividuals.

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