User login
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at [email protected].
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at [email protected].
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at [email protected].
