1. What is consultation-liaison psychiatry, and how does it differ from psychosomatic medicine?
Consultation-liaison (C-L) psychiatry is a subspecialty within psychiatry that involves the interface between psychiatry and other medical specialties. A C-L psychiatrist may work in the inpatient medical setting, the emergency medical setting, or the outpatient medical setting. In each, the C-L psychiatrist provides direct patient care and/or collaborates with other medical specialists as they care for patients. Training in C-L begins in psychiatry residency, when every resident must complete a C-L rotation. Individuals can then pursue a one-year fellowship in C-L psychiatry and subsequently pursue board-certification in C-L psychiatry through the American Board of Psychiatry and Neurology (ABPN). Whereas C-L psychiatry was the term used to describe the field throughout much of the twentieth century, “psychosomatic medicine” was the officially approved name of the subspecialty when it was first recognized by the American Board of Medical Specialties (ABMS) in 2003. The name of the subspecialty was changed to consultation-liaison psychiatry in 2018 in part to address frequent misunderstanding by other physicians and the public regarding the meaning of the term psychosomatic.
Sources:
2. What patient populations do C-L psychiatrists serve?
C-L psychiatrists serve patients of all ages from diverse demographic, cultural, and psychosocial backgrounds with complex medical, surgical, neurologic, and obstetric conditions. C-L psychiatrists frequently work as inpatient consultants with patients and families on general hospital medical and surgical units, care for outpatients in outpatient specialty medical clinics, and provide collaborative and integrated care in partnership with primary care providers and other medical specialties. They also provide consultation and education for the patients of teams specializing in organ transplantation, cardiac care, critical care, cancer, burns, women’s health, infectious diseases, neurologic illness, brain injuries, trauma, and many other general medical and surgical problems.
The breadth and medical complexity of populations served by C-L requires expertise in managing behavioral syndromes that are directly caused by medical problems, as well as the physical and emotional difficulties that arise in patients coping with life changing illnesses. C-L psychiatrists serve patients across the lifespan, developing expertise in managing delirium and other neurocognitive problems, risk assessment, psychopharmacology, pain, addiction and forensic issues, end-of-life care, and the psychiatric sequelae of medical disorders. C-L psychiatrists advocate for high quality, integrated care and help develop ongoing treatment plans for patients with psychiatric needs at hospital discharge and across outpatient levels of care.
3. What is the role of the liaison?
The role of the C-L psychiatrist as a liaison is to establish professional relationships, interact, and communicate findings and recommendations to consultees and other clinicians involved in the care of mutual patients. The liaison educates the patient’s healthcare team in a way that enhances adherence to management recommendations. In contrast to the standard medical-referral model, in which the consultation psychiatrist is called to provide an expert second opinion, this additional liaison role is based on an early detection strategy to identify potential problems. In liaison-enhanced models, the psychiatrist is integrated within the patient’s multidisciplinary healthcare team and may participate in ward rounds and team meetings. Liaison services lead to heightened sensitivity by medical staff, which results in earlier detection and more cost-effective management of patients with psychiatric problems.
4. How does C-L Psychiatry training relate to hospital administration and/or quality of care?
C-L Psychiatrists’ roles universally involve collaboration with other medical and surgical specialties across inpatient, outpatient, and emergency settings. As a result, the role of the C-L psychiatrist involves several important considerations beyond the traditional doctor-patient relationship. C-L psychiatrists are accountable to patients, families, other physician teams, nursing and other allied health providers, and to administrative leadership. Understanding that our work impacts multiple stakeholders is key to developing as an effective C-L psychiatrist. This is the core principle of quality care: to produce beneficial, measurable outcomes for those involved. This is also different from traditional models of clinical care, which focus on quantity and types of service as performance metrics.
Hospital administrators often have complementary goals to those of physicians, namely how to provide a system of care that effectively and efficiently manages the health care needs of a population of patients while maintaining the financial and structural resources necessary to continue providing care. Care delivery to patients with comorbid behavioral health and general medical needs can be challenging. Difficulty with adherence, adverse effects of chronic psychotropic medications, maladaptive coping styles, and behavioral disturbances arising from neurobehavioral syndromes are common sources of increased cost and distress, and C-L psychiatrists are often involved in helping patients and other clinicians navigate these challenges. By improving the care quality through direct patient care, clinician education, and advocacy for integrated models of care, C-L psychiatrists strive to meet the goals of patients, staff, and administrators simultaneously. Common quality metrics include reductions in length of stay through recognition and management of psychiatric conditions, improvements in patient and family satisfaction, enhanced care adherence, and reduction in agitation and violence toward staff. Each hospital system will have unique challenges and opportunities for skilled C-L psychiatrists.
A final and important aspect of training involves the liaison role. As a liaison, the C-L psychiatrist bridges gaps in communication and understanding among patients, clinicians, administrators, and other staff. C-L psychiatrists are often involved in cases with medicolegal, ethical, or system-level implications. The unique skill set of the C-L psychiatrist is well suited to serving on quality improvement committees, morbidity and mortality series, health systems research, and clinical program development. Through a focus on quality of care, C-L psychiatrists can approach problems flexibly and pragmatically, often functioning closely with hospital leadership to develop systems of care to better meet the needs of all involved.
5. What is the typical psychiatry residency experience in C-L psychiatry?
The Accreditation Council for Graduate Medical Education (ACGME) requires that every general psychiatry residency training program provide a resident experience in C-L psychiatry including at least two months full-time (or equivalent) in which residents consult under supervision to other medical and surgical services.
Across residency programs, there is variation in C-L rotation length (ranging from less than three months to over six months), timing throughout the four years of residency (with many occurring over multiple years, most often including the second or third years of residency), and structure (for example, part-time vs. full-time rotations). Historically, most required C-L rotations have occurred in the inpatient C-L setting. However, over recent years there has been increased focus on providing outpatient C-L experiences as well. Some residency programs may offer an option of rotating in pediatric C-L psychiatry, which is often of interest for residents pursuing a career in child and adolescent psychiatry. Most C-L rotations include didactics, either during the rotation itself and/or integrated into a broader residency didactic curriculum. Beyond C-L rotations during typical business hours, many residents are also scheduled on periodic weekend and overnight call coverage of an inpatient C-L service.
Depending on the institution, resident supervision in C-L may be performed by psychiatrists trained in C-L and/or by other psychiatrists working in this setting. As there is prominent overlap between C-L psychiatry and geriatric psychiatry, addictions psychiatry, women’s mental health, and neuropsychiatry, some supervising faculty may have specialized training in these areas. For residents at institutions affiliated with a C-L psychiatry fellowship program, residents may work closely with C-L psychiatry fellows.
For medical students with an interest in C-L, it can be helpful to ask during residency interviews about each program’s C-L experience for its residents.
Sources:
6. What is the day-to-day life of a C-L fellow?
The C-L fellowship is a one-year program. The majority of time is spent performing consultations in a general medical hospital. Consults are received from all inpatient services in the hospital, while only some fellowship programs also involve consults in the emergency department. Many fellowships will involve rotations at different medical hospitals throughout the year, and some offer the chance to participate in multidisciplinary activities such as transplant committee meetings. Programs differ in the roles of team members and how closely the fellow works with them, such as medical students, residents, nurse practitioners, social workers, and psychotherapists. Programs also differ in average hours per week (this information is available online and hours mostly range from 40 to 80 per week). Very few programs have on-call requirements. Fellows rotate in a variety of subspecialty clinics such as the options described below (transplant, psycho-oncology, cardiology, etc.). The weekly time devoted to clinic typically ranges from 10% to 50% depending upon the program. Most fellows are actively involved in serving a triage role when consultations are received by the service.
7. What C-L sub-specialties can be practiced after completing a fellowship in C-L psychiatry?
C-L psychiatrists develop close working relationships with clinicians from different departments or divisions, often focusing on a certain specialty or subset of medical conditions. For example, a psycho-oncologist works closely with a cancer treatment team (medical oncology, radiation oncology, social work) to deliver psychiatric care. A transplant psychiatrist assists in the transplant candidacy evaluation, manages psychiatric issues pre- and post-transplant, and works closely with the transplant team (medicine, transplant surgery, social work, often infectious disease). Other common subspecialties are HIV psychiatry, cardiovascular psychiatry, and neuropsychiatry (in which one often further subspecializes). C-L–trained psychiatrists can pursue a variety of options, including women’s mental health with a focus on peripartum psychiatry, psychodermatology, addiction psychiatry, geropsychiatry, collaborative and integrated psychiatric care, burn- and trauma-related psychiatry, pain psychiatry, and ICU and post-ICU psychiatry.
8. What’s the difference between C-L Psychiatry fellowships and other combined medicine-psychiatry residency programs?
For medical students interested in both psychiatry and another medical subspecialty, there are several training programs that provide dual and even triple board certification. The type of program has its own time span, however the amount of time spent in each specialty—while generally equal—may differ based on the institution. Among these are the following:
Internal Medicine-Psychiatry Residency: These programs are 5 years with equal exposure to both fields. Trainees who complete this type of residency are eligible for both Internal Medicine and Psychiatry board certification. There are currently 15 institutions that offer this type of combined specialty track training.
Family Medicine-Psychiatry Residency: These programs also span 5 years with equal amounts of training in both fields. Trainees who complete this type of residency are eligible for both Family Medicine and Psychiatry board certification. There are currently 6 institutions that offer this type of combined specialty track training.
Pediatrics-Psychiatry-Child Psychiatry Triple Board Program: This is a combined training program that spans 5 years. At the end of residency, trainees are eligible for board certification in Pediatrics, Psychiatry and Child and Adolescent Psychiatry. There are currently 10 institutions that offer this type of combined specialty track training.
Neurology-Psychiatry Residency: This is a combined training program that spans 6 years. At the end of residency, trainees are eligible for board certification in Neurology and Psychiatry. Currently there are 4 institutions that offer this type of combined training.
Post-Pediatric Portal Fellowship: This is a program that can be pursued by trainees who have completed a 3-year residency in Pediatrics. After completing residency, a trainee then applies to a Post-Pediatric Portal Program where they receive an additional 3 years of training consisting of both general adult psychiatry and child and adolescent psychiatry. Upon program completion, the trainee is eligible for board certification in both Psychiatry and Child and Adolescent Psychiatry, in addition to Pediatrics. There are currently 4 institutions that offer this type of training.
Additional information about combined and alternative pathway programs is available from the American Board of Psychiatry and Neurology here and the Association of Medicine and Psychiatry here.
9. What are the benefits of pursuing a C-L Psychiatry fellowship?
A trainee can pursue a fellowship in C-L Psychiatry after completing a 4-year general Psychiatry residency. Most fellowships are one year, although a few institutions allow an additional year dedicated to research. Upon fellowship completion, a trainee is eligible for board certification in Psychiatry and Consultation-Liaison Psychiatry. Nationally, there are 63 institutions offering an ACGME approved fellowship in C-L Psychiatry, dispersed across the nation.
The focus of C-L Psychiatry training is on the interplay between mental health and physical health. A trainee who completes a C-L fellowship will not only learn the skillsets needed to adequately identify and treat psychiatric symptoms in medically ill patients, but will also be able to identify how those psychiatric symptoms may affect the patient’s medical care. This is where the liaison portion of C-L psychiatry becomes a vital part of training. Often, the C-L psychiatrist is the “front door” of the psychiatry department to other medical specialties, which requires unique leadership roles. This kind of expertise meaningfully influences patient care and is instrumental in supporting guideline development in other departments. While many combined residency training programs may provide exposure to each type of discipline in their own respective setting, C-L psychiatry focuses on the integration of the disciplines with an emphasis on how mental health may be affecting a patient’s physical health and vice versa.
10. Can I become board certified in C-L Psychiatry?
C-L Psychiatry was officially approved as a board-certified subspecialty within the field of Psychiatry in 2003 (initially named Psychosomatic Medicine and subsequently changed to Consultation-Liaison Psychiatry in 2018). Board certification in C-L requires completion of a C-L Fellowship at an accredited program (see the “Career” menu on the ACLP website for more information). Psychiatrists who complete a C-L Fellowship and pass the written exam offered by the American Board of Psychiatrists and Neurologists (ABPN) are awarded board certification in the subspecialty.
11. What are possible career options after completing a fellowship in Consultation-Liaison Psychiatry?
A psychiatrist who is board certified in C-L has many career options, spanning clinical, academic, and administrative positions across multiple practice settings.
The C-L psychiatrist in a general hospital: The general hospital C-L psychiatrist performs psychiatric consultations on patients admitted to the various services in the hospital (internal medicine, surgery, etc.). In addition, the C-L psychiatrist may serve as the psychiatric liaison to a specific clinical program or programs. In that role, the psychiatrist may attend clinical rounds with the team, listening to case presentations and suggest which patients might benefit from earlier psychiatric intervention, or offering the team suggestions on how to collaborate more effectively with patients who are, for example, exhibiting behavioral problems that are complicating their medical management. The C-L psychiatrist in the general hospital is commonly asked to be involved in the most challenging of clinical situations, with multiple legal, ethical and clinical implications. The C-L psychiatrist is therefore often invited to be a member of various hospital-wide committees, such as the Ethics Committee.
The psychiatric expert on a clinical service: The C-L psychiatrist may be the identified psychiatrist for a clinical team or service in the hospital, such as a transplant program. In this role, the psychiatrist may be responsible for doing psychiatric evaluations and subsequent treatment for the patients in that service or clinic, collaborating as a member of the team (commonly consisting of other physicians, social workers, nurse practitioners or physician assistants, and other staff) in clinical activities, such as team rounds, treatment planning, and—in the case of a transplant service—selection processes to determine acceptability for transplant.
The psychiatrist in a collaborative care model: The C-L psychiatrist may provide psychiatric consultations and oversight of a large medical setting, such as an outpatient medical clinic. In this position, the psychiatrist may perform consultations on patients where psychiatric evaluation is needed, listen to case presentations and offer suggestions to the patients’ primary care clinicians on how to manage clinical concerns, and provide education to the program staff about psychiatric illness and behavioral disorders. Collaborative care has received substantial attention in recent years, with increasing emphasis on centralizing the care of patients and containing healthcare costs. The C-L psychiatrist is in a position to serve a central role in this exciting movement.
Outpatient psychiatrist: The C-L psychiatrist may have an outpatient practice treating patients with complex medical conditions. This can be as a solo-practitioner, or in a group practice, often with an interdisciplinary approach to patient care (for example, with access to a variety of services, such as social work, nutrition, case management, etc.). The C-L psychiatrist is not committed to treating only medically-ill patients and might treat a range of types of patients in the same or concurrent practices or settings.
Hospital administrator: The C-L psychiatrist, through close involvement in several clinical and hospital-wide activities, may assume an administrative role, running programs, serving on executive committees, or providing other forms of leadership within hospitals or other organizations.
Educator: Though the C-L psychiatrist naturally serves as an educator in each of the above practice settings, the C-L psychiatrist is also in a unique position to take on a formal role as an educator at the level of the hospital or medical college. The C-L psychiatrist has been trained to work with non-psychiatrists and to help them understand and manage emotional and behavioral issues in their patients. This skill set is well suited to educate medical students, as well as non-psychiatric clinicians, faculty and other hospital staff.
Researcher: The C-L psychiatrist is uniquely positioned to investigate research questions occurring at the intersection of mental health and non-psychiatric medical illness. Given the impact of psychiatric comorbidity on medical outcomes across numerous conditions, the C-L psychiatrist is eligible for a broad range of federal and foundation funding opportunities within and outside of mental health.
12. How do I learn more about C-L Psychiatry? What if my medical school doesn’t have C-L electives?
Recommended websites for further information and links to opportunities:
We welcome medical students to join the ACLP, and there is NO CHARGE for membership. https://www.clpsychiatry.org/about-ACLP/join-ACLP/
Consider attending the annual meeting, which takes place each November. The schedule, speakers, abstracts, and final program for several years of Annual Meetings can be found on the ACLP website. https://www.clpsychiatry.org/advocacy/annual-meeting/
The Annual Meeting also hosts a “meet and greet” for trainees, where you can meet ACLP members and leaders, learn about opportunities for C-L psychiatrists, find a mentor, and have your questions answered.
Smith FA, Levenson JL, Stern TA. Chapter 1: Psychiatric Assessment and Consultation. Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry. American Psychiatric Association Publishing, 2019. Available here
Marcantonio, E. Delirium in Hospitalized Older Adults. New England Journal of Medicine, 2017.
Available here
Appelbaum P. Assessment of Patients’ Competence to Consent to Treatment. New England Journal of Medicine, 2007. Available here
Beach SR, Celano CM ,Noseworthy PA, Januzzi J, Huffman JC. QTc Prolongation, Torsades de Pointes, and Psychotropic Medications. Psychosomatics, 2013. Available here
Strawn JR, Keck PE, Caroff SN. Neuroleptic Malignant Syndrome. American Journal of Psychiatry, 2007.
Available here
Viederman M, Perry SW. Use of psychodynamic life narrative in the treatment of depression in the physically ill. General Hospital Psychiatry, 1980. Available here
Francis A. Catatonia: Diagnosis, Classification, and Treatment. Current Psychiatry Reports, 2010. Available here
Thom R, Silbersweig DA, Boland RJ. Major Depressive Disorder in Medical Illness: A Review of Assessment, Prevalence, and Treatment Options. Psychosomatic Medicine, 2019.
Available here
Srivastava AB, Mariani JJ, Levin FR. New directions in the treatment of opioid withdrawal. Lancet, 2020. Available here
Chernyavsky S, Dharapak P, Hui J, et al. Alcohol and the hospitalized patient. Med Clin N Am, 2020.
Available here
A copy of this Bibliography is available here