Recommended Guidelines for
Consultation-Liaison Psychiatry Training in
Psychiatry Residency Programs

A Report from the APM Task Force on Psychiatric Resident Training in Consultation-Liaison Psychiatry

David F. Gitlin, MD (University of Massachusetts Medical School),
Barbara A. Schindler, MD (Medical College of Pennsylvania),
Theodore A. Stern, MD (Harvard University School of Medicine),
Steven A. Epstein, MD (Georgetown University School of Medicine),
Ruth Lamdan, MD (Medical College of Pennsylvania),
Teresita McCarty, MD (University of New Mexico School of Medicine),
P.V. Nickell, MD (West Virginia University School of Medicine),
Robert B. Santulli, MD (Dartmouth Medical School),
John L. Shuster, MD (University of Alabama School of Medicine),
Victor Stiebel, MD (University of Pittsburgh School of Medicine),
Linda Worley, MD (University of Arkansas School for Medical Science)

Contents:

Over the past 30 or more years, Consultation-Liaison (C-L) psychiatry has developed as a unique area of expertise in psychiatry. As a result, many have recommended that C-L psychiatry be recognized as a distinct sub-specialty.^1,2,3,4,5,6 Several experts have discussed the nature of C-L training and education within the general psychiatry residency training program,^7,8 most notably the report of the AAP's Task Force on C-L Objectives.⁹ This report recommended setting broad knowledge and skills objectives. Knowledge objectives were in the areas of the consultation process, biopsychosocial dimensions of practice, core clinical syndromes, somatic and non- somatic treatments. Skills objectives included data gathering, interview process, case formulation, and interventions. There have been a few surveys assessing C-L training practices,^7,8,10,11 the most recent of which was a large scale survey of all accredited psychiatry residency programs, under the auspices of the Academy of Psychosomatic Medicine.¹²

Despite the above work, there are no current guidelines or standards for C-L training within general psychiatry residency programs. Survey results confirm the opinion of many C-L training directors that each program's approach is idiosyncratic, with minimal sharing of practices across programs.¹² The training is often handed down from one C-L director to the next, or brought in with a new director from his/her previous training setting. Consultation-Liaison psychiatry bibliographies have been published,^{13,14,15,16,17,18,19} but a recent review of recommended readings in C-L psychiatry across 16 training programs²⁰ revealed almost no consistency in C-L literature lists disseminated to residents.

A review of formal training guidelines in C-L psychiatry is equally revealing. As far back as 1941, the Accreditation Council for Graduate Medical Education (ACGME) and its review counterpart, the Residency Review Committee (RRC) in Psychiatry and Neurology, have published required essentials for accredited residency programs. These have been published and updated at irregular intervals in what has come to be known as the RRC "Green Book."

The Green Book of Psychiatry essentials from the earliest known version, in 1941, make virtually no comment on training in C-L or psychosomatic medicine.²¹ It is not until 1961 that the RRC accreditation requirements describe anything to do with C-L. Even these come with the caveat that the:

RRC for Psychiatry, representing the American Board of Psychiatry and Neurology, Inc. . . . is unalterably opposed to specifying rigidly either course content or course sequence",²²

preferring to make "suggestions" for directors of training programs. The provisions related to C- L include:

"sufficient contact through consultation and associated conferences with the services other than their own, such as general medicine, neurology, surgery, and pediatrics, so that the residents may become cognizant of the content and operational framework of these other fields of clinical experience and learn to apply their special training relevantly and helpfully to these fields",²² and

"Psychosomatic medicine is the term now commonly used to describe many disorders such as anorexia nervosa, peptic ulcer, ulcerative colitis, bronchial asthma, urticaria, eczema, and many others in the causal mechanism of which the emotional psychological factors appear to play an important role. The body of information on these disorders and the methods useful for diagnosis and treatment in this field of clinical experience deserve a special place in the program and are to be distinguished from the psychiatric problems common to general medical and surgical practice . . .".²²

This initial description of training guidelines in C-L were felt to be reflective of the burgeoning appreciation of psychosomatic factors championed in the 1940s and 1950s by psychiatrists such as Franz Alexander,²³ Felix Deutsch,24 and Flanders Dunbar.²⁵ While not detailed in the specifics of how to achieve these goals, these essentials nonetheless made a clear statement about the acceptance of psychosomatic constructs in the training of general psychiatry residents. In retrospect, they were remarkable for their elaboration, relative to RRC guidelines to follow.

The next updated RRC Green Book from 1969-1970 was completely unchanged from the 1961 text as regards C-L training,²⁶ including continued specific recommendations derived from the "specificity theory" of Alexander.²³ Subsequently the Green Book was updated in 1977-1978. Here we see an entirely new wording of essentials relevant to C-L. Gone are the reservations regarding recommendations about program content. Also gone are all references to specific psychosomatic theories. In its place are general guidelines about C-L training consisting of:

"The clinical portion of the curriculum must provide experience in . . . psychiatric consultation or liaison psychiatry involving patients hospitalized on other clinical services such as pediatrics, medicine, surgery, and obstetrics and gynecology."²⁷

While it is interesting to see the introduction of terminology such as consultation and liaison, there is virtually no other comment about C-L training. It is also notable that the 1977-78 essentials are the first to require training experience in "hospital emergency room" psychiatry, and that it is separate from the C-L training requirements.

In the next RRC Green Book version from 1981 we see the initial postgraduate year requirements elucidated for the first time. Within these are some essentials relevant to C-L but outside the aegis of the C-L services, such as:

"the objectives of the training during the first postgraduate year . . . include . . . being especially conversant with medical disorders displaying symptoms likely to be regarded as psychiatric and with psychiatric disorders displaying symptoms likely to be regarded as medical, and being especially cognizant of the nature of the interactions between psychiatric treatments and medical and surgical treatments."²⁸

The 1981 Essentials also give some guidelines about how to achieve clinical knowledge and skills in various areas, including C-L, stating:

"By means of individual supervision, seminars, lectures, assigned reading case conferences, teaching rounds and supervised patient care, the residency program must provide systematic instruction and substantial experience in . . . the diagnosis and treatment of psychophysiologic disorders, and psychiatric consultation or liaison psychiatry involving patients on other medical and surgical services."²⁸

These requirements remain unchanged in the 1984 accreditation essentials.²⁹

In the 1987 and 1991 Essentials, the guidelines for postgraduate years 2-4 become even more non-specific, consisting of:

"Requisite skills include . . . competence in psychiatric consultation in a variety of medical, surgical and community settings"^30,31 and

"specific clinical experiences must include . . . supervised psychiatric consultation/liaison responsibility involving patients on other medical and surgical services."^30,31

The most recent guidelines from the 1994 Green Book are also the same as the 1987 and 1991 versions, with the notable inclusion of minimum time requirements for C-L. These assert that the resident should have:

"supervised psychiatric consultation/liaison responsibility of a minimum of two months full-time equivalent . . . and while on-call experiences may be a part of this training, such experiences alone will not be sufficient to constitute adequate training in C-L."³²

From the above accreditation requirements review, we see the evolution of C-L training guidelines. These essentials have moved away from content to more general structural elements of training, although there are still few specifics to guide C-L training directors beyond the 1994 requirement of a two month minimum experience.

The Academy of Psychosomatic Medicine appointed a Task Force in 1992, consisting of 11 Consultation-Liaison training directors, to develop guidelines for C-L training in general psychiatry residency programs. The task force surveyed C-L training directors from all 196 U.S. accredited psychiatry programs assessing current C-L training practices as well as recommendations for programmatic changes. This survey, the results of which are reported elsewhere,12 helped in establishing consensus guidelines. In addition, several other groups, including the Association for Academic Psychiatry, American Association of Directors of Residency Training Programs, and the membership of A.P.M., provided invaluable feedback during the review process.

The Academy and its Task Force would like to emphasize that these are training guidelines and not requirements. We acknowledge that programs exist in a wide variety of settings which affect how clinical services and training are accomplished. Despite this, we believe there are minimal guidelines applicable to all training settings. We hope that the establishment of guidelines will encourage communication and consistency between programs as well as support C-L training directors within their own institutions.

The Task Force would like to thank the following individuals for their help and guidance on this project: Michael K. Popkin, MD; Thomas N. Wise, MD; and John Hayes, MD, for their direction and encouragement while serving as A.P.M. presidents; Steven A. Cole, MD; Linda G. Peterson, MD; and Stephen M. Saravay, MD, for their council and support.

The primary goal of the C-L psychiatry core rotation is to insure that residents develop a basic competence in working with patients in inpatient and ambulatory medical settings who have psychiatric presentations. To achieve this goal, it is essential for programs:

1. To expose residents to a wide range of neuropsychiatric presentations in medical and surgical patients.
2. To teach concise interviewing skills and rapid differential diagnostic formulation.
3. To examine the impact of illness, hospitalization and medical care on the psychological functioning of patients.
4. To educate residents about the role of psychiatric, psychological, and behavioral factors in the pathogenesis of medical disorders.
5. To increase residents fund of knowledge in C-L psychiatry through didactics, including case conferences, teaching rounds, literature review, and formal lectures.
6. To promote liaison relationships with medical and surgical services, with a particular focus on Primary Care, that emphasize awareness, assessment, and management of mental disorders in medical patients.
7. To demonstrate appropriate approaches to the execution of a psychiatric consultation, with emphasis on assessment techniques unique to the consultation setting, the nature of communication with the consulted and the responsibilities and limitations of the consultant role.
8. To demonstrate a variety of interventions and therapies relevant to medically ill patients, including time-effective psychotherapy, somatic therapies, behavioral techniques, liaison methods, and multidisciplinary team approaches.

Upon completion of their core Consultation-Liaison Psychiatry rotation, residents should be able to demonstrate the capacity to:

1. Consultation-Liaison Process
   1. Engage in effective interactions with a variety of consultees, including determination of consultation questions, and reporting of findings and recommendations.
   2. Gather data from appropriate sources, including chart, hospital staff, family, and other relevant individuals.
   3. Write a pertinent and useful consultation note.
   4. Monitor the patient's course during hospitalization and provide continuing input as needed.
2. Examination Skills
   1. Interview medically ill patients in a variate of settings.
   2. Quickly develop a therapeutic alliance with medically ill patients.
   3. Evaluate for psychopathologic processes in patients with concomitant medical and surgical conditions.
   4. Evaluate cognitive ability in medically ill patients.
3. Therapeutic Interventions
   1. Advise and guide consultees about the role of the medical disease and medications in the patient's presenting symptoms.
   2. Understand the indications for a variety of somatic therapies in medical and surgical patients.
   3. Understand the use of psychotropic medications and ECT in medical/surgical patients, and appreciate physiological effects, contraindications, drug interactions, and dosing concerns.
   4. Understand the use of non-organic treatments, including brief psychotherapy, behavioral management techniques, family therapy, and psychoeducation.
   5. Work as a member of a multidisciplinary staff to maximize the care of complex medically ill patients.

Training rotations should provide teaching on a variety of topics pertinent to Consultation- Liaison Psychiatry. This may be accomplished by a variety of didactic methods, including case conferences teaching rounds, literature reviews, reading lists, and formal lectures. Each topic is categorized by relative importance, as follows:

Topic is considered essential knowledge for all general psychiatrists and should be covered during the C-L rotation in every program.

Acute Stress Disorders
Aggression/Impulsivity
AIDS/HIV Disease
Alcohol and Drug Abuse in the General Medical Setting (including withdrawal states)
Anxiety in the General Medical Setting
Determination of Capacity and other Forensic Issues in C-L Psychiatry
Coping with Illness
Death, Dying, and Bereavement
Delirium/Agitation
Dementia in the General Medical Setting
Depression in the General Medical Setting
Factitious Disorders and Malingering
Pain
Personality Disorders in the General Medical Setting
Psychiatric Manifestations of Medical and Neurologic Illness
Psychological Factors Affecting Medical Conditions
Psycho-Oncology
Psychopharmacology of the Medically 111 (including drug interactions)
Psychotherapy of the Medically Ill
Somatoform Disorders
Suicide

Category 2

Topic is considered valuable for general psychiatrists. Provision of teaching in these additional topics may require resources beyond those available in some programs or occur in other parts of the residency. However, C-L rotations should attempt to provide residents with this level of didactic material.

Psychiatric Sequelae in Burn Patients
Behavioral Medicine
Eating Disorders
ECT on the C-L Service
History of C-L Psychiatry
Hypnosis in the General Medical Setting
Psychiatric Presentations in Intensive Care Units
Management in Medical Settings of Sexually Abused Patients
Management in Medical Settings of Issues Related to Pregnancy
Management in Medical Settings of Post-Traumatic Stress Disorder
Pediatric C-L
Psychological/Neuropsychological Testing in the General Medical Setting
Transplantation Psychiatry

Category 3

Topic is considered advanced. Though the topic might be important for training at the C-L fellowship level, it is considered above and beyond the level necessary for all general psychiatrists to master. Topic may appropriately be offered to general psychiatry residents by ambitious C-L programs, provided material from Categories 1 and 2 is covered in depth.

Research in C-L Psychiatry
Ethics in C-L Psychiatry
Setting Up a C-L Service
C-L Psychiatry Administration

The C-L experience should be of sufficient intensity for the resident to master the goals and objectives identified above. A rotation that is too brief will not allow for development of this broad expertise. A rotation that is long in duration but limited in frequency (e.g., one day per week for one year, or several one-month blocks) interferes with continuity of care and with exposure to the activities of one's medical colleagues. C-L training is maximized when it is the primary focus of the resident, and other responsibilities should be kept to a minimum. This "block" model will best meet the goals of comprehensive teaching, continuity of care, and a broad-based consultation experience. Based on these considerations, the minimum rotation should be no less than a 3 month full time equivalent, and no less frequent than half-time (20 hours/week). The ideal rotation would be a full time "block" of four to six months in duration. Programs that train residents on a part-time, "longitudinal" basis should schedule formal teaching activities regularly and in a way that won't conflict with other responsibilities. In these cases some provision for patient coverage should be provided when residents are not available.

There is likely a minimum number of new consultations for the psychiatry resident to see to develop the necessary skills in C-L psychiatry. While each program varies in the intensity and depth of consultations, it is felt that approximately 50 consultations during the rotation would serve this function. An ideal of 100 consults allows ample training and sufficient variety of cases. Services that have residents see over 150 consults during a rotation may sacrifice training for service. Consultations should provide the resident with exposure to the widest variety of general hospital medical-surgical patients. The variety of these consults will depend on the nature of the training center. As consultation and liaison in primary care settings has become an important aspect of C-L psychiatry, exposure in this area is strongly encouraged. It is also recommended that some experience be gained in each of the following specialty areas: Forensics; Geriatrics; Intensive Care; Oncology; Ob/Gyn; Transplantation; and AIDS. Neuropsychiatric instruction should also occur here if not done as a separate rotation. Broad exposure is particularly important for programs utilizing specialty hospitals as primary teaching centers (e.g., Veteran's hospitals and oncology centers).

1. Year of Rotation

Because of the complexity of consultation and liaison activities with medically ill populations, the C-L rotation is best covered by the most experienced residents available. While the fourth year resident has the most experience, many programs opt for the third year to allow residents to begin fellowship programs during the fourth year. C-L rotations in the second year may best accommodate the block arrangement, but resident training may be compromised due to a lack of experience. Adequate provision must be made to guarantee that second year residents receive full supervision by faculty for all cases. To ensure that the resident of any year is properly prepared for the service rotations in neurology, inpatient psychiatry emergency psychiatry, and chemical dependence ideally should be completed prior to the C-L rotation.

2. Setting

The clinical facilities should provide exposure to a broad range of patients. In order to provide adequate exposure to the most severe medical/psychiatric problems and complex liaison activities, the principal training site should be the general medical hospital. A variety of "specialty" hospitals (e.g., cancer or transplant centers) will usually provide an equal experience.

Liaison activities will enhance the overall C-L experience and improve understanding of the C-L process. The resident may be assigned to a specialty unit to engage in an intensive liaison experience. There should be sufficient availability of specialty areas that may include, but are not limited to, forensics, geriatrics, intensive care, oncology, ob/gyn, transplant, AIDS, and neuropsychiatry. Ideally this time should be spent with one medical or surgical service for the duration of the rotation to allow for maximum integration of the psychiatrist with the service. While ideal, such a liaison experience is not a training requirement.

An outpatient C-L experience is encouraged because it offers exposure to a different population of medical/psychiatric patients. It also more closely reflects the practice of psychiatry that most residents will have after graduation. This is particularly true with the current emphasis on primary care, and involvement with an ambulatory primary care clinic may become increasingly valuable. Ideally residents should be able to follow the same patients seen in an inpatient setting after discharge from the hospital, ensuring continuity of care. Outpatient training could be provided in any of the following areas: Liaison to outpatient settings (e.g., primary care clinic); Consultation to specific patient populations (e.g., outpatient transplant evaluations); Outpatient consultation-liaison clinics (in which residents evaluate and treat a variety of psychiatric problems in the medically ill). Both the liaison and outpatient experiences should be offered only if there is adequate faculty involvement to provide supervision and an opportunity for learning.

Programs that combine the C-L and emergency psychiatry services into a single rotation should strive to integrate the two services as much as possible. Combined services should continue to apply the C-L guidelines established here. While some patients seen in the emergency service will have also medical/surgical illnesses, the emergency service should not be the principal site for the C-L rotation.

Faculty of the C-L service should be certified by the American Board of Psychiatry and Neurology and have specific expertise in C-L psychiatry. Ideally, faculty should have completed a C-L fellowship, or a combined medical-psychiatric residency, but extensive clinical experience is acceptable. This standard is particularly important for the chief of the service. It is preferable that residents be taught by more than one C-L faculty member to enhance their understanding of different approaches to C-L psychiatry.

Ideally, faculty should be "on service" for a block of time and responsible for all aspects of the service. This arrangement will provide the most comprehensive supervision and ensure continuity of care. A core faculty who rotate on a daily basis is acceptable, if under the supervision of a clinical director who coordinates the service in a cohesive fashion. Utilization of faculty on a part-time and/or rotating basis is not an acceptable alternative unless the program is under the direct full-time direction of a physician who assumes responsibility for all aspects of care within the division. The number of faculty will vary by service requirements, but must be sufficient to provide this level of coverage, and provide for adequate supervision of residents. Typically, this should be a minimum of one full-time equivalent faculty member for 1.5 - 2 full- time equivalent residents. The addition of other trainees such as medical students and psychology interns will further increase the need for faculty.

The following guidelines are suggested for resident supervision/education during the Consultation-Liaison rotation:

1. In the early part of each resident rotation the resident should observe the attending and perform all the elements of a clinical consultation. This may occur over several supervisory sessions and include a preliminary discussion with the consultee and other clinical staff regarding the reason for consultation, a full chart review, the clinical interview, history from outside sources, a follow-up discussion with the consultee, and the written consultation and follow-up chart note.
2. Attending psychiatrists should have the opportunity to observe the resident complete an entire initial consultation, providing the resident with appropriate feedback as part of the process.
3. An attending should have the opportunity to observe the resident complete parts of the consultation process. Emphasis should be placed on supervising the ongoing management of patients in the hospital, not just the initial consult.

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