Consultation-Liaison Psychiatry with a Fellowship Director

Session 172

Dr. Anique Forrester is the Consultation-Liaison Psychiatry Fellowship Program Director at UM SOM. She shares what makes a competitive applicant, talks about lifestyle, and more! To know more about this specialty, check out the Academy of Consultation-Liaison Psychiatry.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:31] Interest in Consultation-Liaison Psychiatry

Anique wanted to do an elective rotation in child psychiatry, but it was full for the month that she wanted to do it. And the only thing available was the consultation rotation. So she did the rotation and loved it, and have never veered away from it since her fourth year of medical school. It was a happy accident.

What drew her to the specialty was the acuity of the work. She knows her mind does better and adapts better when things move quickly, versus something really slow. The other reason that drew her to the specialty was that her mentors modeled the type of career she wanted.

“Consultation psychiatry is a psychiatric care of people who are medically ill.” Click To Tweet

Usually, the medical hospitalization is a finite period of time. But there are aspects in the consultation-liaison that especially occur in the outpatient. So you can have long term relationships in that aspect of consultation.

[05:07] The Biggest Myths or Misconceptions Around Consultation-Liaison Psychiatry

One of the biggest things about Consultation-Liaison (CL) that challenges residents is that it is so changeable and variable. You can have a really busy day one day and then you come in and you have maybe one consultation the whole day. And that’s a challenge for trainees because, at that level, they really like predictability. They like to know what they’re doing every single day. And because of that, one of the myths about CL is that it’s always going to be busy.

Anique explains both consultation-liaison psychiatry and hospitalist psychiatry work in a similar way, only that they have this additional layer where they have to maintain relationships in a different way with the other medical specialties.

Another myth is that psychiatrists will always have the answers. And that if there’s a problem or difficult behavior with a patient, people can just call the psychiatrist. And Anique explains that they have to maintain different levels of relationships with the folks who tend to call them because that’s how they stay in business. But also, so they can help move the care forward for patients.

“One of the myths about Consultation-Liaison Psychiatry is that it’s always going to be busy.”Click To Tweet

[08:04] Traits that Make a Good Consultation-Liaison Psychiatrist

As a program director, Anique explains that when sorting out applicants, they’re looking for people who are thoughtful. They should have good communication skills. And they should have a real interest in psychiatric complications of people who have medical illnesses. And they can see through that from what applicants have done in the past, what they write about in their personal statements, to what they talk about on the interview day.

Anique adds that unless they’re seeing criminal records or something really outrageous, they’re pretty much open to many things. That being said, they’re not as focused on people’s board scores.

'People who do well in taking tests are not the best necessarily in the communication skills that I'm looking for in a CL psychiatrist.'Click To Tweet

Don’t worry though if you don’t have great communication skills. They still look at your application and the foundations within which they can build.

[11:17] What Fellowship Looks Like

Fellowship takes a year and many times, they’re getting fellows coming from outside institutions. They’re just learning how their system works, who they get consults for, etc. And then they also have their fellows go to the VA, where they do a mix of consultation doing outpatient consultation clinic. They see people short term and then return them back to their primary care providers.

And then as the year moves on, they move more into a teaching and liaison role. They’re teaching residents and medical students. Other medical specialties will ask for specific lectures from them so they involve their fellows in that. And so, by the end of the year, not only do those fellows do a lot of complicated consults, but they also know how to communicate and teach in the way that makes the most sense for their program.

[13:32] Types of Patients

There’s a finite set of things that they get consulted for in the hospital. One is delirium, which is usually a change in the person’s mental status because of their medical illness. It’s usually directly related to that, or a combination of illnesses that are acutely worse.

The second is usually a capacity evaluation, which means evaluations about an individual’s decision-making. So whether it’s to accept or refuse a proposed treatment, or to accept or refuse a disposition plan. And then just general evaluation for psychopathology or initiation of medications.

[13:39] Taking Calls

Their program doesn’t have calls because their residency training program has a call system. The residents are on call so they would handle emergency consults, or follow up consultations that are being asked for overnight, or on the weekends if there’s an acute problem.

“The residents are on call.”Click To Tweet

[14:25] How Competitive is Matching into the Residency

Child psychiatry is obviously the most competitive specialty because it has the most level of interest. There’s usually a significant financial difference between somebody who’s done child training or somebody who hasn’t. CL is in the middle.

“CL is a specialty choice by which the people who want to do the fellowship are self-selected.”Click To Tweet

Students who apply to CL are very motivated to do CL because they like the nature of the work, not because they see this huge financial gain from having the fellowship. So they’re really relying on the people that really want to learn how to do CL.

Usually, in the pediatric subspecialties of almost every field, the financial reimbursements are less than the adult counterparts. But it’s different for child psychiatry because there’s a significant shortage of child psychiatrists across the country. So the compensation has increased in response to the shortage.

To be a potential competitive applicant, you should obviously go above and beyond the basic requirements in CL. Most psychiatry residency programs require residents to do at least two months of CL. So what they want to see is if you’ve gone beyond just those two months.

“Most psychiatry residency programs require residents to do at least two months of CL.”Click To Tweet

They also want to see whether you’ve done some experiences that are at the level. Anique would want to see like a more senior resident that has done CL, maybe in their PGY-4 year. She wants to know if they’ve started the process of getting to know the specialty. This means coming to the Academy of Consultation-Liaison Psychiatry (ACLP) annual meeting or they’ve maybe done some individual work with CL psychiatrists practicing in their programs

They just want to see whether the interest in the investment is real. And that they’ve made some attempts to get to know the specialty outside of the core requirements.

[17:24] Opportunities for Premeds and Medical Students

If you’re premed and you shadow somebody, maybe reach out to a CL psychiatrist in a hospital by which you have some affiliation or who is in your area.

In the preclinical years, it depends on the medical school. For example, the University of Maryland has a program where medical students in their first or second year, who are interested in psychiatry, can get accelerated opportunities to work with different psychiatrists over the course of those two years. So those are usually the pathways by which students get exposed to see just because they’re not primarily hospital-based.

[18:25] Message to Future Primary Care Physicians

'Let people be comfortable with the notion that mental health is an essential part of the overall treatment of any patient.'Click To Tweet

Anique says it’s good from an early stage to not separate people’s mental health issues from their physical health issues.

One of the things she tries to stress in the students she works with is that if you’re in a primary care setting, and a patient has a primary psychiatric illness, do not think of them as a psych patient. Because she sees that a lot in the hospital.

Essentially, you have to get familiar with the language. Take time to understand how a psychiatrist would manage that patient. Get the help you need. And really continue to take ownership of the care of a patient who has mental health issues.

[19:48] What She Wished She Knew That She Knows Now About the Field

One of the biggest lessons Anique learned is the importance of relationships. The relationship is so essential to understanding how other medical specialists will receive what she’s saying.

'You have to know how to manage relationships in order to be effective.'Click To Tweet

Anique adds that it takes time to build trust. They have an Integrative Care Initiative, which is a proactive consultation model. They meet with the teams on their interdisciplinary rounds, the primary medicine teams, and just meet with them every day. And they just build relationships where they get to know each other and get people comfortable with what they do.

There’s some continuous reeducation that happens as it’s the nature of academic medicine. But just being there, being around them answering questions, and demystifying some things have really helped.

[23:11] The Most and Least Liked Things

Anique likes the puzzle of bringing together and the puzzle of what’s happening with the patient. She also loves the part where she’s helping another team to take care of a patient.

On the flip side, the hardest thing for her is when she had done all the work and had put the puzzle together and given a wonderful recommendation. Then the person consulting them wouldn’t do it. And Anique admits this is a daily evolution for her.

[25:46] Major Future Changes in the Field

'Medicine, as a whole, is moving much more towards collaborative care.'Click To Tweet

COVID has shown us that telemedicine is the future. At a certain point, they’re probably going to be doing a lot more telemedicine than they have at any point in the past. And so the field could be moving to a more collaborative care system. You have a multidisciplinary team taking care of a patient.

Again, almost every patient is going to have some mental health or emotional health issues going on. So to really be in the space now where they’re more aware of that. They’re working on a team where they have a lot of different conditions and professionals that can help a patient. And Psychiatry is going to be central to that and it’s going to be much more integrated into the everyday care of patients.

[27:08] Final Words of Wisdom

If she had to do it all over again, Anique would still be a CL psychiatrist. Finally, if this is something you’re interested in, be sure to check out the Academy of Consultation-Liaison Psychiatry. They’re very open to students, residents, and fellows because they really want to embrace the next generation of CL psychiatrists.

Think about attending the annual meetings, and getting exposure to a wide swath of CL psychiatrists. Think about reaching out in your local system to see if there are any CL psychiatrists.