‘Curbside’ Consults With Primary Care Involve Quick Response, Education

You’re the consulting psychiatrist in a collaborative care network when you receive the following telephone call from the network’s behavioral health professional: “The primary care provider wanted me to call you. We have this girl who has done well on Strattera 40 mg per day, but now her insurance company won’t pay for it so we need to try something else. She had trouble in the past with Adderall and methylphenidate. What should we do? Try Adderall again?”

As the consulting psychiatrist, what other information do you want to know? Are there any measurement tools you would suggest? What recommendations would you offer, and what kind of education would you offer to the behavioral health provider?

That’s one exercise in “curbside” consultation that psychiatrists attending the session “Effective Curbside Consultation” practiced at APA’s 2016 Annual Meeting in Atlanta. Lori Raney, M.D., chair of the APA Work Group on Integrated Care, and John Kern, M.D., director of the Regional Community Mental Health Center in Merrillville, Ind., described the essentials of curbside consultation, modeled several consultations, and then asked attending psychiatrists to practice with each other using hypothetical scenarios like the one described above.

Every consultation with primary care is an opportunity for education, they emphasized.

Curbside consultation with primary care—either directly or through a behavioral health professional who works in the primary care clinic—is an essential skill for psychiatrists participating in collaborative care networks. Psychiatrists need to be readily available to consult—within two hours of the initial request—and should be welcoming to primary care physicians who may be anxious and worried about a case.

“ ‘I’m here to help you. How can I help you?’ should be your mantra,” Raney said.

Not infrequently, primary care physicians are concerned that they are doing something wrong in a patient’s treatment. “You want to convey that you understand they are calling about something really important,” Raney said. At the same time, the curbside consultation is typically brief—3 to 6 minutes.

“It’s not a lecture. Curbside consultation boils down to how much information we can translate to the primary care physician in a short period,” Raney said. “But it’s more than merely giving someone information. It’s about educating primary care doctors about behavioral and mental health.”

Raney and Kern said the top reasons that primary care physicians call psychiatrists for consults are medication choice, diagnosis clarification, information about behavioral interventions, and general education. The top disorders that primary care physicians call about are anxiety disorders, major depression, substance use, and “difficult” patients.

Raney and Kern also emphasized that psychiatrists should be prepared to consult about all manner of behavioral issues, regardless of specialty training. “Just because you are a general psychiatrist, you can’t say, ‘I don’t do child psychiatry,’ ” Kern said. ■