Consultation and Liaison Practice
The consult question
Effective C-L work begins before the patient is seen: read the chart, identify the requesting team, and clarify the actual question. Many requests (rule out depression) mask a different need: capacity, disposition, agitation management, family conflict or staff distress. Ask what decision hinges on the answer and when it must be made. Triage urgency: agitation or violence, suicidal ideation, catatonia, withdrawal and capacity for an imminent procedure are same-day priorities; routine diagnostic questions can wait. Document the question, assessment and recommendations in a note the primary team will read, and close the loop by talking with them directly.
Communication
Recommendations should be concrete and actionable: name the drug, dose, route, target symptom, monitoring parameter and when to call you. Avoid psychodynamic formulations in the chart. Use a one-line sign-out: problem, risk, plan. Negotiate rather than dictate; the primary team retains responsibility for medical care. Address splitting explicitly by naming the team's concerns and offering a joint plan; countertransference (anger at the manipulative patient, rescue fantasies) is data about the system.
Capacity questions
Capacity is decision-specific and time-specific. Ask which decision is at hand, then assess understanding, appreciation, reasoning and expression of choice. Capacity is not a global judgment and disagreeing with your recommendation does not establish incapacity.
Trap
The commonest error is answering the wrong question, for example performing a full diagnostic assessment when the team needs a disposition or violence-risk opinion, and documenting recommendations without checking whether they were implemented.
Rule of thumb
Before you knock, establish: who asked, what decision, by when, and what happens if no one answers.