Dr. Jillian Evans’ narrative of her busy day as a consultation-liaison fellow in the Georgetown-Fairfax program reflects the varied experiences needed in a consultation-liaison fellowship. Her description denotes three basic elements. First, there needs to be an adequate clinical arena to provide consultative and liaison experience. The 850-bed Inova Fairfax Hospital offers this. The volume must be sufficient to gain experience in a wide variety of medical and psychiatric disorders, but not so onerous that there is not time for reading, teaching and thinking. Such consultations allow development of short-term therapy skills, crisis intervention, and sophisticated psychopharmacology. In our program, compliance with consultant’s recommendations is enhanced by the consultation fellow’s ability to write orders for medication or tests within the chart. Three important aspects of this fellowship deserve mention. First, fellows do not see self-harm or suicide patients. Skills in such evaluations must be mastered during the basic residency. In a consultation fellowship, they would take away valuable time for other clinical experiences. A second aspect of our consultation service is the ability to dictate consultations. This eases the burden of writing up notes and allows for more comprehensive consultative descriptions. Fellows also have their own offices, computers, and access to a wide variety of online library services. Finally, there is a sufficient peer group of two other fellows, residents and students to form an academic cadre of trainees to interact with the faculty. Teaching medical students and junior residents is one of the best ways a trainee can learn and prepare for future work, either in full-time academic positions or as clinical faculty.
Ongoing liaison work complements the consultative experience. This allows the fellow to gain in-depth experience. For Dr. Evans, work with the Breast Cancer Survivors Group, and the human immunodeficiency virus (HIV) Clinic, allows development of an ongoing relationship and expertise in both psycho-oncology and HIV/AIDS psychiatry, which the episode consultation does not afford.
The second element of a successful consultation fellowship is sufficient clinical supervision. As Dr. Evans notes, her supervisors vary from those with a psychodynamic perspective to others who emphasize biologic psychiatry. All attendings, however, must be able to integrate the various perspectives of psychiatry, whether the patient’s life story helps us understand their distress in a particular situation or whether biological factors should be primary foci of attention.
The final element of a successful training program is that of formal didactic forums. A variety of seminars allow the trainee to gain knowledge in the subspecialty. Research is an important elective within the fellowship. Some fellows choose to engage in ongoing research programs, whereas others develop projects during their year of fellowship. It is essential to have adequate research support in the form of medical librarians; transcription services; and statisticians who are able to both teach statistics and help the fellows analyze their data.
Dr. Evans is Associate Director, Inpatient Psychiatry, Georgetown University School of Medicine, Washinton, DC. Dr. Wise is Chairman, Department of Psychiatry, Inova Fairfax Hospital, Falls Church, VA.