Ugh -- "Can I eat over here or over there?"

[Doctor Bagel]

Too snarky to put down as a chief complaint? I'm seriously hating life right now on call, re-admitting a bunch of people I discharged last week for "suicidal ideation" and "depression." Last guy was smiling and asked me the question above about where he'd get his dinner, the ED or the psych unit.

No wonder no one wants to do inpatient psychiatry. Yikes! Any tips to make this experience less miserable. And reassurances that I won't have to do this the rest of my life would also be nice.

And for disclaimer, I do dream of a world where these folks would have access to housing, jobs, food and inpatient rehab. It's just frustrating to admit a bunch of non-psych patients to the psych unit over and over again, especially when they're the same freaking people. And when we're not really going to get them set up with the stuff they really need because it's not there anyway.

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[atsai3]

Too snarky to put down as a chief complaint? I'm seriously hating life right now on call, re-admitting a bunch of people I discharged last week for "suicidal ideation" and "depression." Last guy was smiling and asked me the question above about where he'd get his dinner, the ED or the psych unit.

No wonder no one wants to do inpatient psychiatry. Yikes!

And for disclaimer, I do dream of a world where these folks would have access to housing, jobs, food and inpatient rehab. It's just frustrating to admit a bunch of non-psych patients to the psych unit over and over again, especially when they're the same freaking people.

If your clinical judgment is telling you that you can provide the patient with a reasonable alternative to hospitalization, and your documentation is such that ordinary and reasonable peers would agree that they would have provided similar care, then why not do what your clinical judgment is telling you to do?

-AT.

 

[NJWxMan]

I'm assuming that you don't have a psych. ED. Forcing malingerers to wait and wait until they finally contract for safety is one of the major advantages of a psych. ED. We do it all the time. "Ok. You were here two weeks ago. You aren't psychotic and you aren't depressed. So, you will stay down here for the next two days until you aren't suicidal." Some of my attendings are a bit more courageous and will discharge these folks without a second thought.

BTW, in my center city program, we would put that down as a chief complain because it allows us to document the severity of malingering.

 

[sunlioness]

It's hard to do that when you don't have a psych ED or at least a little psych section of a medical ED. ED people start breathing down your neck after a while. It's very frustrating.

One Flew Over the Cuckoo's Nest is on TV right now. I haven't seen this movie since I was in high school probably. I had forgotten that Jack Nicholson got admitted to that hospital because he was malingering to get out of a prison work detail. Kinda funny given the number of "suicidal" people who came into the ED last week who just coincidentally had a court date or a warrant out for their arrest that they somehow neglected to mention.

 

[Doctor Bagel]

If your clinical judgment is telling you that you can provide the patient with a reasonable alternative to hospitalization, and your documentation is such that ordinary and reasonable peers would agree that they would have provided similar care, then why not do what your clinical judgment is telling you to do?

-AT.

We don't make the decision on whether or not to admit for our university ward. The ED docs do that here. We make the decision in the VA, but it's still not so easy because these people all know how to play the game. Can you send people out if they're endorsing active suicidal ideation? I don't think my attendings would back me on that one.

Now a bigger discussion about the liability inherent in sending these people out would be interesting. Our culture here is pretty conservative in that admission is usually the default. Saying you want to kill yourself while smiling and asking for chocolate cake (true example) meets the admission criteria in my world.

 

[Doctor Bagel]

It's hard to do that when you don't have a psych ED or at least a little psych section of a medical ED. ED people start breathing down your neck after a while. It's very frustrating.

And that's the problem with the VA. We decide whether to admit or not, but there's no place for people to go other than to the ward or out. It doesn't give you a lot of options, especially with people who are intoxicated and voicing SI or it's 2 am and you really can't set up other plans (social work isn't there late, either).

On the malingering note, we've got a patient right now who came to the ED making suicidal statements in a desire to get more pain medications. She wound up getting a hold slapped on her, and now she's in the psych unit with no more pain meds. I guess it can burn you. That's not as bad as getting a labotomy, though.

 

[whopper]

Too snarky to put down as a chief complaint? I'm seriously hating life right now on call, re-admitting a bunch of people I discharged last week for "suicidal ideation" and "depression." Last guy was smiling and asked me the question above about where he'd get his dinner, the ED or the psych unit.

All at a cost of $1500 a day to the taxpayer!

Exactly what I went through in residency. It's interesting. It looks like malingering, it smells like malingering, the patient even says it's malingering (sometimes), and then you got to deal with an attending that writes down "Major depressive disorder" priming the patient to be readmitted whenever they want because now the ER doctor/psychiatry ER doctor will check the record when the patient comes back with his future bullspit claim of being suicidal and sees that diagnosis on the discharge summary.

 

[Sneezing]

Every time I do the admission and its nothing more than malingering I'll get itchy for fast discharge. I'm routinely told to ease up and observe for a day. 1 day gives physician, nursing, and various others 'evidence' that the person is in behavioral control and not really suicidal. I still like to day dream that if I were an attending I would discharge as soon as they hit the unit.

Insurance companies don't pay for malingering... which sadly loosens diagnostic criteria. Just another reason why medicaid is going to bankrupt our country. One malingerer at a time.

 

[Doctor Bagel]

Just bought tickets to the see One Flew Over the Cuckoo's Nest live! It does seem appropriate for my life right now.

You know, about documentation, I try to have my discharge summaries detail reasons why we should be cautious before re-admitting these patients. Of course, I also put in an Axis I code of some BS thing like depression NOS or substance induced mood disorder, for billing purposes. I think we're kind of in a bind on that one, too.

We had this borderline pt at the VA who was admitted 4 times in like 3 weeks. At one of her admissions, I did this really thorough documentation of why we discharged her even though she was still expressing SI and why admission is problematic. She came back that night, and the SW on staff sent her out, which was awesome. Unfortunately, she went to see her outpatient provider early the next week and immediately came back our way.

Now another catch with sending people out early is hospital holds. We have a departmental policy of neither dropping holds ourselves or recommending that other departments drop holds. The ED has a pretty low threshold for places patients on hospital holds. So we wind up stuck with those people for a while.

 

[gbv]

So, are there not Psychiatry residents who rotate through the ER to take ER psych consults and make the final decision? Or do the ER docs do ALL of the decision-making as far as who gets admitted?

Sorry, you may have already answered this above but I just skimmed the rest of the posts in this thread.

 

[Red Beard]

Your situation sounds really annoying, not that we don't have a lot of bounce-backs at our program but it is ALWAYS a psych resident or attending that decides to admit or discharge a patient from the ED at all of our hospitals.

That being said, only something like 3% of psychiatrists are practicing in the inpatient setting. There must be a reason.

 

[Doctor Bagel]

So, are there not Psychiatry residents who rotate through the ER to take ER psych consults and make the final decision? Or do the ER docs do ALL of the decision-making as far as who gets admitted?

Sorry, you may have already answered this above but I just skimmed the rest of the posts in this thread.

As Red Beard pointed out, it varies. We make the decisions in our VA system (although that's probably going to change next year due to service issues/work hour changes). The ED docs make the decision in our university system. Don't really know why it worked out that way. In a way, them making the decision makes call easier, although sometimes more frustrating because I just admit people -- it's pretty simple. In the VA system, I feel like I am engaged in what some other poster here described in another thread as a game of keeping the psychopaths out of the unit. Honestly, I don't really like either.

It's sort of unfortunate that we spend our first two years doing all this stuff that most psychiatrists choose not to do. I try to have a big picture perspective and realize this isn't my whole life, but it still occasionally makes me doubt my specialty selection. I like inpatient psychiatry more than inpatient internal medicine or inpatient neurology, but I can't say I actually like it most of the time, especially not the call stuff.

Anyway, sorry for venting. I'm thinking I'm feeling a little more negative about this whole situation knowing that next year is going to be a lot more of the same just with more call. Stupid ACGME changes.

 

[Red Beard]

People have actually looked at morale over the course of residency and we are smack-dab in the middle of the morale nadir. Supposedly things start slowly but steadily improving around the beginning of the fourth quarter of inter year.

 

[Doctor Bagel]

People have actually looked at morale over the course of residency and we are smack-dab in the middle of the morale nadir. Supposedly things start slowly but steadily improving around the beginning of the fourth quarter of inter year.

I can believe that, because, yeah, this whole month has just been hard. I'm sure the season/crappy weather isn't helping. And as mentioned above, not feeling like year will be better (and actually believing it will be worse) makes it even harder. Hmm, so my morale should improve right about when I start doing IM wards again.

 

[gbv]

We make the decisions in our VA system (although that's probably going to change next year due to service issues/work hour changes). The ED docs make the decision in our university system. Don't really know why it worked out that way.

Ok, I see. Interesting method, but then every program is different I suppose.

 

[Cinnameg]

Just bought tickets to the see One Flew Over the Cuckoo's Nest live!

OMG, where???

 

[whopper]

So, are there not Psychiatry residents who rotate through the ER to take ER psych consults and make the final decision? Or do the ER docs do ALL of the decision-making as far as who gets admitted?

Depends on the ER and the way it's set up in the locality. Where I've worked, there's a crisis center, either in an ER or directly attached to it. While a psychiatrist works in that center who decides if the person is to be admitted or discharged.

But there are complicating factors. E.g. sometimes a patient shows up to an ER other the one mentioned above, and asks the crisis center to send someone to evaluate the patient. That E.R. doctor may have already written involuntary commitment papers or other statements that pretty much force the psychiatrist to admit the patient, some of which may not be accurate.

 

[gbv]

Depends on the ER and the way it's set up in the locality...

I was inquring about her particular program.

 

[Doctor Bagel]

OMG, where???

Portland Center Stage -- it's showing all of March.

 

[Cinnameg]

Portland Center Stage -- it's showing all of March.

Thank you Dr. Bagel! We still have wedding gift certificates to use there, I think. Even though it's a pretty anti-psychiatry story it still was career-inspirational for me, along with "Girl, Interrupted" (the book) and "An Unquiet Mind."

 

[whopper]

Every time I do the admission and its nothing more than malingering I'll get itchy for fast discharge.

Psychiatric misdiagnosis unfortunately is not out of the ordinary in a one time assessment, and that often is the case in an ER.

The best way to handle this is for every doctor on board the treatment, from the admitting doctor, to the inpatient doctor, and outpatient doctor to coordinate together on this.

Often times, patients who are malingering require state-supported services. Many hospital systems offer inpatient and outpatient treatment all under the same umbrella and they can coordinate this effort better.

But the reality, as evidenced by what I saw in residency (and several other places) is only one of the doctors in the chain if any (the ER psychiatrist, the inpatient psychiatrist, and the outpatient psychiatrist) actually gives a damn about calling out the malingerers, and the other two doctors are noncooperative with whatever happens. They are not willing to put in the extra effort. They are merely only concerned about their own end in the big scheme. E.g. putting in the dx of Depressive DO NOS when the inpatient doctor doesn't even believe the patient was depressed.

Often times administration are in a position where they have a hard time finding any psychiatrist to fill a position so they have to make due with the attendings they got, even if those attendings are lousy.

 

[DD214_DOC]

In my program, we are not allowed to refuse consults. The ED docs are happy about this and routinely dump ANYTHING psych related onto us.

I am getting really tired of the 2AM calls from the ED doc who says, "I have a patient down here that I don't have any safety concerns for and he's not manic or psychotic (so why are you calling me???) but he says he's a little sad and wants someone to talk to". WHY OH WHY can't I just tell them to schedule an outpatient f/u for the AM???? Or just tell the pt to call his mom??

We get all of the malingerers too, probably more so in a .mil program. It's so blatantly obvious most of the time. We even get collateral information from the patient's NCOs and commanders stating he's been fine. Sometimes they even say they just want out. Yet we are forced to admit them because nobody wants to "risk" it. Ugh. The best part is that when we get a call from an outside facility for transfer of a REAL psych patient (such as a psychotic guy unresponsive to everything) we can't take him because the ward is full of people who didn't realize joining the military meant they might have to go to war.

 

[NJWxMan]

That's really too bad. That's why it's so important to train an institute where the Department of Psychiatry is respected and not abused. Where I train, psychiatrists are not utilized in the med ER; however, if the ER attending has concerns, they will simply dump the pt into the psych ER. Outside of a mild suicide attempt (50/50 admit vs. discharge), a psychotic pt that presented initially for medical care (typical admit), majority of patients are rightfully discharged. For consults on the med/surg floors, residents are able to kindly challenge the various services when lethality is not an issue and when the service does not have a specific question ("This person was on seroquel a year ago but has been off all meds and we think NOW they should be back on them because they're harrassing staff."-->Bad consult).

 

[whopper]

That's really too bad. That's why it's so important to train an institute where the Department of Psychiatry is respected and not abused

I'm sure it's better in some places vs. others. The word I got from one of my attendings while in residency was that EVERYWHERE was like this in training. The guy worked at some top places like NYU, Dartmouth, U Penn, and he told me this happened everywhere.

He was not at all of the places within the last few years so maybe some things are different now. While I was at AAPL, I asked all the other fellows if the same thing happened where they were...they all said yes.

While I was in residency, typically over 50% of the consults were inappropriate to the point where the attending shouldn't have even ordered it, and they should've known that (e.g. the patient is upset because his football team lost). Of the rest, about 50% were still inappropriate but I could see why someone would've thought the psych consult would've been needed or could have helped (e.g. the patient was depressed about a year ago, not now, and told doctor about it). The rest I thought were actually in need of a psychiatry consult.

I did bring this up the chain of command while in residency, but at that time, the program didn't seem to give a hoot. The problem was compounded my fourth year because NJ passed a law requiring that all women who delivered had to have an Edinburgh Depression Scale performed on them. The nurses in the delivery unit, if they ever got a non-English speaking patient wouldn't get an interpreter like they were supposed to do. Instead they directed the woman to write down every single answer suggesting they were suicidal that in turn demanded a psychiatry consult with the woman not even knowing what she was answering. In short, my fourth year, daily, residents had to deal with about 1-3 bogus delivery consults of the above nature.

I brought it up the chain, no one gave a hoot. In fact it got to the point where I noticed that no one was caring to the point where I felt if I took matters in my own hands, no one would still care. So when the residents on consult duty told me this happened, I told them to call me. I'd told the resident to write "Not appropriate for consult until the Edinburgh scale is done with an interpreter."

This in turn upset the Ob-Gyn dept. I told the residents if there was a complaint for the dept to call the Chief Resident (me at that time). I told the Ob-Gyn attendings that the NJ patient rights demanded that a patient that doesn't speak English be provided a translator and that I wouldnt' have residents perform duties that were supposed to be fulfilled by nurses.

So then I expected one of two things. The Ob-Gyn dept would either acquiesce or they would have to call my direct superior (an attending that at the time wasn't doing jack, and things would stay the same--in my favor). If they weren't happy with my superior's response, they would have to take it up with the head of the dept. The head by the way IMHO was doing a good job but due to an administrative emergency was handling two full-time positions, and I knew that head would've backed me up. A reason why my direct superior wasn't doing jack. He was trying to exploit the fact that the head wouldn't fire him but didn't have enough time to get on his butt. Another factor going for me was that I knew for a fact that several key people in the hospital actually had more respect for me than the attending directly above me. If that attending wanted to back out of his responsibilities again, it would've only looked bad for him and good for me.

Things worked out. I had to play hardball. It worked that time. I do not recommend any resident do the above. Do not challenge attendings. Only bring up the issue to your attending, and if you feel the response is not appropriate, then bring it further up the department in a manner where you will be listened. Challenging attendings is like David v. Goliath minus having a sling. My situation was different because I knew a little of what was going on behind the scenes from the head of the dept. herself and the head's secretary.

Hospital politics are like this, and this is everywhere.

 

[Doctor Bagel]

Jeez, I hate this stuff. I don't know if it's good or bad to hear that this happens everywhere. I guess I was partially sheltered because my medical school's residency was pretty darn protective of the residents. In fact, the C/L service only operated from 8 to 5 on weekdays. No weekends or nights. Sure, some of the consults were bogus, but bogus consults are a lot easier to take when they're not at 2 am. And the medical director of the inpatient unit there was pretty proactive in refusing problem patients. If a pt had been there before and had not followed up with his outpatient plan, they'd get refused admission. It was pretty awesome.

 

[whopper]

The biggest reason where I did my training, IMHO, as to why the problem persisted is because it was the resident, not the attending that had to suffer from bogus consults. Residents are often too eager to please and attendings often too eager to exploit residents.

IMHO, a little exposure to this type of stuff is actually good. Politics like this goes on in hospitals. It's better to learn about these things as a resident than as an attending and not know how to deal with it.

But that's only up to a certain point. You learn the lesson after about a month of the bogus consults. After that it's just pain with no learning.

I did learn that if you want the problem fixed and are willing to work in a cooperative manner with other departments, often times it can be fixed with everyone being happier. I did that with the IM dept on several issues. (A reason why I knew if the problem attending I mentioned above would try to give me crap, I had backing. The IM dept tried to have him fix things that would've improved relations with psychiatry and IM but he blew them off. I worked with the IM dept on the things they wanted fixed and they and the GME were very happy with me).

 

[DD214_DOC]

The biggest reason where I did my training, IMHO, as to why the problem persisted is because it was the resident, not the attending that had to suffer from bogus consults. Residents are often too eager to please and attendings often too eager to exploit residents.

IMHO, a little exposure to this type of stuff is actually good. Politics like this goes on in hospitals. It's better to learn about these things as a resident than as an attending and not know how to deal with it.

But that's only up to a certain point. You learn the lesson after about a month of the bogus consults. After that it's just pain with no learning.

I did learn that if you want the problem fixed and are willing to work in a cooperative manner with other departments, often times it can be fixed with everyone being happier. I did that with the IM dept on several issues. (A reason why I knew if the problem attending I mentioned above would try to give me crap, I had backing. The IM dept tried to have him fix things that would've improved relations with psychiatry and IM but he blew them off. I worked with the IM dept on the things they wanted fixed and they and the GME were very happy with me).

This is the issue. Bogus consults don't matter to attendings, they're not the ones who have to do them.

 

[whopper]

Someone PM'd me so I'll clarify to everyone just in case.

Chain of command: No I didn't train in a military residency, but like the military, there should be a chain by which communication goes up or own. Of course it's going to vary depending on the residency and the specific situation. E.g. kinda like this.

Head of dept
|
Program Director
|
Specific Attending in charge of rotation
|
Chief Resident
|
Senior Resident
|
Junior Resident



A junior resident having a concern could bring it first with a senior resident if one is present. If not, then to the Chief or attending.

 

[Sophie]

Wow, that seriously sucks. Our ED docs are almost all really good about only calling us for truly necessary consults. We don't have a PES, but we do make the decision on whether a patient is admitted or discharged. Sometimes it can be tough to get malingerers out, but the head of our inpatient unit will advise us to d/c people (after discussing them with him first, of course) if we're sure they're malingering (eg they have a h/o admissions and abusing the system), even if they're saying they're suicidal. If the ED isn't too slammed, they'll stick our drunkicidal/methicidal/etc patients in a hallway bed to let them sober up and be reevaluated, but I agree - my med school had a PES and it was way easier to deal with malingerers when psych had control of the ED.

 

[DrStinky]

Sounds like the story of my program!