Being a Psychiatrist in the ER

[J ROD]

I have a real interest in working full time as a Psy ER doc.

I dont know that much about it and was hoping some of you all did.

Like does one need any additional training besides residency?

Also, are there good job opportunities or is it something that is not that common?

Lastly, any clue as to pay compared to what the average Psychiatrist makes would be appreciated too. I cant find any info on it. I assume it is close to the same as regular but I didnt know if it being ER related would increase salary.

Thanks to anyone who replies...........🙂

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[vistaril]

I have a real interest in working full time as a Psy ER doc.

I dont know that much about it and was hoping some of you all did.

Like does one need any additional training besides residency?

Also, are there good job opportunities or is it something that is not that common?

Lastly, any clue as to pay compared to what the average Psychiatrist makes would be appreciated too. I cant find any info on it. I assume it is close to the same as regular but I didnt know if it being ER related would increase salary.

Thanks to anyone who replies...........🙂

no, one doesnt need additional training besides residency.

It's not that common in most community settings(who is going to pay for it?). There are positions in academic hospitals/training programs which will involve some degree of ER coverage.

 

[J ROD]

We have 4 FT Psy ER docs at my home institution, which is not that big compared to other places.

And, the Psy dept says there are plenty of opportunities in doing that FT only.

I have never heard of it that much alone so I was curious. Seems like if it was that popular there would be a fellowship. Maybe it is too new since more and more Psy patients are ending up in the ER.

 

[BobA]

We have 4 FT Psy ER docs at my home institution, which is not that big compared to other places.

And, the Psy dept says there are plenty of opportunities in doing that FT only.

I have never heard of it that much alone so I was curious. Seems like if it was that popular there would be a fellowship. Maybe it is too new since more and more Psy patients are ending up in the ER.

I recently saw a job in a tough part of NYC advertised for $165/ hr for psych ER coverage in a non-academic hospital. It's definitely possible to make a career doing this in more urban centers. That seems a little high, but I don't think it included benefits

 

[vistaril]

We have 4 FT Psy ER docs at my home institution, which is not that big compared to other places.

And, the Psy dept says there are plenty of opportunities in doing that FT only.

I have never heard of it that much alone so I was curious. Seems like if it was that popular there would be a fellowship. Maybe it is too new since more and more Psy patients are ending up in the ER.

why would there be a fellowship even if something were popular?(if the skill set to do it most clearly did not require a fellowship)

Let's keep in mind where the money is coming from. Unless you're at an academic institution with a residency program(as you seem to be), you're salary is going to be generated by your billings. How much revenue you are generating. And generating revenue in a community ER as a psychiatrist is not easy. It's complicated even for patients who have medicare(and a ton wont have anything). Very very few will have private insurance.

Another thing to consider is that there are some jobs that are salaried in some states for large mental health facilities where patients are sent to directly. If you have a job in one of these places, you will be able to see many acute presentations. I don't know if you would call them an 'ER psychiatrist' since they do many different things, but they spend some time admitting patients with acute psych presentations...which is the point of the ER I guess. Tennessee has a few sites like this.

Basically though, what you see in residency on your er psychiatry rotation is NOT the real world. Always remember that when you are down there. Those patients don't need to be seen by a psychiatry resident. In the real world they are not. They are seen by you because you're a resident and you are there for cheap so why not...

 

[billypilgrim37]

Unless you're at an academic institution with a residency program(as you seem to be), you're salary is going to be generated by your billings.

While there's a lot of truth to this, you should also mention that savvy hospital administrators know that psychiatrists get less profitable patients out of the way to make room for more profitable patients. It's not direct revenue, but it's not exactly a well-kept secret that it is possible for a consult psychiatrist or an ED psychiatrist to increase revenues by getting the schizophrenic out of the bed so that an acute MI can be there instead.

 

[hamstergang]

We have 4 FT Psy ER docs at my home institution

I bet they have answers to your questions.

 

[J ROD]

I bet they have answers to your questions.

they gave me some. I also like to see what others think around the country. I dont see it being that large a market as I am being lead to believe.

I do think I can find something like that with time and effort after residency.

 

[vistaril]

While there's a lot of truth to this, you should also mention that savvy hospital administrators know that psychiatrists get less profitable patients out of the way to make room for more profitable patients. It's not direct revenue, but it's not exactly a well-kept secret that it is possible for a consult psychiatrist or an ED psychiatrist to increase revenues by getting the schizophrenic out of the bed so that an acute MI can be there instead.

some psychiatrists facilitate turnover sure. But I think it's a mistake to assume that all C-L psychiatrists are going to facilitate turnover. A very conservative one may actually extend pt stays. Regardless, I don't think most hospital administrators view it that way. Maybe some.

But all the C-L positions I looked at were not FT salaried positions but would have been a string of part time(and a large string would be required) contract positions. Maybe a mid sized community hospital would like psych consult coverage, so they just pay the psychiatrist x amount to do the first y number of consults for the term of the contract. Generally you have so many hours to do it. So a typical scenario for someone who wanted to do C-L only in a community setting would be to get 5-6 different such contracts (small and medium sized community hospitals) and just check in a couple times daily with all their different contracted hospitals. You'd obviously want to arrange how you see the consults in order so you arent driving all over the city. But that would be a hassle...I think that's why most people who do end up covering those contracts make it 20% or so of their practice and just do one contract.

The VA is one employer I can think of that sometimes does employ a FT salaried C-L person. But some VAs rotate this position and calll it crisis team.

I think fonzie was looking at possible C-L work, and he said that in his area the very large hospital systems(which maybe could support enough work for a single psych to do mostly C-L within the same system) just hires midlevels to do them.

I may do consults for a community hospital on some sort of contract in my career, but I don't anticipate it would take up more than a quarter or so of my total practice. Depending on the size of the hospital of course.

No psych is going to agree to contraqt out with a community hospital to bill the consults themselves obviously. That would be lunacy even with the best possible payer mix. But likewise, community hospitals also have leverage in that most don't have to hire a full-time salaried psychiatrist to do C-L.

 

[F0nzie]

I used to REALLY want to do Psych ER but then I realized I worked waaaayyyy harder than my colleagues.

The end result was me giving 0 hand offs to the next shift and receiving 7 new consults when I start my shift. Pretty much every single time! The bitterness and resentment became unbearable. I have even tried gently pointing out that patients have been sitting around for 6 hours without an evaluation and that I didn't appreciate getting all of the hand offs.

ER docs at our program respect each other and work hard. They do an excellent job of wrapping up their work without burdening the next shift. Psychiatry does not seem to value this. Which is why IMO, psych ER sucks. Moonlighting outside of the program was no different.

Advice to psych residents-- do your work if you want your colleagues to respect and support you. Yea, it isn't hard to land a psych residency and yea you probably don't have to work all too hard while you're in residency... maybe just enough to not get kicked out, but the relationships you build with your colleagues matter.

 

[shan564]

I liked ER psych for the first 4 weeks as a med student on an elective. Then I did a regular ER rotation, and then I did an ER elective. By the end of the third month, I'd grown quite wary of it... it seems like most patients are either "give them a B52 and admit under psych" or "treat the overdose, assess for continued suicidality, and then admit or send them home" or "hey psychiatry, can you tell us if this guy is malingering?"...

 

[SmallBird]

Basically though, what you see in residency on your er psychiatry rotation is NOT the real world.

What do you mean by this? Why are academic medical centers not part of the real world? Our residency program has dedicated psych ER's in both our academic hospital and our VA, and they service the vast majority of the patients in the area. No doubt that there are other places in the state that operate differently, but given how large a chunk of the work is managed by academic medical centers makes it seem silly to exclude them from being part of the "real world".

 

[strangeglove]

There are a couple of emergency psych fellowships in NYC, where the "real world" comprises mostly academic medical centers, especially for uninsured folks.

 

[vistaril]

What do you mean by this? Why are academic medical centers not part of the real world? Our residency program has dedicated psych ER's in both our academic hospital and our VA, and they service the vast majority of the patients in the area. No doubt that there are other places in the state that operate differently, but given how large a chunk of the work is managed by academic medical centers makes it seem silly to exclude them from being part of the "real world".

I didn't mean as disrespect....just saying that many states have just 1 psych residency in the whole state where there is a dedicated and fully staffed ER with psychiatrists in house. Obviously there are a heck of a lot more than 1 hospital in those states. And while the volume is likely higher at the academic hospital, it doesn't come close to matching the number of psych presentations at all ERs across the state. So by 'real world', I'm really referring to what goes on in the vast majority of patient encounters which are not inside the walls of an academic hospital with a psych residency program.

 

[digitlnoize]

We don't even have a dedicated psych ER at the academic medical centers around here!

We do, however provide 24h service to our own ER, as well as telemed services to some of the community hospitals.

 

[SmallBird]

I didn't mean as disrespect....just saying that many states have just 1 psych residency in the whole state where there is a dedicated and fully staffed ER with psychiatrists in house. Obviously there are a heck of a lot more than 1 hospital in those states. And while the volume is likely higher at the academic hospital, it doesn't come close to matching the number of psych presentations at all ERs across the state. So by 'real world', I'm really referring to what goes on in the vast majority of patient encounters which are not inside the walls of an academic hospital with a psych residency program.

Sure, that makes sense, and it I guess its area dependant. In Connecticut my sense is that the majority of emergency psychiatric services fall under academic centers, but I can imagine this is not the case for a lot of places.

 

[vistaril]

Sure, that makes sense, and it I guess its area dependant. In Connecticut my sense is that the majority of emergency psychiatric services fall under academic centers, but I can imagine this is not the case for a lot of places.

what is an 'emergency psychiatry service'?

Where I'm at, drunk guy on cocaine comes into the ER saying he wants to kill himself and a psychiatrist sees him(at least a resident). I guess that's obviously a psychiatric service. 50 miles away at another hospital the same guy walks into their ER and a psychiatrist would never see that same patient in the ER. The thought would never even enter the mind of the ER physician. Now of course the patient may get admitted somewhere and eventually see psych(most likely er staff will just give him a cab voucher and a turkey sandwich and let him rest for a couple hours), but the psych isn't going to be working out of the ER in that situation. Is that a 'psychiatric service' that was provided?

I think in general some residents have this idea that what goes on their academic program resembles life in the community in some way. When I was a med student and intern I believed the same thing. then I started working in the community in a lot of different settings and realized that it is much different out there.

 

[notdeadyet]

There are a few different levels of Emergency Psychiatry.

1. Psych ERs. Very rare. These are facilities with their own team of psychiatrists, NPs, nurses, and social workers that see emergency psych cases who have been (at least reasonably) medically cleared. They can be either completely standalone or connected to a MER. They tend to almost always be associated with academic medical centers, typically county facilities.

2. Psychiatrists working full-time in ERs. More common, but still rare. Psychiatrists are assigned to work the ER. In some cases, a portion of ER beds is devoted to psych cases. The psychiatrist works with the medical ER staff (nursing, SW, etc.).

3. Consult psychiatrists workng ERs. Probably most common for non-rural areas. When a psych case comes in that the ED needs assistance for (or to be evaluated for inpatient admission), the psychiatrist comes in from either the consult team or the inpatient psych unit. A majority of their workload has nothing to do with the ED.

4. Psychiatrists called in or telepsych. More common in smaller hospitals and in rural areas where there is not the volume and no inpatient unit nearby.

OP- You sound like you're interested in #1? There are jobs like this, but you will have to be very open about where to live as they are not common.

what is an 'emergency psychiatry service'?

Where I'm at...

You've mentioned before that the practice of emergency psych at your place down there was pretty weak. I remember that thread when everyone was puzzled at that being the standard of care for a "top NE program." It's a big world out there. Other places do it very differently.

 

[michaelrack]

4. Psychiatrists called in or telepsych. More common in smaller hospitals and in rural areas where there is not the volume and no inpatient unit nearby.
.

5. Social worker type person sees psych patient in ER. Arranges either 1) inpt admission to a psych ward/hospital or 2) outpatient psychiatric follow up .
Sometimes this social worker is supervised by the inpatient psychiatrist

 

[J ROD]

There are a few different levels of Emergency Psychiatry.

1. Psych ERs. Very rare. These are facilities with their own team of psychiatrists, NPs, nurses, and social workers that see emergency psych cases who have been (at least reasonably) medically cleared. They can be either completely standalone or connected to a MER. They tend to almost always be associated with academic medical centers, typically county facilities.

2. Psychiatrists working full-time in ERs. More common, but still rare. Psychiatrists are assigned to work the ER. In some cases, a portion of ER beds is devoted to psych cases. The psychiatrist works with the medical ER staff (nursing, SW, etc.).

3. Consult psychiatrists workng ERs. Probably most common for non-rural areas. When a psych case comes in that the ED needs assistance for (or to be evaluated for inpatient admission), the psychiatrist comes in from either the consult team or the inpatient psych unit. A majority of their workload has nothing to do with the ED.

4. Psychiatrists called in or telepsych. More common in smaller hospitals and in rural areas where there is not the volume and no inpatient unit nearby.

OP- You sound like you're interested in #1? There are jobs like this, but you will have to be very open about where to live as they are not common.

You've mentioned before that the practice of emergency psych at your place down there was pretty weak. I remember that thread when everyone was puzzled at that being the standard of care for a "top NE program." It's a big world out there. Other places do it very differently.

Well, my place has 4 spots. I guess I better get competitive......lol.

I dont mind working in other areas and waiting for something I want to come up. There are many areas that interest me so I am flexible in what I do. I just really liked it. I am somewhat flexible where I live.

It just confirms my thoughts that it is not that common. My dept had it sound like there were plenty of jobs doing that. I dont mind being in an academic place. I like teaching others and have thought about it in the clinical arena.

 

[notdeadyet]

Well, my place has 4 spots. I guess I better get competitive......lol.

4 spots on the team or 4 vacancies?

It just confirms my thoughts that it is not that common. My dept had it sound like there were plenty of jobs doing that.

There are lots of emergency psychiatry shifts at various places. It's the full-time jobs that aren't as common.

 

[vistaril]

There are a few different levels of Emergency Psychiatry.

1. Psych ERs. Very rare. These are facilities with their own team of psychiatrists, NPs, nurses, and social workers that see emergency psych cases who have been (at least reasonably) medically cleared. They can be either completely standalone or connected to a MER. They tend to almost always be associated with academic medical centers, typically county facilities.

2. Psychiatrists working full-time in ERs. More common, but still rare. Psychiatrists are assigned to work the ER. In some cases, a portion of ER beds is devoted to psych cases. The psychiatrist works with the medical ER staff (nursing, SW, etc.).

3. Consult psychiatrists workng ERs. Probably most common for non-rural areas. When a psych case comes in that the ED needs assistance for (or to be evaluated for inpatient admission), the psychiatrist comes in from either the consult team or the inpatient psych unit. A majority of their workload has nothing to do with the ED.

4. Psychiatrists called in or telepsych. More common in smaller hospitals and in rural areas where there is not the volume and no inpatient unit nearby.

OP- You sound like you're interested in #1? There are jobs like this, but you will have to be very open about where to live as they are not common.

You've mentioned before that the practice of emergency psych at your place down there was pretty weak. I remember that thread when everyone was puzzled at that being the standard of care for a "top NE program." It's a big world out there. Other places do it very differently.

I work at 4 different places. I'm pretty familar with a variety of settings.

 

[vistaril]

There are a few different levels of Emergency Psychiatry.

1. Psych ERs. Very rare. These are facilities with their own team of psychiatrists, NPs, nurses, and social workers that see emergency psych cases who have been (at least reasonably) medically cleared. They can be either completely standalone or connected to a MER. They tend to almost always be associated with academic medical centers, typically county facilities.

2. Psychiatrists working full-time in ERs. More common, but still rare. Psychiatrists are assigned to work the ER. In some cases, a portion of ER beds is devoted to psych cases. The psychiatrist works with the medical ER staff (nursing, SW, etc.).

3. Consult psychiatrists workng ERs. Probably most common for non-rural areas. When a psych case comes in that the ED needs assistance for (or to be evaluated for inpatient admission), the psychiatrist comes in from either the consult team or the inpatient psych unit. A majority of their workload has nothing to do with the ED.

The most common scenario in community hospitals for non-rural areas is the second part of #3. Most large community hospitals with a decent sized inpatient psych unit are going to have a few different psychs on staff. Those psychs are going to cover inpatient(most of their job if there is no associated outpt contract), consults, and admissions. When there is a patient to be evaluated in the ER, one of the psychs on staff will go down and do it. When there is a consult from medicine floor, one of the psychs on staff will go down and do it. The psychiatrists can decide who goes down and does these things(consults and admissions through ER) any way they like usually. Divide coverage up by weeks at a time, certain days, etc....

but when these psychiatrists go down to the ER to evaluate a patient there is nothing special about it. It's no different than a neurologist going down to the ER to examine a pt as opposed to their clinic.

 

[markglt]

is the term B52 common...and is the mix the same everywhere?

 

[michaelrack]

but when these psychiatrists go down to the ER to evaluate a patient there is nothing special about it. It's no different than a neurologist going down to the ER to examine a pt as opposed to their clinic.

But psychiatrists feel that they need a one year fellowship for every location in which they might see a patient

 

[michaelrack]

is the term B52 common...and is the mix the same everywhere?

It's too soon to have this discussion again.

 

[dl2dp2]

But psychiatrists feel that they need a one year fellowship for every location in which they might see a patient

I kind of agree. These "psych ER fellowships" are a waste of time. The way it works is that the ER director budgets some small amount, say $65k out of the ER operating budget and give it to this "fellow", and it constitutes some part time job where the fellow staffs the ER and does various administrative work, while building a private practice so he doesn't have to think about health insurance and various other sundries. If you want to work at an ER, you can just pitch yourself to various psych ERs and see if they have spots for moonlighting, and work your way to more shifts if you want. The pay, unfortunately, isn't as good as a private practice at the same time...and the lifestyle definitely sucks...so it's not something most psychiatrists want to do except on a part time basis.

 

[Ceke2002]

J DUB, depending on where you live you might consider trying to do some residency work in Australia. I think we have some of what you're interested in here. Full disclosure I'm not a health care professional, I'm a patient.

In South Australia we have something known as ACIS (acute crisis intervention service). It's basically like not dead yet described, a free standing building (ours does have ties to the local hospital) with nurses, social workers, resident students and specialist psychiatrists who assess patients considered 'at risk' or experiencing any sort of acute crisis episode. At least out my way a lot of the ACIS psychs also do rotations at hospital as well. The people I've seen working there as well always seem pretty happy and satisfied with their jobs, the place has a good vibe to it. Something like that might be right up your alley.

Good luck in your search. 🙂

 

[J ROD]

4 spots on the team or 4 vacancies?

There are lots of emergency psychiatry shifts at various places. It's the full-time jobs that aren't as common.

4 FT jobs. They are taken at the moment. I am sure with time I can find a spot in my general region when I am done or within a couple of yrs.

 

[softballtennis]

I haven't ever heard of a psych er, but you could work at a Behavioral Health Hospital. It's basically a hospital with people who have mental illnesses.