Call Schedule alternatives for new job?

[UnderdogMD]

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Hello all,

Recently got a job offer to be the sole doc at small community hospital on a 16 bed general adult psych unit. Mon-Fri. No weekends. They have 3 PRN/moonlighting psychiatrists for nearby hospitals that have agreed to cover all the weekends and vacation that I take but do not want to be responsible for taking any more call than that. Any alternative options to me being on call Mon-Fri every week? The hospital seems to expect just that. Is that reasonable? Could in house medicine hospitalists take the call or would it have to be a psychiatrist? Are there any requirements that state a psychiatrist has to be on call for a psych unit (Joint Commission perhaps?). Really like the job offer, just don't think call every night is possible and still continue to function multiple days in a row. In comparison currently I am at a much larger hospital with about 8 psychiatrists and take call 1 x a week which seems very reasonable. Thoughts? Sorry for all the dumb questions.

 

[wolfvgang22]

There's no joint commission requirement a psychiatrist must be on call. Some states require an MD evaluate a patient in a seclusion within a certain amount of time. Most states require an evaluation of involuntary patients within 72 hours. But these things are only tangential to being on call. Being on call every night is not reasonable in any way. Since they are so short staffed, they should be delighted you desire to work there, at all, for any amount of time. How have they survived thus far? They could keep doing that.

Ask yourself why these moonlighting psychiatrists that provide some coverage aren't doing this job and prefer to stay where they are.

 

[UnderdogMD]

They've had the same psychiatrist for the last 20 years who is retiring and apparently took call every night. When I asked about alternative staffing for the call schedule they reported that it 'has to be a psychiatrist for regulatory reasons.'

 

[MBBSMOM]

I would recommend you walk away from this job unless they change it to minimal call. Also are they proving you compensation for being on call M-F? If I were you I would walk away. I had a job like this but it was even worse. I had to go in 7 days they later changed it to 6. I was on call Monday-Sunday. One of the worst attending jobs I’ve had. Also 16 pts sound rough.

 

[wolfvgang22]

They've had the same psychiatrist for the last 20 years who is retiring and apparently took call every night. When I asked about alternative staffing for the call schedule they reported that it 'has to be a psychiatrist for regulatory reasons.'

So they had a sucker for masochism before and want you to sacrifice yourself on the same altar of making money for the hospital...I mean, serving patients. How much salary are they offering? Half a million?

 

[downwithDTB]

Half a million would only be $86/hour primarily responsible for inpatients, assuming 4 weeks of vacation... Now maybe it's an almost entirely voluntary unit with very medically stable patients and no after hours admissions and amazing nurses and they never call you for medical complaints or insomnia.

 

[MBBSMOM]

Half a million would only be $86/hour primarily responsible for inpatients, assuming 4 weeks of vacation... Now maybe it's an almost entirely voluntary unit with very medically stable patients and no after hours admissions and amazing nurses and they never call you for medical complaints or insomnia.

At my job when I was on call 24/7 the pay was still 260k. Which was very low at least the RNs didn't page me for medical complaints. They usually paged the IM doctor. If there was a behavioral complaint Insomnia, Anxiety or Agitation they would page the psychiatrist. I make around 5k less now but I'm only on call 1x a week.

 

[RangerBob]

I’m in PM&R, not psych. But how many times do you really get called at night? I’m on call for our unit 24hrs/day Mon-Fri. 24 beds. I get woken up about once every two weeks. Almost always for something I can answer very quickly and fall back asleep. I typically call the unit at night before I go to bed. We have hospitalists consulted, so anything “medical” goes to them overnight.

I had much less call in residency. But I also covered far more patients on call, so it was a given I’d be woken up multiple times each night. With call every night, I can’t drink on weekdays, but then I don’t drink anyway.

Having all weekends off sounds pretty amazing to me, but maybe for inpatient psych that’s expected? It’s not for PM&R-I wish it were.

Sounds like they really need you. I’d recommend negotiating to have any “medical” call (chest pain, UTI, etc) go to hospitalists overnight. Or if you just aren’t willing to do any call, be up front and tell them you don’t want to waste your time or theirs and that they need to figure something else out for overnight call or find someone else.

Remember, it’s easier to ask for everything you want now then try to ask once you’ve settled in and the odds of you leaving are lower.

 

[Sushirolls]

Set it up so the hospitalists have admitting privileges to the psych unit, too.
If patients are coming from the same ED, they ED doc talks with the nocturnist, who then admits the patient to the psych unit. Puts in the routine orders, PRN meds, and a consult psychiatry order.
In the AM, you come on to the unit, do the consult, and officially take over management for the patient.

Outside ED transfers consider them until 10PM, and after that just have them fax all the records to the unit charge nurse, and review them in the morning.

That's about the only way to make it more manageable, besides splitting the unit with another doc and supplementing with some outpatient clinic time.

I'm technically on call for my own little out patient private practice every night. I've only been called twice in past 9 months.

 

[Bartelby]

16 inpatients with M-F call every week sounds brutal. Do you know how often they contacted the last psychiatrist?

 

[Sushirolls]

I’m in PM&R, not psych. But how many times do you really get called at night? ....

It can be a lot. Some training of unit staff can reduce the volume of prn meds or other random things like "i just gave patient motrin, but they are asking for some thing else and its not yet 6 hours since last dose, what would like us to do?" But when you have new nurses, you will just be getting paged. The other issue is psych units admit 24/7 at many places, which means you are called at all hours. "Psych time" is essentially noon to midnight, when people show up to say they are suicidal and want to be admitted. The delay in the ED adds three hours, so real psych time for when people set foot on a unit is typically 3PM-3AM.

Then, some ED docs for outside admissions want or require a doc to doc when they do the admission, which means another phone call typically just before they put the person in transport - which is actually 1-5 hours after you already reviewed all the paper work and decided to admit the patient and gave anticipatory admit orders to the charge nurse.

Depending on the population served, you also have the AMA discharges of people wanting to leave at 3AM, which typically gets a doc page. Some patients not an issue, others may warrant an escalation in that state's specific detention laws.

Inpatient units typically have new admits in range of 10-15% of the bed census per day. so for a 16 bed unit that's 1-3 admits per day - and again, those fall in during "psych time."

 

[Sushirolls]

... I’d recommend negotiating to have any “medical” call (chest pain, UTI, etc) go to hospitalists overnight. ...

This is routine for psych units. But before these medical issues get consulted to them, typically the unit nurses call you and say hey, Pt XYZ is having chest pain, what would you like to do? "order an EKG, order a troponin, and call the hospitalist for a consult, thanks [click]" This is typically because Psych is the attending of record, and the nurses prefer talking to psych, and depending which hospitalist is on they loathe dealing with their grumpy push back unless they have no choice.

Hospitalists typically loathe setting foot on pysych units, sign off as quick as they can, and push back on new issue consults during mid course of the hospitalization. This is one of the frustrating things about psychiatry is the stigma other services place on our patients

Long story short, it goes back to the 60's I believe when CMS basically set the standard that Psych units must have IM/FM med consults and "clearance" with admissions. Psych can't do psych and the medical H&P, CMS does not approve.

Units attached to hospitals have more responsive medical services. Free standing psych hospitals have much less responsive IM/FM services.

 

[clausewitz2]

Long story short, it goes back to the 60's I believe when CMS basically set the standard that Psych units must have IM/FM med consults and "clearance" with admissions. Psych can't do psych and the medical H&P, CMS does not approve.

This is untrue. Easily 75% of the medical H&Ps done on newly admitted patients at our shop are done by psychiatry residents on call or moonlighting. I have done them occasionally when they slipped through the cracks as the psychiatry resident taking care of them during my normal clinical duties. We have an in-house FM service but they are consulted about a distinct minority of cases. We have dedicated PAs for the geriatric floor but then we have relatively medically complex folks (on dialysis, IV antibiotics, O2, needing a hospital bed, etc). The psychiatry team is allowed to manage just as much medical complexity as they feel comfortable with, main limitation our state nursing board does not let psych nurses do any IV pushes. Residents and attendings are allowed, though (this rarely happens)

The only time there has been any resistance to the psychiatry team managing medical issues at our hospital is when a resident who had transferred from EM was starting diltiazem drips on people and trying to manage their unstable afib. He was told to knock it off and transfer the patient to the medical hospital already.

Our building is free-standing but is connected via tunnel to a major medical center and is part of the same license, so we are technically a 200+ bed unit of the hospital, so I don't think there is a payor issue here.

Now, it is true that often the payments are structured per diem and medical services provided just have to come off the top so it is easy to lose money very quickly taking care of a lot of medical problems, but that is a money issue, not a regulatory one.

 

[TexasPhysician]

I’m in PM&R, not psych. But how many times do you really get called at night? I’m on call for our unit 24hrs/day Mon-Fri. 24 beds. I get woken up about once every two weeks.

Much different. Even at a voluntary addiction facility with slightly higher volume but longer stays with good nurses and medical staff on call with me, I’m getting 1 call/night or more.

Without medical, add involuntary patients, high turnover, seclusion orders may require you going in, etc and it’ll be a few calls every night.

I wouldn’t take this job of M-F inpatient psych call for under $600k/year, and they’ll never pay that.

 

[UnderdogMD]

Much different. Even at a voluntary addiction facility with slightly higher volume but longer stays with good nurses and medical staff on call with me, I’m getting 1 call/night or more.

Without medical, add involuntary patients, high turnover, seclusion orders may require you going in, etc and it’ll be a few calls every night.

I wouldn’t take this job of M-F inpatient psych call for under $600k/year, and they’ll never pay that.

I agree with you and do not plan to be on call M-F. Are there any other options though? They have 24/7 hospitalist coverage...could the hospitalist not take the call? Tried to do some research but I can't seem to figure out if a psychiatrist must be on call for a psychiatric unit.

 

[finalpsychyear]

I agree with you and do not plan to be on call M-F. Are there any other options though? They have 24/7 hospitalist coverage...could the hospitalist not take the call? Tried to do some research but I can't seem to figure out if a psychiatrist must be on call for a psychiatric unit.

I feel since their previous provider did it like that its going to be a learning experience for them that this is not the norm.You need to stand your ground and say this is a deal breaker for me and keep looking. They will see that literally no one in this generation of psych docs are willing to do that 24/7 call M-F then you might get a call later with them being more negotiable. I wouldn't take an inpatient job like this EVER.

 

[TexasPhysician]

I agree with you and do not plan to be on call M-F. Are there any other options though? They have 24/7 hospitalist coverage...could the hospitalist not take the call? Tried to do some research but I can't seem to figure out if a psychiatrist must be on call for a psychiatric unit.

Does not need to be a psychiatrist. I took call for a 140 bed psych hospital as a PGY-3.

 

[Taddy Mason]

This is routine for psych units. But before these medical issues get consulted to them, typically the unit nurses call you and say hey, Pt XYZ is having chest pain, what would you like to do? "order an EKG, order a troponin, and call the hospitalist for a consult, thanks [click]" This is typically because Psych is the attending of record, and the nurses prefer talking to psych, and depending which hospitalist is on they loathe dealing with their grumpy push back unless they have no choice,

Why would nursing be expected to place/initiate a consult to another service without first contacting the primary service to initially evaluate if a consult is even warranted?

Long story short, it goes back to the 60's I believe when CMS basically set the standard that Psych units must have IM/FM med consults and "clearance" with admissions. Psych can't do psych and the medical H&P, CMS does not approve.

This isn’t true. Where I’m at currently, we’re the arbiters as to whether or not someone is “medically cleared” for “psychiatric hospitalization” and do full medical and psych H&Ps for all admissions and work-up and manage bread and butter medical issues (e.g., uti, uri, chest pain, etc.) without consulting medicine all the time. Also, my spouse does CMS claims/billing......

 

[Shufflin]

Why would nursing be expected to place/initiate a consult to another service without first contacting the primary service to initially evaluate if a consult is even warranted?


This isn’t true. Where I’m at currently, we’re the arbiters as to whether or not someone is “medically cleared” for “psychiatric hospitalization” and do full medical and psych H&Ps for all admissions and work-up and manage bread and butter medical issues (e.g., uti, uri, chest pain, etc.) without consulting medicine all the time. Also, my spouse does CMS claims/billing......

I think what Sushirolls is saying, and to your point too TM, is that the primary cannot do a consult on the same patient. The same psychiatrist can be the primary for patient A, and do a psych consult for patient B, but not be the primary and do a psych consult for the same patient. Apologies if this is already widely known, just clarifying.

 

[Jules A]

That is essentially a 2 psychiatrist unit especially because I would bet there are medical floor consults and likely some ED psych consults also. Consider your medical director duties such as treatment team, dealing with RNs, therapists and UR staff...unless this is inner city hardcore where everyone is psychotic it is doubtful this will be a 40h a week position not even considering the call. I take call for 3 hospitals and generally average 1-2 admissions and 2-3 phone calls per night depending on acuity and how proficient the attending was at adding prns.