Capacity consults?

[Chinnychin]

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First of all I think capacity consults are BS because medicine is too lazy to do them-but besides that there are a few things I am unclear on.

So for example say a patient refuses treatment for whatever reason and he refuses. Medicine tries to convince him that it is in his best interest but cannot and calls a capacity consult. So psych is consulted and from my understanding can ONLY assess their capacity for this ONE decision-rather they cannot label them having no capcity for any decision etc. So anyway-a couple scenarios

1.Psych deems that they Do have capacity to make that decision and their mental state is not being influenced by any other psych issues. Now once a psych consluts determines that-does medicine have to follow or can they do a 2-doc or anything else to force treatment(say it is treatment needed to save their life but is not emergent-I understand if emergent a 2-doc can be done)

2. IF psych deems them to have no capacity due to psych illness-what is the next step-how do they force treatment-does it have to go through court befre treatment-if there is only a limited time to treat?

Also if any other forensic dudes are out there-my understanding is capacity is something psych assesses and is for each decision. Competence is something decided by a judge and if found incompetent than that means they have no capacity to make ANY decision.

I love forensics but know so little!

 

[Anasazi23]

First of all I think capacity consults are BS because medicine is too lazy to do them-but besides that there are a few things I am unclear on.

In some ways, you're right. You usually don't need a psychiatrist to determine capacity. We don't have a magic bag of questions, contrary to what they think. Oftentimes, simply explaining the procedure causes them to consent to the procedure. Of course, keep in mind that convincing the patient what is best is not your role - but we're all human sometimes.

So for example say a patient refuses treatment for whatever reason and he refuses. Medicine tries to convince him that it is in his best interest but cannot and calls a capacity consult. So psych is consulted and from my understanding can ONLY assess their capacity for this ONE decision-rather they cannot label them having no capcity for any decision etc. So anyway-a couple scenarios

You're right. You can only determine capacity for a particular question, not for all affairs.

1.Psych deems that they Do have capacity to make that decision and their mental state is not being influenced by any other psych issues. Now once a psych consluts determines that-does medicine have to follow or can they do a 2-doc or anything else to force treatment(say it is treatment needed to save their life but is not emergent-I understand if emergent a 2-doc can be done)

The patient has the right to make a stupid decision if they are capacitated. Unless the treatment is emergent and life saving, they cannot be forced under most circumstances. There are more tricky situations that are beyond this scope, too.

2. IF psych deems them to have no capacity due to psych illness-what is the next step-how do they force treatment-does it have to go through court befre treatment-if there is only a limited time to treat?

This is a very misunderstood and confusing area. The answer also depends on state laws, which vary. The official answer is in most cases, that a hearing must be had to force the patient into the treatment that is deemed necessary by the treating medical team. In actuality, and as I'm sure you've wittnessed, this almost never happens.

I attended a series of lectures by some very notable forensic psychiatrists that explained this in exquisite detail. Dr. Appelbaum, the authority on the subject, explained that the laws in this area are left deliberately vague. The truth is that a hearing will often cost more time than the patient reasonably has to allow for successful treatment (meningitis or sepsis tx, for example). In other words, waiting 2 weeks for a hearing will result in a dead patient. Knowing this, there has been relatively few to no successful lawsuits against psychiatrists resulting from unauthorized medical treatment secondary to psychiatric opinion. By not having laws that are entirely clear, to sum, more leeway is given to the treating physicians to provide treatment when the situation regarding capacity is unclear.

Also if any other forensic dudes are out there-my understanding is capacity is something psych assesses and is for each decision. Competence is something decided by a judge and if found incompetent than that means they have no capacity to make ANY decision.

I love forensics but know so little!

For the boards, yes.....capacity is determined by a psychiatrist, and competency is determined by a judge. In practical forensic practice, the terms are used interchangably. Another famous forensic psychiatrist told us, "Capacity and competence terms are the stuff of morning rounds bull****). I wouldn't say that capacity if for one decision, and competence is for global ability. i.e. it's not unreasonable to say that someone does not have competence to refuse the BKA, for example.

 

[whopper]

A consult is just that--only a consult--a reccomendation.

If a consult reccomends something, doesn't mean it must be done by the doctor who ordered the consult. A doc can still refuse to do what a consult reccomends. However if a doc does so, he/she better have a good reason because a consult is usually done by someone who has more knowledge in the respective field.

One thing I don't like about capacity consults (at least in my hospital) is the docs who order them hardly ever write down why it was ordered.

For example, if a patient refuses a procedure, the doc ought to specify the reason. So when I end up doing the consult, I don't know the reason, and when I ask the nurse, often times they give me an answer, but they tell me they're not certain.

So I beep the doc who ordered the consult and end up waiting there for about 40 minutes like a shmuck waiting for this doc who should've written down the reason in the first place. If I'm on consult service, it wastes about 2 hrs a day.

Also, most of the time, the doc never documents that they explained to the patient the benefits, cons and alternatives to the therapy the patient refuses. Often times when I see the patient, it turned out the patient refused service because the doctor was rude to them and would not answer their questions, and then introduced an invasive procedure to the patient without explaining why it was needed.

So I end up wasting about 1 hr figuring out this is really the case (because I have to at least give the doctor the benefit of the doubt, while I investigate what really happened) and when I talk to the patient, after discussing the benefits to the patient, they agree to it.

I really don't like doing that because I'm telling the patient benefits on a procedure that is not in my own field. However the alternative is to just write down on the consult sheet "will not do consult until the doctor documents the reason for the consult and that he/she explained the benefits, risks and alternatives to the procedure". My program tells me not to do that. Or I could waste that hour waiting for the doctor to respond to my beep and a significant amount of the time they untruthfully tell me they explained it to the patient.

So altogether, at least in my hospital about 80% of the time I spend on consult duty is just having to figure out what's really going on based on no to limited data in the chart.

The worst thing that happened was a patient was deemed 'psychotic" because she was concerned about her dog. She was put into the hospital after her PCP found an arrhythmia. She was immediately hospitalized, and she had a dog at home with no means to feed the dog from the hospital. Everytime the staff or docs attended to her she kept asking them to feed her dog. She was judged to be psychotic and a consult was ordered.

I talked to the patient, and couldn't find anything wrong with her. I spent 4 hours that day having to unravel what happened. 3 nurses, 2 social workers and 1 attending were claiming she was psychotic. I would've just slapped the case as BS in the first 5 minutes but when you got so many people claiming you're wrong you have to double check yourself.

Then when I finally was 99.9% confident and willing to write down the consult, they then asked me "Doctor, since you're the one telling us she's not psychotic, and that she has a dog at home that needs feeding, how are you going to fix that?" Man that was adding insult to injury. They were actually expecting me to somehow figure out how to get that dog fed.

I'm a psychiatrist. Not a pet detective.

"Dx:
I: No Axis I dx
II: deferred
III: atrial fibrillation per chart, HTN per chart
IV: patient was reccomended immediatel hospitalization after an arhythmia was discovered with no means to feed her dog at home
V: 75
The patient shows no sx of psychosis and is understandibly frustrated & upset because she was sent to the hospital without being able to make arrangements for someone to watch after her pets at home, which at this point may possibly be dead from starvation or dehydration.
Plan:
To clarify to the staff and attending: Psychiatry is not responsible for making sure her dog is fed & given water. I do though reccomend that the social worker discuss the matter with the patient and see if it is possible on their end to see that her dog is fed"

 

[Hurricane]

This is a very misunderstood and confusing area. The answer also depends on state laws, which vary. The official answer is in most cases, that a hearing must be had to force the patient into the treatment that is deemed necessary by the treating medical team. In actuality, and as I'm sure you've wittnessed, this almost never happens.

I thought that if the patient lacked capacity, you checked to see if a proxy or power of attorney was specified, and if not, the hospital was supposed to appoint a guardian...

I'm a psychiatrist. Not a pet detective.

That is the funniest thing I've read all day


Anyway, the last psychiatrist had some interesting posts on capacity on his blog recently. Scroll down to the 5th or 6th post on the front page.

 

[juddson]

The patient has the right to make a stupid decision if they are capacitated. Unless the treatment is emergent and life saving, they cannot be forced under most circumstances. There are more tricky situations that are beyond this scope, too.

Is this the current state of the law? As I understand it, if the patient has capacity, doesn't he have the right to refuse medical treatment even if it is life-saving and/or emergent? My understanding was that emergent treatment may be used in the incapacitated patient precisely because the consent is "implied". However, here, where capacity is found and consent is explicitely withheld, can two doctor's still override? I don't get it.

Judd

 

[Anasazi23]

I thought that if the patient lacked capacity, you checked to see if a proxy or power of attorney was specified, and if not, the hospital was supposed to appoint a guardian...

Yah, that's basically true, and sort of goes without saying. I was skipping to the end.

Of course, you know how long it takes for a hospital to get guardianship of a patient?

 

[Anasazi23]

Is this the current state of the law? As I understand it, if the patient has capacity, doesn't he have the right to refuse medical treatment even if it is life-saving and/or emergent? My understanding was that emergent treatment may be used in the incapacitated patient precisely because the consent is "implied". However, here, where capacity is found and consent is explicitely withheld, can two doctor's still override? I don't get it.

Judd

Yes, you're right...I was just sort of unclear in my post. I basically and unclearly implied that if someone comes in and is incapacitated in the literal sense (i.e. unconscious), then consent is implied.

I'm not sure about the two doctor thing....

 

[Big Lebowski]

First of all I think capacity consults are BS because medicine is too lazy to do them-but besides that there are a few things I am unclear on.

I would like to respond to this. Though it can be frustrating to be consulted for something the primary service can do, I wouldn't be so quickly angered about it. In reality, a medicine doc can do a lot of things and not necessarily request (renal, endo, cardiac, etc). However, consults are requested to a specialized service because the consulting team is looking for some expertise. As psychiatrists, we specialize in mental health which includes cognitive disorders. Personally, I think we should take ownership of things like this. It is good for our profession. Same goes for areas like addictions. We have specialized training in areas that might not make us experts in all things pertaining to the mind/brain, but more than the average physician. Otherwise, we limit our potential and services to other providers. Just my 2 cents....

 

[Chinnychin]

I would like to respond to this. Though it can be frustrating to be consulted for something the primary service can do, I wouldn't be so quickly angered about it. In reality, a medicine doc can do a lot of things and not necessarily request (renal, endo, cardiac, etc). However, consults are requested to a specialized service because the consulting team is looking for some expertise. As psychiatrists, we specialize in mental health which includes cognitive disorders. Personally, I think we should take ownership of things like this. It is good for our profession. Same goes for areas like addictions. We have specialized training in areas that might not make us experts in all things pertaining to the mind/brain, but more than the average physician. Otherwise, we limit our potential and services to other providers. Just my 2 cents....

Come on do you really believe medicine consults only because they are lookign for exptertise-?? I am not sure if you are a student or resident or how long it has been since you have done medicine but it is still fresh in my mind after doing many months of medicine this last year and a half in school that medicine AUTOMATICALLY consults psych if a patient refuses. They do not even talk to the patient about it for more than 5 seconds and do not want to be bothered with doing it-there are tons of BS consults because one team is too lazy (or too busy that they think its ok) to pawn off work. There is no reason a medicine resident cannot sit down and talk to the patient first-if they still do not pick up on any obviously depression, mania, psychosis etc that would be effecting their judement than call psych to "make sure" there is nothing going on-to use their expertise-but running the basic list of depression questions and talking for 5 minutes is hardly utlizing expertise.

But we all have are opinions in a hospital about what is a BS consult and not and to be honest depends on the service-when I was on medicine I cannot blame them because they are busy-yet seeing it from psych its b.s-technically it is b.s to me however I do understand why medicine does it-its just what side you choose to take. Either way I hear what you are saying.

Thanks for all the replies-that helps out a lot on a very confusing subject.

So can anyone elaborate on when the 2 doc thing can be used. For example I was at an inpatient facility that saw all involuntary type patients. One of the patients had a court date set up to eval for court ordered treatment and was in the unit awaiting that. 2 screw ups getting him over there and the judge dismissed the case so he was allowed to go-however he was spitting on patients and threatning staff-and they docs did a 2 doc to basically keep him there against his will and treat him with ativan to calm him down with the rationale that he was being a threat to othres (and the other criteria was threat to self, and one more which I do not recal)

So that is in a psych setting but how about a 2 doc to make patient get a procedure that he does not want (assuming he has capacity)?

 

[whopper]

it is still fresh in my mind after doing many months of medicine this last year and a half in school that medicine AUTOMATICALLY consults psych if a patient refuses. They do not even talk to the patient about it for more than 5 seconds and do not want to be bothered with doing it-there are tons of BS consults because one team is too lazy

I agree with you, and my above post shows a clear case of just pure laziness.

However take into consideration that some consults are valid and that several people in several fields are just lazy bums.

I know several psyche doctors that order a med consult based on the most idiotic of reasons--a simple cough--Med CONSULT!

 

[Chinnychin]

I agree with you, and my above post shows a clear case of just pure laziness.

However take into consideration that some consults are valid and that several people in several fields are just lazy bums.

I know several psyche doctors that order a med consult based on the most idiotic of reasons--a simple cough--Med CONSULT!

Oh Exactly I despise psych docs that need a med consult for everything-ESPECIALLY HTN-drives me crazy. I mean one thing if you are outpatient PP and has been years since you have been up to date on recent BP control but anyone in a hospital should be up on the basics of HTN,DM, lipids and even stuff like, basic renal function dx and managment etc. Totally agree its needed sometimes from both sides but honestly more often than not I donot believe this.

 

[Big Lebowski]

Come on do you really believe medicine consults only because they are lookign for exptertise-?? I am not sure if you are a student or resident or how long it has been since you have done medicine but it is still fresh in my mind after doing many months of medicine this last year and a half in school that medicine AUTOMATICALLY consults psych if a patient refuses.

You do have a point.

I am a PGY-4 general psych resident and will be going into private practice and contracting 50% of my time to provide psych consultations for a private hospital. Though I'm not going to say I have not received BS consults; I have started to look at this differently over the years; particularly from a psych practice point of view. Whether it is "expertise" being sought or just pure laziness; I look at it as providing what someone feels is a need. The more resistant, as a professional, to performing capacity consults, the less valuable a psychiatrist becomes. With psych consult services; hospitals do not provide them to make money. They exist generally because there is some perceived value to what you provide. If you take that away, you're less valuable to the system as a whole. I guess this also pertains to my feelings about addictions. There are certain areas we can make claim to and a "need" that can be filled. I believe this is healthy for the profession. Some might argue it is not.

I have had fair luck with getting reasonable "capacity" consults; therefore, I've not been frustrated with them. Though I have gotten my fair share of BS consults for other issues. However, this is a consult attitude and extends far beyond those for "capacity". Now your situation sounds inappropriate (requesting a consult without really speaking with the patient). I would equate that to requesting a cardiac consult without having percussed the chest or performing an ECG. There are just some lazy docs out there...

 

[Anasazi23]

My favorite consult I had on c/L was still (for an apparently unrelenting and annoying patient who was quite sick): "Capacity to refuse to sign his own DNR."

 

[TheWowEffect]

-but running the basic list of depression questions

Do you really think "running the basic list of depression questions" by the primary team will help rule out depression. If you do, something is missing in the training you are receiving.

I do agree with big lebowski on "taking ownership" and the "need" to be filled.

 

[whopper]

Totally agree its needed sometimes from both sides but honestly more often than not I donot believe this.

Its a laziness thing, not a psychiatry, or medical or surgical thing.

You'll see a lot of this bull (and I do mean BULL!) in any hospital setting. The more people, the higher the chance you'll get lazy bums.

Remember, medschool is tough, but that doesn't mean everyone who graduates isn't lazy. Lots of people get lazy at the first oppurtunity. Some people only do well in medschool & residency when they got the whip behind them. When its gone, they go lazy.

You'll see this thing EVERYWHERE in the hospital in various forms. From the ER doc that medically clears patients he hasn't even seen and dumps the guy to psyche (guy has chest pain!), to a psych doctor that brands a patient as psychotic simply because the guy doesn't speak English without offering a translator, to a "teaching attending" who doesn't do any real teaching, then finally gives a decent lecture only at drug dinners where he's paid extra.

It happens everywhere in hospital politics. Its called "Turfing". The only way you can avoid it is to do private outpatient practice-and that has its own fair share of problems, though different.

 

[Faebinder]

A consult is just that--only a consult--a reccomendation.

If a consult reccomends something, doesn't mean it must be done by the doctor who ordered the consult. A doc can still refuse to do what a consult reccomends. However if a doc does so, he/she better have a good reason because a consult is usually done by someone who has more knowledge in the respective field.

One thing I don't like about capacity consults (at least in my hospital) is the docs who order them hardly ever write down why it was ordered.

For example, if a patient refuses a procedure, the doc ought to specify the reason. So when I end up doing the consult, I don't know the reason, and when I ask the nurse, often times they give me an answer, but they tell me they're not certain.

So I beep the doc who ordered the consult and end up waiting there for about 40 minutes like a shmuck waiting for this doc who should've written down the reason in the first place. If I'm on consult service, it wastes about 2 hrs a day.

Also, most of the time, the doc never documents that they explained to the patient the benefits, cons and alternatives to the therapy the patient refuses. Often times when I see the patient, it turned out the patient refused service because the doctor was rude to them and would not answer their questions, and then introduced an invasive procedure to the patient without explaining why it was needed.

So I end up wasting about 1 hr figuring out this is really the case (because I have to at least give the doctor the benefit of the doubt, while I investigate what really happened) and when I talk to the patient, after discussing the benefits to the patient, they agree to it.

I really don't like doing that because I'm telling the patient benefits on a procedure that is not in my own field. However the alternative is to just write down on the consult sheet "will not do consult until the doctor documents the reason for the consult and that he/she explained the benefits, risks and alternatives to the procedure". My program tells me not to do that. Or I could waste that hour waiting for the doctor to respond to my beep and a significant amount of the time they untruthfully tell me they explained it to the patient.

So altogether, at least in my hospital about 80% of the time I spend on consult duty is just having to figure out what's really going on based on no to limited data in the chart.

The worst thing that happened was a patient was deemed 'psychotic" because she was concerned about her dog. She was put into the hospital after her PCP found an arrhythmia. She was immediately hospitalized, and she had a dog at home with no means to feed the dog from the hospital. Everytime the staff or docs attended to her she kept asking them to feed her dog. She was judged to be psychotic and a consult was ordered.

I talked to the patient, and couldn't find anything wrong with her. I spent 4 hours that day having to unravel what happened. 3 nurses, 2 social workers and 1 attending were claiming she was psychotic. I would've just slapped the case as BS in the first 5 minutes but when you got so many people claiming you're wrong you have to double check yourself.

Then when I finally was 99.9% confident and willing to write down the consult, they then asked me "Doctor, since you're the one telling us she's not psychotic, and that she has a dog at home that needs feeding, how are you going to fix that?" Man that was adding insult to injury. They were actually expecting me to somehow figure out how to get that dog fed.

I'm a psychiatrist. Not a pet detective.

"Dx:
I: No Axis I dx
II: deferred
III: atrial fibrillation per chart, HTN per chart
IV: patient was reccomended immediatel hospitalization after an arhythmia was discovered with no means to feed her dog at home
V: 75
The patient shows no sx of psychosis and is understandibly frustrated & upset because she was sent to the hospital without being able to make arrangements for someone to watch after her pets at home, which at this point may possibly be dead from starvation or dehydration.
Plan:
To clarify to the staff and attending: Psychiatry is not responsible for making sure her dog is fed & given water. I do though reccomend that the social worker discuss the matter with the patient and see if it is possible on their end to see that her dog is fed"

I raise this old thread because I wanted to discuss how pissed off I am at the system, mainly regarding the bolded point made by Whopper.

We had a 1 hour meeting with the coding lady at our hospital and I just wanted to bang my head on the wall. 🙁 No matter how I try to manipulate it, putting No Diagnosis on Axis I in a capacity consult = You will get paid NADA!

I can't believe this BS... especially the one without an obvious Axis I and worse the one truly without an Axis I... both take sooooo much time... and yet they wont get paid if you put no diagnosis under axis I.

I feel like someone's little pet. I spoke about it with one attending, he was "try and refuse that consult and watch how you will get hanged in the middle of the street and no one will even bat an eye even though you are correct." How sad is that? So you see a surgeon get called and not get paid for a consult even if they do nothing? They refuse consults to the inpatient unit all the time. I think they don't believe mentally ill people can fall and cut themselves.

 

[whopper]

We had a 1 hour meeting with the coding lady at our hospital and I just wanted to bang my head on the wall.

Oh-the dragon, cough cough, I mean coding lady. The lady that seems like she's into S&M from her condescending demeanor & cold look.

You're going to have to forgive me, but Faebinder is in the program I graduated from. He knows what I'm talking about. Just a little locker room humor & bonding. Before anyone condemns--admit it--you do it too. If you don't do it, you don't have a sense of humor.

OK, well Faebinder, what's going on IMHO is the psyche attendings really are the people who ought to talk to the other depts to reduce this type of BS consults phenomenon, but its not their time wasted. Its the resident's time that is wasted. So they more or less just let it happen.

I mentioned this is another thread & this one but most of the time they consult psyche, its hardly for a real psyche reason. Its usually because the patient is giving the staff a problem & they don't want to deal with it so they consult psyche--from the lady who couldn't get her dog fed, to a lady who is upset that they don't have HBO on the TVs to a guy who is upset because the Eagles lost a game--all branded as psychotic or suicidal when they clearly are not.

Happens in several programs--for the same reason it happens in ours. Its the attendings that need to really solve this problem by communicating it to the other depts--but since its not the psyche attending's time wasted, its the resident's time, they don't exactly seem to care about that. No hospital will tolerate a resident complaining to another department. You could of course do some passive protesting by putting your vacation days only on the consult days--> forcing the attending that will be forced to cover consult duty to now deal with the problem the residents face. You could also bring this up in the resident evaluations of the program. Dr. Cagande does listen to these as does the GME. Trust me on that. Dr. Bekes & Sharon in the GME
@ Cooper really do listen to all complaints & do what they can to fix these things.

Anyways, Dr. Hasson took charge of ARMC and she knows what she's doing, is a good doctor & got an impression that she'd do what she could to tackle these things. Problem though is she's in charge of a huge psyche operation covering almost 1/3 of one of the most densely populated states in the country. She's got a lot of stuff to handle on her plate. Dr. Zwil is aware of the stuff, but he can only do so much. He advises residents to try to surf the situation---try to do what you can to handle it, go with the flow but don't fight it head on. Follow his advice.

 

[Faebinder]

Oh-the dragon, cough cough, I mean coding lady. The lady that seems like she's into S&M from her condescending demeanor & cold look.

That's a pretty darn good description of her. 😀

 

[Anasazi23]

I can't believe this BS... especially the one without an obvious Axis I and worse the one truly without an Axis I... both take sooooo much time... and yet they wont get paid if you put no diagnosis under axis I.

That's why God gave us Adjustment disorder.

 

[PsychedUp]

most of the time they consult psyche, its hardly for a real psyche reason. Its usually because the patient is giving the staff a problem & they don't want to deal with it so they consult psychequote]


This is the difficult thing about c/l psychiatry: for every interesting ("real") case of NMS, psychosis, catatonia, unidentified delirium, etc there are about 10 cases of "the patient seems unhappy" (my snowblower didn't start yesterday, I was unhappy...wanna consult psych on me?), or "new diagnosis of 'insert chronic or terminal illness', anticipate pt will become depressed" (if he was going on a ski trip, would you consult ortho in anticipation of a broken leg?), it goes on...

Consults was one of the best learning experiences in my residency, but also one of the most frustrating. What helped was the chief attending was great about making sure the consulting teams had a direct question they were asking of us. We blocked a fair share of BS consults on our busy service.

 

[michaelrack]

2. IF psych deems them to have no capacity due to psych illness-what is the next step-how do they force treatment-does it have to go through court befre treatment-if there is only a limited time to treat?

In one of the states I practiced in, once lack of capacity was determined, a surrogate decision maker was appointed by the SW from a hiearchy of choices (spouse if avail, then child, then sibling etc).

If the patient was old and weak, then the surrogate's decisions could be enforced. Problems arose when the pt was mentally clouded but otherwise relatively healthy- for example, a 2o y.o pt with TBI and significant UE soft tissue infx demanding to leave ama and still requiring iv abx and not considered stable enuf for home abx. If he is deemed incompetent or incapacitated, how do you enforce a surrogate's decision to keep him in the hospital? There typically aren't locked med wards- do you station 4 security guards around the clock to keep him in the room? do you sedate him with psychotropics (even though other than trying to leave, he is not agitated?). Often the medical team will try to transfer him to a locked psych ward even though the pt is in need of medical rather than primary psych tx.

In situations like this, the consulting psychiatrist becomes more of a sw, trying to negotiate with the various involved parties to negotiate a soln such as home abx, even if it isn't considered the optimum tx by the medical team.

 

[Faebinder]

That's why God gave us Adjustment disorder.

In many institutes, Adjustment disorder is not paid.

I'm told insurance refuses/resistant to pay for the following Axis I diagnosis:

1) Substance-Induced Mood Disorder.

2) Mood Disorder NOS.

3) Anxiety Disorder NOS.

4) Adjustment Disorder.

5) Schizophreniform. (Although they will pay for Psychosis NOS).

6) All the dependence diagnosis as a primary diagnosis.

I'm still trying to learn this dumb paying game... what will insurance pay and wont pay.

 

[Doc Samson]

In many institutes, Adjustment disorder is not paid.

I'm told insurance refuses/resistant to pay for the following Axis I diagnosis:

1) Substance-Induced Mood Disorder.

2) Mood Disorder NOS.

3) Anxiety Disorder NOS.

4) Adjustment Disorder.

5) Schizophreniform. (Although they will pay for Psychosis NOS).

6) All the dependence diagnosis as a primary diagnosis.

I'm still trying to learn this dumb paying game... what will insurance pay and wont pay.

Insurance doesn't pay for very much at all when it comes to consults. Diagnose to the best of your ability and don't perjure yourself based on insurance. It also sounds like there's a lot of attending level hypogonadism out there when it comes to dealing with other services - almost to the point of learned helplessness.

One of my favorite quotes from CL fellowship: "You need this year so we can surgically reattach the b@lls they removed during your residency."

 

[whopper]

Another way to look at this is if you start putting more honest diagnoses that don't get paid, its more stimulus for the hospital to start investigating the excessive number of frivolous requests for consults. Remember its not your pay that's affected since your a resident, and its ethical--an honest diagnosis is a good thing.

 

[Anasazi23]

In many institutes, Adjustment disorder is not paid.

Adjustment disorder makes up a large portion of hospital-based diagnoses, since many people's psychopathology worsens during a hospital stay. Adjustment disorder is often not paid for as an inpatient psychiatric admission, since it usually won't warrant an admission to begin with. It's different for a consult on the floors.

 

[Faebinder]

Adjustment disorder makes up a large portion of hospital-based diagnoses, since many people's psychopathology worsens during a hospital stay. Adjustment disorder is often not paid for as an inpatient psychiatric admission, since it usually won't warrant an admission to begin with. It's different for a consult on the floors.

Thanks for the info. 👍

 

[whopper]

I can think of only 1 Adjustment DO consult that really needed psychiatric consultation.

Person had a +PPD & other indicators of possible TB. He was put into a special room that was airtight. The guy was not allowed to leave & had to stay there for several weeks. He had nothing to do in that room other than watch the crappy 8 channels on the TV.

After about 5 days of being there he started complaining of depression. One could argue it was depressive DO NOS, but he never had a history of it and wasn't giving enough of the classic sx of depression, it was only 5 days & it was to an understandable stressor.

But I knew he was going to be there for weeks so I knew where this was going to lead--full blown depression. I reccomended psychotherapy for the guy, & an SSRI. He refused the SSRI, and the attending told me we cannot provide psychotherapy....

So its about 2 weeks later & the guy tried to hang himself in his room. It became full blown MDD.

 

[Anasazi23]

Person had a +PPD & other indicators of possible TB. He was put into a special room that was airtight. The guy was not allowed to leave & had to stay there for several weeks. He had nothing to do in that room other than watch the crappy 8 channels on the TV.

I can't even imagine doing psychotherapy in a negative pressure room. I dislike it so much in a cush office, let alone that.

I wonder what I would have done if I were forced to do it as a resident. Thankfully were weren't made to do psychotherapy on the floors, as time just wouldn't allow it. That might have been one of the rare cases where I abused my chief powers or gave one of my "hang in there buddy" pep talks for 3 minutes and dropped off a motortrend.

 

[michaelrack]

It also sounds like there's a lot of attending level hypogonadism out there when it comes to dealing with other services - almost to the point of learned helplessness.

One of my favorite quotes from CL fellowship: "You need this year so we can surgically reattach the b@lls they removed during your residency."

The composite example I gave was from my residency days. I am no longer hypogonadal.

During a year I spent as an academic consult attending, I was at times hypergonadal and once hung up on the chairman of pediatrics (for a brief time I was also doing child psych consults) when he was giving me a hard time. I am no longer in academics, though that wasn't the reason.

 

[michaelrack]

In many institutes, Adjustment disorder is not paid.

I'm told insurance refuses/resistant to pay for the following Axis I diagnosis:

5) Schizophreniform. (Although they will pay for Psychosis NOS).



.

that's surprising

 

[Doc Samson]

The composite example I gave was from my residency days. I am no longer hypogonadal.

During a year I spent as an academic consult attending, I was at times hypergonadal and once hung up on the chairman of pediatrics (for a brief time I was also doing child psych consults) when he was giving me a hard time. I am no longer in academics, though that wasn't the reason.

Wasn't referring to you in particular - more the lack of support that the residents felt from their attendings.

 

[kcrd]

I can't even imagine doing psychotherapy in a negative pressure room. I dislike it so much in a cush office, let alone that.

I wonder what I would have done if I were forced to do it as a resident. Thankfully were weren't made to do psychotherapy on the floors, as time just wouldn't allow it. That might have been one of the rare cases where I abused my chief powers or gave one of my "hang in there buddy" pep talks for 3 minutes and dropped off a motortrend.

We have Psychology interns rotate through CL with us, and it's fantastic. They actually WANT to sit and do supportive therapy with our adjustment d/o or personality d/o patients on the floors. I feel like it gives us another tool to offer on the consult service.

 

[whopper]

It also sounds like there's a lot of attending level hypogonadism out there when it comes to dealing with other services - almost to the point of learned helplessness.

Pretty much that. Its really that the attendings don't care because its the resident's time that's wasted, not their own.

There were a few attendings in the program that did do what they could do fight this type of thing, others were passive aggressive about it.

E.g. (for you Faebinder)-Dr. Daclan if she suspected a BS consult would call the floor, ask the nurse what was going on & then just tell the nurse that the consult was BS, and asked them to cancel the order for a psyche consult. Since the staff trusted her, was cooperative & she really did listen to their needs, she could do that. Others didn't care or didn't have that understanding with the staff because of their own limitations in their skill as an attending.

Bottom line from what I learned as Chief Resident when I was there was the program couldn't just immediately & easily replace some of the more complacent attendings. Some of the excellent attendings told me they completely agreed with me & the complaints of the residents, but due to politics couldn't do anything...some of the other "good" attendings, well they gave me the body language, even the eye contact that they agreed with me, but to be diplomatic wouldn't call out another attending as lazy.

OK rant over. As much as this sounds like a knock on my old program, I've seen this type of thing happen at almost every residency program I've seen. Also to get this bull to some degree is a good training experience because it teaches you the reality of hospital politics.

I'm not seeing it at the place I'm at now because there are no residents--only medstudents & attendings. The attendings (minus the administration) are all on the same level, so usually we don't dump things onto others, and if it does happen, we don't have a resident to clean up the mess for us. We tell the doctor that did the dump to not do it again. You do a good job, & avoid that type of thing, your stock goes up here.

 

[whopper]

I wonder what I would have done if I were forced to do it as a resident. Thankfully were weren't made to do psychotherapy on the floors, as time just wouldn't allow it. That might have been one of the rare cases where I abused my chief powers or gave one of my "hang in there buddy" pep talks for 3 minutes and dropped off a motortrend.

I asked the staff if we could drop off some magazines, a tablet computer with access to the internet, maybe a video game system & tell social services to contact the guy's family to have them visit often.

Magazines-that was done though the hospital had a crappy selection of various Susie Homemaker magazines such as Good Housekeeping--and this guy was a 30ish male.

Computer & Game system--nope. They couldn't do it. I've seen various peds hospitals have that for the kids, but this place only had an adult units. They do have computers with internet access now for the patients, but didn't have it then.

The social worker on the medical floor-well they really didn't do much. Medical social workers & psyche social workers really are different. The med SW's just hooked them up with their payment options. They hardly did anything with contacting family & friends. The guy if I remember didn't really have anyone to visit him either.

I then even considered calling the hospital psychologists (we had a few) to look into this on the psychotherapy end. However, the attending just cut me off short & said we don't do that type of thing & told me to finish my work on the consult.

As bad as that sounded...I was somewhat relieved. If I were the attending I would've worked & told the resident to still work on it. I did feel the attending told me to stop out of some laziness on his part. However the "fight" would've been uphill & asking the hospital to do things where I know they would've said "no". The hospital's not going to buy a game system for 1 patient, and I sure as heck wasn't going to shelve out $500 out of my own pocket.

 

[Anasazi23]

Magazines-that was done though the hospital had a crappy selection of various Susie Homemaker magazines such as Good Housekeeping--and this guy was a 30ish male.

The Motortrend and/or Road & Track came from my 'private' collection.