consult-liasion rotation

[YoungPsychDoc]

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Hi. I am starting my first consult-liasion rotation. I saw some good tips for psych emergency earlier. Anyone have simiilar advice for consult-liasion? Not really sure what CL does to be honest. Thanks!🙂

 

[digitlnoize]

Get more familiar with Delirium. Causes treatments, etc. EtOH withdrawal is a popular one too.

 

[notdeadyet]

And spend some time learning what ISN'T delirium. Many of your delirium consults will turn out to be something else entirely,

 

[ELOVL4]

I've just finished my 3rd C&L rotation. Most of my consult request were for AMS, Agitation, Capacity Evaluation, Depression, Suicide attempt by OD or Intoxication, Psych Clearance after Delivery etc.
The most challenging task is Capacity Evaluation. But If you have good understanding of the process to evaluate the capacity , it would be piece of Cake. Delirium is another tricky situation. You may find pt totally incoherent but the resident who called for consult might find the patient totally in good shape after your consult. So, try to get collateral history form Nurses from previous shift also. ICU delirium is most common, For PGY-1's please consult your seniors before calling Psych consults.

 

[nitemagi]

I've just finished my 3rd C&L rotation. Most of my consult request were for AMS, Agitation, Capacity Evaluation, Depression, Suicide attempt by OD or Intoxication, Psych Clearance after Delivery etc.
The most challenging task is Capacity Evaluation. But If you have good understanding of the process to evaluate the capacity , it would be piece of Cake. Delirium is another tricky situation. You may find pt totally incoherent but the resident who called for consult might find the patient totally in good shape after your consult. So, try to get collateral history form Nurses from previous shift also. ICU delirium is most common, For PGY-1's please consult your seniors before calling Psych consults.

That was my favorite conversation:
Me:"Yeah, so the patient is delirious, they have waxing and waning mental status, totally confused about..."
Consulting MD: "Wait, that can't be. I just saw them an hour ago, and they were fine. Seemed totally oriented."
Me: "You do understand the idea of Waxing and Waning, right?"

 

[vistaril]

Hi. I am starting my first consult-liasion rotation. I saw some good tips for psych emergency earlier. Anyone have simiilar advice for consult-liasion? Not really sure what CL does to be honest. Thanks!🙂

1) When primary teams call in consults, use that opportunity to convert it into a curbside. Things like etoh withdrawl is NOT a psych consult at good institutions.

2) When routine delirium consults were called in by pgy1s, I just talked them through it and emailed them a basic article with a med list they could use. This is superior to actually
doing the consult because now that intern will have learned how to manage something he shouldnt be consulting on in the future.

3) A lot of your SI consults are going to be attempted dumps. Don't take the bait. For example, 55 yo with horrible DM needs maybe a picc for a foot infection. Well for whatever reasons he doesnt qualify for home health, so he may have to stay another 2 weeks in the hospital. Conveniently for the medicine team, he mentioned suicide yesterday....and now they want to send him to psych. No no no. Always find out why the person presented to the ER in the first place for SI consults. If someone came in with a cc of being suicidal and got admitted to medicine because of same lame psych turf/refusal in the er, that's different than if the pt came to the ER for copd or whatever and then 2 days later you get an SI consult....

 

[digitlnoize]

2) When routine delirium consults were called in by pgy1s, I just talked them through it and emailed them a basic article with a med list they could use. This is superior to actually doing the consult because now that intern will have learned how to manage something he shouldnt be consulting on in the future.

My institution used to do this, until we realized that we were both losing easy money and making ourselves obsolete.

In my mind, if someone wants to consult me because they can't/won't write a detox protocol, that only makes my job more valuable, and only earns my department/attending/me/whoever some easy money.

I agree that most of these cases are so easy that any doc should be able to manage them, but if they don't want to, I'm more than happy to take the credit and the billing, while bolstering the world's need for psychiatrists.

 

[splik]

The 4 D's of c-l psychiatry: 1) Delirium 2) Dementia (including decisional capacity evaluation) 3) Depression (including adjustment d/o and grief) and 4) The Dud referral.

For all consulting services there are Dud referrals but the path of least resistance is often the best way to go which is to say JFDI. If the team are consulting you about something you think they should know how to deal with, it means either they don't, or they are lazy. Teach them.

Also sometimes a dud referral like "this patient cried during rounds" turns out to be a pt with acute polymorphic psychotic disorder. You would have missed this if you curbsided and refused to see the patient. Or the alcohol withdrawal pt turns out not to have withdrawal but alcohol hallucinosis with good-going schneiderian symptoms. Again you would have missed this if didn't see the patient. Or that depressed patient turns out to have PTSD. Or the pt with brittle epilepsy who they think has PTSD, is actually a brittle borderline with multiple previous psych admissions etc etc.

Sadly most of the time the dud referrals really are just ridiculous but you were asked for your psychiatric opinion.

 

[vistaril]

My institution used to do this, until we realized that we were both losing easy money and making ourselves obsolete.

In my mind, if someone wants to consult me because they can't write a detox protocol, that only makes my job more valuable, and only earns my department/attending/me/whoever some easy money.

I agree that most of these cases are so easy that any doc should be able to manage them, but if they don't want to, I'm more than happy to take the credit and the billing, while bolstering the world's need for psychiatrists.

a lot of it depends on the payer source/demographics of the patient at your institution. A lot of academic hospitals are set up that a small number of consults(especially if they arent medicare age) actually get reimbursed. Also, a lot of insurers only pay for so many consults in a given time period/cycle. My guess is that teams who are consulting for etoh withdrawl are also consulting a whole bunch of other services for a whole bunch of other nonsense.....

and they arent consulting you because they "cant"....they are consulting you because they are lazy, dont want to do anything, and are just dumping scutwork on you. there is a difference.

 

[digitlnoize]

a lot of it depends on the payer source/demographics of the patient at your institution. A lot of academic hospitals are set up that a small number of consults(especially if they arent medicare age) actually get reimbursed. Also, a lot of insurers only pay for so many consults in a given time period/cycle.

Well, not everywhere is like that. Some places get a set fee for each consult, so it's to their advantage to see more consults.

and they arent consulting you because they "cant"....they are consulting you because they are lazy, dont want to do anything, and are just dumping scutwork on you. there is a difference.

🙄 Fixed it above, just for you and the other concrete thinkers out there.

 

[notdeadyet]

and they arent consulting you because they "cant"....they are consulting you because they are lazy, dont want to do anything, and are just dumping scutwork on you. there is a difference.

Again, I'm curious where you're at. If your descriptions are accurate, which i wonder, then both medicine and psychiatry at your place might need some inservicing.

I also agree with splik that curbsides are bad juju and should be avoided. Block the flagrantly inappropriate use of your services and staff the rest. Agreeing to consult doesn't mean you're necessarily taking on the patient. They just need advice much of the time, either because it'd outside their scope of practice or is inside their scope of practice and they're rusty. A good consult teaches them and reduces repeated requests for your services later and helps the reputation of your department.

Maybe they're lazy, but more often they're probably not. It takes them long to relay all the information you need then meet with you to go over recs than it would be to write their own CIWA and other instructions to nursing.

And curb siding can lead to badness. You're relying on another department to essentially let you make a diagnosis and treatment plan with all second hand info. This can lead to mistakes, and you're at least partially accountable.

 

[vistaril]

Well, not everywhere is like that. Some places get a set fee for each consult, so it's to their advantage to see more consults.
.

set fee? that typically only happens with small community hospitals that couldn't find people to do consults......

 

[vistaril]

Again, I'm curious where you're at. If your descriptions are accurate, which i wonder, then both medicine and psychiatry at your place might need some inservicing.
.

hehe....the medicine program here(Im in the northeast) is generally regarded as a top 10 program nationally.....the idea that they would need "in servicing" is ludicrous.

 

[surftheiop]

hehe....the medicine program here(Im in the northeast) is generally regarded as a top 10 program nationally.....the idea that they would need "in servicing" is ludicrous.

After quick look at IM forums seems like MGH, UPenn, and Coumbia are the only top-10 IM programs in the northeast with psych programs and all those places have foreign medical grads in their psych programs, so your stories about going to a foreign grad free program dont seem to be adding up.

 

[vistaril]

After quick look at IM forums seems like MGH, UPenn, and Coumbia are the only top-10 IM programs in the northeast with psych programs and all those places have foreign medical grads in their psych programs, so your stories about going to a foreign grad free program dont seem to be adding up.

I thought I said I went to a program that "typically doesnt recruit" imgs or somesuch.....Im not going to give away my program, but clearly having 5-10% of residents in a program being img's can go along with img-unfriendly.....needless to say if(because we dont many years)/when we take an img, they are super special

for example columbia's img% is FOUR percent. Most years they have zero. Similar for penn. Harvard is even lower, having only 2(and none the last two classes) out of 60+...meanng they have less than TWO percent.

So, in over 100 residents total, there are ~5 imgs........5%.

That's about as good as you're going to find in psychiatry.

 

[whopper]

.Im not going to give away my program

Why not?

 

[vistaril]

Why not?

because I don't know who else reads these....I prefer to be honest and say what I feel(in both a good and bad way), and certainly being anon makes that more feasible. I'm not bothered by people who are not anonymous; it's just not for me.

 

[whopper]

I get that, but there's also something to be said for those willing to be honest and take the responsibility for their words. I would like to think your program would be willing to hear what you'd be saying good or about it.

 

[notdeadyet]

hehe....the medicine program here(Im in the northeast) is generally regarded as a top 10 program nationally.....the idea that they would need "in servicing" is ludicrous.

You've made it very clear you're big into rankings, but if your medicine department is calling in soft consults as frequently to your psych c/l team as you say that require you to try to block and curbside so much, they need in servicing.

Incidentally, this isn't necessarily a knock on the medicine team. If your psych department allows what you're indicating, it's a shared problem.

 

[splik]

for example columbia's img% is FOUR percent. Most years they have zero. Similar for penn. Harvard is even lower, having only 2(and none the last two classes) out of 60+...meanng they have less than TWO percent.

So, in over 100 residents total, there are ~5 imgs........5%.

That's about as good as you're going to find in psychiatry.

Err..if by Harvard you mean MGH/McLean - there are currently 3 IMGs, not 2, and there was 1 in this years graduating class (so there had been 4 which would be over 6%). Longwood had none, CHA had none. Moot point, still small numbers but the idea that foreigners are subpar is not all that true. Even in less desirable programs, I can't help but feel they often get a better deal with foreigners in many case than they would with poorer home-grown applicants.

(as for columbia's lack of IMGs - part of this is selection bias - the IMGs i know rank columbia and cornell low because they don't sponsor H1 visas. i didn't even bother applying in the end).

 

[DOC PENGUIN]

because I don't know who else reads these....I prefer to be honest and say what I feel(in both a good and bad way), and certainly being anon makes that more feasible. I'm not bothered by people who are not anonymous; it's just not for me.

Honestly, everyone here knows that i am a failed student and have a imaginary girlfriend. Thus Pre-Health. Anasazi is from florida and Whopper is from the University of Cincinnati, OPD is a higher up and is in psychiatric education. I sent you a PM to verify your presence. As you might work at a really bad program.

 

[nitemagi]

because I don't know who else reads these....I prefer to be honest and say what I feel(in both a good and bad way), and certainly being anon makes that more feasible. I'm not bothered by people who are not anonymous; it's just not for me.

I'm just working on the hypothesis that you're not a real resident. Your posts seem to indicate a basic understanding of psychiatric terminology, which could be a med student or psych nurse or perhaps a resident. But your relative oversimplification of all complex issues, black and white thinking, and dismissiveness of others, combined with factual inaccuracies and inflammatory phrasing in my eyes eliminates any benefit from your contributions. At worst you're a troll, at best you're a resident without much substance to contribute.

 

[surftheiop]

Seems like a decent chance his "GI fiance" is actually him (or who he hopes to be).

If nothing else I find it rather unlikely that he is really at a top psych program, he never seems to have any respect for the clinical or intellectual ability of the majority of his attendings (save for the couple that apparently think exactly like he does). Additionally he made it pretty clear he doesn't learn anything (except for moonlighting) during his 4th year which seems to be inconsistent with the top northeastern programs that tend to value psychotherapy?

 

[digitlnoize]

set fee? that typically only happens with small community hospitals that couldn't find people to do consults......

Interesting...because I'm at a large academic institution...

And where do you get this information? Each contract is negotiated with each payor separately, and the variety of arrangements seen at each type of hospital is sure to vary considerably from one place to another.

 

[vistaril]

I'm just working on the hypothesis that you're not a real resident. Your posts seem to indicate a basic understanding of psychiatric terminology, which could be a med student or psych nurse or perhaps a resident. But your relative oversimplification of all complex issues, black and white thinking, and dismissiveness of others, combined with factual inaccuracies and inflammatory phrasing in my eyes eliminates any benefit from your contributions. At worst you're a troll, at best you're a resident without much substance to contribute.

Well we'll just have to disagree.....(shrug)

 

[vistaril]

Seems like a decent chance his "GI fiance" is actually him (or who he hopes to be).

If nothing else I find it rather unlikely that he is really at a top psych program, he never seems to have any respect for the clinical or intellectual ability of the majority of his attendings (save for the couple that apparently think exactly like he does). Additionally he made it pretty clear he doesn't learn anything (except for moonlighting) during his 4th year which seems to be inconsistent with the top northeastern programs that tend to value psychotherapy?

there are a lot of residents at my program who do really get into psychotherapy. Maybe half. There are a lot(including me) who don't. While certain programs in the northeast do tend to emphasize psychotherapy more than some other programs, except for the basic core requirements(that supposedly every program must have to be accredited) you're free to devote as little or as much time to it as one wants.....

 

[michaelrack]

. I'm not bothered by people who are not anonymous.

that's good

 

[PikminOC]

there are a lot of residents at my program who do really get into psychotherapy. Maybe half. There are a lot(including me) who don't. While certain programs in the northeast do tend to emphasize psychotherapy more than some other programs, except for the basic core requirements(that supposedly every program must have to be accredited) you're free to devote as little or as much time to it as one wants.....

As a resident, how do you post 7.5 messages on SDN per day?

 

[vistaril]

As a resident, how do you post 7.5 messages on SDN per day?

residency in psychiatry is not all that demanding time wise....I do work A LOT, but the vast majority of this is moonlighting now.

 

[PikminOC]

Quantity over quality I suppose.

 

[BS81]

residency in psychiatry is not all that demanding time wise....I do work A LOT, but the vast majority of this is moonlighting now.

You mind sharing what kind of moonlighting, how much you're able to do, and how much you're getting? I've always wondered what kind of options these were

 

[vistaril]

You mind sharing what kind of moonlighting, how much you're able to do, and how much you're getting? I've always wondered what kind of options these were

sure....

I moonlight an average of 12 hrs/week at 100 dollars an hour at an outpt clinic that sees a lot of medicaid pts. This is high volume med mgt. 4 pts scheduled in 1 hr(q15 minute appts)

I moonlight an average of ~16 hrs a week at an average of 90 dollars(anywhere from 75 to 110 depending on the shift)

Once a month, I do weekend coverage for a whole hospital. This means new admissions from the er and direct admits, cover the floor, any weekend consults and see all pts(about 25 total on floor) with notes both sat and sunday. Generally I start work at 730am sat and finish about 430pm, then go home and take call from home. Then do it again on sunday(same schedule) and do home call sun overnight. This pays 2650 for the whole weekend. Good money but it's also real work and fairly busy.

So my average moonlighting $ this year in a given month is going to be almost 6k in a normal month.

This is good, but I know of people in IM and family who do better if they really work hard and get can a lot of "overnight coverage" shifts as a hospitalist moonlighter.

 

[vistaril]

Quantity over quality I suppose.

not sure who you are(and not particularly concerned either way) and I am also not sure why you have decided to pop off here unprovoked, but I assure you the quality of training I have recieved and care I provide is excellent.

 

[PikminOC]

Quantity of posts. We all know your training is magnificent and you have ample time to post on SDN since you are moonlighting.

Interesting you would even bring up the notion of wanting to know who I am.

 

[vistaril]

Quantity of posts. We all know your training is magnificent and you have ample time to post on SDN since you are moonlighting.

a lot of inpt moonlighting is sitting around carrying a pager and waiting for cross coverage issues or the occasional admit.......plenty of time to do whatever much of the time.

 

[211519]

Sorry to bump this, but regaring the OP: I'm starting on C-L after I finish my current rotation. Any other pointers or suggested reading?