Consulting medicine

[TheWowEffect]

There is discussion going on in another thread about psychiatry getting majority of BS consults. In essence, I totally agree with this. However, talking to IM folks gives me the impression that they really look down on psychiatrists because we consult them for even something as innocuous as BP of 140/90 or blood sugar of 140.

I have thought over this for a long time and find myself agreeing with the medicine folks. I think we need to step up and change the way we do things, especially in inpatient. We need to start treating by ourselves these simple conditions like rhinitis, mild elevation of HTN, mild rise in blood sugar esp. if pt is already a diabetic, or simple UTIs. At the very least, we need to initiate most of the stuff and then call medicine once something concrete is established. There is also a need, when convenient, to start conducting our own physical exams in inpatient.

I know this is a controversial subject and practice may vary from hospital to hospital. There are going to be strong opinions on this, both for and against. I will, therefore, put up a poll asking the question- Do we need to change the way we consult medicine for every patient in inpatient and why?

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[TheWowEffect]

For ones responding to the poll: Please give your reasons to move this discussion forward.

 

[billypilgrim37]

For ones responding to the poll: Please give your reasons to move this discussion forward.

My only qualm with the above is with the psychiatrist regularly performing the physical exam. If, say, a patient on my floor was short of breath, I better be there with a stethoscope. And perhaps I'm envisioning a particularly small subset of our patients, but too many of our patients have significant boundary issues and/or histories of physical abuse that make us doing the routine physical exam possibly antagonistic to the therapeutic relationship.

But yes, we should be managing far more medical comorbidities than we do.

 

[TheWowEffect]

My only qualm with the above is with the psychiatrist regularly performing the physical exam. If, say, a patient on my floor was short of breath, I better be there with a stethoscope. And perhaps I'm envisioning a particularly small subset of our patients, but too many of our patients have significant boundary issues and/or histories of physical abuse that make us doing the routine physical exam possibly antagonistic to the therapeutic relationship.

But yes, we should be managing far more medical comorbidities than we do.

Good point and I am also somewhat torn on that one. I'll edit that part to make it more clear.

 

[OldPsychDoc]

I didn't respond because the way the question is worded implies that "we" do it the same way in every inpatient setting. For example, we have a large (96 bed) inpatient setting with a fulltime FP and PA covering most of our medical needs, and consulting out as needed for cards, endo, etc. At the same time, I feel comfortable managing some basics, so often don't even consult them. So no, I don't feel the need to change the way our service is run, but I know that other hospitals do things quite differently.

 

[TheWowEffect]

I didn't respond because the way the question is worded implies that "we" do it the same way in every inpatient setting. For example, we have a large (96 bed) inpatient setting with a fulltime FP and PA covering most of our medical needs, and consulting out as needed for cards, endo, etc. At the same time, I feel comfortable managing some basics, so often don't even consult them. So no, I don't feel the need to change the way our service is run, but I know that other hospitals do things quite differently.

Well, I did say that this may vary from hospital to hospital. However, one can safely make a generalization about how things are done at most psychiatry inpatients. I think the model you have is pretty interesting. Most VAs have PAs or FPs like you do. I think it is much better than having a medical consult for every patient that comes in.

 

[Doc Samson]

I didn't respond because the way the question is worded implies that "we" do it the same way in every inpatient setting. For example, we have a large (96 bed) inpatient setting with a fulltime FP and PA covering most of our medical needs, and consulting out as needed for cards, endo, etc. At the same time, I feel comfortable managing some basics, so often don't even consult them. So no, I don't feel the need to change the way our service is run, but I know that other hospitals do things quite differently.

Ditto. Even without a fulltime FP or PA, the majority of the times I called medicine were when the pt needed to be transferred to their service.

 

[Faebinder]

I am one of those witnessing the "call medicine for High BP" or "call medicine for high sugar" or "call medicine for high WBC and white cells in the urine".

I agree, we consult medicine a lot for BS stuff we should manage. I can't help but think that this happens a lot for old school attendings.

I mean come on... person with 150/90 BP and pulse of 100.... on two readings.... is it that bad to put lopressor on board? A high/low TSH should not equal medicine consult automatically. Order repeat TSH with T3 and T4 levels.

Usually I meet the resistance at the nurse level actually who just refuse to think of psychiatry patients as people who might actually have medical problems. "The patient is just med seeking".

 

[Solideliquid]

The main problems on our unit is the attendings. At first I felt that the attendings didn't trust our medical knowledge. As the first year went on, I figured out what the problem was. The attendings' own medical knowledge was lacking. At one point my attending asked me to clarify what the numbers meant when I noted a BMP in the chart in a skeleton form.

I really feel that when an attending asks me what if any does a 133 sodium have on a patient's mental status and isn't happy with my answer he asks for a medicine consult. If a patient had a cough, no sputum, no fever, no white count but the patient was concerned, my explanation of a URI wasn't good enough. Another medicine consult. "Why?" I would ask, the answer was usually "maybe another perspective can help us, and even if this is a little thing, maybe fixing this small problem will correct some portion of the mental status". Me: "ooooohhhhhhkkkkkk"

 

[TheWowEffect]

The main problems on our unit is the attendings. At first I felt that the attendings didn't trust our medical knowledge. As the first year went on, I figured out what the problem was. The attendings' own medical knowledge was lacking. At one point my attending asked me to clarify what the numbers meant when I noted a BMP in the chart in a skeleton form.

I really feel that when an attending asks me what if any does a 133 sodium have on a patient's mental status and isn't happy with my answer he asks for a medicine consult. If a patient had a cough, no sputum, no fever, no white count but the patient was concerned, my explanation of a URI wasn't good enough. Another medicine consult. "Why?" I would ask, the answer was usually "maybe another perspective can help us, and even if this is a little thing, maybe fixing this small problem will correct some portion of the mental status". Me: "ooooohhhhhhkkkkkk"

This is the kind of stuff I used to get frustrated with when I was doing inpatient. Some attendings either have forgotton everything or they just don't want to do the extra work. There is also this fear of liability "if something happens." This attitude needs to change if psychiatrists want to earn more respect and not have psychiatry trashed as an "easy and non-medical speciality."

 

[TheWowEffect]

Ditto. Even without a fulltime FP or PA, the majority of the times I called medicine were when the pt needed to be transferred to their service.

I don't know when and where you trained but this is no more the case at most inpatient facilities.

 

[Doc Samson]

I don't know when and where you trained but this is no more the case at most inpatient facilities.

I think it does depend on where you train and the local culture of psychiatry. In Boston, the departmental wish to "prove" that we ARE actually physicians and not "just" psychiatrists has led to a culture of psychiatrists taking care of medical problems. I can't imagine asking someone from another department to do an admit H+P as mentioned above. Also, any attending that couldn't demonstrate an understanding of basic medicine wouldn't last too long. I was happy to find the situation to be pretty similar when I left Boston for Arizona (although the NP model is more pervasive here). I'm curious as to what your N is for "most inpatient facilities."

 

[TheWowEffect]

I think it does depend on where you train and the local culture of psychiatry. In Boston, the departmental wish to "prove" that we ARE actually physicians and not "just" psychiatrists has led to a culture of psychiatrists taking care of medical problems. I can't imagine asking someone from another department to do an admit H+P as mentioned above. Also, any attending that couldn't demonstrate an understanding of basic medicine wouldn't last too long. I was happy to find the situation to be pretty similar when I left Boston for Arizona (although the NP model is more pervasive here). I'm curious as to what your N is for "most inpatient facilities."

I am happy to know that this is happening in Boston. This culture needs to spread. As a personal experience, I am aware of may be only less than 10 facilities that have this practice but I keep hearing stuff from my IM friends and acquaintances, psychiatry residents from other programs etc. There is an automatic consult placed for an H & P. Many posters on SDN can attest to the fact that this happens at their facilities. So, I believe this is pretty widespread.

 

[Solideliquid]

This is the kind of stuff I used to get frustrated with when I was doing inpatient. Some attendings either have forgotton everything or they just don't want to do the extra work. There is also this fear of liability "if something happens." This attitude needs to change if psychiatrists want to earn more respect and not have psychiatry trashed as an "easy and non-medical speciality."

Ha ha, this really reminded me of one attending. A patient with a normal BP and a PR of 108 on the inpatient unit. The patient had a normal PR on admission in the ER. So the attending looks at me and ASKS(!!) why is the PR so high? I kind of stare at her for a few seconds and, to tell you the truth I don't know what to say to her! I tell her perhaps the patient is anxious about being on a locked psych ward. However before we do anything I should go and check it again manually. "I think we should maybe get a medicine consult"...then she actually has the balls to write in my evaluation that I need to pay more attention to medical issues.

 

[Faebinder]

Ha ha, this really reminded me of one attending. A patient with a normal BP and a PR of 108 on the inpatient unit. The patient had a normal PR on admission in the ER. So the attending looks at me and ASKS(!!) why is the PR so high? I kind of stare at her for a few seconds and, to tell you the truth I don't know what to say to her! I tell her perhaps the patient is anxious about being on a locked psych ward. However before we do anything I should go and check it again manually. "I think we should maybe get a medicine consult"...then she actually has the balls to write in my evaluation that I need to pay more attention to medical issues.

Argh... so sorry to hear that.

Our inpatient unit carries about 30 beds. We are consult happy as well, but fortunately I think the resident skill level is high enough not to call consults at a crazy rate... only semi-crazy rate.

Maybe more IM time is warranted in psychiatry.

 

[hippiedoc13]

I am happy to know that this is happening in Boston. This culture needs to spread. As a personal experience, I am aware of may be only less than 10 facilities that have this practice but I keep hearing stuff from my IM friends and acquaintances, psychiatry residents from other programs etc. There is an automatic consult placed for an H & P. Many posters on SDN can attest to the fact that this happens at their facilities. So, I believe this is pretty widespread.

I can't even imagine an "automatic consult for H&P." Every single patient admitted to inpatient psych gets an H&P by the psych resident admitting them. The only aspects of the physical that I won't do in the psych setting are breast, genital, and rectal exam, for obvious boundary reasons. And by the way, I'm far away from Boston!

 

[BabyPsychDoc]

In my experience, the cultural perception of psychiatrists being unable/unwilling/unqualified is very wide-spread to the extent that I would have called it universal was it not for DocSamson's comment about Boston.

In fact, this culture was the reason I am training in FM now. When I was undecided whether to go for FM or Psych, my Psych attending counselled me to try FM out first; in his words, "you can always re-train in Psych after FM, but not the other way round".

When I was working on inpatient, I was doing night float over w/e. There was this woman with bipolar on valproate and olanzapine that was handed over to me by the day resident - apparently, she had been sitting on the ward with T of 38-39 C for a WEEK, treated for a "presumed UTI" with no improvement. So, they switched her to a different ABx, and continued to treat "the presumed UTI". You know, actually you examine her and she had PR of 120/min - and BP of 90/70 mm Hg! I could not find any focus of infection, but she was obviously septic, so I arranged a transfer to a medical ward (the only thing that was concerning in her PMH was that she had some abdo surgery a few months earlier). Guess what? She ended up on a surgical ward (after medic worked her up, of course!), with multiple abscesses in spleen, paravertebral space and liver.

I could not believe that I was the only person in the entire mental health hospital that realised the woman needed being sorted out URGENTLY, and not just sat on her with another course of ABx.

 

[michaelrack]

In private practice, this is common. In the private psych hosp I occasionally cover on weekends, a family nurse practitioner is pretty much automatically consulted for each admission. I go along with this system (even though I'm also BC in Internal Med) because doing a physical exam and detailed medical hx would add 15 minutes to the admission, and would add no additional payment for me (I usually bill 90801 for an admission). In addition, then the calls go to the NP instead of me for middle of the night chest pain, etc.

 

[HCE]

As an "outsider" , I wonder if the practice of referring medical issues to medicine rather then allowing psych docs to handle routine medical issues isn't dictated by liability insurers, hospital lawyers and hospital policies dictated by these two groups. Imagine, some patient condition looks routine, the psych doc. treats, and something very bad results. Even though the psych may have treated exactly the same way that the IM doc. would have done, in the resulting malpractice case, the first thing patient's counsel would raise is that a non-IM doc. should not have, but did treat the routine condition, and that perhaps the IM doc. would have caught the problem quicker. Just a thought...

 

[BabyPsychDoc]

As an "outsider" , I wonder if the practice of referring medical issues to medicine rather then allowing psych docs to handle routine medical issues isn't dictated by liability insurers, hospital lawyers and hospital policies dictated by these two groups. Imagine, some patient condition looks routine, the psych doc. treats, and something very bad results. Even though the psych may have treated exactly the same way that the IM doc. would have done, in the resulting malpractice case, the first thing patient's counsel would raise is that a non-IM doc. should not have, but did treat the routine condition, and that perhaps the IM doc. would have caught the problem quicker. Just a thought...

I am sure this is certainly contributing to the problem. Attendings in "non-medical" specialties (eg, OBGYN, ortho, psych - sorry guys!) have always driven me up the wall when it comes to management of some rather common - but potentially complex - medical conditions. Getting an IM consult for, say, WPW syndrome patient is one thing - but calling a (potentially less experienced) IM resident to discuss a patient with a minor MI... I mean, I can read and ECG and order trop levels just as well - but "we just need to cover all bases, and make sure it is all documented..." Cover your arse, in other words.

 

[michaelrack]

Getting an IM consult for, say, WPW syndrome patient is one thing - but calling a (potentially less experienced) IM resident to discuss a patient with a minor MI... I mean, I can read and ECG and order trop levels just as well - but "we just need to cover all bases, and make sure it is all documented..." Cover your arse, in other words.

BabyPsychDoc, when you say "minor MI", I hope you're talking about a patient who had an MI in the past. IM and/or cardiology should be called immediately if a psych patient is having an acute coronary syndrome. Time is (cardiac) muscle.

 

[Solideliquid]

BabyPsychDoc, when you say "minor MI", I hope you're talking about a patient who had an MI in the past. IM and/or cardiology should be called immediately if a psych patient is having an acute coronary syndrome. Time is (cardiac) muscle.

Well here's the thing, chest pain without SOB, diaphoresis, radiation of pain, syncope, has a long list of differential diagnosis. Would you immediately call a consult? I had this situation come up recently. I did a STAT EKG, CBC, CMP, D-Dimer, and Cardiac Enzymes x3, also checked her vitals (normal) and set vitals q2h. The first set of enzymes came back in less than 45 minutes and were normal. So I checked on the patient and she was fine, except her complaint had not resolved. I gave her 325mg aspirin and waited it out. The next set came back at about 7:45 am (elevated) after I had left at 7:30, the resident on rounds called a medicine and cards consult and she was transfered.

On cards they didn't do anything except give her aspirin daily, she was on telemetry for two days and discharged. They diagnosed her with a possible MI or NSTEMI. She may have had a minor MI. She was in her 80s, and cards didn't bother to do a cath so I never found out if any of her heart muscle had been damaged.

 

[michaelrack]

Well here's the thing, chest pain without SOB, diaphoresis, radiation of pain, syncope, has a long list of differential diagnosis. Would you immediately call a consult? I had this situation come up recently. I did a STAT EKG, CBC, CMP, D-Dimer, and Cardiac Enzymes x3, also checked her vitals (normal) and set vitals q2h. The first set of enzymes came back in less than 45 minutes and were normal. So I checked on the patient and she was fine, except her complaint had not resolved. I gave her 325mg aspirin and waited it out. The next set came back at about 7:45 am (elevated) after I had left at 7:30, the resident on rounds called a medicine and cards consult and she was transfered.

On cards they didn't do anything except give her aspirin daily, she was on telemetry for two days and discharged. They diagnosed her with a possible MI or NSTEMI. She may have had a minor MI. She was in her 80s, and cards didn't bother to do a cath so I never found out if any of her heart muscle had been damaged.

BabyPsychDoc didn't say "chest pain", he said "minor MI". I do think a consult should immediately be called in the situation you describe- basically any time there is a reasonable suspicion of cardiac ischemia. I am surprised that in your patient cards didn't give her heparin or enoxaparin. I am surprised that NTG wasn't given. I am surprised that cards didn't do anything other than ASA- was a beta blocker or ACE inhibitor started? What about a statin? There are several ways to check for cardiac muscle damage. Was an echocardiogram done?

If all that cards did in your institution, for a patient with "possible MI or NSTEMI", was ASA/telemetry, I can see why you may not see the need to consult them.

 

[Solideliquid]

BabyPsychDoc didn't say "chest pain", he said "minor MI". I do think a consult should immediately be called in the situation you describe- basically any time there is a reasonable suspicion of cardiac ischemia. I am surprised that in your patient cards didn't give her heparin or enoxaparin. I am surprised that NTG wasn't given. I am surprised that cards didn't do anything other than ASA- was a beta blocker or ACE inhibitor started? What about a statin? There are several ways to check for cardiac muscle damage. Was an echocardiogram done?

If all that cards did in your institution, for a patient with "possible MI or NSTEMI", was ASA/telemetry, I can see why you may not see the need to consult them.

Do you work with residents at your position? I mean here I could ONLY consult a resident, therefore the resident would normally tell me to order all the above (see previous post) and let them know when the results are in. The only way a consult resident (cards or IM) would come charging into the psych unit is if I was ready to call a code or if the patient collapsed. Basically if someone has chest pain in the night with normal vitals, normal EKG, and normal cardiac enzymes the cards resident would tell me someone would see them in the morning and get two more sets of cardiac enzymes. That's what I ended up doing anyway, except I did it without hearing the cards residents' attitude at 4am.

Edit: about the echo: This was about three-four months ago is it's a little hazy, but since we are talking about someone in their 80's with a history (at least I think she had) of HTN you would likely see some LV dysfunction on echo, if not also hypertrophy/cardiomegaly so the echo wouldn't really help you unless you had a recent one to compare, right?

 

[BabyPsychDoc]

Believe it or not, but here where I work (tertiary referral centre affiliated with a world-renown university) we do not get very excited about possible NSTEMIs. Unless the ST segment is elevated at least 2 mm, all that we do for ACS is analgesia, nitrates, oxygen, aspirin, consider ACE-i and beta-blocker, observe, symptomatic support (I am just talking treatment, not invx like echo, angio etc). So, cards get pretty pissed off if you call them about a ( possible) NSTEMI - especially in the middle of the night.

I managed a case very similar to the one described by solideliquide recently: except the patient was day 3 postop and had a weakly positive Homan sign, so the ?PE muddled the differential further. Well, the patient's trop-I came back at 2 (12 hours), the cards grudgingly made an appearance, scribbled in the notes that they recommended echo and CTPA, advised to continue ACS protocol and graciously disappeared. Well, I would have done exactly those things without wasting 15 min on the phone trying to get them over to see my patient...

 

[Solideliquid]

Believe it or not, but here where I work (tertiary referral centre affiliated with a world-renown university) we do not get very excited about possible NSTEMIs. Unless the ST segment is elevated at least 2 mm, all that we do for ACS is analgesia, nitrates, oxygen, aspirin, consider ACE-i and beta-blocker, observe, symptomatic support (I am just talking treatment, not invx like echo, angio etc). So, cards get pretty pissed off if you call them about a ( possible) NSTEMI - especially in the middle of the night.

I managed a case very similar to the one described by solideliquide recently: except the patient was day 3 postop and had a weakly positive Homan sign, so the ?PE muddled the differential further. Well, the patient's trop-I came back at 2 (12 hours), the cards grudgingly made an appearance, scribbled in the notes that they recommended echo and CTPA, advised to continue ACS protocol and graciously disappeared. Well, I would have done exactly those things without wasting 15 min on the phone trying to get them over to see my patient...

You mean someone is going to come over at 4am to do an echo at your institution?

 

[michaelrack]

BabyPsychDoc, Solideliquid, I am sorry the cardiologists/internists are so lazy/unconcerned at your institutions. I guess you're doing the best you can under the circumstances.

Are you allowed to give anticoagulant dose heparin/enoxaparin on the psych wards? When I was a med resident, these were routinely given for NSTEMI.

Echo findings in chronic htn would include LV hypertrophy, maybe some diastolic dysfunction. Usually ejection fraction is fairly well preserved (EF greater than 50%). In some cases, after a recent MI there might be decreased EF. There could be cardiac wall motion abnormalities during acute ischemia.

I work in a private sleep lab without residents. The last time I covered a private psych hospital for the weekend was about 4 months ago. A Nurse practitioner is called for medical problems (she is supervised by a FP).

 

[CaMD]

So it sounds like Boston and Arizona have psychiatrists that practice some general medicine. Can anyone speak for any west coast programs that do or do not have an environment where psychiatrists do some good ole fashioned IM?

 

[radslooking]

I don't know of a situation for which heparin/lovenox is not indicated for NSTEMI. Unless there's some massive ongoing bleeding or a head bleed. Not sure what's going on there. I'd say for chest pain, a consult is in order.

Moreover, to what im used to, Cards usually caths NSTEMI's within a few days, or at least risk stratifies and then chooses to cath or not cath based on those tests. I don't think you'd find an institution that apathetic in the US. Im not saying which system is better, I'm just saying you wouldnt find an institution quite like that here.

 

[ronin12]

It seems most of these simple IM consults are in academic sectors of psych rather in non academics. as far i know almost all of the psych hosp/non academic psych units have designated PA's or NP's to take care of medical issues. actually when our Np or PA's admits the pt, he/she staffs the pt with psychiatrist to discuss both medical and psychiatric aspects of patient. on several occasions they directly asked my help to manage more complex medical illnesses. to my surprise I was able to discuss and guide them about management of fairly complex medical issues. As far As my hosp is concerned, privileges for psychiatrists are pretty much limited to psych disorders. I guess the whole issue of liability holds us back from managing these simple or semi complex medical problems.
I am kinda uncertain about this liability as being physicians we are authorized to treat medical illnesses, but our privileges are exclusively for psychiatric disorders.

Anyone have thoughts how it effects liability ?, As our degree allows us to be physicians but privileges restricts the scope of practice to only psychiatry.

 

[whopper]

I'll apologize in advance for not reading every single post above. I might be writing something already addressed.

I've whined about this several times in the board. However that was when I was a resident. Now I'm an attending & I've worked in a handful of institutions now outside of my residency.

This problem that was mentioned above definitely was true in my residency. While my program was in a university hospital, one of the hospitals that 1/3 of the residents worked in was a community hospital and the IM attendings had to be used before residents.

The IM-hospitalists doing the consults would always get ticked off with the consults ordered by psyche, and most of them were BS on the part of the psychiatrists. Further IMHO, much of it was sheer laziness.

E.g. a psyche attending ordered a med consult because the patient had hypertension, yet the patient was on a BP med for years that was clearly known, but the psyche attending was too lazy & chicken to order it. This was especially true of the weekend docs covering the inpatient unit because they weren't going to be present on Mondays--the days when the consults finally got to the hospitalists who'd be ticked off with the consults.

At other institutions, this problem was not happening or not happening as much because the psyche attending & IM/hospitalists were in better communication over how to handle this. However at the place I was at, they were not.

I could whine about the specifics of this bad relationship, but it really wouldn't advance the thread. It'd only be of use if you were at the institution. Now of course, as I mentioned in other threads, the IM dept also ordered BS consults quite a bit from psyche as well.

Another layer that added to the problem was ER docs were dumping patients to psychiatry. They were stamped as medically cleared but the ER doc really did no inspection of the patient. E.g. one patient had 2 broken legs, the ER doc said nothing was wrong & wrote that the phys exam was completely normal. When you're a psyche doc and you get this type of dump, of course you're going to order a stat consult--which in turn ticks off the IM doc--> who then blames the psyche dept for accepting this type of patient when in fact the psyche dept must accept the ER doc's word on his report.


The answer IMHO should've been someone above all the depts asking both on how to reduce this problem & set better & clearer guidelines on what justifies a consult. However no one was doing that while I was there. I actually brought that up a few times to my superiors, but they just shrugged it off.

The fact that residents were there actually added to the problem because the attendings in both depts would simply try to assign blame to the residents for ordering BS consults when often times it was the attending-not the resident who was the problem. (Faebinder is currently at my program--FB--its not all the attendings creating this problem. You'll figure out which are the problem ones by the end of first year--and they pretty much are the lazy attendings. The problem I'm mentioning may also have lessened because right before I graduated, the dept got a new program head that was going to tackle a lot of the problems the lazy attendings weren't solving on their own).

Now overall, I did love my residency program. None are perfect, and I've heard this same problem happen in several hospitals.

The place I'm at now, the IM doctor is part of my team and we are on the same page. She has never given me a problem and is quite helpful. I've also seen this happen at other institutions as well.

 

[BabyPsychDoc]

You mean someone is going to come over at 4am to do an echo at your institution?

Nope, I did not say that. Hell, they would not do it even at 4 pm. The standard response is, "And how is that going to change your management?"

 

[BabyPsychDoc]

BabyPsychDoc, Solideliquid, I am sorry the cardiologists/internists are so lazy/unconcerned at your institutions. I guess you're doing the best you can under the circumstances.

Are you allowed to give anticoagulant dose heparin/enoxaparin on the psych wards? When I was a med resident, these were routinely given for NSTEMI.

Echo findings in chronic htn would include LV hypertrophy, maybe some diastolic dysfunction. Usually ejection fraction is fairly well preserved (EF greater than 50%). In some cases, after a recent MI there might be decreased EF. There could be cardiac wall motion abnormalities during acute ischemia.

I work in a private sleep lab without residents. The last time I covered a private psych hospital for the weekend was about 4 months ago. A Nurse practitioner is called for medical problems (she is supervised by a FP).

In theory, yes, we can give anticoagulants on psych wards. In practice, the nurses are so twitchy about it, you practically need a verbal authorisation from an attending to do that.

 

[Solideliquid]

In theory, yes, we can give anticoagulants on psych wards. In practice, the nurses are so twitchy about it, you practically need a verbal authorisation from an attending to do that.

Also in my case, the cardiac enzymes were normal so why would you give lovenox (now, the second set arrived after I was already post-call at about 7:45, and then a consult was called).

About your earlier comment, I agree in that an echo wouldn't had really changed anything.

As I type this I remember another example. I had an overweight patient on the unit one night on call. As I remember she had just undergone surgery (about one day ago) on her breast for I think a torn vessel or something like this (vascular repair), don't know the details this was six months ago. However I get a call from the unit nurse stating that the patient is in pain and claims the breast is getting larger. I go and examine the patient (with a female nurse of course) and the breast does appear red, but I have no objective idea as to its size 12 hours ago so I can't compare. The patient states it's getting bigger but I feel she is somewhat unreliable. Anyway why take a chance? On the chance that there is some bleeding I call the surgeon on consults and guess what, he REFUSES to come to the unit. Straight up refuses. Says even something like "no there is absolutely nothing I can do for you" when I ask for help with this patient. How do you like that? Promised to send whoever was on in the AM up to see her first thing. Their team came in the afternoon, I heard the next day the patient had to go back to the OR. Sorry long post, it's 1am.

 

[Faebinder]

Also in my case, the cardiac enzymes were normal so why would you give lovenox (now, the second set arrived after I was already post-call at about 7:45, and then a consult was called).

About your earlier comment, I agree in that an echo wouldn't had really changed anything.

As I type this I remember another example. I had an overweight patient on the unit one night on call. As I remember she had just undergone surgery (about one day ago) on her breast for I think a torn vessel or something like this (vascular repair), don't know the details this was six months ago. However I get a call from the unit nurse stating that the patient is in pain and claims the breast is getting larger. I go and examine the patient (with a female nurse of course) and the breast does appear red, but I have no objective idea as to its size 12 hours ago so I can't compare. The patient states it's getting bigger but I feel she is somewhat unreliable. Anyway why take a chance? On the chance that there is some bleeding I call the surgeon on consults and guess what, he REFUSES to come to the unit. Straight up refuses. Says even something like "no there is absolutely nothing I can do for you" when I ask for help with this patient. How do you like that? Promised to send whoever was on in the AM up to see her first thing. Their team came in the afternoon, I heard the next day the patient had to go back to the OR. Sorry long post, it's 1am.

I get refused consults all the time. I consulted ophthalmology for a patient with cataract in one eye and glaucoma in the other eye. The patient's vision has been worsening and never addressed it with anyone. Consult was refused.

I am pretty convinced it's all supply and demand. Procedure oriented services wont come see the likely none procedure issues if they are overbooked.

 

[whopper]

Ditto. Even without a fulltime FP or PA, the majority of the times I called medicine were when the pt needed to be transferred to their service.

Well, Doc Samson is a psychiatrist of quality, and has trained at one of the top institutions. From his posts, he knows what he's talking about.

However, several psychiatrists are not of this quality. Several forget their medicine.

Yes, we are not supposed to know medicine as well as someone in IM, but some psychiatrists appear to know almost nothing. E.g. not knowing how to normalize a pt's potassium level (and nothing's wrong with the kidneys), & hypokalemia is a common occurrence I've noticed in crisis psychiatry among several other very blatant markers of lack of knowledge.

Some psychiatrists I've seen are even deficient in the medical knowledge they will need for psychiatry. E.g. I've known of a few that have not ordered lithium levels on their patients for years, nor did they check into the person's electrolytes. Had another who had a patient with hypothyroidism, and never considered that as a cause for the person's depression. The patient didn't have a GP & was never told to have their thyroid checked. The psychiatrists for years used several antidepressants to improve the patient & obviously with no success.

IMHO, the ones that didn't know their medicine well often times didn't know their psychiatry well either. They were, well ahem, just lazy, and went into the field because its one of the easier fields to pick for residency.

As a profession, our tolerance for this type of psychiatrist should be low.

 

[Doc Samson]

I think another aspect of this may be that I've always worked in hospitals with strong CL and Emergency Psychiatry presences - thus patients really are medically stable by the time they hit the inpatient psychiatry unit. Anything "new" that comes up tends to be either run-of-the-mill (we can take care of it) or urgent (enjoy your stay on the medical floor).

 

[deleted77919]

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[TheWowEffect]

We had a medicine attending assigned to the psychiatric service (it's a huge service at this hospital) who would round on each inpatient unit every day. He'd come in during psych rounds and pass along his thoughts on pts we had and we'd bring up issues related to any new admissions. This system pretty much prevented medicine from ever having to be consulted prn. If someone came in who'd been on BP meds for years they would be ordered while the pt was in CPEP, we'd double check the orders were in when they came to our unit, and IM would say a quick hello to the pt when they rounded in the morning. Occassionally there would be cases where transfer to medicine should be considered; during these times the IM attending would discuss the situation with the psych attending during morning rounds and a mutually agreeable solution would be reached. BS was always at a minimum and we always had easy access to IM, seemed like a pretty slick system to me.

Well, we have a similar system in our main teaching hospital. A team of attendings is assigned to the unit and they take turns in doing H & P on each patient after they are admitted. Residents manage the medical issues until that attending comes in. Residents actually end up doing a lot of stuff. So, it's actually not a bad system. Our VA on the other hand has the PA system and they do most of their stuff after discussion with residents.

I think my main point of starting this thread was to point out a serious flaw that may have crept in the attitude of some psychiatrists. A lot of criticism directed towards us in this context is relevant and we need to be more self reflective.

 

[michaelrack]

Also in my case, the cardiac enzymes were normal so why would you give lovenox (now, the second set arrived after I was already post-call at about 7:45, and then a consult was called).

It's possible to be having unstable angina or NSTEMI with a normal first set of enzymes. I am not going to comment on your specific case, but in general in someone with suspicious chest pain, it would be reasonable to give Lovenox/heparin even if the first set of enzymes was normal.

 

[Hurricane]

We rotate at four different inpatient sites and the amount of IM we do varies by site.

County Hospital:
We do physicals and manage med problems. Basic things like HTN I would manage myself, but we get a lot of medically complicated patients, so it was not uncommon to have people with IM, Renal, rheum, etc following them. Psych is well respected, probably in part because our consult team kicks ass.

University Hospital:
Same as above except one of the attending is double-boarded in psych and IM, so we can curbside him and avoid formal consults a lot of the time.

Private Hospital:
They have a contract with an IM group so a private attending (no residents) automatically does an H&P and takes care of any medical needs that arise. They get paid per patient, so they don't seem annoyed at having to do this.

VA:
We used to do physicals and take care of all the medical needs ourselves. We actually took care of a lot more medical needs ourselves than any other site. Not by choice, but because a lot of the time when you'd call a consult, the consulting team would never show up, despite repeated calls. It was appalling, and we had a some unstable patients and bad outcomes as a result. Things kind of reached a crisis point, and now we have a new system where all patients automatically get an H+P by a hospitalist attending, and there is a hospitalist on call that we can call. We don't deal with other services residents anymore - the hospitalists call the consults and the consulting teams actually show up now, and the patients get much better care. I think this scenario reflects a lack of professionalism on the part of the medical consult services rather than deficient medical knowledge on the part of the psychiatrists.

All in all, I think psychiatrists should manage the medical problems they feel comfortable managing, and they should be aware of their limitations. I'd rather see a consult called for something minor than see someone manage something wrong because they don't want to look stupid to the consult team. Right now, 1-2 years out of doing inpatient medicine, it's easy to roll our eyes at attendings who consult for simple things. But how confident are we going to be in our medical knowledge when it's been 50 years since we did our 2 months of inpatient medicine?

And regarding the comment above from the guy who couldn't believe any of the psychiatrists didn't recognize his patient was septic, that goes both ways. Just ask any C/L psychiatrist to tell you some delirium horror stories. I had one where I got consulted for depression, and I diagnosed him with meningitis, it took days for the primary team to finally order an LP, which confirmed my diagnosis. There are good and bad doctors on both "sides."

 

[kugel]

One rule that (I hope) has kept me from over-utilizing consults:
"Your response must be in the form of a question."
If my consult request is formatted as a discreet, answerable question, the consultant knows exactly what I need. This prevents the consultant from needing to review the entire case and comment on every possible medical problem, all the forms of treatment, etc. It often limits the consultant's time to only a few minutes. In addition, sometimes forcing myself to form a question makes me realize I already know the answer, i.e. don't need a consult. Then, part my treatment plan becomes, "If the response to this treatment is unsatisfactory, a consult may be required."

When I'm the consultant, I try to discern the question implied in the (sometimes vague) consult request. If in doubt, I go ask the requesting doc what, specifically, I can do to be of the most help. That way, I can make sure my consult is useful to the primary team. If I comment on broader issues in the case, that's just icing (or wasted paper, depending on your viewpoint).