Consulting medicine

[heyjack70]

I didn't want to derail the VA ED rant thread, so I started this one.

Nancy Sinatra quote:
"I've also gotten some very silly medical questions from psych attendings. Totally unnecessary consult requests, for example. Or asking me to consult medicine about very mild hypertension without first trying a first line treatment."


What are people's opinions on the issue of inpatient psychiatry consulting medicine? Should it be for every little thing? As a resident, fresh out of medicine, I thought it was fun and rewarding to manage basic issues, HTN, DM, etc. But as I progress through training, and my medicine knowledge slightly fades, and I think more about the real world after residency, I'm more inclined to consult medicine. I do this to save time, plus to avoid possible litigation in case something bad happens.

What are you thoughts?

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[nitemagi]

I tried to never consult medicine unless it was a situation where I really didn't know what to do. My philosophy was we all went to med school and we should all be comfortable doing the basics. I didn't call surgery without being able to tell them my abdominal exam (flawed though it may have been), never called medicine for basic HTN, and expected them to be able to report the basics to me for a psychiatric consult. In fact went by the basic rule that inpt consults should be for 1)urgent evaluations for anyone possibly needing transfer to another service, or 2)subacute issues that needed evaluation for anyone likely to have a prolonged stay.

Many attendings, though, do consults more as a CYA thing.

 

[atsai3]

I agree -- I really do think psychiatrists should be able to manage basic medical issues. When I was a resident I just felt sheepish consulting medicine for dumb things, and now I still feel the same.

Medicine should get involved if (a) you have no idea what you're doing (eg., weird cardiac problem, critical ID issue, etc), or (b) your patient is deteriorating and requiring progressively higher levels of care, pushing the limits of your psych nurses, and looking like she is headed for a transfer to medicine. Getting med consults involved early can potentially prevent the transfer; in the event that the transfer happens anyway, then if the consult team knows the patient by the time she is transferred it could potentially improve her care on the med ward.

 

[Doctor Bagel]

I agree -- I really do think psychiatrists should be able to manage basic medical issues. When I was a resident I just felt sheepish consulting medicine for dumb things, and now I still feel the same.

Medicine should get involved if (a) you have no idea what you're doing (eg., weird cardiac problem, critical ID issue, etc), or (b) your patient is deteriorating and requiring progressively higher levels of care, pushing the limits of your psych nurses, and looking like she is headed for a transfer to medicine. Getting med consults involved early can potentially prevent the transfer; in the event that the transfer happens anyway, then if the consult team knows the patient by the time she is transferred it could potentially improve her care on the med ward.

I agree that I'm not a fan of consulting medicine for things like basic htn/lipid management, UTIs, general DM stuff, etc.. However, if a patient seems borderline fishy, I consult medicine now. I don't want a patient tanking on my service without medicine being on board.

I agree, though, that a lot of the bigger issues with dealing with medically ill patients revolve around services on the unit and the staff in the unit. For example, our nurses don't place IVs. I had a borderline crashing patient on call a few months ago, and we had to wait forever to get the IV placed. I was consulting medicine, but in retrospect, I should have been more aggressive about pushing for a transfer just because of issues like that. I actually ordered the things to appropriately diagnose and then treat the guy. However, when you can't get a stat IV placed, it's a problem.

 

[nancysinatra]

Ok, here is a question I have. If a patient gets admitted to the psych service in the middle of the night and turns out to have a whopping heart murmur, and it's never been worked up, and they're otherwise stable, do you consult medicine--either right then and there, or later? I had this happen when I was on call over the weekend. What medicine is going to do is just order an echo. I have never in my life seen psychiatry order an echo. But that is the initial workup for a newfound murmur, correct? Could we order that? I don't see why not, but I also would feel rather pretentious just going and ordering an echo from psych--kind of like how I'd feel ordering a with-contrast MRI or head CT for some reason. For some reason there are just certain tests we order in psych and others we don't.

I couldn't believe it about this murmur either--the pt was an 89 y/o female, in otherwise good health, with no cardiac history, except some hypertension and hyperlipidemia. She came in for mild depression, to a hospital where if you walk in the door you get admitted. This murmur was like a V/VI, pansystolic or maybe pan-systolic-diasotlic--I really couldn't hear any actual heart sounds. It was LUSB and LLSB, but honestly, it was so loud it radiated everywhere. If I'd had a medical student nearby I would have made them listen because they'd never forget it!

Of course the actual ER note said simply "RRR, no M/R/G." And her family said she had no heart problems. I didn't want to ask them if she had been worked up for a murmur because I didn't want to worry them and I know that as the psych resident--you know, I could be wrong. And maybe it would go away by the morning or something and I'd eat my words.

So what would you all do in this case, especially it being the middle of a Sunday night, about 2 am?

 

[nitemagi]

Ok, here is a question I have. If a patient gets admitted to the psych service in the middle of the night and turns out to have a whopping heart murmur, and it's never been worked up, and they're otherwise stable, do you consult medicine--either right then and there, or later? I had this happen when I was on call over the weekend. What medicine is going to do is just order an echo. I have never in my life seen psychiatry order an echo. But that is the initial workup for a newfound murmur, correct? Could we order that? I don't see why not, but I also would feel rather pretentious just going and ordering an echo from psych--kind of like how I'd feel ordering a with-contrast MRI or head CT for some reason. For some reason there are just certain tests we order in psych and others we don't.

I couldn't believe it about this murmur either--the pt was an 89 y/o female, in otherwise good health, with no cardiac history, except some hypertension and hyperlipidemia. She came in for mild depression, to a hospital where if you walk in the door you get admitted. This murmur was like a V/VI, pansystolic or maybe pan-systolic-diasotlic--I really couldn't hear any actual heart sounds. It was LUSB and LLSB, but honestly, it was so loud it radiated everywhere. If I'd had a medical student nearby I would have made them listen because they'd never forget it!

Of course the actual ER note said simply "RRR, no M/R/G." And her family said she had no heart problems. I didn't want to ask them if she had been worked up for a murmur because I didn't want to worry them and I know that as the psych resident--you know, I could be wrong. And maybe it would go away by the morning or something and I'd eat my words.

So what would you all do in this case, especially it being the middle of a Sunday night, about 2 am?

Later. If they're asymptomatic, the psych hospitalization is likely short-term, and there's no reason to think that a heart condition is causing their mental illness, is there a rush? What's the urgency/emergency? The question I'd ask myself is -- can this be worked up as an outpatient? If it's a gray area or you're not sure, I start with the curbside, such as - "I've go this 89yo F with a whopping murmur, never been worked up, she's probably going to be with us for months because she also has dementia, so outpt workup isn't really feasible. Is there any reason to get a full consult inpt?"
They might put the pt. on the schedule in an outpt clinic, and assuming they're stable for transport, can be wheeled down for an eval with a chaperon, then wheeled back up after.

 

[whopper]

HTN (that is not through the roof), headaches, elevated cholesterol, and NIDDM can be easily managed by a psychiatrist, and those are the health issues often faced in this field given the dietary habits of psychiatric patients and the side effects of meds. Treatment of those problems are pretty much automatic on a algorithmic decision making tree and pretty much any medstudent wouldn't (edit: should've wrote would've) known it by the time they graduated no matter the field.

Even as a resident, I was frustrated and angry with attendings who ordered silly IM consults. The IM doctors that showed up would often ask me with frustration why it was ordered, and I begrudgingly told them that I agreed with them that the IM consult was not needed, but that I had to follow orders because the psychiatry attending ordered it. I even tried to talk the attending out of it a few times.

By the time I graduated, this led to some groundswell by the IM docs to try to get me hired at the same hospital because they knew I'd lead a momentum in the psychiatry dept. to stop frivolous consults. Nope, I went to fellowship in another state.

 

[atsai3]

Agree with nitemagi about considering whether the workup can be delayed until after discharge. However, one social reason to consider in-house workup is whether or not you think the patient will fall through the cracks. There is a substantial literature on excess mortality among people with mental illness, and at least part of the explanation must be poor retention in care. If I thought an inpatient wasn't going to follow up with an outpatient TTE and I thought it might alter the trajectory of the patient's medical care, I might consider consulting cards (with an apology) to do it in-house.

 

[sunlioness]

The culture of different hospitals is really interesting. I did a year of IM at the biggest game in town and then completed 3 years of psychiatry residency at the flagship hospital of the crosstown rivals. At both of those places, the culture was to avoid frivolous consults and to work up yourselves what you were able to work up. Sure there still were frivolous consults both ask for and received, but these were seen as frustrating, annoying things.

Fast forward to now working at an affiliate hospital of the crosstown rivals. This affiliate is undergoing a transition in identity from a local community hospital to that of an academic teaching hospital. And the culture here is different. There are a lot more frivolous consults. And up until the psychiatry residency program moved here, it was apparently unit policy to order a routine medical consult on everybody. When I commented to my boss about the high level of frivolous consults I thought we were receiving (and to some extent ordering), he said that the culture of community hospitals is different. That a lot of docs on staff here are private and they see ordering a consult as throwing you some business. Whereas we were coming from a culture of being salaried employees of a health system who make the same whether we're seeing BS consults or not. It's just a different mindset.

 

[michaelrack]

xxx

 

[nancysinatra]

Later. If they're asymptomatic, the psych hospitalization is likely short-term, and there's no reason to think that a heart condition is causing their mental illness, is there a rush? What's the urgency/emergency? The question I'd ask myself is -- can this be worked up as an outpatient? If it's a gray area or you're not sure, I start with the curbside, such as - "I've go this 89yo F with a whopping murmur, never been worked up, she's probably going to be with us for months because she also has dementia, so outpt workup isn't really feasible. Is there any reason to get a full consult inpt?"
They might put the pt. on the schedule in an outpt clinic, and assuming they're stable for transport, can be wheeled down for an eval with a chaperon, then wheeled back up after.

Thanks for your response. I'm thinking that part of the issue here might be the state I'm working in and the absolute lack of resources here. Even an asymptomatic murmur needs evaluation, but I have zero confidence that most of my inpatients will ever see either an outpatient psychiatrist or an outpatient internist after their admission. We make appointments and stuff, but follow up is zilch and the main issue is resources. I've discharged people with a diagnosis of psychosis 2/2 tertiary syphilis who were supposed to then go and get their penicillin, but never showed up.

This particular case happened at a private hospital, and this patient I think had insurance--but even then, what am I going to do--send her back to her internist and tell her HE needs to do something about her "heart murmur"? He had already seen her recently. And I could totally be wrong! That's my whole point--we don't typically refer lots of IM issues back to outpatient IM because the bar is so high for admitting to psych to begin with that we don't usually run into that situation. I have seen patients at this hospital refused by psych because they had asymptomatic thyroid lab abnormalities. After awhile, what I've realized is, the two systems just aren't talking to each other--that's the problem! And I'm sure not going to ask my attending for advice. My attending hasn't picked up a stethoscope in 10 years. She'd just say to call medicine!

Plus, a heart murmur is a little different from a lot of other non-acute things. There are many reasons for a heart murmur, but usually the reason is known. Unlike HTN where it's usually idiopathic. This patient was 89 and she was not entirely coherent when I interviewed her. I don't know if she was "symptomatic" or not. I don't think she needed an urgent workup but she needed A workup.

I do see your point--that ideally, we'd just refer her for outpatient management for this. Wow, if only that worked where I am!

 

[michaelrack]

I do see your point--that ideally, we'd just refer her for outpatient management for this. Wow, if only that worked where I am!

What if an IM resident has a patient hospitalized for cellulitis, and discovers that the patient has seemingly mild depression (denies SI, etc). He feels that an outpt w/u for depression would be sufficient, but has zero confidence that the patient would f/u with outpt psych or even a pcp. Should he consult psychiatry on every such patient? After all, how could he be sure that he isn't missing bipolar d/o or a more serious form of depression?

By the way, murmurs often do not require echocardiograms

 

[billypilgrim37]

The SMI population is a discrete, well-research entity with known risk factors for extremely elevated morbidity. The "general medical population with mild depression" is not.

It might seem like the "well if psych is going to consult for outpt medicine stuff, then medicine should consult for outpt psych stuff" argument has some face validity, but it's apples and oranges for many reasons.

Having a TTE or a thyroid biopsy done while inpt for a psychiatric patient might save the health care system money anyway, as it's not cheap to have the case manager, the ACT team, the mobile medication team, the outpt therapist, the county transportation system for the medically ill, have to spend hours and hours of valuable resources trying to get a psychotic person to have an important procedure.

Your heart disease and diabetes don't prevent you from going to the psychiatrist (unless homebound). A severe mental illness which impairs executive function, motivation, organization of thoughts and behaviors, and lack of insight does prevent a psychiatric patient from getting medical care.

For psychiatric care to be of much value, it has to be longitudinal. A psych consult for someone who isn't going to follow up is of little or no value. Having an SMI pt have more workup while an inpatient could be of tremendous value.

I can understand how internists could be frustrated with psychiatrists having this attitude, but psychiatrists spent 4 years in medical school then did a psychiatry residency. Internists didn't spend 4 years in psychiatry school and then do a medicine residency. We're specialists in a position to advocate for our patients to be treated differently based on known epidemiologic, cognitive, morbidity, and health systems issues that have been fairly well studied.

I know you're dually trained, but you're also a Republican, so I think somewhere those two things cancel out.*

*This was 100% a joke.