Covid

[Sushirolls]

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Maybe I'm naive, but what has been the issue thus far? Our University hospital (in a million person city) is slightly less busy than normal. When is this tsunami of patients supposed to be coming?

Please say this exact same thing to at least 5 (five) of your resident colleagues of any specialty.

For violating the rules of medical superstition they will now likely verbally accost you, or if a good friend, maybe smack you for jinxing things.

 

[Mass Effect]

Maybe I'm naive, but what has been the issue thus far? Our University hospital (in a million person city) is slightly less busy than normal. When is this tsunami of patients supposed to be coming?

Do you pay attention to current events? Don't watch the media if you don't want, but at the very least read about doctor's accounts internationally and nationally.

 

[Stagg737]

I don't think we'll be called to manage vents, but I would bet we'll be called to do H&Ps in non-COVID patients. My hospital has already put us on standby.

I could see that. I don’t mind managing stuff like CHF exacerbations or cellulitis (especially since most of my attendings are med/psych trained). I’m not going within 50 feet of a vent though, for mine and the patient’s safety...

If I didn't already know where you are in residency, I'd think you were at one of the two hospitals we rotate at. Pretty much the same exact experience here.

Our consult service occasionally gets slammed, but fortunately when that happens our attendings take a more lax view of the less necessary parts (idc if my lady with serotonin syndrome lives in an apartment with 6 cats) and focus on the actual issue. Another advantage of having several med/psych attendings running our consult service. I can’t imagine what it would be like doing full in-depth H&Ps on 15+ people in a day.

 

[Mass Effect]

Our consult service occasionally gets slammed, but fortunately when that happens our attendings take a more lax view of the less necessary parts (idc if my lady with serotonin syndrome lives in an apartment with 6 cats) and focus on the actual issue. Another advantage of having several med/psych attendings running our consult service. I can’t imagine what it would be like doing full in-depth H&Ps on 15+ people in a day.

What do you mean when you say med/psych? Your CL attendings did dual residencies in IM and psych?

 

[clausewitz2]

I could see that. I don’t mind managing stuff like CHF exacerbations or cellulitis (especially since most of my attendings are med/psych trained). I’m not going within 50 feet of a vent though, for mine and the patient’s safety...



Our consult service occasionally gets slammed, but fortunately when that happens our attendings take a more lax view of the less necessary parts (idc if my lady with serotonin syndrome lives in an apartment with 6 cats) and focus on the actual issue. Another advantage of having several med/psych attendings running our consult service. I can’t imagine what it would be like doing full in-depth H&Ps on 15+ people in a day.

Our one weekend day new consult record for our flagship hospital was 24. The resident on call is responsible for all of them. They are all H&Ps, you stay till you're done. If your attending is feeling generous they may see one or two solo.

 

[calvnandhobbs68]

Our one weekend day new consult record for our flagship hospital was 24. The resident on call is responsible for all of them. They are all H&Ps, you stay till you're done. If your attending is feeling generous they may see one or two solo.

wtf

There is no way there were 24 consults that had to be seen within 24 hours. That’s when attendings need to have the residents back and start deferring stuff to the next day and Monday.

 

[BorderlineQueen]

How does this affect freestanding psych units ?

 

[clausewitz2]

wtf

There is no way there were 24 consults that had to be seen within 24 hours. That’s when attendings need to have the residents back and start deferring stuff to the next day and Monday.

Our c&l service recognizes "urgent" consults that need to be seen within 2 hours and "routine" consults that need to be seen in 24. We were told that under circumstances should we ever question the need for a consult or say the dread words "any physician can do a capacity evaluation". We were allowed to may suggest an urgent consult should be routine, e.g. the time I got called at 3 AM because someone being admitted scored a 12 on PHQ-9 and the triage nurse just clicked their standard orderset.

In practice on weekends once 3 pm came around residents often did start conversations with primary teams about whether it could wait till Monday but this was on the DL.

I agree there was no possible way it was necessary. I got one memorable one that had a consult reason of "patient would benefit from psychotherapy"

 

[calvnandhobbs68]

Our c&l service recognizes "urgent" consults that need to be seen within 2 hours and "routine" consults that need to be seen in 24. We were told that under circumstances should we ever question the need for a consult or say the dread words "any physician can do a capacity evaluation". We were allowed to may suggest an urgent consult should be routine, e.g. the time I got called at 3 AM because someone being admitted scored a 12 on PHQ-9 and the triage nurse just clicked their standard orderset.

In practice on weekends once 3 pm came around residents often did start conversations with primary teams about whether it could wait till Monday but this was on the DL.

I agree there was no possible way it was necessary. I got one memorable one that had a consult reason of "patient would benefit from psychotherapy"

wtf

 

[FlowRate]

Our one weekend day new consult record for our flagship hospital was 24. The resident on call is responsible for all of them. They are all H&Ps, you stay till you're done. If your attending is feeling generous they may see one or two solo.

My record was 19 consults in an overnight '14, 12 by myself and 7 handled by the PG1 and backup home call PG4..

 

[SourceOfDenial]

Maybe I'm naive, but what has been the issue thus far? Our University hospital (in a million person city) is slightly less busy than normal. When is this tsunami of patients supposed to be coming?

*thats the whole point*
Average time on vent is more than 2wks
Many who survive will need rehab, and post acute care facilities are rightfully reluctant to take pts w infection. Short of opening closed facilities, repurposing beds from psych to acute medicine, building new capacity, you need to build in throughput with what you have, hence working to make things less busy.

*i stayed at a holiday inn last night*

 

[Stagg737]

What do you mean when you say med/psych? Your CL attendings did dual residencies in IM and psych?

Yes, most of them did a combined residency. We have a very med-psych heavy presence in my program, and about 2/3 of our consult attendings have board certification in both fields.

Our one weekend day new consult record for our flagship hospital was 24. The resident on call is responsible for all of them. They are all H&Ps, you stay till you're done. If your attending is feeling generous they may see one or two solo.

Idk what our record is for new consults but I believe it's 20+ at my program as well (900+ bed hospital). We typically do full H&P on every new consult unless the day is absolutely insane. We have one resident working from 8am-6pm, a senior resident who comes in for internal moonlighting from 10-30 just to help pick up however many cases they can, and the attendings usually come in around 11 to staff and help out. If there are already 7 or 8 new consults overnight the attending usually comes in early to help out. Most total new ones I've seen in a weekend day was about 15 and I saw 10 or 11 of them myself.

wtf

There is no way there were 24 consults that had to be seen within 24 hours. That’s when attendings need to have the residents back and start deferring stuff to the next day and Monday.

We basically did this yesterday, but it's also exceptionally rare at my program to have less than 3 people seeing consults in a day.

 

[Mass Effect]

wtf

There is no way there were 24 consults that had to be seen within 24 hours. That’s when attendings need to have the residents back and start deferring stuff to the next day and Monday.

That kinda thing should be what residents put on the DO NOT APPLY list. Once you graduate, name and shame. That's not only unreasonable and asinine, but it's also unsafe.

 

[clausewitz2]

Yes, most of them did a combined residency. We have a very med-psych heavy presence in my program, and about 2/3 of our consult attendings have board certification in both fields.



Idk what our record is for new consults but I believe it's 20+ at my program as well (900+ bed hospital). We typically do full H&P on every new consult unless the day is absolutely insane. We have one resident working from 8am-6pm, a senior resident who comes in for internal moonlighting from 10-30 just to help pick up however many cases they can, and the attendings usually come in around 11 to staff and help out. If there are already 7 or 8 new consults overnight the attending usually comes in early to help out. Most total new ones I've seen in a weekend day was about 15 and I saw 10 or 11 of them myself.



We basically did this yesterday, but it's also exceptionally rare at my program to have less than 3 people seeing consults in a day.

We have a senior resident moonlighter who is sometimes able to pick up a couple new consults but their main job is seeing every single follow-up who has to be seen over the weekend. Our legal department gives us broad authority to basically temporarily detain people in medical hospitals but the flipside is we have to see them daily.

If the outlying hospitals aren't too busy the residents moonlighting there on the weekend can sometimes pitch in to help.

My two personal favorites have been "patient has a flat affect" (mind you, no one bothered to ask the patient a single question about their mood before placing the consult), and "psych history" (for an intubated and sedated patient.)

I got a "patient on psych meds" for an unfortunate gentleman who absolutely had a history of SMI. Unfortunately he was also on a neurosurgery service s/p a really brutal assault, intubated , and extensor posturing. MRI with diffuse axonal injury. For some reason I was the first to document the posturing and no one had noted these MRI findings. No family or friends identifiable. I called the attending to staff and he said he would swing by but never showed. I felt pretty good signing off.

 

[Jules A]

take a more lax view of the less necessary parts (idc if my lady with serotonin syndrome lives in an apartment with 6 cats)

Update regarding my crash course into Doxy.me, so far the video quality is okay for the free version. Gets the job done, not crisp enough to point out my wrinkles or random acne.
-Discovered its best to do two browsers, one for the EMR charting, and another for the doxy.me video, side by side.
-Actively reminded myself to look at the camera to simulate eye contact.
-Pre-run trials, noted that cell phones on cellular data didn't connect, but cell phones with wifi connection do. Computers worked. Lap tops work.
-Getting paperwork like PHQ/GAD, pre appointment questionnaires done are a bit more tedious.
-Needed to review billing criteria for 99214 as not doing any vitals, and making sure I was still on track for it.
-GT modifier from very brief reading seems to be what I'll be putting down
-Laborious process to reach out to the whole patient panel 'we now have telepsych! Click on in!'
-For better or worse you get a glimpse into the back drop of the living arrangement of your patient.

I had reached out to Luminello folks, and they have no immediate plans to implement their own de novo program or third party integration.

I did Doxy.me too. It was decent. One thing I learned is with the free version you can't do a three way which was only a slight snafu with a parent who was at work and wanted to link in for kid's med check who was at home with babysitter. I put parent on speaker phone it worked ok.

 

[randomdoc1]

I use doxy.me. Setting my calls to call forwarding. We are still taking new patients, continuing to see patients. I'm now the proud owner of a practice! We are billing usual CPT codes with place of service as telehealth (02) instead of office (11) and using GT modifier. Bam, done 😀.

 

[splik]

I use doxy.me. Setting my calls to call forwarding. We are still taking new patients, continuing to see patients. I'm now the proud owner of a practice! We are billing usual CPT codes with place of service as telehealth (02) instead of office (11) and using GT modifier. Bam, done 😀.

The GT modifier is dead. Use modifier 95 for commercial insurance. No modifier needed for Medicare only need to list POS as 02. Also remember to have an informed consent statement re: telemedicine included in all notes.

 

[randomdoc1]

The GT modifier is dead. Use modifier 95 for commercial insurance. No modifier needed for Medicare only need to list POS as 02. Also remember to have an informed consent statement re: telemedicine included in all notes.

Cigna has asked GT be used and a few other payers. I've seen 95 modifier be used too. Not quite sure which is best. Guess we'll see what happens. With our in house billing we can always resubmit corrected claims.

 

[Sushirolls]

Consent form, really? We need consent forms for everything. Sigh.

 

[Mass Effect]

Consent form, really? We need consent forms for everything. Sigh.

Verbal consent for everything.

 

[romanticscience]

Going 100% tele, starting tomorrow.


Sent from my iPhone using SDN

 

[hebel]

Going 100% tele, starting tomorrow.


Sent from my iPhone using SDN

You do a lot of therapy, right? What do you think of therapy done over telepsych. Is it as suboptimal compared to in person as it sounds, or surprisingly ok?

 

[Nudexta]

Our outpatient center closed. They are planning to transition to 100 percent tele. What are other people experiences?

 

[romanticscience]

You do a lot of therapy, right? What do you think of therapy done over telepsych. Is it as suboptimal compared to in-person as it sounds, or surprisingly ok?

I've actually found that the med-management sessions are more difficult through this means (eg, evaluating phenomenology of symptoms, completing rating, scales, higher acuity/risk assessment).

The therapy sessions have been going quite well. There is an initial awkward feeling in the beginning (people seeing themselves) but as the hour progresses, people seem more comfortable (maybe they feel more "at home"), and are free-associating better.

 

[Sushirolls]

Luminello just posted they plan to integrate soon with doxy.me.

"...Given the urgency of the situation, we have also fast-tracked a partial integration with our video partner, doxy.me. More information to come on this soon. ..."

 

[gucci2020]

These past two weeks have been crazy. At least ONE of our residents is COVID positive, and ONE of our attendings (who sees patients on CL) tested positive for COVID--and they still came to work, seeing and probably infecting patients and other mental health providers and hospital employees. The department head and hospital administration isn't taking the COVID epidemic seriously at all.

We have had the capability for over a year to use telepsychiatry to see patients on inpatient and in outpatient clinics.

But the chairman is dragging his feet and risking the lives of everyone, from the security guard to the janitor to the front desk staff, nurses, social workers, residents, attendings, and most of all the hundreds and hundreds of patients that come to our hospital. The excuse he gives is that he has to check with "legal."

The patients trust us and come to us hoping to get better. But the chairman has decided to put off using the technology we already have. Some residents have called in sick and stayed home. It's rumored that by next week, maybe, maybe we will see patients using telepsychiatry. But don't bet on it. In the meantime, we're expected to come to work and risk getting each other sick and hundreds of patients sick. Patients who already have one or more illnesses are at much higher risk to die from coronavirus.

When patients and current employees file lawsuits against the hospital for negligence and for exposing them to sick providers, that will be the end of SIUH.

There's a state psychiatry hospital just down the street from SIUH where just this week, a tent was put up for testing, but the catch is that you have to tell them what symptoms you have, otherwise they send you home.

 

[Jules A]

These past two weeks have been crazy. At least ONE of our residents is COVID positive, and ONE of our attendings (who sees patients on CL) tested positive for COVID--and they still came to work, seeing and probably infecting patients and other mental health providers and hospital employees.

Am I reading correctly, they knowingly came to work when COVID positive?

 

[gucci2020]

Am I reading correctly, they knowingly came to work when COVID positive?

They had symptoms. They still came to work. It's unconscionable. It takes time to for test results to get back, I get it. But the department head has endangered patients and staff by dragging his feet about telepsychiatry.

It is absolutely outrageous that the department refuses to provide protective gear to our staff and that there's been a delay in using telepsychiatry. We're in NY. Most of our patients are poor. They fit the demographic of people who are going to get sick, very sick.

 

[Jules A]

Anyone care to speculate on why Italy and France look like this and Germany looks like that?

Coronavirus Update (Live): 139,816,716 Cases and 3,002,419 Deaths from COVID-19 Virus Pandemic - Worldometer

Live statistics and coronavirus news tracking the number of confirmed cases, recovered patients, tests, and death toll due to the COVID-19 coronavirus from Wuhan, China. Coronavirus counter with new cases, deaths, and number of tests per 1 Million population. Historical data and info. Daily...

www.worldometers.info

 

[Ironspy]

Anyone care to speculate on why Italy and France look like this and Germany looks like that?

Coronavirus Update (Live): 139,816,716 Cases and 3,002,419 Deaths from COVID-19 Virus Pandemic - Worldometer

Live statistics and coronavirus news tracking the number of confirmed cases, recovered patients, tests, and death toll due to the COVID-19 coronavirus from Wuhan, China. Coronavirus counter with new cases, deaths, and number of tests per 1 Million population. Historical data and info. Daily...

www.worldometers.info

I think it’s because Germany is doing widespread testing on people with mild symptoms and Italy and France are testing mostly sicker patients.

 

[meow1985]

Looping back to how everyone is adapting their practice to COVID-19...

My residency has moved all outpatient care to telemed, but they are making us do phone appointments and actual telemed (aka video) is still “coming.” IDK what the holdup is, since we are a large, well resourced academic department. My own personal providers who are part of a small group private practice in the community have moved to telemed with video last week.

Irrational thought of the day: psychiatry will be de-prioritized, my future employers’ psych department will be too daft to move to telemedicine and just shut down or downsize, and my job will no longer exist. I know the rational thing is just to email them and ask how they are adapting to COVID-19, and in our day and age no doc or department in their right mind is not capable of changing to telemed... but still I just needed to get that out there.

 

[Monocles]

These past two weeks have been crazy. At least ONE of our residents is COVID positive, and ONE of our attendings (who sees patients on CL) tested positive for COVID--and they still came to work, seeing and probably infecting patients and other mental health providers and hospital employees.

Wtf, how is this not criminal?

 

[wolfvgang22]

Wtf, how is this not criminal?

Because the culture of medicine dictates that we are all meant to be superheroes that sacrifice our health and well being, working long hours and sacrificing ourselves on the alter of being a real doctor, who never gets sick, never has weakness, and cannot possibly die or spread disease. I'm surprised you haven't had this tattooed on your soul by now...

 

[OldPsychDoc]

Looping back to how everyone is adapting their practice to COVID-19...

My residency has moved all outpatient care to telemed, but they are making us do phone appointments and actual telemed (aka video) is still “coming.” IDK what the holdup is, since we are a large, well resourced academic department. My own personal providers who are part of a small group private practice in the community have moved to telemed with video last week.

Irrational thought of the day: psychiatry will be de-prioritized, my future employers’ psych department will be too daft to move to telemedicine and just shut down or downsize, and my job will no longer exist. I know the rational thing is just to email them and ask how they are adapting to COVID-19, and in our day and age no doc or department in their right mind is not capable of changing to telemed... but still I just needed to get that out there.

I'm finding that in our system, a five year process of developing telepsych protocols is suddenly getting expedited into a two week crash dive.
Hopefully when the dust all clears we have a better system because of it.

 

[Pezistential]

My residency *might* implement telepsych for outpatient starting this week and for inpatient, but limited to attending physicians- residents need not apply. It's been communicated to the chiefs that residents will still be expected to perform physical exams, etc despite limited (read no) PPE availability for nurses, techs, or physicians. We screen-out what we can, but we're in a hotspot and testing is limited to the sickest at the moment, so were playing a corona roulette with every admission.

Fortunately, my colleagues in the IM program have thus far been spared from the bulk of the COVID-19 cases. In effort to conserve PPE, physical exams have been limited to attendings and residents get HPI, etc. remotely.

 

[meow1985]

Does anyone work in IOP? I don't really know how those sorts of services would be adapted to telemedicine, unless you can do group patient meetings in doxy.

The reason I ask is because the place I signed with does psych IOP, though that's not going to be what I'll be doing for them. Where will those IOP docs go and will they make me not needed as a new hire? So many questions... I need to go reread my contract. I emailed the administration with my questions posed in a less alarmist way, but who the heck knows when they will get to it.

 

[meow1985]

It's been communicated to the chiefs that residents will still be expected to perform physical exams, etc despite limited (read no) PPE availability for nurses, techs, or physicians. We screen-out what we can, but we're in a hotspot and testing is limited to the sickest at the moment, so were playing a corona roulette with every admission.

That should be illegal. Maybe contact GME and make some noise about this?

 

[splik]

You do a lot of therapy, right? What do you think of therapy done over telepsych. Is it as suboptimal compared to in person as it sounds, or surprisingly ok?

It is inferior to in person from my perspective but many patients prefer it. I have been using tele for some yrs for therapy as many of my patients live far away and there is no one that can treat their problem (FND) close by. There is obviously less connection and you might not pick up on some subtle thing. The main thing I struggle with is being present, I get distracted more easily. However it is infinitely better than not meeting at all which is really the circumstance I use it in (and what we're faced with in the current situation).

 

[SourceOfDenial]

It is inferior to in person from my perspective but many patients prefer it. I have been using tele for some yrs for therapy as many of my patients live far away and there is no one that can treat their problem (FND) close by. There is obviously less connection and you might not pick up on some subtle thing. The main thing I struggle with is being present, I get distracted more easily. However it is infinitely better than not meeting at all which is really the circumstance I use it in (and what we're faced with in the current situation).

the distraction part is big for me too—I found I’m much better when I’m using a dedicated camera or phone versus camera that’s on top of my computer. With the computer it’s too easy to want to click something or get distracted by email pop ups, etc

 

[meow1985]

That said, so far a lot of people still have their jobs.

What if with the economic recession people lose their jobs en masse and no one has health insurance and no one can go to their psychiatrist?

 

[Jules A]

Does anyone work in IOP? I don't really know how those sorts of services would be adapted to telemedicine, unless you can do group patient meetings in doxy.

The reason I ask is because the place I signed with does psych IOP, though that's not going to be what I'll be doing for them. Where will those IOP docs go and will they make me not needed as a new hire? So many questions... I need to go reread my contract. I emailed the administration with my questions posed in a less alarmist way, but who the heck knows when they will get to it.

I think my hospital is using Zoom for IOP group therapy?

 

[Nudexta]

I feel there are limitations with Telepsychiatry. I feel I can’t connect to the patient as an in person evaluation. Also it is easy to miss many signs. It’s all about access to care not quality so far.

 

[wolfvgang22]

I like telepsych for the most part, but not being able to do an AIMS in person is a drawback. I end up having an NP do it.

 

[Mass Effect]

My residency *might* implement telepsych for outpatient starting this week and for inpatient, but limited to attending physicians- residents need not apply. It's been communicated to the chiefs that residents will still be expected to perform physical exams, etc despite limited (read no) PPE availability for nurses, techs, or physicians. We screen-out what we can, but we're in a hotspot and testing is limited to the sickest at the moment, so were playing a corona roulette with every admission.

Fortunately, my colleagues in the IM program have thus far been spared from the bulk of the COVID-19 cases. In effort to conserve PPE, physical exams have been limited to attendings and residents get HPI, etc. remotely.

Organize a resident call-out. Every single resident calls out sick and it'll be up to the PD or the Chair to go work with patients without PPE. This is wrong on so many levels. Notice they didn't pull that crap on attendings? The attendings should also be sticking up for you guys. I'm an attending and if this was happening in my hospital, I would raise hell.

 

[Mass Effect]

Does anyone work in IOP? I don't really know how those sorts of services would be adapted to telemedicine, unless you can do group patient meetings in doxy.

The reason I ask is because the place I signed with does psych IOP, though that's not going to be what I'll be doing for them. Where will those IOP docs go and will they make me not needed as a new hire? So many questions... I need to go reread my contract. I emailed the administration with my questions posed in a less alarmist way, but who the heck knows when they will get to it.

Just trying to help you out here, but stop emailing your new job with these questions. They have their hands full and I would bet the last thing they need is a new hire wondering what their job will be in 3 months if this happens and if that happens. Just let things play out.

 

[clausewitz2]

Does anyone work in IOP? I don't really know how those sorts of services would be adapted to telemedicine, unless you can do group patient meetings in doxy.

The reason I ask is because the place I signed with does psych IOP, though that's not going to be what I'll be doing for them. Where will those IOP docs go and will they make me not needed as a new hire? So many questions... I need to go reread my contract. I emailed the administration with my questions posed in a less alarmist way, but who the heck knows when they will get to it.

I am working in two IOPs at the moment. There was a brief hiccup and then we started doing group and individual appointments via Vidyo. IOP ain't going anywhere, far too lucrative.