"Don't alienate the internist"? Why the hell not?

[gibits]

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So I got some "friendly advise" from my senior today. Apparently he got a few complaints about me from primary teams asking our practice for consults. It appears I over stepped my bounds for making medical diagnoses that could be the cause for a patient's strange behavior.
I said a pt with Tmax of 102, leukocytosis with left shift and psychosis had sepsis/SIRS. Recommended blood/urine cultures and chest X-ray. My senior says I should have just ordered haldol and Ativan.
I said a pt with bulging eyes, thin habitus, wirey hair, and psychosis. I suggested to get TSH levels since she could have Grave's disease. I should have just ordered haldol and Ativan.

I said a female pt with hirutism, central obesity, DM, and psychosis should have Cushings disease/syndrome ruled out. I should have just ordered just ordered Haldol and Ativan.

Am I getting too big for my breeches here or are the doctors just trying to save face?

 

[Extralong]

So I got some "friendly advise" from my senior today. Apparently he got a few complaints about me from primary teams asking our practice for consults. It appears I over stepped my bounds for making medical diagnoses that could be the cause for a patient's strange behavior.
I said a pt with Tmax of 102, leukocytosis with left shift and psychosis had sepsis/SIRS. Recommended blood/urine cultures and chest X-ray. My senior says I should have just ordered haldol and Ativan.
I said a pt with bulging eyes, thin habitus, wirey hair, and psychosis. I suggested to get TSH levels since she could have Grave's disease. I should have just ordered haldol and Ativan.

I said a female pt with hirutism, central obesity, DM, and psychosis should have Cushings disease/syndrome ruled out. I should have just ordered just ordered Haldol and Ativan.

Am I getting too big for my breeches here or are the doctors just trying to save face?

I believe you did everything right. Way to be a strong physician. Many places have screwed up, unavoidable politics.👍

 

[PhinyGage]

I think its amazing that you approach psychosis from a biological perspective, and clearly you are able to keep up with the liason/consultative portion of what we do.

I think the concept of "overstepping your bounds" is absolutely ridiculous unless you're out doing pelvic exams and ordering weird lab panels. We are medical doctors and we all take the same general boards.

I dream of a day where treating an STD is standard. I do not wish to send my disorganized patient across town to get a shot in the booty. I do not like the idea that prescribing a couple days of antibiotics for "unusual penile discharge after exposure" is not within the scope of our practices (if our situation allows it).

I'm sorry, but its just really not that serious.

 

[Armadillos]

This thread is kind of hard for me to believe, does this sort of situation with the primary team really happen frequently? First off seems weird the primary team wouldn't be working this stuff up before calling psych and secondly seems weird that they would complain about you making a diagnosis that helps the patient.

 

[Therapist4Chnge]

You are a physician first, then a psychiatrist....so I don't see an issue. Maybe they took exception to how you said what you said?

 

[Wilf]

So I got some "friendly advise" from my senior today. Apparently he got a few complaints about me from primary teams asking our practice for consults. It appears I over stepped my bounds for making medical diagnoses that could be the cause for a patient's strange behavior.
I said a pt with Tmax of 102, leukocytosis with left shift and psychosis had sepsis/SIRS. Recommended blood/urine cultures and chest X-ray. My senior says I should have just ordered haldol and Ativan.
I said a pt with bulging eyes, thin habitus, wirey hair, and psychosis. I suggested to get TSH levels since she could have Grave's disease. I should have just ordered haldol and Ativan.

I said a female pt with hirutism, central obesity, DM, and psychosis should have Cushings disease/syndrome ruled out. I should have just ordered just ordered Haldol and Ativan.

Am I getting too big for my breeches here or are the doctors just trying to save face?

Those all seem like very obvious diagnoses for the primary team to make. Almost all patients get a TSH here if they have psychiatric symptoms.

 

[peppy]

You are a physician first, then a psychiatrist....so I don't see an issue. Maybe they took exception to how you said what you said?

That's what I am thinking. Maybe the way you worded came across as if you thought they weren't doing their jobs correctly?
Any psychiatrist whose approach is limited to haldol and Ativan is a pretty crappy CL psychiatrist.
The consult service at my program is pretty solid and they suggest further medical work up all the time...but you do have to be diplomatic about how you say it.

Does the attending on your service just rec haldol and Ativan?

 

[kugel]

I am very grateful to an attending who helped me write consults so that they were more likely to be read and the recommendations enacted. And then when those were ignored, he was happy to ask the Chief of Medicine how his resident could better communicate the (rather obvious) recommendations. That usually prompted action on the part of the primary team.

 

[whopper]

I don't think you did anything wrong. If you want to be safe you could call up the IM doctor or order a consult.

Some psychiatrist have forgotten their medicine and are trapped in the mental box of doing psychiatry all the time when often times the answer isn't psychiatric. Further, some psychiatrists get trapped in a psychopharm only box too and medicate personality disorders.

When you mentioned senior, do you mean resident or a senior attending? Your description says you're an attending.

And if you really want to be snarky, I'd remind the senior that typicals have plenty of data that have emerged in the last ten years showing they cause large amounts of free-radical damage to the brain, thus Haldol may not be a good first line med.

While I was a resident, I noticed that the psychiatrists I worked with for the most part forgot their medicine to the degree where a 3rd year medstudent could've intellectually picked them up, spun them around, and then pile-drive them when it came to general medicine. Yeah, I know psychiatrists won't be on top of medicine as much as an IM doc but we ought to still retain our primary medicine skills. I had to talk my attending out of ordering consults for a BP of less than 140/90 that he thought were hypertension, or a borderline reading--just one reading.

 

[gibits]

You are a physician first, then a psychiatrist....so I don't see an issue. Maybe they took exception to how you said what you said?

I wrote it in a matter of fact manner like it write all my notes. "combination of altered mental status combined with blah blah blah blah point towards possibility of organic cause likely blah blah blah. Further work is recommended". I always end a dictation with "thank you for giving a chance to participate in the care of this patient".

I personally don't feel my notes are anymore impersonal than my coworkers.

 

[gibits]

Just to clarify: my senior is just the guy who I give 30% of my earnings to. He's basically the head honcho of the practice and I am an associate.

He didn't really recommend haldol and Ativan for all of them, he just said I should focus on the psych meds and let the internist worry about the rest.

The Cushing like one happened twice with two different internists that round in the psych ward. The thyroid one was really amazing since I read about a goiter in her chart from the SNF she was transferred from. All the examples I listed were from SNFs with the exception of the septic guy. He was in the ICU.

 

[MLT2MT2DO]

So I got some "friendly advise" from my senior today. Apparently he got a few complaints about me from primary teams asking our practice for consults. It appears I over stepped my bounds for making medical diagnoses that could be the cause for a patient's strange behavior.
I said a pt with Tmax of 102, leukocytosis with left shift and psychosis had sepsis/SIRS. Recommended blood/urine cultures and chest X-ray. My senior says I should have just ordered haldol and Ativan.
I said a pt with bulging eyes, thin habitus, wirey hair, and psychosis. I suggested to get TSH levels since she could have Grave's disease. I should have just ordered haldol and Ativan.

I said a female pt with hirutism, central obesity, DM, and psychosis should have Cushings disease/syndrome ruled out. I should have just ordered just ordered Haldol and Ativan.

Am I getting too big for my breeches here or are the doctors just trying to save face?

Only a 3rd year med student here, but it really seems that you work for a lazy butt that is only interested in collecting a paycheck (no only from this post but your previous posts about the practice you work for). Your posts make me sad, as practices and people like the guy you work for make me take a "step back" and think about if psychiatry would be right for me.
Am I really supposed to throw all my knowledge of medicine out the window, no matter how obvious the medical diagnose may be?
This just seems like bad medicine.

 

[gibits]

Only a 3rd year med student here, but it really seems that you work for a lazy butt that is only interested in collecting a paycheck (no only from this post but your previous posts about the practice you work for). Your posts make me sad, as practices and people like the guy you work for make me take a "step back" and think about if psychiatry would be right for me.
Am I really supposed to throw all my knowledge of medicine out the window, no matter how obvious the medical diagnose may be?
This just seems like bad medicine.

Yeah the practice I'm in engages in some things I really don't care for. I don't really know if the internists really said anything or if it is this guys own opinion. SNF patients tend to have MDs who just "phone it in". God I hate going to them.

I don't think all practices are like this, or at least I hope not. I have already put my CV to some recruiters and old associates. Wish me luck.

 

[michaelrack]

#2 and #3 would be ok if carefully worded, something like "I suspect the patient is exhibiting psychiatric manifestations of hyperthyroidism. While this possible etiology is being evaluated, Zyprexa 5 mg qhs can be used for control of psychosis".

For # 1, you overstepped your bounds, especially in recommending a specific medical workup. You should have been nonspecific: " Patient is delirious (due to infectious process?). Recommend zyprexa 5 mg qhs while etiology is being evaluated; I will continue to monitor the patient's mental status"

 

[SmallBird]

#2 and #3 would be ok if carefully worded, something like "I suspect the patient is exhibiting psychiatric manifestations of hyperthyroidism. While this possible etiology is being evaluated, Zyprexa 5 mg qhs can be used for control of psychosis".

For # 1, you overstepped your bounds, especially in recommending a specific medical workup. You should have been nonspecific: " Patient is delirious (due to infectious process?). Recommend zyprexa 5 mg qhs while etiology is being evaluated; I will continue to monitor the patient's mental status"

Agreed - thanks for stepping in and saying this!

 

[gibits]

So I should just give my impression of the diagnosis without suggesting work up or treatment for said condition? I can do that. Thanks.

 

[gibits]

For # 1, you overstepped your bounds, especially in recommending a specific medical workup. You should have been nonspecific: " Patient is delirious (due to infectious process?). Recommend zyprexa 5 mg qhs while etiology is being evaluated; I will continue to monitor the patient's mental status"

honestly, the septic/SIRS case makes me wonder if my boss is really relaying honest info from the internists. I discussed the case with the IM doc and he was receptive to my diagnosis. I did this because the pt was in the ICU and not on any antibiotics. They thought he was just having withdrawal symptoms from EtOH as he is known to be a heavy drinker. I offered to write the orders for him so he didn't have to TO it. He even thanked me for being considerate..... Unless he is a very two faced person I find it hard to believe he would be offended by me.

 

[michaelrack]

honestly, the septic/SIRS case makes me wonder if my boss is really relaying honest info from the internists. I discussed the case with the IM doc and he was receptive to my diagnosis. I did this because the pt was in the ICU and not on any antibiotics. They thought he was just having withdrawal symptoms from EtOH as he is known to be a heavy drinker. I offered to write the orders for him so he didn't have to TO it. He even thanked me for being considerate..... Unless he is a very two faced person I find it hard to believe he would be offended by me.

You are basically doing the right thing, you just need to be humble about it. IF you make the IM doc look stupid (especially in writing), he is going to be less likely to take your advice and the patient will suffer. In the sepsis case, you would have probably been better of calling the IM in person and give him your impression (and your written note would have said something like "delirium, probably not entirely due to alcohol. Ativan at 2 mg q 6 hr. Work up for etiology as per dr. X. Case discussed with Dr. X".

 

[hrandani]

The hardest lesson for me to learn in medical school was that politics is everything and the actual practice of medicine (that is to say, the diagnosis and treatment of disease) is frequently the very last concern for staff and administration.

I guess that's because I come from a culture and mindset where the majority of what I see on a daily basis in the hospital would be considered either stupid administrative bull**** or blatant profiteering. Overall, it's discouraging how few people even see that it is a problem, even when it's right under their nose.

I've actually gotten lectures about how this is a business just like any other and I need to learn to be a member of the team. No big deal though, right. We're just dealing with the lives of people at their most vulnerable, in desperate need of someone who actually gives a ****.

 

[Therapist4Chnge]

IF you make the IM doc look stupid (especially in writing), he is going to be less likely to take your advice and the patient will suffer.

Agreed. The OP would have done better by addressing the consult as asked, and then pulled the person aside and said, "Hey...it wasn't ABC. I've seen cases of XYZ or 123 with similar symptoms, but I figured you'd have already considered them. If there is anything else that you think psych might be able to address, let us know."

 

[billypilgrim37]

With our local politics, we would routinely do exactly what the OP did. When consulted for delirium, we would regularly make specific diagnostic recommendations for speicific medical problems we were concerned about, not because the primary team is stupid, but because we're all trying to help this patient and at the same time be appropriately conservative with ordering diagnostic tests. In community hospitals we covered, we would even order the labs ourselves, and that was expected. At the same time, a cardiologist would comment on a low TSH, etc. It's medicine. Organ systems aren't isolated. There was never any sort of "this person is making us look bad" dynamic going on. The consult team asked for an opinion because they wanted someone else's opinion. They either appreciated it or ignored it, but there was never any sort of "don't tell me to order a TSH on my patient, you stupid psychiatrist" thing happening.

So, I can appreciate that a local culture would be different, but the tip-toeing around seems bizarre to me. So it doesn't have to be that way.

 

[nitemagi]

What was the consult Question?

Diagnosis? Management?

Agree that the How it's said is as important as the What, especially when dealing with egos in medicine. Unfortunately. Really it's the same everywhere in the world, not just in medicine. The difference in medicine is the one who might pay the price for the internist getting defensive is the patient.

 

[gibits]

What was the consult Question?

Diagnosis? Management?

Agree that the How it's said is as important as the What, especially when dealing with egos in medicine. Unfortunately. Really it's the same everywhere in the world, not just in medicine. The difference in medicine is the one who might pay the price for the internist getting defensive is the patient.

The septic guy was a suspected OD on EtOH and pain meds (long history of abusing both). The thyroid and Cushings was psychosis and med management.

 

[nitemagi]

The septic guy was a suspected OD on EtOH and pain meds (long history of abusing both). The thyroid and Cushings was psychosis and med management.

Let me rephrase.

Were they consulting you to help with the diagnosis or the management? Or they didn't specify what they wanted? And if mgmt, was it mgmt of agitation, etc. Answer the question, and then use it as the entry point to add other info.

"Thank you for this consult on individual with concern for psychosis. Based on the current examination, it appears that his psychotic symptoms don't appear to be attributable to a classic psychiatric disorder with psychosis, such as schizophrenia, particularly due its rapid onset and his particular co-morbidities. On further examination some medical conditions such as cushings may be contributing, and should ideally be evaluated, as monotherapy with antipsychotic medications may not be effective if such a medical etiology is responsible for his sx's. During workup, recommendations for management of his symptoms should include... but should be focused on behavioral management while other medical causes are ruled out.

You probably did this already. But just my $.02

 

[gibits]

If I had to be completely honest, I usually have no Idea why I am consulted. None whatsoever. I usually have to guess or call them and ask. I asked on the septic patient, the other two I just assumed since my practice has been following them for a few months and all they did was med/behavioral management.

I'm always frustrated doing a consult because I never have a clue as to why I'm being asked to see the patient. The order literally says:
Type of consult: psych for Dr gibits
Reason for consult:

Yeah, it's almost always blank or it will be really vague like EtOH, or mental disorder or hx of psych. God I ****ing hate doing consults for these asshats who can't even dignify their request with a reason. You know what? I don't give hoot about making them look bad.

 

[strangeglove]

Figuring out the reason for the consult is half the fun/skill of CL psychiatry.

 

[Therapist4Chnge]

Have you talked to them about what you'd like/need for a consult description? It sounds simple, but a bit of guidance could go a long way. Most ppl probably won't change, but maybe you'll get a few. I have literally written out consult examples for common consults and given them to ppl who regularly consult me.