I've found some threads on this topic in the past but I haven't quite found anything up to date. I'm a fourth year medical student applying for a Psychiatry residency this fall. I'm rather interested in the idea of Emergency Psychiatry but i'm unsure as to the actual prospects of pursuing it as a full time career. Is doing so only possible in major cities e.g. New York City, LA? What are the challenges if any that you have faced in trying to pursue this subspeciaity? Would you be spreading yourself too thin if you were to pursue two concurrent subspecialities? is this viewed as being indecisive during interview season? Sorry if these questions aren't at the level of this forum but I wasn't sure where else to ask.
emergency psychiatry only for moonlighting?
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Demand massively outweighs supply for emergency psych, even more so than in other areas. The reason why you don't see more people doing ER psych full-time is because most of us don't want to do it.
No.
Burnout. ER psych is interesting to do once in a while, but everyday practice can get pretty tiresome and monotonous.
Not at all. A large percentage of psychiatrists do multiple things, and having a more balanced practice can actually help you stay sharp in the other areas. i.e. practicing inpatient/outpatient/ER psych together helps you understand what your outpatients can expect in the ER and the inpatient unit, what your inpatients can expect in the ER and in outpatient follow-up, and what your ER patients will get in the other settings.
As far as interview season, the only potential downside to saying that you want to do ER psych is that it might come across a a bit naive. It would actually seem more realistic if you said that you want to do a combination of things. Especially at academic programs.
emergency psychiatry is not a subspecialty. I suppose it falls under consult psychiatry(psychosomatic medicine)....but not really imo(and that's not really a subspecialty either btw...anymore than a neurologist seeing patients on consults is a subspecialist consult neurologist). The issues in emergency psychiatry are much different than those when we think of psychosomatic medicine.
And no you aren't being too indecisive. A little too neurotic maybe.....don't even worry about this
another quick point- I think many med students and residents who have never worked outside their academic program view emergency psychiatry to mean "emergency department psychiatry"........I take emergency psychiatry to mean acute presentations, not necessarily in an amergency dept setting, as hopefully in the future we can move out of there if we get more funding.....looking at it this way I would consider an emergency psychiatrist to be someone who may ork in a number of different settings.
In my experience, many hospitals don't have the volume to support a full time emergency psychiatrist, so usually the emergency room is covered by an inpatient psychiatrist who also does consults. There are usually ED social workers who manage the mental health patients that don't need to see a doctor (e.g. referrals to outpatient services, drug treatment info, respite beds, shelter placement, etc.) The places I've seen with dedicated psych ED's have been at VA hospitals and academic county hospitals.
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Shan564's response is pretty spot on; I can add a coupe of points based on my own research/experiences - for one, the psych ED is a setting, not a subspecialty. You will see children, addicts, geri, etc. No additional training required.
As an adjunct and learning tool, shifts in the psych ED are priceless. If you aspire to work exclusively in a psych ED for the rest of your career, however, you will probably end up with the title of 'director' doing the workflow/political stuff and overseeing residents and recent grads. As far as full time clinical work, I don't think this is a sought after position; financially you'll earn about the same or less annually as a normal M-F gig but you'll be working those weird EM hours.
Vistaril makes a great point about funding - most psych ED patients will have already been screened by the medical ED; you are then in charge of the dispo which in and of itself doesn't earn the hospital more money unless you are generating an admission. If the units are full they will be pushing back against your admissions. This is the recipe for burnout.
As an adjunct and learning tool, shifts in the psych ED are priceless. If you aspire to work exclusively in a psych ED for the rest of your career, however, you will probably end up with the title of 'director' doing the workflow/political stuff and overseeing residents and recent grads. As far as full time clinical work, I don't think this is a sought after position; financially you'll earn about the same or less annually as a normal M-F gig but you'll be working those weird EM hours.
Vistaril makes a great point about funding - most psych ED patients will have already been screened by the medical ED; you are then in charge of the dispo which in and of itself doesn't earn the hospital more money unless you are generating an admission. If the units are full they will be pushing back against your admissions. This is the recipe for burnout.
quality post. I will agree that the psych ED is a good place for 1st year residents to learn some psychiatry. So at least in the academic center setting they serve that purpose.
In most of the real world- er consults and even medicine floor consults are just handled by the psychiatrist already working at the hospital.....either on salary(psych hospitalist position) or contract(bills himself), and as part of the right to get access to those patients admitted and bill for them they have to see the consults(and they can bill for them too of course). Heck most inpatient psychiatrists can go down to the ER if they want before a pt is admitted and see them. Most choose not to though, and opt to wait for them to arrive on the floor.
Much of psychiatry in the ED setting is social work....probably between 97 and 99%. In other 'emergency' settings, the percentage is a bit lower sometimes.
yes, and the first(VA) is from an organization that manages money about as well as a heroin addict who wins powerball....so it's not surprising to see some VA's do this.
The second(academic county hospitals)....those situations can very greatly, but if there is a residency program they likely can justify the cost based on the educational end of things. If there isn't a residency program, you better have your eyes open going into it because you may be asked to do the work of 4 social workers....
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If you do look at fairly large cities, many do have dedicated psychiatry emergency rooms and are not just tacked on consultation to medicine ERs. These don’t have to be NYC, Chicago or LA. If you look at the American Association of Emergency Psychiatry, (http://emergencypsychiatry.org/executive_board.html) about half of the presidents are from these cities, but about half are not. They do tend to be run in the public sector, and this is because the structure of Medicaid/Medicare subsumes the ER costs in the bed day rate. This means that you need a large enough system to hire a half a dozen MDs for 24 x 7 coverage that bring in very little revenue, but is made up for by the overall system. This type of career is not for the faint of heart. It can be very tough as the resources never seem to match demand. It can feel like you are constantly deciding who the next least unwell person is that will not get the bed they need.
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I lately got some interesting numbers for psych ER of a major metro. $145 per night, shift 5PM-8AM. You can do 2 shifts a week and bank 200k. Kind of exhausting though, I hear you don't get much sleep.
Given it's the night shift and the potentially high stress nature of the work, $200K seems light.
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Really? For only two shifts a week?
They are 15 hours long
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Many ERs may not have a full-time psychiatrist, but you can work in multiple ERs to have a full-time job.
A lot of ER psych is handled by social workers, but that's more related to shortage of psychiatrists than shortage of funding, since psychiatrist can bill a lot more and bring more money into the hospital.
A lot of ER psych is handled by social workers, but that's more related to shortage of psychiatrists than shortage of funding, since psychiatrist can bill a lot more and bring more money into the hospital.
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Yes. This sounds exactly like a shift at my program and there's no way in hell I'd take that gig for 200k. Maybe for 3 months. I'd rather have a normal weekday job.
I have more thoughts on this thread but will share later. The bottom line is that ER psych is mostly 1. borderlines who don't need to be in the hospital but end up forcing your hand 2. people who come in under dubious involuntary holds and don't meet admission criteria but the ED wants you to see them because, aparently, they can't see how to discharge someone not suicidal who has good collateral from family and a safety plan 3. someone who's delerious but medicine won't take and they insist it's psychiatric 4. someone who's medically unstable (think OD) but they say they are and 5. a demented patient that the family can't deal with. Maybe 10-20% of the time you may see some legitimately sick people. And then lots of in between. In short, it sucks.
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huh? Do you have any idea how psych services are billed in the ER? From the above it doesn't sound like it.....the shortage of funding(meaning ways to get paid...I don't know that funding is the right word) is very much behind why there aren't lots of 'er psych' people outside of training programs. What is your fantasy about how an er psych would generate their income? What codes and what payer source?
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Ever notice how you can go into a psychiatry ER setting on a weekend and look over who is there, the patients the residents haven’t made decisions on and just know what is going to happen? I swear you could put them in a circle and ask anyone who wants to be admitted to raise their hand. “OK, all of you with your hands up, call your family to come get you, it is time to go.”
“OK, who thinks they shouldn’t be here, raise your hand… Ok you have to stay.” “You two, you haven’t raised your hands, we need to talk.”
Of course I’m not suggesting doing this, but I would guess that a more thorough examination would come to the same conclusions 90% of the time.
“OK, who thinks they shouldn’t be here, raise your hand… Ok you have to stay.” “You two, you haven’t raised your hands, we need to talk.”
Of course I’m not suggesting doing this, but I would guess that a more thorough examination would come to the same conclusions 90% of the time.
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I figure if a place has a PES/emergency psychiatry center, they'd be very open to having moonlighting doctors. It's one of the only things in this field where you can work and once you leave there's not much of a continuity of care issue making it the best "single serving" setting in psychiatry I can think of at this moment. Every place I've worked with a PES allowed psychiatrists to work in there to fill in needed gaps.
The only way I can see a place not allowing this with a PES is if their own attendings wanted to do emergency psych to the degree where they weren't hiring outsiders.
The only way I can see a place not allowing this with a PES is if their own attendings wanted to do emergency psych to the degree where they weren't hiring outsiders.
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Emergency psychiatry in a nutshell.
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I call it the rule of opposites. An attending I had in residency called in "Z.E.S.T." therapy. The guy's last name was Zwil, and it stood for Zwil's Existential Slap Therapy.
If the patient had good insight, you do what they want. They want to quit smoking? You help them. They're depressed but want to do their best without going into the hospital? You do what they want. The schizophrenia wants to stay on his meds? You do everything the guy wants that is likely all appropriate. Schizophrenic and good insight and wants discharge? Discharge him.
Poor insight? You do the opposite of what they want. Guy wants to smoke in the hospital? He's not allowed. Suicidal guy wants discharge? No. Malingerer wants admission? No. Borderline PD patient wants admission? No. Schizophrenic wants discharge and he has no insight? He's staying.
Long-story short, seemed like most of the patients I've ever had followed this rule and for better or worse, most of them in PES or inpatient were in the "poor-insight" category. Outpatient most of them were of the good insight category because the ones with the bad insight never showed or followed up.
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I know assessing insight is part of the mental status exam, but am unsure how it's done exactly. How does one look at things like cognition, abstraction, judgement, and insight so consistently?
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well people get lazy and usually use a one word descriptor which is meaningless like "good", "fair" or "poor". insight as i learned it and teach is is broken down into 3 parts - 1. is the patient willing to accept that their problems may be seen as the result of a mental disorder? 2. are they willing/engaging with providers 3. are they willing to engage in treatment? i will comment on all of them. note that i allow people to reject having a mental illness to still have good insight if they are able to understand why someone might view their problems as the result of a mental disorder but they personally choose to reject the label. but that's just me.
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Excellent post.
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I wouldn't simplify it this much. In our large university hospital we see everything from pregnant patients, mania, psychosis, stroke alerts that turn out to be conversion, children/teen evals, at times prisoners, medical comorbidities, other psych hospitals sending patients to ED as they are catatonic and they don't know whats going on, etc. The consults can be challenging and very stimulating. Similar to consult service.
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+1. A good mental status exam should include documentation of all of these factors.
Thanks again for the various replies. Particulary MacDonaldTriad and st2205 for the more bleak and humorous generalizations. I've had tremendous fun during my few ER psych shifts with residents and I realize this is a small slice of what is to come (it's not a large focus of my psychiatry rotation as with most schools I imagine). At any rate, I must have been very lucky on those shifts I rotated. ER psych seemed high stress with high impact patients and less full of the BS I encountered on other services (I realize the oddity of this statement). I also have a natural tendency to live as a night owl and thought this might be a nice answer to my less professional circadian sleep cycle. Unfortunately as mentioned several times during this thread I could very well see myself burning out even with a desire to work in an ER setting.
