Emergency Psychiatry

[gapeach06]

Hey everyone,
I do not enjoy the ER as evidenced by my serious disdain of my ER rotation. As I look into residencies to apply to, I notice some of them don't even have ER Psychiatry experience (at least not clearly listed in their info sheets) while some of them have an abundance of it. I was just wondering, does this put people at a disadvantage even if someone eventually wants to do outpatient eventually? Also, does this affect the programs accreditation in any way, as far as rotation credit? I imagine ER Psychiatry is not a required part of programs for the most part.

I just hate being in the ER, both as a patient and as a medical student, I hate the fast paced nature which makes me more appreciative of the calm, soothing atmosphere of outpatient Psych.

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[sunlioness]

My residency program didn't have a psych ED. We served as consultants to the medical ED. My med school, on the other hand, had a very large and active psych ED. I had to do two shifts there as a third year med student and if I recall correctly I left both of them in tears. Residency was way better.

However, I am currently typing at you from the call room of a dedicated psych ED run by my current employer. I should try to get some sleep, but I can't because I'm a bit freaked out.

Point being ... Seek out the experiences that scare you. They don't get any less scary as an attending if you don't work at it and one of my regrets is that I didn't seek out those experiences and become comfortable as a resident when I had all kinds of back up. If you want to do outpatient, you'll do outpatient. But you still might work somewhere where you're asked to cover a crisis shift. Or even want to cover a crisis shift because it's well paid. And when that happens, you don't want to be having to consciously control your breathing while chilling in the call room.

Your program should have emergency experience in some fashion. My program had us rotate through the medical ER, I think. I say I think because my ED rotation as an IM intern counted toward that and I didn't do it. But our overnight calls the first two years (this was back when interns were still allowed to take call alone) were a lot of consults to the ED. Didn't like it. But it was important.


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[Bartelby]

I'm pretty sure every program will have you work in the ER (either a dedicated psychiatric ER or as a consultant to the medical ER). This experience is crucial no matter what you do in the future. Having the experience of seeing hundreds of acutely decompensated or suicidal patients and understanding how to acutely manage them, what level of care to send them to, etc. will be important as an outpatient psychiatrist and is one of the things that separates us from many other mental health disciplines.

I agree with Sunlioness, if it scares you seek it out.

 

[notdeadyet]

Agree with sunlioness and bartelby.

One of the most important jobs as an outpatient psych is knowing when someone is decompensating to the point of requiring hospitalization and a good emergency psych experience will give you plenty of cases of folks right on the edge of admit vs discharge home. Those cases, under good supervision, will make you a better outpatient psychiatrist.

Good inpatient and emergency training will make you a better outpatient doc, just like good outpatient and psychotherapy training will make you a better inpatient doc. I think it's wise to just use residency to first build a solid foundation as a good psychiatrist with diverse skills. That'll make you a better psychiatrist later no matter what you specialize in.

 

[MacDonaldTriad]

The biggest bane to an ER psychiatrist’s existence is to be fed patients from a large ambulatory mental health care system that has no clue as to the job of a psych ER. “I don’t understand this; I keep sending that ER my acutely suicidal borderline patient and they keep sending her back without doing anything? I keep promising her that the ER will lead to her ultimate corrective emotional experience she seeks and I cannot figure out why they will not give it to her. Bad psych hospital, bad bad psych hospital. Why do we give them our money anyway?”

 

[sunlioness]

Yeah. That's a no no. And last night I had to explain to the nice ED resident that I wasn't going to come over to the medical ED to talk to the sad crying lady who wasn't in any danger, but needed to be started on an antidepressant and get a curative pep talk from me right that second. No. She can go to the walk in intake place Monday morning. Which is all I would have told her in my curative pep talk and two days of an ssri would make no difference anyway.


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[nexus73]

My residency program didn't have a psych ED. We served as consultants to the medical ED. My med school, on the other hand, had a very large and active psych ED. I had to do two shifts there as a third year med student and if I recall correctly I left both of them in tears. Residency was way better.

However, I am currently typing at you from the call room of a dedicated psych ED run by my current employer. I should try to get some sleep, but I can't because I'm a bit freaked out.

Point being ... Seek out the experiences that scare you. They don't get any less scary as an attending if you don't work at it and one of my regrets is that I didn't seek out those experiences and become comfortable as a resident when I had all kinds of back up. If you want to do outpatient, you'll do outpatient. But you still might work somewhere where you're asked to cover a crisis shift. Or even want to cover a crisis shift because it's well paid. And when that happens, you don't want to be having to consciously control your breathing while chilling in the call room.

Your program should have emergency experience in some fashion. My program had us rotate through the medical ER, I think. I say I think because my ED rotation as an IM intern counted toward that and I didn't do it. But our overnight calls the first two years (this was back when interns were still allowed to take call alone) were a lot of consults to the ED. Didn't like it. But it was important.


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Great point in general.

 

[alina_s]

Although it may sound backwards, I'd recommend looking for a program with a dedicated rotation or preferably, a psych ER. Especially if you don't like emergency work, it's much better to work with a team (nursing, social work, and if you're lucky, an on-site attending) than to be the solo mental health staff working with ED staff who hate dealing with emotional patients.

 

[Ceke2002]

The biggest bane to an ER psychiatrist’s existence is to be fed patients from a large ambulatory mental health care system that has no clue as to the job of a psych ER. “I don’t understand this; I keep sending that ER my acutely suicidal borderline patient and they keep sending her back without doing anything? I keep promising her that the ER will lead to her ultimate corrective emotional experience she seeks and I cannot figure out why they will not give it to her. Bad psych hospital, bad bad psych hospital. Why do we give them our money anyway?”

That's one very big reason I'm glad the CMHC where I live is actually connected to the local hospital, so the same Psychiatrists that work outpatient at the Community Clinic are the same ones that work the floor in the ER and/or work the inpatient Psych unit at the same hospital. Not that I'm going to need to go to hospital for Psychiatric reasons anytime soon, at all, but at least if I did I know it's not going to be a case of the left hand doesn't know what the right hand is doing.

 

[MacDonaldTriad]

All “community” psychiatrists should be required to spend two weeks in a psych ER so they can say “Oh…. I get it!”. If they did, they wouldn’t have to put up with 90% of the ridicule academics half justifiably heap upon them.
Sounds like your CMHC has their act together.
Let me say Ceke, it is very cool of you to take the time to participate in these discussions as you are the foil to our tendency to retreat into an artificial world of mutual but self contained validation. (Those who can't teach).

 

[DD214_DOC]

Isn't ER psych an ACGME requirement?

 

[WingedOx]

A few points, tangentially related...

Isn't ER psych an ACGME requirement?

Even without a dedicated facility it's not exactly hard for residents to get plenty of emergency/triage experience. I'm not sure that a dedicated facility is necessarily better. Doing the psych work in a medical ER where the patients may or may not have been medically cleared adds a layer of ambiguity to your work that makes you better at triaging what you're seeing. Remember the point is for you to get good at what you're doing, not for it to be easy during training.

I hate the fast paced nature which makes me more appreciative of the calm, soothing atmosphere of outpatient Psych.

It's hard to appreciate this as a student, but when you're the consultant alone in the ED, you basically have total control over the pace of things, in some ways more-so than even the set-appointment world of outpatient. Once I got good at what I was doing, my night shifts in the ED were some of the least-stressful parts of residency. The ED physicians all knew me and trusted my judgment calls. I could triage what I needed to see and what could wait, and the ED night staff were always the most chill.


Also, has anyone else seen the new Dick Wolf show "Chicago Med"? I saw it for the first time this week and I love how the guy who works the ER overnight is the hospital "Chief of Psychiatry"

 

[Ceke2002]

All “community” psychiatrists should be required to spend two weeks in a psych ER so they can say “Oh…. I get it!”. If they did, they wouldn’t have to put up with 90% of the ridicule academics half justifiably heap upon them.
Sounds like your CMHC has their act together.
Let me say Ceke, it is very cool of you to take the time to participate in these discussions as you are the foil to our tendency to retreat into an artificial world of mutual but self contained validation. (Those who can't teach).

I'm sorry I didn't see this earlier - thank you, I do like to try and contribute where I can 🙂

The CMHC I used to attend might have had their **** together, other CMHCs in Adelaide...not so much. There was one place that was completely understaffed, little to no continuity in patient care, actively hallucinating and suicidal patients ringing their emergency triage line only to be told to 'take a nice hot bath and relax', etc etc -- and instead of spending their allocated funding on hiring more staff, or working on overhauling their system so it actually freakin' worked properly, they decided to fork out to have the centre painted lovely bright colours because that would cheer the patient's up.

My Psychiatrist's response to what they'd done was basically "Enforced happiness, yeah great that'll work...🙄"

 

[Shikima]

yes but most programs don't have a dedicated psych ER. the ACGME requirements are so loosely interpreted and enforced as to be useless. many programs have no geriatric psychiatry rotation. or addictions. many programs don't teach psychodynamic therapy or CBT. They never shut down any psychiatry programs.

Truth. PG education is far from standardized for quality. No offense to the PDs in the forum, it's not your fault, it's the inherent problems from bureaucracy.

 

[Leo Aquarius]

To the OP, I know you hate the ER. I didn't like Psych ER either and still don't. But I'm glad I got trained in it because when I step out into the real world I want to say 'yep, I can handle that no problem' in all major facets of psychiatry.

Which brings me to a little rant which is most residents can be better trained in reproductive psychiatry. Wish we all had more training in that arena.

 

[gapeach06]

Thanks for the feedback guys. I guess it's a part of residency that I'll have to suck up and learn as much as I can from.

 

[notdeadyet]

Thanks for the feedback guys. I guess it's a part of residency that I'll have to suck up and learn as much as I can from.

Good attitude to have. Odds are you'll find other areas of residency that this applies to as well, and having an open mind and viewing it as a learning experience will only help you and those around you.

 

[Rogue Penguin]

Is there any exhaustive list of programs that have a dedicated psych ER? What counts as a dedicated psych ER? Do the CPEPs in NYC count? How important or beneficial is attending a residency with a psych ER?

 

[MacDonaldTriad]

I don’t think +/- dedicated ER is as telling as what is the source of patients your ER sees. Jail, residential homes, Med ER triages, psychiatric mobile teams, the police, walk ins? These can be very different.

 

[notdeadyet]

Finding a kind of master list is going to be challenging because there isn't much in the way of standardization. Not even on nomenclature.

Some programs point out what are actually Crisis Stabilization Units (CSU) and use it in the same breath as "emergency" that folks start to confuse it with Psychiatric Emergency Services (PES, or Psychiatric Emergency Departments or Psychiatric Emergency Rooms... see nomenclature comment above).

A true PES qualifies under EMTALA rules as seeing patients having an "Emergency Medical Condition." As such, a PES has to have the capacity to screen fro all "Emergency Medical Conditions," so they are open 24/7, have physicians available 24/7, and are typically co-located in very close proximity to a Medical Emergency Room (these are often across or down the hall and have a very close working relationship). A PES is required to take all comers. They an bill Medicare or under Medicaid waivers, but they are required to assess all who present. They are allowed to receive law enforcement drop-offs.

This is different from a Crisis Stabilization Unit . They are not required to have physicians present or be open 24/7. They don't need to screen for all "Emergency Medical Conditions" and do not qualify as EMTALA providers. They can not bill Medicare but typically can Medicaid. They are not a law enforcement drop-off.

Crisis stabilization is great experience, but it isn't synonymous with PES. The value of training in a PES is that you will be receiving patients who can be more diagnostically complex from a medical standpoint (e.g.: what is causing the altered mental status?). In a CSU, these patient would be sent to a medical ER with psych consulting.

When you ask about programs having a "dedicated psych ER," these have an advantage because if it's a dedicated psych ER, it has it's own staff, budget, and medical director. This tends to create a better learning and clinical environment since psychiatry has more control. Some programs will not have a facility like that and instead what they may call a Psych ER is in actuality a psychiatry consult service in the medical Emergency Department. In some cases, the EDs actually have a wing of the ER dedicated to psych patients, though this model didn't really take off. There's nothing wrong with it, and as long as the PES is a dedicated department with its own budget, staff, and medical director, the physical plant is probably less important. But I much prefer PES having it's own facility just because it's easier to maintain control that can sometimes get hinky when you're sharing a space.

 

[MacDonaldTriad]

The best duck test is to ask yourself, when I write orders for a psych patient in the ER, who carries out my orders? Is it a psychiatry RN, or an RN that tries to avoid the psych patients.

 

[Rogue Penguin]

Thank you. These are helpful posts.

 

[whopper]

All “community” psychiatrists should be required to spend two weeks in a psych ER so they can say “Oh…. I get it!

I'd make it 3 months.

I remember getting people in a PES with no business being there. E.g. school counselor referred kid to us because his grades were Bs an Cs ,not As and Bs.

 

[HarryMTieboutMD]

At my program (big academic medical center in urban environment where we see basically everything) we have a dedicated ED month as well as Q7ish overnight call in the ED on our other PGY2 rotations. As PGY2 residents we are the only psychiatrists in the ED (the attending is on call but we don't have to staff- just in case we have questions), and 99% of the time the ED attendings listen to what we say (the other 1% is largely political/bureaucratic). The ED experience has been absolutely indispensable in my training: becoming very efficient at history taking, honing my mental status exam (which needs to be pristine in an emergency setting where we have to determine dispo), making decisions without oversight (love this part), interacting with lots of other specialties, making decisions based upon incomplete information, and really thinking about dangerousness (which we gets a lot of exposure to as interns on the inpatient unit because the interns do the involuntary petitions and hearings, not the attendings). All of these skills are requisite for the skilled psychiatrist (at least in the eyes of our department), and I'm SO grateful that we have this as part of our training.

 

[MacDonaldTriad]

At my program (big academic medical center in urban environment where we see basically everything) we have a dedicated ED month as well as Q7ish overnight call in the ED on our other PGY2 rotations. As PGY2 residents we are the only psychiatrists in the ED (the attending is on call but we don't have to staff- just in case we have questions), and 99% of the time the ED attendings listen to what we say (the other 1% is largely political/bureaucratic). The ED experience has been absolutely indispensable in my training: becoming very efficient at history taking, honing my mental status exam (which needs to be pristine in an emergency setting where we have to determine dispo), making decisions without oversight (love this part), interacting with lots of other specialties, making decisions based upon incomplete information, and really thinking about dangerousness (which we gets a lot of exposure to as interns on the inpatient unit because the interns do the involuntary petitions and hearings, not the attendings). All of these skills are requisite for the skilled psychiatrist (at least in the eyes of our department), and I'm SO grateful that we have this as part of our training.

This in spades.

 

[Rogue Penguin]

At my program (big academic medical center in urban environment where we see basically everything) we have a dedicated ED month as well as Q7ish overnight call in the ED on our other PGY2 rotations. As PGY2 residents we are the only psychiatrists in the ED (the attending is on call but we don't have to staff- just in case we have questions), and 99% of the time the ED attendings listen to what we say (the other 1% is largely political/bureaucratic). The ED experience has been absolutely indispensable in my training: becoming very efficient at history taking, honing my mental status exam (which needs to be pristine in an emergency setting where we have to determine dispo), making decisions without oversight (love this part), interacting with lots of other specialties, making decisions based upon incomplete information, and really thinking about dangerousness (which we gets a lot of exposure to as interns on the inpatient unit because the interns do the involuntary petitions and hearings, not the attendings). All of these skills are requisite for the skilled psychiatrist (at least in the eyes of our department), and I'm SO grateful that we have this as part of our training.

I'm sure I'll change a lot and learn a lot over the course of intern year, but staffing an ED as a PGY2 with almost no supervision seems scary to me. It's interesting to hear from people who are strongly in favor of that sort of scenario. How do you know if you did the right thing?

 

[Bartelby]

I'm sure I'll change a lot and learn a lot over the course of intern year, but staffing an ED as a PGY2 with almost no supervision seems scary to me. It's interesting to hear from people who are strongly in favor of that sort of scenario. How do you know if you did the right thing?

Getting that opportunity is hugely helpful. When an attending is looking over your shoulder it is too easy to lapse into letting them making the call, or tentatively saying "well I think we should [x]" knowing that if it is a bad plan they will immediately correct it. When you are on your own you really feel the decision much more heavily and learn how to think like an independent doctor.

As for how you know if you did a right thing, there should be sufficient supervisory safeguards for that. For instance, if you want to discharge anyone who is potentially risky the program should at least make you run the full decision by an attending or a more senior resident so that you know you are doing something reasonable. There will be someone available to you to discuss cases where you are stuck (for instance dealing with a very agitated patient in the consult setting). Also remember that your shift will probably be 14 hours (~6p to 8a), so any patient that you find tricky to deal with will rarely be more than 10 hours away from a morning attending doing a full evaluation. You then get to see how they approached the case differently (if they do), which provides tremendously valuable real world feedback.

Is it intimidating? Absolutely! Having gone through it though I am so glad that I ran across these issues pseudo-independently for the first time taking call as a PGY-2 and 3 rather than as a new attending when there is truly no one who has to answer your questions or check up on your work the next day.

 

[HarryMTieboutMD]

Getting that opportunity is hugely helpful. When an attending is looking over your shoulder it is too easy to lapse into letting them making the call, or tentatively saying "well I think we should [x]" knowing that if it is a bad plan they will immediately correct it. When you are on your own you really feel the decision much more heavily and learn how to think like an independent doctor.

As for how you know if you did a right thing, there should be sufficient supervisory safeguards for that. For instance, if you want to discharge anyone who is potentially risky the program should at least make you run the full decision by an attending or a more senior resident so that you know you are doing something reasonable. There will be someone available to you to discuss cases where you are stuck (for instance dealing with a very agitated patient in the consult setting). Also remember that your shift will probably be 14 hours (~6p to 8a), so any patient that you find tricky to deal with will rarely be more than 10 hours away from a morning attending doing a full evaluation. You then get to see how they approached the case differently (if they do), which provides tremendously valuable real world feedback.

Is it intimidating? Absolutely! Having gone through it though I am so glad that I ran across these issues pseudo-independently for the first time taking call as a PGY-2 and 3 rather than as a new attending when there is truly no one who has to answer your questions or check up on your work the next day.

Agree with everything in this post. Also, it's natural to feel overwhelmed and intimidated as a med student when looking ahead to residency. Basically, as a medical student at a US MD school you have zero actual responsibility and virtually contribute nothing to patient care (cue people arguing on this but I don't care). MS3 is all a game of finding the appropriate balance between confidence, amicability, demonstrating medical knowledge, and not one upping your residents. Looking back during my MS3 days and seeing the med students that I supervise now (at different US allopathic med schools nonetheless), this is absolutely true. Whereas as a resident, for the first time you actually have decision making power, and by the end of intern year, you should be confident in your decision making abilities while maintaining the humility that you need to keep learning, reading, and getting feedback from more experienced people. Most competent interns grow weary about the constant oversight after about ~6-9 months in. By the my 3rd month of internal med, I stopped even discussing what I was doing with my senior and just did it (unless I had a serious question or the patient was very unstable). Similarly, on psych inpatient when it was just the attending, the med students, and me, by the end of the year I would have my plans done and orders entered before rounding with the attending- and they trusted me.

Bottom line- I love the autonomy I have in the ED and the respect I get from the ED residents and attendings. I hardly ever need to call the attending (we don't staff the patients we see in the ED), and when I do, it's usually just a logistical issue. And part of learning is making mistakes (and I've made plenty as an intern/resident). But I learn from them, read, and discuss them, which is part of growing as a physician.

 

[notdeadyet]

Agree with the above with a big caveat:

As intern year progresses, most interns do not recognize all that they know and all they are capable of doing independently. But for many, they will hit a point near the end of intern year or the start of PGY-2 year in which they get overconfident and cocky. This is common and not problematic and it usually just takes one clinical encounter (or a faculty encounter) to recalibrate them as to their capabilities and experience level so that they don't fall prey to common mistakes like early closure. Most folks in residency have this little period and it gets corrected. Those who don't have it corrected are the overconfident docs who make mistakes that hurt patients and are too vested in themselves to recognize it and learn from it. Bad docs.

Believe in the cumulative feedback you get from folks and keep an open mind and open ear in residency. Don't feel the need to "prove" how capable you are through what you say. Work hard people will notice. Do it well and people will notice that too. Attend a decent program and people will comment on it.