Geri psych turf

[thelastpsych]

So, I'm in my last year of psych residency, and deciding on doing an additional geri psych year of training (had a very weak rotation on geri psych, but was deeply interested by it). I know what most people say about fellowships in psych: the only truly necessary seem to be child and forensic, but I'm very interested in the topics covered by geri psych - cognition and BPDS, depression, end-of-life and all the existential problems of old age, the overlap with neuro/IM that sometimes come into play, complex psychopharmacology, etc...

My question is regarding the large overlap with IM/geri and neuro: I know most geriatric patients aren't very fond of psychiatrists, and most have "non-psych" manifestations of psych problems (e.g chronic pain or fatigue as depression for instance) - in that regard, is there a job market for geri psych, one in which you are mostly seeing older folks with MH problems? I actually don't care for the pay cut since most patients are insurance only, just worried about the demand.

Thanks in advance!

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[allantois]

If you wanna do ALF work, you cant get neuro to come see these patients where I am and IM will happily give them to you

 

[FlowRate]

Just to share a perspective that you can see plenty of old folks for typical psych issues (BPSD, depression, anxiety, etc.) without geri training: my organization, despite being quite large, is not specifically hiring anyone to do geri, despite having a significant cohort of medicare patients. The idea being that any psychiatrist can/should be able to see most BPSD and geri w/ otherwise vanilla psych complaints. We do have a geri team for the rare complex cases that need more testing/consideration from people who are geri trained. But those geri trained docs don't actually see the pts directly, a NP does, mostly to administer additional tests/communicate recs--the geri folks just sit on the once a week team meeting. One thing that isn't well defined is the line between what we own and what neuro owns.

Seems like neuropsych is more likely to get you specialized expertise with some of the geri presentations that are not as well served by the average general psychiatrist.

 

[splik]

We have an ageing population, so yes there is a need for geriatric psychiatrists. Unfortunately, geriatric psychiatrists have been undervalued, but there is definitely need for experts in older adult mental health working in community settings, private practice, doing home visits, general hospitals, inpatient geropsychiatry units, palliative care, geropsych day programs, memory clinics, geropsych IOP/PHPS, nursing homes, C-L, ECT services, and also as expert witnesses regarding issues related to civil competencies (e.g. testamentary capacity), undue influence, elder abuse and so on.

I'm not sure where you got the idea that most geriatric patients aren't presenting with psychiatric symptoms. Psychiatric symptoms are extremely commonly in older patients, and things like depression are probably way overdiagnosed in older adults. Nowadays many patients geriatric psychiatrist see are patients who have longstanding psychiatric problems (remember most psychiatric disorders begin before the age of 25) who are now over the age of 65. There are also patients presenting with disorders of late life such as very very late onset schizophrenia, late paraphrenia, psychotic depression and so on. And then there are patients with neurodegenerative disorders (e.g. AD, PD, DLB) and delirium.

I am also not sure where you got the idea that older patients don't want to see psychiatrists. Not that older people can't be dinguses, but they are usually very appreciative and respectful compared to younger pts. Patients with dementia often don't want to see physicians, but that is not limited to psychiatrists. There are some occasions where patients might refuse to meet with a psychiatrist, and you might use "therapeutic deception" and not tell them you are a psychiatrist.

Most patients have medicare, which actually reimburses decently, and more than many commercial plans will pay a solo physician. In addition, 42% of pts with medicare have medicare advantage which means that you can charge those pts cash if you're not enrolled in those medicare advantage plans. Depending on where you are, there is a burgeoning market for high quality geropsychiatric care.

While all psychiatrists should be able to manage bread and butter issues in older adults, a large proportion of psychiatrists won't see older adults, and many do not feel comfortable doing so.

 

[SmallBird]

We have an ageing population, so yes there is a need for geriatric psychiatrists. Unfortunately, geriatric psychiatrists have been undervalued, but there is definitely need for experts in older adult mental health working in community settings, private practice, doing home visits, general hospitals, inpatient geropsychiatry units, palliative care, geropsych day programs, memory clinics, geropsych IOP/PHPS, nursing homes, C-L, ECT services, and also as expert witnesses regarding issues related to civil competencies (e.g. testamentary capacity), undue influence, elder abuse and so on.

I'm not sure where you got the idea that most geriatric patients aren't presenting with psychiatric symptoms. Psychiatric symptoms are extremely commonly in older patients, and things like depression are probably way overdiagnosed in older adults. Nowadays many patients geriatric psychiatrist see are patients who have longstanding psychiatric problems (remember most psychiatric disorders begin before the age of 25) who are now over the age of 65. There are also patients presenting with disorders of late life such as very very late onset schizophrenia, late paraphrenia, psychotic depression and so on. And then there are patients with neurodegenerative disorders (e.g. AD, PD, DLB) and delirium.

I am also not sure where you got the idea that older patients don't want to see psychiatrists. Not that older people can't be dinguses, but they are usually very appreciative and respectful compared to younger pts. Patients with dementia often don't want to see physicians, but that is not limited to psychiatrists. There are some occasions where patients might refuse to meet with a psychiatrist, and you might use "therapeutic deception" and not tell them you are a psychiatrist.

Most patients have medicare, which actually reimburses decently, and more than many commercial plans will pay a solo physician. In addition, 42% of pts with medicare have medicare advantage which means that you can charge those pts cash if you're not enrolled in those medicare advantage plans. Depending on where you are, there is a burgeoning market for high quality geropsychiatric care.

While all psychiatrists should be able to manage bread and butter issues in older adults, a large proportion of psychiatrists won't see older adults, and many do not feel comfortable doing so.

Would you agree that the standard of care is extremely variable across locations and treatment settings? I am struck by how in some settings a patient with abrupt cognitive decline may end up on a medical service, assumed to be at a baseline, and get sent to a nursing home in their 60s, whereas if the same patient had seen a behavioral neurologist at Mayo Clinic they likely would have had an MRI and PET scan to characterize their dementia subtype, and then somewhere in the middle they may have scene a psychiatrist who would at least order some labs and then try and recommend options for optimizing behavioral and psychological symptoms of dementia.

 

[thelastpsych]

Just to share a perspective that you can see plenty of old folks for typical psych issues (BPSD, depression, anxiety, etc.) without geri training: my organization, despite being quite large, is not specifically hiring anyone to do geri, despite having a significant cohort of medicare patients. The idea being that any psychiatrist can/should be able to see most BPSD and geri w/ otherwise vanilla psych complaints. We do have a geri team for the rare complex cases that need more testing/consideration from people who are geri trained. But those geri trained docs don't actually see the pts directly, a NP does, mostly to administer additional tests/communicate recs--the geri folks just sit on the once a week team meeting. One thing that isn't well defined is the line between what we own and what neuro owns.

Seems like neuropsych is more likely to get you specialized expertise with some of the geri presentations that are not as well served by the average general psychiatrist.

Thanks for the response Flow! You commented on neuropsych, which is something I tried looking into a bit. From what I could gather, neuropsych is a much more research oriented subspecialty than geri psych, with most programs focusing heavily on the academic side of things, although I've come across a few clinically oriented programs - as a disclaimer, I'm not very interested in research, but would actually enjoy a position in a teaching/academic hospital (if that is even feasible). Also, it seems that neuropsych is much more restricted in terms of job options, since it is a very niche subspecialty, specially for those not interested in research. Is that true? Since I didn't have a proper neuropsych I'm just speculating from things I read and heard from other people...

 

[whopper]

While I was at U of Cincinnati I used to work on a geriatric psych floor.

You're going to get a lot of medical disaster cases in such a unit. E.g. someone with brittle diabetes and CHF. That wasn't the main problem I had with the floor. If anything I am especially proud that I know more IM than most psychiatrists.

The problem became that when we needed consults they wouldn't show up and in several of these cases patients were in acute medical emergencies. What happened at the time and this was fixed only after literally dozens of complaints and near death incidents was UC put all psych units in another facility about 10 blocks away. So if you ordered a consult the consult had to drive over 10 blocks. 10 blocks in busy city traffic, plus the walking to the unit and back could be literally over 30 minutes one way. Consultants refused to show up. We weren't allowed to send the patients to the ER cause consultants on paper were supposed to show up but refusing and the institution wasn't forcing them to show up.

To alleviate the problem they assigned an IM doctor to be on site every day. Even that didn't solve the problem. The IM doctor would even be saying the person needed a specialized consultant and the consultant refused to show up. IM doctors who were assigned to us were telling me they saw it as the "horror month" where they hoped no one would die on their watch. So what do you think I, not an IM doctor, but a psychiatrist was thinking about this? E.g. we had a seizure patient and no one could get her seizures under control. The neurologist refused to show up. We had a guy with a spinal cord infection and an infectious disease doctor and surgeon refused to show up.

We finally had a case of a guy with CSF leakage and probably infection of his spinal cord and still consultants refused to show up. Despite that it was a violation I had the patient sent to the ER cause I said to myself this was a violation of my Hippocratic Oath. The ER doctor was fuming pissed. I told him what was going on and he was screaming "Why aren't these consultants showing up?!"!"! For added transparency and cause I was sick of it, and cause I knew several people weren't doing their jobs, I told the patient and his family to complain to the state medical board.

Finally then, and this was after months of horror incidents happening about weekly they finally forcing some people to show up and then moved the psych units close to the main hospital.

 

[allantois]

While I was at U of Cincinnati I used to work on a geriatric psych floor.

You're going to get a lot of medical disaster cases in such a unit. E.g. someone with brittle diabetes and CHF. That wasn't the main problem I had with the floor. If anything I am especially proud that I know more IM than most psychiatrists.

The problem became that when we needed consults they wouldn't show up and in several of these cases patients were in acute medical emergencies. What happened at the time and this was fixed only after literally dozens of complaints and near death incidents was UC put all psych units in another facility about 10 blocks away. So if you ordered a consult the consult had to drive over 10 blocks. 10 blocks in busy city traffic, plus the walking to the unit and back could be literally over 30 minutes one way. Consultants refused to show up. We weren't allowed to send the patients to the ER cause consultants on paper were supposed to show up but refusing and the institution wasn't forcing them to show up.

To alleviate the problem they assigned an IM doctor to be on site every day. Even that didn't solve the problem. The IM doctor would even be saying the person needed a specialized consultant and the consultant refused to show up. IM doctors who were assigned to us were telling me they saw it as the "horror month" where they hoped no one would die on their watch. So what do you think I, not an IM doctor, but a psychiatrist was thinking about this? E.g. we had a seizure patient and no one could get her seizures under control. The neurologist refused to show up. We had a guy with a spinal cord infection and an infectious disease doctor and surgeon refused to show up.

We finally had a case of a guy with CSF leakage and probably infection of his spinal cord and still consultants refused to show up. Despite that it was a violation I had the patient sent to the ER cause I said to myself this was a violation of my Hippocratic Oath. The ER doctor was fuming pissed. I told him what was going on and he was screaming "Why aren't these consultants showing up?!"!"! For added transparency and cause I was sick of it, and cause I knew several people weren't doing their jobs, I told the patient and his family to complain to the state medical board.

Finally then, and this was after months of horror incidents happening about weekly they finally forcing some people to show up and then moved the psych units close to the main hospital.

Just wow.. admin can't just block ER transfers.. if they need to go, they need to go

 

[splik]

Would you agree that the standard of care is extremely variable across locations and treatment settings? I am struck by how in some settings a patient with abrupt cognitive decline may end up on a medical service, assumed to be at a baseline, and get sent to a nursing home in their 60s, whereas if the same patient had seen a behavioral neurologist at Mayo Clinic they likely would have had an MRI and PET scan to characterize their dementia subtype, and then somewhere in the middle they may have scene a psychiatrist who would at least order some labs and then try and recommend options for optimizing behavioral and psychological symptoms of dementia.

Yes. In many settings, things have not advanced since the 1970s. I have seen pts end up on comfort care being allowed to die, misdiagnosed as dementia when actually they had treatable severe MDD with stupor or psychosis and responded readily to ECT. I have seen pts written off as having DLB when actually they had acute mania (again readily treatable). I see many cases where I can dramatically improve care (and I am a place where neuro is actually interested in AMS, we have a first class memory clinic, lots of behavioral neurologists, we have nurses who just focus on delirium and a geriatric nurse specialist, a robust geriatric medicine consult service, several QI initiatives related to delirium and dementia, and other resources that aren't rountinely available elsewhere). many patients get zero workup. Even patients with simple UTIs sometimes get written off as having dementia or terminal delirium. In many settings, there is no one to spend the time. There may be no specialists interested in providing care. Some patients have no one to advocate for them. While it is true there are many cases where there is not much that can be done, there are still a good handful where a thorough thoughtful evaluation and formulation can change management for the better including making the difference between life and death or whether a patient can stay in their home or needs care in a locked memory care unit.

 

[whopper]

ust wow.. admin can't just block ER transfers.. if they need to go, they need to go

It's an EMTALA violation to send a patient out of the hospital to an ER if the hospital is supposed to be providing services.

In this case the hospital alleged to other authorities those patients were getting needed consults if requested. What they didn't count on was doctors themselves refusing to show up.

So I was told I can't send patients to the ER despite that the doctors weren't showing up for consults. I told the hospital if I get a WTF life or death situation you can sure as heck expect me to send them to the ER and report this to the state medical board which did happen. Adding to the fire (and I was glad it happened cause it forced idiots who wanted the geri-unit to stay where it was) the specific patient in question was high up in the medical field as was several of his family members! I knew them complaining was going to make people who wanted to ignore the problem look even worse.

In my department's defense when it finally did happen the department fully backed me up and upon reviewing the case defended me saying I had no choice cause the other idiots weren't showing up for consult requests.

 

[thelastpsych]

We have an ageing population, so yes there is a need for geriatric psychiatrists. Unfortunately, geriatric psychiatrists have been undervalued, but there is definitely need for experts in older adult mental health working in community settings, private practice, doing home visits, general hospitals, inpatient geropsychiatry units, palliative care, geropsych day programs, memory clinics, geropsych IOP/PHPS, nursing homes, C-L, ECT services, and also as expert witnesses regarding issues related to civil competencies (e.g. testamentary capacity), undue influence, elder abuse and so on.

I'm not sure where you got the idea that most geriatric patients aren't presenting with psychiatric symptoms. Psychiatric symptoms are extremely commonly in older patients, and things like depression are probably way overdiagnosed in older adults. Nowadays many patients geriatric psychiatrist see are patients who have longstanding psychiatric problems (remember most psychiatric disorders begin before the age of 25) who are now over the age of 65. There are also patients presenting with disorders of late life such as very very late onset schizophrenia, late paraphrenia, psychotic depression and so on. And then there are patients with neurodegenerative disorders (e.g. AD, PD, DLB) and delirium.

I am also not sure where you got the idea that older patients don't want to see psychiatrists. Not that older people can't be dinguses, but they are usually very appreciative and respectful compared to younger pts. Patients with dementia often don't want to see physicians, but that is not limited to psychiatrists. There are some occasions where patients might refuse to meet with a psychiatrist, and you might use "therapeutic deception" and not tell them you are a psychiatrist.

Most patients have medicare, which actually reimburses decently, and more than many commercial plans will pay a solo physician. In addition, 42% of pts with medicare have medicare advantage which means that you can charge those pts cash if you're not enrolled in those medicare advantage plans. Depending on where you are, there is a burgeoning market for high quality geropsychiatric care.

While all psychiatrists should be able to manage bread and butter issues in older adults, a large proportion of psychiatrists won't see older adults, and many do not feel comfortable doing so.

Thanks for the corrections splik, my choice of words was inaccurate - to generalize that most elderly patients dislike psychiatrists, or most psychiatric problems in this age present with non-psychiatric complaints is simply wrong, and a manifestation of the snide remarks I've listened from colleagues and mentors when I said I wanted to do geropsych, and my lack of experience in the field (which hopefully will be corrected with a fellowship).

Your thoughts on geriatric patients being respectful and appreciative ring a bell to me: there seems to be less patients with severe personality disorders, and ageing can make even low-functioning BPD much less symptomatic (although I've met a few elderly PD patients and these were probably some of the worst cases I've ever seen).

One thing I am in doubt however is the type of complaints I'll receive: I love to manage the BPSD but I am kind of confused if geropsych receives patients for the diagnostic work-up of dementia from the get-go, since I actually also enjoy the differential diagnosis of these conditions. Or are these cases managed by neuro/neuropsych?

 

[splik]

One thing I am in doubt however is the type of complaints I'll receive: I love to manage the BPSD but I am kind of confused if geropsych receives patients for the diagnostic work-up of dementia from the get-go, since I actually also enjoy the differential diagnosis of these conditions. Or are these cases managed by neuro/neuropsych?

I think this will very much depend on the setting you work in. I am neuropsych rather than geri but there is obviously a lot of overlap (though I probably see more pts with young onset dementia, which you could totally do as a geriatric psychiatrist too). If you are well trained and work in a memory clinic you should be able to see patients presenting prior to dx of dementia and make the dx, particularly for older patients. a lot of the patients will likely have depression, anxiety, psychosis, PTSD, functional cognitive disorder etc rather than true dementia. In our memory clinic there is one geriatric psychiatrist, who sees pts in the same way as the neurologists including doing a full neuro exam, reviewing imaging, order LPs etc etc. Some places the memory clinics are run by geropsych, some places by geriatric medicine, some places by cognitive neuro, and some places it is very multidisciplinary. Each discipline brings something different. I think geriatric medicine is great for the oldest old and those with lots of medical comorbidities. Geriatric psychiatry is going to be best for patients with significant BPSD, comorbid psychiatric disorders, for pts who need ECT, for having discussions with family regarding diagnosis and goals of care planning, and for thinking about medicolegal things like decision making capacity. Neurology is going to be best for pts under 40 who need extensive workup, for patients with aphasias (e.g. PNFA, lvPPA etc), for patients with movement disorder, gait, or autonomic symptoms. Neuropsych is going to be best for patients with functional cognitive disorders, bvFTD phenocopy pts, the C9 repeat expansion patients with a more manic or psychotic presentation, for TBI cases, for pts with a history of serious mental illness presenting with cognitive impairment etc.

 

[whopper]

My biggest problem other than the bad medical situations without appropriate medical support was that I had way more defeats than victories the way I interpret it. E.g. you can't really make a huge difference with dementia. Having so many patients where I could only at best slightly improve symptoms instead of the "doc, you really made me get so much better thank you!" after awhile got to me making me enjoy non-geri far more.

Not that this is bad for everyone. If you can tolerate the above better than me maybe you should go into that field cause there certainly is a demand.

 

[Candidate2017]

Most patients have medicare, which actually reimburses decently, and more than many commercial plans will pay a solo physician.

While all psychiatrists should be able to manage bread and butter issues in older adults, a large proportion of psychiatrists won't see older adults, and many do not feel comfortable doing so.

Even if Medicare pays a little more, the amount of work in geri makes it untenable. Outpatient geri is basically the psychosocial parts of child psych on steroids, plus IM and neuro issues.

Instead of two warring parents, you have an elderly spouse and several arguing adult children who can't agree on a family representative, and call at separate times wanting to know the plan or demanding med changes or that contraindicated meds continue indefinitely ("I know mom's kidneys aren't the best and she's been falling, but why can't mom stay on the Lithium, Depakote, Haldol, Trilafon, and Xanax she's been on for decades?"). Geri patients' collateral is even more unreliable than child patients: their spouse struggles with their own health issues, they live alone, and/or have busy adult children that check on them once a month or never.

There are also 20 page med recs that change at every visit ("Dad's cardiologist changed his heart meds, I don't remember them but one of them starts with a P"), as well as several new/worsening med conditions, and constantly fluctuating abnormal labs. Is that acute hyponatremia due to my SSRI or their 50 other meds, HF, CVA, CKD, psychogenic polydipsia, or something else? Chasing labs, keeping up with their meds/med interactions, and trying to coordinate care at every visit is exhausting and leaves 3 minutes to try to get an accurate psych interval history and come up with a psych plan.

I can't do all of that in a follow up visit. Geri is only practical in academic centers, i.e., you have residents doing all of the above for minimal compensation. Given most geri patients' 50 meds are for medical conditions, maybe it's best for their IM doc to handle their handful of psych meds as well.

 

[splik]

Even if Medicare pays a little more, the amount of work in geri makes it untenable. Outpatient geri is basically the psychosocial parts of child psych on steroids, plus IM and neuro issues.

Instead of two warring parents, you have an elderly spouse and several arguing adult children who can't agree on a family representative, and call at separate times wanting to know the plan or demanding med changes or that contraindicated meds continue indefinitely ("I know mom's kidneys aren't the best and she's been falling, but why can't mom stay on the Lithium, Depakote, Haldol, Trilafon, and Xanax she's been on for decades?"). Geri patients' collateral is even more unreliable than child patients: their spouse struggles with their own health issues, they live alone, and/or have busy adult children that check on them once a month or never.

There are also 20 page med recs that change at every visit ("Dad's cardiologist changed his heart meds, I don't remember them but one of them starts with a P"), as well as several new/worsening med conditions, and constantly fluctuating abnormal labs. Is that acute hyponatremia due to my SSRI or their 50 other meds, HF, CVA, CKD, psychogenic polydipsia, or something else? Chasing labs, keeping up with their meds/med interactions, and trying to coordinate care at every visit is exhausting and leaves 3 minutes to try to get an accurate psych interval history and come up with a psych plan.

I can't do all of that in a follow up visit. Geri is only practical in academic centers, i.e., you have residents doing all of the above for minimal compensation. Given most geri patients' 50 meds are for medical conditions, maybe it's best for their IM doc to handle their handful of psych meds as well.

I would agree that working with older adults can be labor intensive and there can be a lot of other fluff to deal with. On the flip side, medicare reliably pays for G2212 prolonged services codes as well as 99358 and medical advice messages (99421-99423). Not exactly the big bucks but it is something.

Also, for non-demented pts in private practice you don't have to deal with this. certain patients do need to be treated in a hospital system but many older non-demented pts can be treated perfectly fine in private practice settings. I have pts who are retired physicians, professors, executives, attorneys or spouses of such etc who are cognitively intact, physically active but with very interesting psychopathology who are also happy to pay privately for high quality care. There is such a need pts fly in from out of state. You have to be selective about which pts are appropriate for your practice vs needing a hospital clinic etc. I do not respond to calls or messages from family members unless it is an emergency, and I won't see cognitively intact pts who aren't making the appts for themselves. Even with the ones with cognitive impairment, you can usually tell which families will be a pleasure to deal with and which will not. That said, I don't have any issues with handholding worried family members and taking the time to go through stuff, but I don't get sucked into the vortex of family dysfunction. All family members are invited to family meetings, and each family has to designate one point of contact. I don't repeat myself.

 

[thelastpsych]

My biggest problem other than the bad medical situations without appropriate medical support was that I had way more defeats than victories the way I interpret it. E.g. you can't really make a huge difference with dementia. Having so many patients where I could only at best slightly improve symptoms instead of the "doc, you really made me get so much better thank you!" after awhile got to me making me enjoy non-geri far more.

Not that this is bad for everyone. If you can tolerate the above better than me maybe you should go into that field cause there certainly is a demand.

Yeah, young, healthy patients with depression and anxiety tend to improve much faster than older patients with neurodegenerative or even depressive symptoms, but some of the best results I've ever seen on psychiatry were of psychotically depressed elderly patients treated with ECT, or older patients with catatonia who were at first unable to even eat or move.

Also, the diagnostic aspect of geropsych is really intriguing...I think splik said it once, that geri psych is one of the only areas of psychiatry that diagnosis actually matter, and I find it to be the case when I'm dealing with elderly folk: I have to be always on the lookout for not only primarily psychiatric problems, but also organic/secondary as well. Of course, these cases can become messy really fast, because as Candidate2017 pointed out, a case with a patient with 10 comorbidities that is taking 20 medications (most of which they don't even know the name) can become extremely time-consuming and clogged, but I actually enjoyed sorting through the complexity (for now lol).

 

[Candidate2017]

Also, for non-demented pts in private practice you don't have to deal with this. certain patients do need to be treated in a hospital system but many older non-demented pts can be treated perfectly fine in private practice settings. I have pts who are retired physicians, professors, executives, attorneys or spouses of such etc who are cognitively intact, physically active but with very interesting psychopathology who are also happy to pay privately for high quality care. There is such a need pts fly in from out of state.

Yes, there are some highly functional patients who just happen to get old. But they are atypical. Where I trained, faculty took these highly functional geri patients. The residents got the usual geri patients typical of the general geri population in the community, for "learning opportunities".

 

[clausewitz2]

Yes, there are some highly functional patients who just happen to get old. But they are atypical. Where I trained, faculty took these highly functional geri patients. The residents got the usual geri patients typical of the general geri population in the community, for "learning opportunities".

Funny how "learning opportunities" is so often equivalent to "pain in the ***"

 

[Ironspy]

Funny how "learning opportunities" is so often equivalent to "pain in the ***"

Learning to tolerate your own distress

 

[whopper]

Also, the diagnostic aspect of geropsych is really intriguing...I think splik said it once, that geri psych is one of the only areas of psychiatry that diagnosis actually matter, and I find it to be the case when I'm dealing with elderly folk: I have to be always on the lookout for not only primarily psychiatric problems, but also organic/secondary as well. Of course, these cases can become messy really fast, because as Candidate2017 pointed out, a case with a patient with 10 comorbidities that is taking 20 medications (most of which they don't even know the name) can become extremely time-consuming and clogged, but I actually enjoyed sorting through the complexity (for now lol).

My problem, and this might not be your problem, was the lack of "victories" as I call it, but also the lack of support in very serious physical medical situations. I also had a rep as one of the few psychiatrists that was more comfortable with handling physical medical problems, but like I wrote above, spinal cord infection, even the IM doc is like "I can't handle this. This is way too dangerous," and the institution not forcing the consultants to show up was a nightmare. Point being make sure you got good physical medicine support as a geri-psych doctor.

 

[Bartelby]

Is sending a medically unstable patient from a freestanding hospital (or a hospital-based psych ward) to the ER even an EMTALA violation? That seems like standard protocol everywhere I have worked. The alternative, which would be watching someone die of a medical emergency on the psych ward with no real tools to help, seems unconscionable. If you were sending them to the ER from the psych ward for a psychiatric issue I could see that being a much bigger issue.

 

[whopper]

The way the law stands you can send from a hospital to an ER if the hospital cannot provide the needed services. E.g. I used to work in a psych-only hospital. We didn't have a cardiac unit or a cardiologist so we could send from the psych only hospital to an ER if a patient had chest pain.

If the patient with chest pain is in a psych unit in a hospital with an IM unit, cardiology, and a cardiologist it would be an EMTALA violation to send them to the ER.

So, and this was more like my own situation above, what if your cardiologist refuses to show up even when the patient is having chest pain and the IM doctor is now stating it's outside of his league, and the hospital has reported to state authorities that consultants will show up within the guidelines despite that they're not doing it?

What should've happened was when I told the hospital consultants weren't showing up they should've gotten the issue fixed but sat on their asses until the crap hit the fan.

That seems like standard protocol everywhere I have worked.

I can only assume your organization was regularly violating EMTALA (and this can entail very expensive fines for the hospital) if you were regularly sending patients to the ER from our own organization, or the place where you worked didn't have several treatment options most university hospitals have.

 

[Bartelby]

I'm glad you got out of that situation, sounds horrific. If you are sending to your hospital's own ER though isn't that acceptable? Your system would only be dumping on itself (in contrast to dumping the patient onto another system via an ER transfer). I don't know the answer, but what you describe is a nightmare scenario.

You for sure made the right call, I would rather defend an inappropriate transfer complaint than a wrongful death suit.

 

[whopper]

If you are sending to your hospital's own ER though isn't that acceptable?

No because your own hospital's consultants were supposed to be doing their jobs and they weren't. It is still considered an EMTALA violation, but then the fault is not the provider who ordered the ER transfer but the person in the organization who alleged consultants were showing up when they were not, or the consultant not showing up. The punishment many not fall onto your lap but there very well could be a punishment to someone else in the organization.

While the person (in this case it was me) who ordered the ER transfer did the right thing and an investigation would clear this up, do not assume your institution is the moral, ethical place that will not be upset with you at all for doing the right thing. They get slapped with a 6-figure fine they could be the scumbag place that'll try to pin the blame on you even if you didn't do anything wrong.

I've seen situations at U of Cincinnati where the department (at least while I was there) defended their doctors when their doctors did the right thing. They did so for me and a friend despite paying 6 figures in legal defense for that doctor. I strongly encourage doctors if working in a place that will defend them to strongly consider this factor in determining their desire to stay at that institution.

While I was a resident I had another situation where the consultant refused to show up. Patient attempted suicide, jumped off a building, broke both legs, and was shipped to psych from the ER with the ER doctor writing nothing was physically wrong on his ER intake. I called the hospital lawyer and told the lawyer what was going on and that if the consultant didn't show up I'd be forced to send the person to the ER. The hospital lawyer got on the ball and made the consultant show up (by telling the consultant he'd be directly held legally and financially accountable for not fulfilling his required consultant duties. The consultant allegedly still refused to show and then the hospital CEO, lawyer, and department chair told him he had to show up. A few hours later, while this guy with broken legs is lying in the psych unit, he finally showed up).

 

[nexus73]

The way the law stands you can send from a hospital to an ER if the hospital cannot provide the needed services. E.g. I used to work in a psych-only hospital. We didn't have a cardiac unit or a cardiologist so we could send from the psych only hospital to an ER if a patient had chest pain.

If the patient with chest pain is in a psych unit in a hospital with an IM unit, cardiology, and a cardiologist it would be an EMTALA violation to send them to the ER.

So, and this was more like my own situation above, what if your cardiologist refuses to show up even when the patient is having chest pain and the IM doctor is now stating it's outside of his league, and the hospital has reported to state authorities that consultants will show up within the guidelines despite that they're not doing it?

What should've happened was when I told the hospital consultants weren't showing up they should've gotten the issue fixed but sat on their asses until the crap hit the fan.



I can only assume your organization was regularly violating EMTALA (and this can entail very expensive fines for the hospital) or the place where you worked didn't have several treatment options most university hospitals have.

First start looking for another job. Then escalate via emails to CMO, and other layers of admin plus risk and hospital attorney. If nothing gets done then leave for the other job. Then report the doctors to the state medical board, hospital to cms maybe JCAHO.

 

[whopper]

Instead of two warring parents, you have an elderly spouse and several arguing adult children who can't agree on a family representative, and call at separate times wanting to know the plan or demanding med changes or that contraindicated meds continue indefinitely ("I know mom's kidneys aren't the best and she's been falling, but why can't mom stay on the Lithium, Depakote, Haldol, Trilafon, and Xanax she's been on for decades?"). Geri patients' collateral is even more unreliable than child patients: their spouse struggles with their own health issues, they live alone, and/or have busy adult children that check on them once a month or never.

Forgot to also address this problem. Frequently geri-psych patients have family members, usually adult children, who range from reasonably concerned to helicopter-kids who want to know everything going on.

Now of course I don't blame them for wanting to know their mother or father is doing well. The frustration was sometimes these people would call you up every hour on the hour as if you were their personal therapist. Sometimes the patient refused to involve their family and the family starts threatening you with a lawsuit if you don't call them back. Sometimes the children are very upset (understandably so but it's not your problem) that the parent, now demented, didn't set up their will, and they start screaming at you despite that you are nothing to in this issue to get it rectified other than to simply continue doing your job.

I had 3 great social workers when I worked on a geri-unit that tried to deflect everything they could away from me making this issue more tolerable but yes at times it did upset me. Also, often times the hospital was able to provide the family member with the appropriate referral but they still wanted me, the doctor, to lay my hands on the issue even if I had nothing to do with the issue. "My father didn't leave a will. Tell Dr. Whopper to fix that!" So I tell the family, 1-I can't write the will nor do I want to open that pandora's box, 2-patient already lacks capacity, I've already done my end on this issue so everything else now is a legal matter, then they keep calling me and calling me despite that everything I was doing concerning the will is now over and they need to talk to a lawyer.

The above issue happens in all of psychiatry but happens in geri-psych A LOT. This also happens to be a pet-peeve of mine because 1-you can't bill for it so there's no "at least I'm making money off of this suffering" feeling 2-your involvement is not ethically appealing either as you aren't supposed to enter this territory for ethical and legal reasons, 3-they keep on bugging the heck out of me like a sore spot they keep deciding to pinch over and over and over 4-the biggest people likely to sue over psych care are often times the family members not happy with your care, and while you will win the lawsuit it could be after you've wasted a lot of time and legal expenses, so what some people recommend is to make this dysfunctional family that's driving you nuts happy by spending a lot of time with them despite that you don't have the time, nor want to spend that time, nor are supposed to spend that time.

 

[Barfalamule]

So, I'm in my last year of psych residency, and deciding on doing an additional geri psych year of training (had a very weak rotation on geri psych, but was deeply interested by it). I know what most people say about fellowships in psych: the only truly necessary seem to be child and forensic, but I'm very interested in the topics covered by geri psych - cognition and BPDS, depression, end-of-life and all the existential problems of old age, the overlap with neuro/IM that sometimes come into play, complex psychopharmacology, etc...

My question is regarding the large overlap with IM/geri and neuro: I know most geriatric patients aren't very fond of psychiatrists, and most have "non-psych" manifestations of psych problems (e.g chronic pain or fatigue as depression for instance) - in that regard, is there a job market for geri psych, one in which you are mostly seeing older folks with MH problems? I actually don't care for the pay cut since most patients are insurance only, just worried about the demand.

Thanks in advance!

For outpatient, the key would be to carve out a practice in swanky nursing homes where you can charge cash and families are largely aware of the issues their loved ones are having as the nursing home has flagged their residents for care and generally communicated this to the families. The facilities have a vested interest in seeing the patient do well as there is a lot of money on the line. Getting access to these places may be difficult. I have had access just by function of placing patients at these facilities and having conversations with staff about how they are doing and potential suggestions about how to improve their care.

As an inpatient doctor in an academic setting, I can say that inpatient geripsych has changes substantially in the past few years with COVID and massive human capital shortages, and I often feel like I am running a nursing home. Add to the situation that my state doesn't have much in terms of resources for TBI patients or the extreme end of MNCD with behavioral disturbances. A way out of the inpatient trap in the academic setting is to move into a neuromodulation service where you can do TMS and ECT. But I agree, you can get pigeon-holed in geripsych and feel underappreciated. A lot of these work dynamics are going to fluctuate depending on where you want to live and your work/life balance preference. I know I could just make a lot more money doing emergency psychiatry, but the cost is steep. I value my sleep.

 

[thelastpsych]

Forgot to also address this problem. Frequently geri-psych patients have family members, usually adult children, who range from reasonably concerned to helicopter-kids who want to know everything going on.

Now of course I don't blame them for wanting to know their mother or father is doing well. The frustration was sometimes these people would call you up every hour on the hour as if you were their personal therapist. Sometimes the patient refused to involve their family and the family starts threatening you with a lawsuit if you don't call them back. Sometimes the children are very upset (understandably so but it's not your problem) that the parent, now demented, didn't set up their will, and they start screaming at you despite that you are nothing to in this issue to get it rectified other than to simply continue doing your job.

I had 3 great social workers when I worked on a geri-unit that tried to deflect everything they could away from me making this issue more tolerable but yes at times it did upset me. Also, often times the hospital was able to provide the family member with the appropriate referral but they still wanted me, the doctor, to lay my hands on the issue even if I had nothing to do with the issue. "My father didn't leave a will. Tell Dr. Whopper to fix that!" So I tell the family, 1-I can't write the will nor do I want to open that pandora's box, 2-patient already lacks capacity, I've already done my end on this issue so everything else now is a legal matter, then they keep calling me and calling me despite that everything I was doing concerning the will is now over and they need to talk to a lawyer.

The above issue happens in all of psychiatry but happens in geri-psych A LOT. This also happens to be a pet-peeve of mine because 1-you can't bill for it so there's no "at least I'm making money off of this suffering" feeling 2-your involvement is not ethically appealing either as you aren't supposed to enter this territory for ethical and legal reasons, 3-they keep on bugging the heck out of me like a sore spot they keep deciding to pinch over and over and over 4-the biggest people likely to sue over psych care are often times the family members not happy with your care, and while you will win the lawsuit it could be after you've wasted a lot of time and legal expenses, so what some people recommend is to make this dysfunctional family that's driving you nuts happy by spending a lot of time with them despite that you don't have the time, nor want to spend that time, nor are supposed to spend that time.

I find it funny that geri and child seem to have some similar problems regarding family dynamics while being in the opposite side of the age spectrum. One thing that I guess can be quite unpleasing is that patients often have very serious clinical complaints, like CHF exacerbations and whatnot, and I keep wondering if it's your job in an outpatient setting to coordinate clinical care for these patients (like tell family members to get the patient to an ER ASAP), or if these patients usually have a primary care doctor (geriatrics/FM/IM) that usually handles these situations. Sorry if these questions seem basic, as I said before, I didn't have that much exposure to geri psych.

 

[allantois]

I find it funny that geri and child seem to have some similar problems regarding family dynamics while being in the opposite side of the age spectrum. One thing that I guess can be quite unpleasing is that patients often have very serious clinical complaints, like CHF exacerbations and whatnot, and I keep wondering if it's your job in an outpatient setting to coordinate clinical care for these patients (like tell family members to get the patient to an ER ASAP), or if these patients usually have a primary care doctor (geriatrics/FM/IM) that usually handles these situations. Sorry if these questions seem basic, as I said before, I didn't have that much exposure to geri psych.

These patients will have a PCP who should me monitoring their medical condition; of course if you notice an acute change you may need to tell the patient and or the family to take the patient to ED or to see their PCP