How common are consult services outside of academic settings?

[st2205]

---

Members don't see this ad.

I know it's been discussed on here that a lot of hospitals won't have a consult service because it's not necessarily "profitable" so to speak, but generally speaking how common/uncommon is it for a community hospital to have a consult service/hire a CL psychiatrist? Obviously it'd have to be a bigger hospital, I'd assume, but what size hospital would generally be the minimum threshold to support the service or at least justify hiring a CL psychiatrist?

Does doing a CL fellowship predominately open academic windows rather than expand employment opportunities in community hospitals?

 

[hippiedoc13]

I can't speak to the specific question of a hospital "hiring" a C/L psychiatrist, exactly. (I am from California, where hospitals can't technically directly employ physicians anyway.)

However, earlier in my residency I rotated at a community hospital where there was one psychiatrist who did all the psych consults for that hospital. She did not work for the hospital; rather, she was a community psychiatrist who had inpatient privileges for psych consults at that hospital. She spent about half of her time doing her regular outpatient psych office practice in the mornings, and came to the hospital in the afternoons to see the consults. She had this arrangement with both of the hospitals in that community (each about 200 beds) and seemed pretty busy.

I do not think she had done a C/L fellowship, I think she was a general psychiatrist.

 

[whopper]

I've seen similar with regards to Hippiedoc's posts. A community hospital will typically (from what I've seen) have at least a psychiatrist for consult service.

I don't know what type of number a hospital may want before they consider it's effective or not to have a psychiatrist on board.

I've never seen any program specifically needing a CL psychiatrist for that service. Having a fellowship in this field is definitely going to advance your knowledge of this area, and it is a very big area. All medical disorders can have some psychiatric impact. There can sometimes be very complex interplay between a mental and physical disorder. That said, in terms of finding a job, in general (unless you're going for academia), I don't see it being a big opportunity maker.

A possibly irrelevant personal note: From my own experience, most psychiatric consults tend to be lame ducks. The patient could be a disgruntled (but not mentally ill) patient that the nursing staff didn't want to deal with, so they call up the attending and ask for a psychiatry consult, then write "psychotic" or "depressed", when in fact there was no reason to believe the patient was either.

As a resident, this was frustrating because I had to spend at least an hour (sometimes 5) trying to figure out why the consult was called in the first place, calling up the attending ("I only ordered it because the nurse asked me.", asking the nurse on duty ("I'm not the one who ordered it, I don't know why the 3rd shift nurse ordered it. Mr. X has been fine all day), and then talking to the patient ("Doctor, I'm not depressed. The only thing that happened last night was I told the nurse I miss my cat.")

The attending in the program didn't seem to care because all he or she had to do was briefly read my note and sign it. They didn't have to shlept for 1-5 hours trying to play detective over an issue where it really was a nurse spot diagnosing depression without using any DSM critiera--because someone said they missed their cat.

At the state hospital where I work, we typically ask for consults from other psychiatrists because we have very dangerous patients. If a patient murdered 3 people, then ritualistically burned their bodies, you will likely want more than one doctor confirming the patient is safe for discharge. We also have several patients who are treatment resistant to Clozaril. When that happens we sometimes consult Henry Nasrallah, M.D. (yes, THE Henry Nasrallah) to check out the case after we've tried everything we could think of short of ECT.

 

[Doc Samson]

Consult psychiatrists see a few different types of patients:

1) The chronically mentally ill admitted to the hospital with a medical complaint

2) The acutely medically ill patient that develops neuropsychiatric s/s (e.g., delirium)

3) Suicide attempts

4) Folks who are suffering mood disturbances due to chronic illness

5) Zebras that the primary team can't figure out, they say "hey, maybe it's psychiatric!" and consult you as a last resort.


All of these are rewarding in their own way (e.g., advocating that the pt's chest pain is a "delusion" for group 1) though personally I do this job to see group 5. A CL fellowship will help you most with groups 2 and 5.

In terms of jobs, I know of plenty of non-academic hospitals that contract with an individual or a group to provide consults. Contracts vary from allowing the provider to do the billing (works when the population is insured) to a set fee paid by the hospital per consult done (works when the population is not insured).