How does your inpatient psychiatry unit assess medical stability prior to psychiatry admit?

[DrDoxie]

I am a PGY1 at a large academic program where residents work at both our institution’s home hospital as well as the VA. The VA inpatient psychiatry unit has a list of criteria meant to assist residents and attendings and ED staff in determining medical clearance of a patient prior to admission to the inpatient psychiatry unit. It includes required labs from the ED and exclusionary parameters of lab results as well as vital signs parameters and potential medical conditions that would be inappropriate to manage on an inpatient psychiatry unit with limited interventions (ongoing transfusion, active infection etc).

Due to COVID our medical beds have become a very limited resource and our service has been getting pressured to accept patients whom historically might not have been accepted directly to the unit in the past. The pressure has been especially high to admit patients requesting EtOH detox who might have electrolyte abnormalities or a history of complicated withdrawal (seizures, DTs).

I am curious to know:
1. How does your program or hospital assess medical stability of a patient prior to being admitted to an inpatient psychiatry? Do you have exclusionary criteria or simply rely on ED evaluation of stability?
2. Is acute alcohol detox/withdrawal viewed as a medicine or psychiatry admission? Or is it “both” with guidelines agreed upon between services to delineate gray areas?

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[samac]

I am a PGY1 at a large academic program where residents work at both our institution’s home hospital as well as the VA. The VA inpatient psychiatry unit has a list of criteria meant to assist residents and attendings and ED staff in determining medical clearance of a patient prior to admission to the inpatient psychiatry unit. It includes required labs from the ED and exclusionary parameters of lab results as well as vital signs parameters and potential medical conditions that would be inappropriate to manage on an inpatient psychiatry unit with limited interventions (ongoing transfusion, active infection etc).

Due to COVID our medical beds have become a very limited resource and our service has been getting pressured to accept patients whom historically might not have been accepted directly to the unit in the past. The pressure has been especially high to admit patients requesting EtOH detox who might have electrolyte abnormalities or a history of complicated withdrawal (seizures, DTs).

I am curious to know:
1. How does your program or hospital assess medical stability of a patient prior to being admitted to an inpatient psychiatry? Do you have exclusionary criteria or simply rely on ED evaluation of stability?
2. Is acute alcohol detox/withdrawal viewed as a medicine or psychiatry admission? Or is it “both” with guidelines agreed upon between services to delineate gray areas?

1. Our program is trying to make clearer guidelines for medical clearance but it’s still kind of a gray area and left up to our discretion.
2. Acute alcohol detox is a mix of both. If they don’t have a history of DTs well usually take them on the psych floor. We don’t particularly like taking those with DT history given that we don’t have IV access on the psych floor.

 

[clausewitz2]

IVs were fine where I trained, but if a patient needed any IV push medications it couldn't happen regularly on the floor due to nursing restrictions. However if they were going regularly over to the medical hospital and getting such meds over there, fine.

 

[Bartelby]

Our stance had been that medical issues should be at an ambulatory level; that if they were not coming to psychiatry outpatient followup would be appropriate. This can be bypassed on a case by case basis if appropriate. We do handle alcohol withdrawal but not for those with a history of ICU stays or seizure during withdrawal, or of people who appear to be headed that way based on current s/s.

 

[HowAreYaNow]

I'll echo @samac and say that "medical clearance" is a grey area.

Typically what happens in our ED is, if a patient comes in with primarily a psychiatric complaint, they will be eyeball'd by the med ED and sent over to psych with a brief note in the chart ("vital signs stable, grossly normal physical exam, cleared for psych"). Subsequent to that we do our assessment as well as basic labs once they get to psych, particularly if we think they're a candiate for admission (we pretty much reflexively order CBC/BMP/LFT/Utox). Then if there's anything revelatory in those labs we would call the med ED back and have them re-assess and go from there.

In general alcohol detox is treated as a medical admission as we no longer have a detox unit (which was run by psych). If there's a comorbid psych we can admit them under psych and do a Serax taper on the unit. Again, if there's any other medical comorbidites that arise those would ideally be addressed prior to going upstairs but that's not always the case.

 

[nowaysanjose]

If a patient with medical comorbidities does make it on the unit, are psych residents managing them or is it primarily NPs? I’ve seen a move towards NPs and this worries me because things are often missed by them, and also it’s taking away valuable medical management experience for residents

 

[Candidate2017]

I am a PGY1 at a large academic program where residents work at both our institution’s home hospital as well as the VA. The VA inpatient psychiatry unit has a list of criteria meant to assist residents and attendings and ED staff in determining medical clearance of a patient prior to admission to the inpatient psychiatry unit. It includes required labs from the ED and exclusionary parameters of lab results as well as vital signs parameters and potential medical conditions that would be inappropriate to manage on an inpatient psychiatry unit with limited interventions (ongoing transfusion, active infection etc).

Due to COVID our medical beds have become a very limited resource and our service has been getting pressured to accept patients whom historically might not have been accepted directly to the unit in the past. The pressure has been especially high to admit patients requesting EtOH detox who might have electrolyte abnormalities or a history of complicated withdrawal (seizures, DTs).

I am curious to know:
1. How does your program or hospital assess medical stability of a patient prior to being admitted to an inpatient psychiatry? Do you have exclusionary criteria or simply rely on ED evaluation of stability?
2. Is acute alcohol detox/withdrawal viewed as a medicine or psychiatry admission? Or is it “both” with guidelines agreed upon between services to delineate gray areas?

1. I don't rely on the ED. They are incentivized to "move the meat." ED stands for "Everyone Duped."
2. Depends on how severe. Will the majority of time be spent on detox or treatment of underlying primary psychiatric illness? If the latter, they can go to the medical floors first.

Have you done IM yet? That's where you learn what is too sick for the psych ward. The Man will always pressure you but being a professional means shouldering the responsibility of saying no and exercising judgment, since you and your license (which you don't even have yet) are personally liable.

 

[whopper]

More or less I didn't have a problem with medical clearance except for one major issue.

If it turned out the ER or IM doctor who cleared the patient was wrong, or if you had suspicions they were off, they'd pull this major attitude problem if you wanted to talk to them.

People make mistakes, I don't mind that. I minded when it's pretty obvious the patient shouldn't have been cleared and you call the doctor that cleared them and then they pull the high school bull$hit behavior card like refusing to talk to you or then getting on the phone and exhibiting defensiveness or anger especially when no one was being rude with them. Also most of the time I actually chose to debate the other doctor I would only do so if I double and triple checked to make sure I knew what I was talking about and almost every time the debate (or argument if you wanted to call it that) ended up with me winning. I would only allow it to escalate to that level if I was confident I was right while trying to maintain a neutral demeanor and if escalation was increased it was always on the other doctor's part with clear actions on my part that I wouldn't further escalate it, even better if there were witnesses.

One time such an event happened with several doctors and nurses witnessing the event and it turned out the other doctor was completely in the wrong. IT was a patient with a spinal cord infection who was medically cleared into my psych unit. He just had a surgery and his surgery site was draining and it involved his spinal canal. We ordered a consult and the surgery consultant refused to show up. We tried to get him transferred out but the other units refused to take him. It got to the point where I told the head of my department that I was ethically bound to force something to happen such as bringing him to the ER because he had an active infection and no one in the surgery department was doing their thing. We asked IM to take over but IM said it's a surgery issue so surgery needs to see him. After 3 days of this infection, with me calling surgery (and them blowing me off) literally every day and me documenting it, I told the head of my department and my clinical director. The clinical director told me he thought this was completely inappropriate, agreed with me and still surgery refused to show up.

So I talked to my department told them it's either he stays here with me trying to treat something I shouldn't be treating or making him go to the ER despite that this could be a COBRA violation. I even talked to the hospital lawyer and said I was going to use a defense that the surgery consultation service elevated this to an emergency so I could use a good samaritan defense in court. So the patient was sent to the ER, and they called in a surgery resident who refused to show up when he was told what was going on and this delayed care for several hours while this hot mess of narcissism was being flared out. The head of the ER department had to call the head of the surgery department to force the resident to come back.

I told the resident what was going on (and remember I was an attending at that time, not a resident) and he kept yelling this was BS and the patient was fine without even seeing the patient. He finally went up to the patient and started saying in the patient's face this case was bull$hit and the patient's family was present. He undressed his wound, his jaw dropped and said "oh my god" after seeing clear evidence of an infection that was draining. Within minutes the patient was being prepped for surgery.

Now bear in mind the patient with the surgery wound was corporate officer of a neighboring hospital and only showed up to our hospital to avoid the conflict of interest with being treated by employees, so this guy knew what was going on was completely inappropriate. Anyone even without medical training would've known this was wrong. Further several of his family members present were also medical professionals.

The family called me up and told me they were very upset, but also were respectful to me because they knew from the beginning I was trying to get this guy the right care. Guess what? I told them to report the incident to the state medical board and spare no one involved. I told them "Even include me in there. I'm fine with that. I did nothing wrong." I told them I didn't care if heads rolled. This entire this was frustrating to me and the institution IMHO had failed.

For the next several weeks the hospital had to play damage control and several meetings over this situation. I told the surgery department that frankly they should kick out this resident because his behavior was clearly below professional standards, not excusable, and quite wantonly bold for him to yell at me and some high up people in the medical community while he was absolutely in the wrong. And whoever was heading the surgery consults for those 3 days also needed to get some type of professional reaming. I don't know what happened to the other people but my stock in the hospital actually dramatically went up after that event so I was confident the heads of the hospital knew I didn't do anything wrong. The hospital lawyer told me no action would be taken against me for sending to the patient to the ER in light that this was a true emergency and I had no other options.

I moved out of the town where it happened but came back 1.5 years later because my program director, Doug Mossman, a very great man and one of the top psychiatrists of his era had terminal cancer. So I drove over to see him knowing it would likely be the very last time. He died a week later. While back in my old stomping grounds the clinical director and I hung and he asked me if I ever wanted to come back they'd have a place for me, and then showed me a new psych unit and kept mentioning "we made a solid plans so the other consultants have to show up and can't refuse."

 

[Liquid8]

My training network used to have so many problems with junior Emergency Department doctors doing half assed assessments on psych patients for a “medical clearance” that they mandated that the admitting psych registrars had to do it ourselves. There were a few times where I had sent inpatients back to the ED to get sutured or for other minor surgical issues – I found out later that the correct process was apparently to contact the on-call surgical resident, but this would eventually lead to pointless to and fro about demanding we do it ourselves. Usually the residents were in the ED to begin with, so sending the patient down with a nurse escort usually got the best result for the patient.

Here our public EDs have a lot more power to force admissions (and less so to psych wards due to fixed bed numbers), so while transferring a patient between different units is what is normally expected, this only works where the receiving team is functional and lacking in negative personality traits. In most cases it will escalate to the respective bosses of each department who can work things out, but if that doesn’t work it also can be a lot more efficient to get the desired outcome via the ED.

At the private hospital I admit to now, we have GP and physician support in the hospital which is always helpful. On the off chance that someone comes in who isn’t medically stable, out senior nurses are very helpful and it’s not hard to organise an ambulance to have patients taken to emergency. The rules are such that involuntary patients can only be held in certain (mainly public) facilities, so while it’s not in the spirit of the mental health act, occasionally this can be thrown around to ensure the transfer – usually the main barrier is in the form of egotistical paramedics who have limited understanding of mental health and want to call the shots.

On the subject of alcohol detox admissions, I recently discovered that many other private psych hospitals were demanding that new admissions had to be reviewed as an outpatient prior to any admission - thus limiting access (and acuity) due to an appointment shortage, and pushing the acute phase towards medically inclined facilities. When I had started out, this wasn't required and a patient typically only got turned away if they presented with an elevated BAC - anything above 0.05 needed a medical observation/clearance.

 

[hallowmann]

As long as they don't meet criteria for medical hospitalization, i.e. their medical condition can be managed in the outpatient setting, they are eligible for admission. The only caveat to this is for patients who need dialysis, they usually go to the Med-Psych unit.

 

[cbrons]

2. Acute alcohol detox is a mix of both. If they don’t have a history of DTs well usually take them on the psych floor. We don’t particularly like taking those with DT history given that we don’t have IV access on the psych floor.

I'd like to just point out that true "DTs" are extremely rare and what is often called such is really just mild-moderate alcohol withdrawal syndrome or alcoholic hallucinosis. I feel I am having to explain the differences to medicine residents constantly.


Alcohol withdrawal syndrome: Syndrome characterized by hyperactivity,
tachycardia, diaphoresis, tremulousness, anxiety, insomnia, nausea/vomiting, possibly
perceptual abnormalities (hallucinations) but without delirium, and seizure. Typically begin within 8-12 hours of last drink.

• Alcoholic hallucinosis: Withdrawal hallucinations (usually visual) that typically
begin within 12-48 hours after last drink and resolve shortly thereafter. Not
associated with abnormal vital signs (no autonomic instability).

• Delirium tremens (alcohol withdrawal delirium): Severe withdrawal syndrome
characterized by profound autonomic hyperactivity, confusion, agitation, vivid
delusions/hallucinations (including visual and tactile) which typically begin within 3-
5 days after the last drink.

only #2 is really appropriate for a psych unit.
#1 requires at least some time in medically supervised detox
#3 is severe enough you won't be asked to admit them to psych or in the scarier scenario will develop symptoms a coupke days into their stay on the psych unit (true DT almost never occurs immediately after stopping drinking, usually takes 2-3 days).

pay attention to vital signs. Any remote sign of autonomic instability should make you wary.
History of ICU stays for alcohol withdrawal should also be a big red flag.

 

[thegenius]

I'll echo @samac and say that "medical clearance" is a grey area.

Typically what happens in our ED is, if a patient comes in with primarily a psychiatric complaint, they will be eyeball'd by the med ED and sent over to psych with a brief note in the chart ("vital signs stable, grossly normal physical exam, cleared for psych"). Subsequent to that we do our assessment as well as basic labs once they get to psych, particularly if we think they're a candiate for admission (we pretty much reflexively order CBC/BMP/LFT/Utox). Then if there's anything revelatory in those labs we would call the med ED back and have them re-assess and go from there.

In general alcohol detox is treated as a medical admission as we no longer have a detox unit (which was run by psych). If there's a comorbid psych we can admit them under psych and do a Serax taper on the unit. Again, if there's any other medical comorbidites that arise those would ideally be addressed prior to going upstairs but that's not always the case.

I wish our ED did that.

 

[NickNaylor]

We have some specific, objective exclusionary criteria (e.g., parameters around vital signs, parameters around certain vital signs, etc.), however our unit is generally pretty accepting of even medically complicated patients. We also tend to take a lot of patients that can’t go anywhere else since they will just sit in the ED otherwise - in a worst case scenario, they will be admitted to a hospitalist service while the C/L service actively manages their psychiatric issues.

As far as alcohol withdrawal goes, acute alcohol-related delirium would be an exclusion criterion - things can go south fast and management on a medical floor is appropriate given that IV administration of medications may be necessary. In the absence of delirium, though, we will typically admit withdrawal patients even with pretty significant withdrawal symptoms.

 

[comp1]

As others said, self managed outpatient level of medical care is the appropriate level of need for any inpatient unit except for a med-psych unit. IVs are a non-starter for my unit and any previous ones I've worked at. IVs aren't really outpatient and they make excellent strangulation devices. That said, what else constitutes outpatient levels of care is one of the biggest questions in inpatient psychiatry. For me, I like to make it a team decision. I bring in nurses and nurse management and I discuss a specific situation and see what they have to say. They are the ones who are going to have to be actually doing whatever complicated, not really quite outpatient thing that the patient needs. It also helps when you are arguing with medicine about whether they need to take a patient to have nursing management backing you up.

 

[Stagg737]

I am a PGY1 at a large academic program where residents work at both our institution’s home hospital as well as the VA. The VA inpatient psychiatry unit has a list of criteria meant to assist residents and attendings and ED staff in determining medical clearance of a patient prior to admission to the inpatient psychiatry unit. It includes required labs from the ED and exclusionary parameters of lab results as well as vital signs parameters and potential medical conditions that would be inappropriate to manage on an inpatient psychiatry unit with limited interventions (ongoing transfusion, active infection etc).

Due to COVID our medical beds have become a very limited resource and our service has been getting pressured to accept patients whom historically might not have been accepted directly to the unit in the past. The pressure has been especially high to admit patients requesting EtOH detox who might have electrolyte abnormalities or a history of complicated withdrawal (seizures, DTs).

I am curious to know:
1. How does your program or hospital assess medical stability of a patient prior to being admitted to an inpatient psychiatry? Do you have exclusionary criteria or simply rely on ED evaluation of stability?
2. Is acute alcohol detox/withdrawal viewed as a medicine or psychiatry admission? Or is it “both” with guidelines agreed upon between services to delineate gray areas?

1. EDs evaluate the patient and run it by inpatient attending for approval. Technically ED docs can admit to our unit, but doing so without talking to psych attending means s*** hits the fan. At our VA we have hard exclusion criteria, and our academic center we don't.
2. At our academic center alcohol detox always goes to medicine. At our VA it depends on the patient and we frequently detox them ourselves if they're not high risk. Our unit will occasionally take a patient requiring IV thiamine and they just have to sit at the nursing station while it runs, otherwise IVs are exclusion criteria. We have some hard criteria but there is significant wiggle room with other aspects. Otherwise I agree with others, generally "medically stable" means that other than psych issues they could be treated as an outpatient. Occasionally there is a battle between medicine and psych regarding who takes a detox patient, but given an event that happened on the psych unit when a patient was inappropriately forced to psych by the higher ups, ties now go to medicine by default.

I'd like to just point out that true "DTs" are extremely rare and what is often called such is really just mild-moderate alcohol withdrawal syndrome or alcoholic hallucinosis. I feel I am having to explain the differences to medicine residents constantly.


Alcohol withdrawal syndrome: Syndrome characterized by hyperactivity,
tachycardia, diaphoresis, tremulousness, anxiety, insomnia, nausea/vomiting, possibly
perceptual abnormalities (hallucinations) but without delirium, and seizure. Typically begin within 8-12 hours of last drink.

• Alcoholic hallucinosis: Withdrawal hallucinations (usually visual) that typically
begin within 12-48 hours after last drink and resolve shortly thereafter. Not
associated with abnormal vital signs (no autonomic instability).

• Delirium tremens (alcohol withdrawal delirium): Severe withdrawal syndrome
characterized by profound autonomic hyperactivity, confusion, agitation, vivid
delusions/hallucinations (including visual and tactile) which typically begin within 3-
5 days after the last drink.

only #2 is really appropriate for a psych unit.
#1 requires at least some time in medically supervised detox
#3 is severe enough you won't be asked to admit them to psych or in the scarier scenario will develop symptoms a coupke days into their stay on the psych unit (true DT almost never occurs immediately after stopping drinking, usually takes 2-3 days).

pay attention to vital signs. Any remote sign of autonomic instability should make you wary.
History of ICU stays for alcohol withdrawal should also be a big red flag.

Overall agree, but slightly disagree with bolded. if a patient's CIWA is 15 and 30 minutes after getting some Ativan/Librium it's a 3, we typically bring them up with a scheduled taper barring significant autonomic instability or h/o DT or multiple detoxes needing ICU level care. As you said, DTs typically take several days to occur, and if there's no complicated hx and low(ish) doses of benzos fix the withdrawal symptoms, they get to come play on the psych unit where I'm at.

 

[HowAreYaNow]

in a worst case scenario, they will be admitted to a hospitalist service while the C/L service actively manages their psychiatric issues.

We recently had an issues with this regarding a patient who was morbidly obese and couldn't be admitted to psych. (We thought) we had a plan worked out where they could be admitted to medicine and C/L could follow. However a ****storm ensued with administrators and attendings and the patient ended up boarding on a medicine floor with psychiatry as the primary team.

 

[nexus73]

Our medical "clearance" is per ED doctors...though it sometimes leaves something to be desired, it is generally adequate.

Our hospital policy on psych evaluation of people with alcohol intoxication requires them to be below 0.08 before ED social workers will assess them. As they sober up it generally gives us a sense of how severe the alcohol withdrawal will be. The ED doc will start CIWA. They come to psych for uncomplicated withdrawal. Obviously delirium, seizures, or significant autonomic instability they go to medicine and with psych consult.

 

[whopper]

One time we had a patient with a Staph aureus infection in the medical unit that was cleared. I knew who this patient was because she was frequently in the ER either for drug abuse or a recurrent Staph aureus infection. Turned out she had that that rare type of gene that makes the patient very susceptible to Staph, and because she was an IVDA she kept getting one over and over, usually at least monthly. So this particular time she had a severe rash on her skin and was yet was cleared by the ER and they told the inpatient unit everything was fine.

So she ends up in inpatient and I see her, her rash and I'm like who the eff cleared her. Again the defensiveness thing happened where the doctor who cleared her denied there was a rash and I asked him to put that into the record and he refused. So I called IM and they showed up, and like me were like who the eff cleared this patient.

OK so despite the above, I wasn't upset about this cause if I allowed that to get me upset I'd be upset every few days. What caused the big headache was that due to regulations anyone with a Staph aureus infection on their skin had to be quarantined to their room. Also the psych unit, at least per New Jersey laws, didn't allow for patient to be quarantined to their room due to non-psych reasons (argument being they should be on the medical floor) and the medical floor refused to take her.

So the psych unit, the medical floors, and the ER were all screaming at each other "ain't our problem" when it was clear and obvious the medical floor should take her. Oh it only took about 15 hours of everyone screaming at each other to clear it up, again with me maintaining a calm demeanor while being screamed at, hung up upon, having messages ignored etc. We had to get the head of Infectious Disease to have her transferred off. Also at the time I was a chief resident and the attending completely chickened out on it and I and the nurse manager had to take command of the situation. I remember telling the attending about the patient and he was like, "Staph aureus, I don't deal with that." and I responded, "sir you're going to have to deal with it cause it's on your unit now," and he just pretended nothing was going on while the nurses were all upset and asking me what to do and I gave them clear orders.

 

[michaelrack]

. Also the psych unit, at least per New Jersey laws, didn't allow for patient to be quarantined to their room due to non-psych reasons (argument being they should be on the medical floor) and the medical floor refused to take her.

so how are psych inpatients who become COVID + handled in New Jersey? Automatic transfer to medical ward (if not stable for discharge)?

 

[whopper]

I'm no longer in NJ so I don't know.

I haven't worked inpatient for a few years but the people I do know who still work inpatient told me that the units are half-full because several of the frequent flyers stopped showing up wanting to avoid risk of COVID, well at least that was happening the first 3-4 months of the pandemic. Haven't asked them about it recently.

 

[samac]

I'm no longer in NJ so I don't know.

I haven't worked inpatient for a few years but the people I do know who still work inpatient told me that the units are half-full because several of the frequent flyers stopped showing up wanting to avoid risk of COVID, well at least that was happening the first 3-4 months of the pandemic. Haven't asked them about it recently.

Not specific to New Jersey but it’s not that way anymore. Word got out that we covid test everyone we admit I guess

 

[whopper]

Like I said above, I don't mind it if a patient now or then gets cleared that shouldn't have been. Everyone's human, even the best doctors will clear someone where it only obvious later on that person shouldn't have been cleared. What I did mind was when it was obvious the patient shouldn't have been cleared and needs transfer out of the psych unit the ego-defense mechanism responses that are clearly adversarial instead of cooperative and not good-adversarial (such as competition to make a better product) but pure territorialism as if their unit is too good to take a psych patient.

Whenever a colleague of mine caught something I've missed, my attitude was usually on the order of "thank God you caught it!" and being very humbled and thankful. I remember working on a geriatric psych unit with an excellent colleague who was a dual FP/psych residency graduate and he taught me and enhanced my medical skills tremendously more than what they were as an attending despite me being proud of having more use of my non-psych medical skills vs my psych colleagues.

Overall the amount of healthy and cooperative interactions among physician colleagues have been the majority but not the overwhelming majority. You figure such bad interactions should be extremely rare but they were on the order of every few days to every few weeks. Whenever I had a stretch of over 2 weeks where such an occurrence didn't happen I'd be telling everyone at lunch, "you know another doctor hasn't screamed at me for about 2 weeks so I guess I'm due."

Hospital politics if anything didn't help the situation. Nice and cooperative doctors are often times called more by their physician colleagues and nursing staff, it's almost as if the rabid personality act by the more vociferous attendings is a predetermined strategy to discourage anyone from calling them. It's not like the nicer doctors get better pay or the meaner doctors get less pay or are fired.

 

[NickNaylor]

Like I said above, I don't mind it if a patient now or then gets cleared that shouldn't have been. Everyone's human, even the best doctors will clear someone where it only obvious later on that person shouldn't have been cleared. What I did mind was when it was obvious the patient shouldn't have been cleared and needs transfer out of the psych unit the ego-defense mechanism responses that are clearly adversarial instead of cooperative and not good-adversarial (such as competition to make a better product) but pure territorialism as if their unit is too good to take a psych patient.

Whenever a colleague of mine caught something I've missed, my attitude was usually on the order of "thank God you caught it!" and being very humbled and thankful. I remember working on a geriatric psych unit with an excellent colleague who was a dual FP/psych residency graduate and he taught me and enhanced my medical skills tremendously more than what they were as an attending despite me being proud of having more use of my non-psych medical skills vs my psych colleagues.

Overall the amount of healthy and cooperative interactions among physician colleagues have been the majority but not the overwhelming majority. You figure such bad interactions should be extremely rare but they were on the order of every few days to every few weeks. Whenever I had a stretch of over 2 weeks where such an occurrence didn't happen I'd be telling everyone at lunch, "you know another doctor hasn't screamed at me for about 2 weeks so I guess I'm due."

Hospital politics if anything didn't help the situation. Nice and cooperative doctors are often times called more by their physician colleagues and nursing staff, it's almost as if the rabid personality act by the more vociferous attendings is a predetermined strategy to discourage anyone from calling them. It's not like the nicer doctors get better pay or the meaner doctors get less pay or are fired.

It’s pretty incredible how the institutional culture can make such a difference in your work experience. At the hospital I work at, we have a pretty good relationship with our medical services and will occasionally have patients with primarily psychiatric issues that, for one reason or another, can’t come to the inpatient unit and are essentially boarded on a hospitalist service (with medicine as primary) while they receive psychiatric care. No conflicts, no trying to push the patient elsewhere... the hospitalists generally get it and are more than willing to work with the psychiatric team.

At another affiliated hospital that I work at, the dynamic between psychiatry and medical services is terrible. Nurses are pretty overt about their disdain for psychiatric patients. Physicians get frustrated with these patients remaining on their service despite requiring essentially zero meaningful follow-up. “Administration” harasses the C/L service to get the patient moved despite this very often being outside of the control of the C/L service. It’s like having a psychiatric patient on a medical floor is a national emergency.

 

[samac]

It’s pretty incredible how the institutional culture can make such a difference in your work experience. At the hospital I work at, we have a pretty good relationship with our medical services and will occasionally have patients with primarily psychiatric issues that, for one reason or another, can’t come to the inpatient unit and are essentially boarded on a hospitalist service (with medicine as primary) while they receive psychiatric care. No conflicts, no trying to push the patient elsewhere... the hospitalists generally get it and are more than willing to work with the psychiatric team.

At another affiliated hospital that I work at, the dynamic between psychiatry and medical services is terrible. Nurses are pretty overt about their disdain for psychiatric patients. Physicians get frustrated with these patients remaining on their service despite requiring essentially zero meaningful follow-up. “Administration” harasses the C/L service to get the patient moved despite this very often being outside of the control of the C/L service. It’s like having a psychiatric patient on a medical floor is a national emergency.

My hospital hates psychiatric patients.
We cover 2 hospitals. We’re based out of the smaller lower acuity hospital and we cover the other with CL services.
I had them calling me trying to admit a patient to our unit at the lower acuity hospital with a pneumomediastinum who needed repeat CXRs. Medicine and thoracic surgery were arguing with who should admit them and the guy is acting weird so they tried to get him on my unit.
in the hospital without thoracic surgery if it does happen to worsen.
lol

 

[Stagg737]

So the psych unit, the medical floors, and the ER were all screaming at each other "ain't our problem" when it was clear and obvious the medical floor should take her. Oh it only took about 15 hours of everyone screaming at each other to clear it up, again with me maintaining a calm demeanor while being screamed at, hung up upon, having messages ignored etc. We had to get the head of Infectious Disease to have her transferred off.

I get why ER was defensive, but why wouldn't the med floors take her? Sounds like a pretty obvious medical admission if the IM consult felt she needed it and it's not like they screwed up the initial eval. That just sounds like a malignant relationship between teams...

 

[whopper]

ER-you can't transfer back. It's a COBRA violation, but the ER was involved cause the IM doctor had to know what was going on, why the patient was cleared and when the IM doctor and I contacted the ER department they were hyper-defensive, not working in a cooperative manner, making degrading comments. Also there were obvious issues such as the ER doctor wrote on the record there was nothing physically wrong while it was obvious there were several gross skin lesions.

IM: It was obvious they were supposed to take the patient. They were mad the patient went to psych and was cleared in the ER, but while it was obvious the patient should've gone to IM they were hyper-defensive and didn't want a psych patient along with the typical "oh she's a crazy" or "I don't want to deal with a needy patient" BS. Oh yeah, of course this is unfortunate, unethical disrespectful, even illegal from a disability point of view but it happens and anyone thinking it doesn't happen in a hospital hasn't worked in one.

Like I said regulations required the patient be confined to the room due to Staph aureus, but regulations also required that patients in psych units cannot be confined to their room for physical health problems, making this issue medically and legally necessary that the patient be taken out of psych and quickly.

Also, we all knew it was going to happen anyways. Did those IM people really accomplish anything by whining about it and delaying the process for several hours while throwing inflammatory statements? No but hey, that's what they did. I do remember the Infectious Disease doctor having to be called in cause IM was refusing to take the patient and at least he acted with a cool and diplomatic head. In fact he even know who this patient was. When I told him her name he was like "who put her in the psych unit? She's always here for a Staph aureus infection." I also remember him walking into the psych unit, being very cordial and making the right calls to make the patient get off the psych unit.

You are right-malignant relationship indeed.

While I was a professor I told the students, "my emphasis is on what you need to know in the exam, and what you need to know in real life not in the books." Whenever this type of thing happened, I'd tell the medstudents something to the effect of "this is what happens in the hospital, no not the mature intelligent doctor acting reasonable but a bunch of defensive, territorial and narcissistic types you'd see on Scrubs," and point out that I wanted them to see it now to inoculate them for when they are in this situation.