How much medical management (HTN, diabetes, HLD, etc) do you do on inpatient psych? Did you do any of it as a resident (after off-service IM)?

[psyspy]

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[Bartelby]

I continue medications for stable problems. I will handle minor issues (like tweaking a BP regimen or small increases in insulin, etc). I also evaluate minor acute complaints where there is low risk of a very bad outcome (for example I will handle allergic rhinitis but avoid going solo on acute crushing chest pain). More complicated issues or more extensive medication changes I have managed by an IM consultant. And really I prefer setups where someone is the default general medical co-manager and I just focus on psychiatric management.

 

[Old&InTheWay]

Depends on the setup. At our program, while on call overnight, we are the only doctors covering our inpatient med-psych unit. So we end up doing a lot of management/work up of medical issues that arise (but will often call medicine for consult or curbside recs).

 

[Merovinge]

Your specific examples of HTN, HL, and DM are really worth knowing in psychiatry for a few different reasons. First, we use a fair number of antihypertensives (propranolol, guanfacine, clonidine, prazosin), so you want as much familarity with these medications as possible. Second, our medications can cause HL and DM (atypicals), so awareness around the treatment of these is ideal. Strong evidence suggest DM2 medications can lower SE burden from atypicals, I wish I had more experience with these medications in training, most of my metformin prescribing started as an attending (and the newer DM2 meds seem possibly even better than Metformin).

 

[OldPsychDoc]

It will depend on the specific setting, but it will always be enough to make you glad that you paid attention on your IM rotations.

We have a large enough (and sick enough) inpatient population that we have a PA who reports directly to the hospitalist service to evaluate and manage the day by day issues for those patients that we feel are enough beyond our comfort zone to merit a consult--new or unmanaged DM, HTN that isn't responding to a simple "tweak", anything we think might need eventual specialty follow up, etc. But being able to recognize where that line is is important, whatever level of training you happen to be at at the moment.

 

[comp1]

This is going to be highly variable. I would say most private for profit psych hospitals are going to have a dedicated internist who handles things like diabetes and hypertension. Academic, county and VA hospitals are going to be much more variable. Personally, every VA I know of has psychiatrists manage minor medical issues with the ability to immediately consult the attached hospital services for anything significant. You're going to be able to find an inpatient job that has some minor medical management inpatient if you want. You're also going to be able to find a job where you absolutely aren't involved with it. That said, I would definitely argue that we should be able to manage at least the simpler part of the conditions that we are a large part of the cause, ie metabolic syndrome.

 

[psyspy]

Thanks all. I’ll be sure to get a lot out of IM/FM rotations in my M3/4 years. I’d ideally like to be able to myself do as much of it myself as possible in residency and when I’m practicing, if it doesn’t mean slowing down my psych care a ton

 

[mistafab]

Our program utilized a lot of our IM knowledge on the floor. We were expected to be "doctors first, psychiatrists second" and managed everything not requiring telemetry or continuous oxygen. So general things such as HTN, DM, HLD absolutely we did (and in outpatient as well, where you may bridge patients to PCP care, or be the only provider the patient actually sees). We would also treat things such as UC/Chron's flares, AKI on CKD, uncontrolled asthma, chronic pain, etc. General medical knowledge can go a long way in helping your psych patients.

 

[jbomba]

Thanks all. I’ll be sure to get a lot out of IM/FM rotations in my M3/4 years. I’d ideally like to be able to myself do as much of it myself as possible in residency and when I’m practicing, if it doesn’t mean slowing down my psych care a ton

Just keep in mind from a malpractice perspective, when you start managing htn, etc you are held to the standard of care that an internist would be held to. I think people sometimes forget this when they begin to dabble in managing medical comorbidities.

 

[docksan]

I'm comfortable with basic management and tweaking. Anything beyond that or folks with a complicated regimen I'm consulting.

I'm familiar with most basic treatments and if there's ever a doubt I'm going to ask someone for help. I expect they do the same when it comes to psychotropics.

We all went to med school. If you're comfortable pushing labetalol for ECT or clonidine for withdrawal why would you not try to be comfortable making mild changes to insulin or starting guideline treatment for HTN/HLD/DM?

 

[splik]

Just keep in mind from a malpractice perspective, when you start managing htn, etc you are held to the standard of care that an internist would be held to. I think people sometimes forget this when they begin to dabble in managing medical comorbidities.

This isn't true. You are held to the standard of your specialty here. The issue would be whether a reasonably prudent psychiatrist would have managed this themselves or consulted someone else. Where I trained as, as an intern, we couldn't really consult anyone else for this so it was very reasonable for the psychiatrists to do this. At some point the hospital came up with a medicine consult service and so we could easily consult an internist for this when I was a PGY-2. Under that circumstance, if you made a mess of the care the pt received, your liability would be higher since you could have consulted someone else. Whereas, if you really couldn't easily consult an internist you would be held to the standard of your own training. Still in either scenario you aren't held to the standard of care of an internist. That is incorrect. Similarly as a resident, you are held to the standard of care of a PGY-x resident, not an attending.

 

[jbomba]

This isn't true. You are held to the standard of your specialty here. The issue would be whether a reasonably prudent psychiatrist would have managed this themselves or consulted someone else. Where I trained as, as an intern, we couldn't really consult anyone else for this so it was very reasonable for the psychiatrists to do this. At some point the hospital came up with a medicine consult service and so we could easily consult an internist for this when I was a PGY-2. Under that circumstance, if you made a mess of the care the pt received, your liability would be higher since you could have consulted someone else. Whereas, if you really couldn't easily consult an internist you would be held to the standard of your own training. Still in either scenario you aren't held to the standard of care of an internist. That is incorrect. Similarly as a resident, you are held to the standard of care of a PGY-x resident, not an attending.

I won't say you are incorrect on this, but I will say at our program we're given lectures on the topic by a prominent forensics psychiatrist and his message is the opposite of this.

 

[Stagg737]

Our program utilized a lot of our IM knowledge on the floor. We were expected to be "doctors first, psychiatrists second" and managed everything not requiring telemetry or continuous oxygen. So general things such as HTN, DM, HLD absolutely we did (and in outpatient as well, where you may bridge patients to PCP care, or be the only provider the patient actually sees). We would also treat things such as UC/Chron's flares, AKI on CKD, uncontrolled asthma, chronic pain, etc. General medical knowledge can go a long way in helping your psych patients.

This is how I think this should be a core tenet of every psych program. Frankly, this is the only thing that truly differentiates psychiatrists from any other mental health professional. Obviously, we don't have to practice at the same level as our IM colleagues, but that knowledge is really what makes our expertise and years of training worthwhile.

 

[psych_0]

Inpatient attending here. I manage 0 medical conditions on my unit. Every patient is seen by an IM hospitalist on day of admission. They reconcile meds, start new meds, adjust meds, order additional labs/workup, etc. If a patient has chest pain, the nurses page our medicine service. High blood sugar? Page medicine. High blood pressure? Page medicine. I handle the psych issues, that's it.