Inappropriate Psych Consults

[Nitsua546]

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So, I'm going to avoid any specifics on where I go so as to simply not stir up drama for myself.

However, I wanted to get some opinions from other residents or even attending docs out there on a few things;

1) Are we whining to much and just need to man up?
2) What are some ways you have dealt with similar problems?
3) (And only if you feel silly) Please tell us the most inappropriate consult you had to go see!

So here's the deal. I'm a psych resident in a very busy metropolitan hospital where there is a huge psych population. This in it self is fine, I love the work. It makes the day go fast when I'm on floor consults or doing Psych ED. But on a given 24 hour call shift shift, I'll probably clear the cache on my pager 4 or 5 times just to make room for new pages.

The hospital that we're primarily based out of has a mentality that psych is required on many issues that should be either managed by the primary inpatient team itself, or non-DO/MD providers (Social workers, nurses, ect)

The worst offender is the dreaded Capacity consult, or more often as they mistakenly request, "competency". I'm looking at you FMG hospitalist! (PC is not one of my strengths) Here in our institution, a long held myth is that only psychiatrists can determine capacity to the extent that they will call us to determine if the septic 80 year old who is delirious and trying to climb out of her bed, has the ability to decide to leave the hospital. This would be fine if it was a simple 1 line note that I could slap down, however, for billing reasons, the hospital requires that we do a full H&P on all patients when we lay eyes on them for the first time while in the role of a consultant. Well, there's my gripe, share your thoughts.

As I've asked people to tell theirs, I'll tell one of my more recent.

92 year old female with long standing history of severe dementia but no prior psych history per family. Septic secondary to infection occurring at site of decubitus ulcer on her bum (weren't rolling her at the nursing home). IM requests psych eval to determine if agitation is secondary to new onset schizophrenia. They don't want any med recs for agitation since they have it under control. They just wanna know if shes new onset schizophrenia.

 

[StECT]

I'm looking at you FMG hospitalist!

I'm sorry to start this thread off with a digression, but what are you implying by that line above?

 

[F0nzie]

I was able to stay sane on CL by telling myself that there was no such thing as an "inappropriate consult". Many times the consult question was poorly articulated and I ended up answering a totally different question-- which made for a good educational teaching point.

The capacity thing is mostly CYA but you may find yourself also making useful recs for psychosis or delirium. It gets tedious after a while and often I found myself getting upset with the consulting team esp at 3am.

But anyways hang in there! There is way more to psych than capacity evals at 3am. Most non-academic hospital do not have this luxury nor do they have the money to pay you for it. Internists will eventually learn on their own after they finish residency.

 

[birchswing]

I'm sorry to start this thread off with a digression, but what are you implying by that line above?

Well does anyone really think they're coming here for the love of sick Americans?

It takes a very motivated person to leave their country. And I'm not saying all doctors aren't motivated by money, but it takes extra motivation to leave home.

 

[StECT]

Well does anyone really think they're coming here for the love of sick Americans?

It takes a very motivated person to leave their country. And I'm not saying all doctors aren't motivated by money, but it takes extra motivation to leave home.

Perhaps. Also think you meant to say "are". Nonetheless, it didn't seem like that was the implication. It seemed more like generalizing their competency (or lack thereof) because they were requesting "competency" evals.

 

[whopper]

A lot of it has to do with the culture of the specific hospital. Where I did residency training, the attendings doing consult did not know their medicine very well, so they accepted patients to the inpatient unit that clearly were not medically cleared. Then when these things happened, the head of the department just let it happen and didn't do M&Ms or department meetings to point out problematic admissions from the medical unit.

Also, whenever we got BS consults, the attendings just made the residents deal with it instead of trying to make sense as to why it was happening. Residents tend to take abuse, so the residents wouldn't fight back, further enabling the flow of BS consults.

The culture was dysfunctional where I did residency.

Now, let's take another example. A colleague of mine in residency became an attending at a hospital and was one of the only psychiatrists there. When she got a BS consult, she piled them up and worked with the other departments and nurses to point out what was BS and they were willing to work with her because she was one of their only attendings and could've easily left them. Things improved significantly after about 6 months of her working with other departments on these issues.

 

[shan564]

I'm sorry to start this thread off with a digression, but what are you implying by that line above?

I think the implication was that foreign-trained doctors often don't understand certain aspects of the American medicolegal system. The word "competency" was referring to inappropriate consults to determine whether the patient has "competency," which is something that can only be done by a judge, not a doctor. And also the fact that they often believe that only psychiatrists can determine capacity, whereas in reality, any doctor can do that... and in many cases, other doctors can do it more effectively than a psychiatrist.

Another part of the implication was that people in many other countries don't do a psychiatry rotation in med school, so FMGs often have a poorer understanding of psychiatry than American grads, who are required to do a psych rotation and pass a psychiatry shelf exam. I've often run into this - I interacted with one attending who didn't know what schizophrenia is (she thought it just means that the patient is violent and unstable, which was certainly not the case for this particular patient) and thought that an antipsychotic is just a form of chemical restraint. As a result, she wouldn't accept the patient into a physical rehab facility after he had a spinal cord injury because she saw that he's on antipsychotics, which gave her the impression that he was violent. He was the most pleasant and cooperative guy in the world, but he'd gotten a bit psychotic because he was unable to take his medications when he was immobilized from his spinal cord injury.

Anyway, I don't think the OP was implying that FMGs are any less competent, just that many of them come from countries in which psychiatry is not really taught in medical school.

So, I'm going to avoid any specifics on where I go so as to simply not stir up drama for myself.

However, I wanted to get some opinions from other residents or even attending docs out there on a few things;

1) Are we whining to much and just need to man up?
2) What are some ways you have dealt with similar problems?
3) (And only if you feel silly) Please tell us the most inappropriate consult you had to go see!

So here's the deal. I'm a psych resident in a very busy metropolitan hospital where there is a huge psych population. This in it self is fine, I love the work. It makes the day go fast when I'm on floor consults or doing Psych ED. But on a given 24 hour call shift shift, I'll probably clear the cache on my pager 4 or 5 times just to make room for new pages.

The hospital that we're primarily based out of has a mentality that psych is required on many issues that should be either managed by the primary inpatient team itself, or non-DO/MD providers (Social workers, nurses, ect)

The worst offender is the dreaded Capacity consult, or more often as they mistakenly request, "competency". I'm looking at you FMG hospitalist! (PC is not one of my strengths) Here in our institution, a long held myth is that only psychiatrists can determine capacity to the extent that they will call us to determine if the septic 80 year old who is delirious and trying to climb out of her bed, has the ability to decide to leave the hospital. This would be fine if it was a simple 1 line note that I could slap down, however, for billing reasons, the hospital requires that we do a full H&P on all patients when we lay eyes on them for the first time while in the role of a consultant. Well, there's my gripe, share your thoughts.

As I've asked people to tell theirs, I'll tell one of my more recent.

92 year old female with long standing history of severe dementia but no prior psych history per family. Septic secondary to infection occurring at site of decubitus ulcer on her bum (weren't rolling her at the nursing home). IM requests psych eval to determine if agitation is secondary to new onset schizophrenia. They don't want any med recs for agitation since they have it under control. They just wanna know if shes new onset schizophrenia.

I think it's reasonable for them to request a consult if they don't know how to best manage the patient... that's what consults are for. Medicine calling a psych consult for a 92-y.o. lady with delirium to r/o new-onset schizophrenia is equivalent to psychiatry calling a medicine consult to treat a 24-year-old otherwise healthy girl with an uncomplicated UTI or an iron deficiency anemia. It's a silly thing that you should have learned adequately in medical school, but if you don't know what to do, that's why the consult team is there.

That said, it's ridiculous to have to do a full H&P for a capacity evaluation on a patient who is obviously delirious. Sounds like that's where the problem lies. Also, it's obviously problematic that people think that only psychiatrists can do capacity assessments. It sounds like it might be worthwhile for you guys to arrange for a psychiatrist to give an IM grand rounds talk about capacity, competency, etc.

 

[Doctor Bagel]

It's the notes that get you -- stupid consults would be so much easier to deal with if you didn't have to write a full note. Hopefully, you're learning that your H&P can be pretty short if there's not much to say. We're lucky in that we don't do decision-making capacity consults in our university hospital. I'm not sure why, but it's a department policy. We do do them at the VA, so it's not like we're missing the experience entirely, but it's still reduced.

It seems like the liaison part is lacking in most psychiatry services.

 

[digitlnoize]

So, I'm going to avoid any specifics on where I go so as to simply not stir up drama for myself.

However, I wanted to get some opinions from other residents or even attending docs out there on a few things;

1) Are we whining to much and just need to man up?
2) What are some ways you have dealt with similar problems?
3) (And only if you feel silly) Please tell us the most inappropriate consult you had to go see!

The worst offender is the dreaded Capacity consult, or more often as they mistakenly request, "competency".

92 year old female with long standing history of severe dementia but no prior psych history per family. Septic secondary to infection occurring at site of decubitus ulcer on her bum (weren't rolling her at the nursing home). IM requests psych eval to determine if agitation is secondary to new onset schizophrenia. They don't want any med recs for agitation since they have it under control. They just wanna know if shes new onset schizophrenia.

How do you take away capacity in your state? 2 doctors' opinions? Where I live, that's what you need. So, they call me asking for the 2nd opinion, and the first thing I always do is explain this to them, then ask if they've done the first opinion. Because my opinion won't matter a lick if they disagree with me. This stops about half the consults (the ones who they find DO have capacity), they only call me back if they think they don't have capacity. I have an EPIC smart phrase for capacity evals that I tell them they can steal. UpToDate also has a great article on how to do a capacity evaluation and I tell them to read that. Because they should learn how to do one.

I hear the 90-year-old new onset schizophrenia all the time too. I use it as an opportunity to educate other docs about psych. I remind them of the age of onset and negative symptoms of schizophrenia.

I think it's a sign that the psychiatric education of non-psych doctors in the US is abysmal. I agree that there's usually a reason they're calling, they just don't know what it is. The more they ignore me and the more serious the patient's condition is, the more strongly worded my note is, in a medico-legal way, which tends to be more likely to get them to comply.

 

[Shikima]

I feel your pain Nitsua. Just hang on, slug through the work, keep venting and this too shall pass.

Beer always helps... I recommend Hefeweizen.

 

[notdeadyet]

In fairness, the medicine folks could undoubtedly start a thread about the abysmally inappropriate medicine consults from psych.

Patience with consults. You'll need them too....


Sent from my iPhone using Tapatalk

 

[Shikima]

True Notdead.... it's a problem with GME education and politics across the country.

 

[Doctor Bagel]

In fairness, the medicine folks could undoubtedly start a thread about the abysmally inappropriate medicine consults from psych.

Patience with consults. You'll need them too....


Sent from my iPhone using Tapatalk

And there are many pretty hilarious videos on youtube dealing with frustrations on both sides. I think part of being on a consulting service is being angry/annoyed about being consulted.

 

[splik]

i really like consultation-liaison work, and do not believe there is such a thing as an "inappropriate" consult though there are certainly duds. if someone is consulting you it means they don't know wtf they're doing. why should the patient suffer?

in terms of writing a full note - if the patient is seen on call and won't be seen by an attending within 24 hours (likely not at weekends) then your note is non-billable anyway (and if they're billing for it, it's fraud) so don't feel like you have to go to the trouble of writing a full note. seriously, if i have a cut and dry capacity assessment consult i usually just document a SOAP note with a brief history, MSE, and then the assessment is my documentation of capacity (which is easily enough templated) and then any recommendations.

i also will rarely see consults overnight. the great thing about psychiatry is that there are few genuine emergencies, and everything always seems much worse overnight. unless a patient is having life-saving surgery overnight and they want a capacity assessment, i am not going to see it.

also bear in mind that psych consults have a latent content as well as a manifest content. the manifest content may be "please see this patient who is refusing surgery for capacity eval" but the latent content is "please make this patient do want I want"; the manifest content may be "please see this patient for evaluation of new onset schizophrenia" but the latent content is "I have a hateful countertransference to anyone who is acting crazy, even if delirious, and would like you to transfer them off my service so I don't have to deal with them."

Also as mentioned about remember the liaison part. in a good C/L service the number of consults for basic things should drop throughout the year as you are teaching the residents on other services to manage basic problems or do their own brief psych evaluation. You should be explaining your rationale, providing brief readings, organizing more formal psychiatry teaching etc for your internal medicine colleagues.

my very favorite consult was simply "will you please send some one to do psychiatry on her". At the time i didn't know what it meant to "do psychiatry" but now I do!

 

[Doctor Bagel]

i also will rarely see consults overnight. the great thing about psychiatry is that there are few genuine emergencies, and everything always seems much worse overnight. unless a patient is having life-saving surgery overnight and they want a capacity assessment, i am not going to see it.

my very favorite consult was simply "will you please send some one to do psychiatry on her". At the time i didn't know what it meant to "do psychiatry" but now I do!

I'm impressed that you have the option to defer a consult. We're generally expected to see the consults when they come in, which in some ways makes sense -- your colleagues in the morning might feel annoyed about having to do a consult that came in overnight. However, that's a unique to residency issue.

I'm glad you know how to "do psychiatry." I think I need to learn.

 

[notdeadyet]

i really like consultation-liaison work, and do not believe there is such a thing as an "inappropriate" consult though there are certainly duds.

You must not have done C/L in July. I saw a couple of definitely inappropriate consults that month. I think a request to evaluate a comatose/intubated patient for suicidality qualifies. It's certainly an opportunity for teaching new residents the role of C/L psychiatry, but I would file it under the inappropriate category. It's up there with a psychiatrist consulting medicine for acetaminophen vs. ibuprofen for tension headaches in a medically sound patient.

 

[splik]

we have to see consults overnight for delirium/behavioral disturbance, and suicide attempt/active SI within 3 hours. anything else can wait til the morning. at the VA we have 24 hours to see a consult that is not safety related.

i tend to be more brazen about things than some people so my co-residents will usually call me up and ask whether its okay not to write a full note or see a patient at a particular time. here, unless it was an urgent thing people usually see it as a favor if the on call resident saw a consult rather than bitching about it if they didn't see a non-urgent one. also sometimes i will go see a patient if its not clear whether a consult is required and if i dont feel it is i won't write a note, or will write a v. brief note. sure, our service would prefer us to see everyone and bill for everything, but that's not practical.

 

[splik]

You must not have done C/L in July. I saw a couple of definitely inappropriate consults that month. I think a request to evaluate a comatose/intubated patient for suicidality qualifies. It's certainly an opportunity for teaching new residents the role of C/L psychiatry, but I would file it under the inappropriate category. It's up there with a psychiatrist consulting medicine for acetaminophen vs. ibuprofen for tension headaches in a medically sound patient.

actually i did do consults in July when we were inundated and yeah the consults were lame, but nothing like that. and i guess you would see the patient eventually. also comatose patients are my favorite!

 

[SmallBird]

I'm impressed that you have the option to defer a consult. We're generally expected to see the consults when they come in, which in some ways makes sense -- your colleagues in the morning might feel annoyed about having to do a consult that came in overnight. However, that's a unique to residency issue.

I'm glad you know how to "do psychiatry." I think I need to learn.

Thats interesting that you are required to do that - I wonder how common that is. I think it makes total sense to defer some consults, in the interests of efficiency, and potentially a better patient experience.

 

[Doctor Bagel]

Thats interesting that you are required to do that - I wonder how common that is. I think it makes total sense to defer some consults, in the interests of efficiency, and potentially a better patient experience.

Honestly, as a resident it's a frustrating policy. I think it's hospital wide, though, that you're expected to do consults within a certain about of time. Of course what that can mean is checking in to see that a patient is asleep, too delirious to participate in an evaluation and writing a preliminary note primarily based on history obtained from a chart review and discussion with staff, which is helpful to the day team who is likely going to be the people making the more detailed recommendations.

 

[vistaril]

I'm looking at you FMG hospitalist!

pretty sure an irony meter just broke somewhere.

 

[jno]

You must not have done C/L in July. I saw a couple of definitely inappropriate consults that month. I think a request to evaluate a comatose/intubated patient for suicidality qualifies. It's certainly an opportunity for teaching new residents the role of C/L psychiatry, but I would file it under the inappropriate category. It's up there with a psychiatrist consulting medicine for acetaminophen vs. ibuprofen for tension headaches in a medically sound patient.

Wowzer!

 

[jno]

Honestly, as a resident it's a frustrating policy. I think it's hospital wide, though, that you're expected to do consults within a certain about of time. Of course what that can mean is checking in to see that a patient is asleep, too delirious to participate in an evaluation and writing a preliminary note primarily based on history obtained from a chart review and discussion with staff, which is helpful to the day team who is likely going to be the people making the more detailed recommendations.

How much time are we talking about here?

 

[notdeadyet]

Thats interesting that you are required to do that - I wonder how common that is. I think it makes total sense to defer some consults, in the interests of efficiency, and potentially a better patient experience.

It probably varies by institution. At our place, residents on call are not allowed to defer consults to the regular consult team and the consult team typically only defers due to bandwidth.

I think it actually makes sense. If you leave it up to the discretion of an on-call resident what s/he sees vs. defers to the next shift, you would have nothing done over the weekend...

 

[splik]

I think it actually makes sense. If you leave it up to the discretion of an on-call resident what s/he sees vs. defers to the next shift, you would have nothing done over the weekend...

well that is exactly what we do and lots gets done over the weekend. but i sure as hell am not going to be seeing some anxious patient, or demoralized patient overnight or at the weekend unless i think there's something more to it. at our main site we also bounce most capacity assessments because if we didn't the service would collapse.

 

[digitlnoize]

It probably varies by institution. At our place, residents on call are not allowed to defer consults to the regular consult team and the consult team typically only defers due to bandwidth.

This is basically what we do. Most floor consults come in during the day. For the rare ones that come at night, if we're slow we'll have the night intern do them. If we're really busy, it'll get pushed off to the day team.

The only problem with this system is if you have too many slackers. I always try to see the night floor consults whenever I can, even though I don't HAVE to. Also, obviously certain things are more emergent and we prioritize those, but most floor consults can wait until morning. We're given 24 hours to see a floor consult, as a general policy. ED consults should be seen faster (it's all the same team for us).

I agree 100% about the liaison part being the most important thing. We have to remember that most physicians spent 1 month on psych in med school and ignored most of that. Now, they're realizing how much psych they encounter from day to day (which is woefully under-represented in medical education) and need our help all the time.

I do try to minimize my bad medical consults. I've currently got a patient with multiple active medical problems that I am managing inpatient. I've been close to calling them a couple of times, but I've got things in hand for the time being. It's good to stay in practice with basic medical management too.

 

[vistaril]

I do try to minimize my bad medical consults. I've currently got a patient with multiple active medical problems that I am managing inpatient. I've been close to calling them a couple of times, but I've got things in hand for the time being. It's good to stay in practice with basic medical management too.

not sure what your post residency plans are, but if you work for a private hospital, community hospital system, etc this approach is unlikely to fly. Not always for pt safety reasons, but the hospital system isn't going to let you allow money to escape like that. When you don't consult the hospitalist group for a pt with htn, that is $$ that are escaping from the system.

With the bottom line within academic medical centers becoming more and more important, I wouldn't be surprised to see this take hold in these places as well.

 

[hamstergang]

Are you saying the hospital would fire you for not ordering inappropriate consults?

 

[vistaril]

Are you saying the hospital would fire you for not ordering inappropriate consults?

consulting the hospitalist group for medical management of your pt's stable chronic medical conditions is not inappropriate.

At many places I went to(again community hospital systems, most non profit and a few for profit), consulting the hospitalist group was automatic for every patient. At the ones where there wasn't an automatic order sent to the hospitalist group when a pt was admitted, it was understood that on most patients(especially of they are on any meds...like bp meds) medicine will need to be consulted.

 

[splik]

not sure what your post residency plans are, but if you work for a private hospital, community hospital system, etc this approach is unlikely to fly. Not always for pt safety reasons, but the hospital system isn't going to let you allow money to escape like that. When you don't consult the hospitalist group for a pt with htn, that is $$ that are escaping from the system.

With the bottom line within academic medical centers becoming more and more important, I wouldn't be surprised to see this take hold in these places as well.

actually as the ACO model takes hold inappropriate consults will probably be slashed because this pernicious financial incentive that you describe won't be there

 

[vistaril]

actually as the ACO model takes hold inappropriate consults will probably be slashed because this pernicious financial incentive that you describe won't be there

I don't know that these are inappropriate. Regardless, I don't see any evidence that this will change. And it could be argued that not having any responsibility for even routine minor medical issues allows psych to be more efficient doing psych. Our dept, to try to increase revenue for the hospital as a whole, is talking about an initiative to increase their medicine consults by a substantial amount for routine medical matters. It wouldn't be through the academic consult service most likely, but through a separate group(mostly staffed by nps) employed by the hospital system. So I think as hospital systems all across the country(even large academic ones) look to increase revenue that we will be copying the community an not the other way around.

Also, if the way things are being done in the community changes, that would not be a good thing for our field. Or at least those peoples taking community inpatient jobs(which do effect salary floors in academic settings). Our salaries in such settings are obviously tied to the money we bring in, both through our billing codes but also by other revenue brought about by the existence of our department. And hospitals keep track of this. They know how much was brought in by one slice of that, such as medicine/hospatilist codes on psych inpatients. Things that reduce this slice of the hurts us.

A new psych who shows up in a hospital system and isn't consulting the hospitalist as per protocol like the other psychs isn't likely to be seen as a team player. Hospitals tend not to be huge fans o employed/salaried physicians who aren't interested in producing revenue for the system that employs them.

 

[hamstergang]

consulting the hospitalist group for medical management of your pt's stable chronic medical conditions is not inappropriate.

No, it most certainly is inappropriate. There's no reason that a psychiatrist should be unable to manage stable, chronic, medical conditions without having to call a consult. The only purpose of such a consult, then, would be to take more money from the patient. That makes it inappropriate and unethical.

 

[vistaril]

No, it most certainly is inappropriate. There's no reason that a psychiatrist should be unable to manage stable, chronic, medical conditions without having to call a consult. The only purpose of such a consult, then, would be to take more money from the patient. That makes it inappropriate and unethical.

no, those last two things do not connect. But again, you likely aren't going to have a choice(depending on what stage of training you are in). Money isn't always the reason either depending on the setting. Most inpatient VAs, for example, have a medicine team/person(depending on unit size) to handle that, often a general PA/NP.

 

[hamstergang]

no, those last two things do not connect.

Simply contradicting me isn't terribly convincing. I've said it's inappropriate to call a consult for the purpose of making more money when you can handle the issue yourself. Can you actually explain the flaw in that reasoning, or are you just going to say it's wrong again?

 

[vistaril]

Simply contradicting me isn't terribly convincing. I've said it's inappropriate to call a consult for the purpose of making more money when you can handle the issue yourself. Can you actually explain the flaw in that reasoning, or are you just going to say it's wrong again?

And I've already stated in this thread that the ethical/moral aspects of it are not particularly relevant, since in most cases it *won't matter* how right or wrong you think it is. But life/work are full of hiring others to do things(and passing them on to other payers) when you could technically do them yourself perhaps.

What setting are you interested in working in? And where exactly do you think the money you will make comes from? It's very likely that a nice chunk(either directly or indirectly) will come from performing services that someone else 'could have handled the issue themselves'. So it's not like we don't benefit as well.....

 

[michaelrack]

And I've already stated in this thread that the ethical/moral aspects of it are not particularly relevant, since in most cases it *won't matter* how right or wrong you think it is. But life/work are full of hiring others to do things(and passing them on to other payers) when you could technically do them yourself perhaps.

What setting are you interested in working in? And where exactly do you think the money you will make comes from? It's very likely that a nice chunk(either directly or indirectly) will come from performing services that someone else 'could have handled the issue themselves'. So it's not like we don't benefit as well.....

Agree to an extent. There are a lot of things that docs do for $, even though the patient may also benefit. For example, doing a complete ROS so a higher level can be billed- sure something may be discovered that benefits the patient, but that's not why it is being done. Another example is a psychiatrist (prior to the new psychotherapy add on codes) referring a pt to a psychologist for psychotherapy that he could do himself (but would lose cash since that would take time from medication management visits).

If you consult IM for simple BP management, maybe something good will come out of it for the pt- maybe the IM doc will consolidate meds or start a once a day instead of multi-day dosing.

I do not admit to doing anything like the above myself

 

[vistaril]

Agree to an extent. There are a lot of things that docs do for $, even though the patient may also benefit. For example, doing a complete ROS so a higher level can be billed- sure something may be discovered that benefits the patient, but that's not why it is being done. Another example is a psychiatrist (prior to the new psychotherapy add on codes) referring a pt to a psychologist for psychotherapy that he could do himself (but would lose cash since that would take time from medication management visits).

If you consult IM for simple BP management, maybe something good will come out of it for the pt- maybe the IM doc will consolidate meds or start a once a day instead of multi-day dosing.

I do not admit to doing anything like the above myself

agree with all this, but my larger point is that the system itself is bigger and more powerful than us. Especially for those who plan on working inpatient. And while that's true moreso obviously for salaried/employed physicians, it's true to some extent for physicians with contracts with units where they bill and collect themselves.

If you work for an HCA hospital(just to pick one....insert your own for profit corporate hospital or large non profit here), you're going to either work within their model.......or not work there. And their model is going to include expecting you to consult their own hospitalist employed group for such things.

 

[hamstergang]

And I've already stated in this thread that the ethical/moral aspects of it are not particularly relevant, since in most cases it *won't matter* how right or wrong you think it is. But life/work are full of hiring others to do things(and passing them on to other payers) when you could technically do them yourself perhaps.

What setting are you interested in working in? And where exactly do you think the money you will make comes from? It's very likely that a nice chunk(either directly or indirectly) will come from performing services that someone else 'could have handled the issue themselves'. So it's not like we don't benefit as well.....

You're deflecting. Just answer my question or admit that you can't.

 

[vistaril]

You're deflecting. Just answer my question or admit that you can't.

I consider your initial question along this topic a deflection in the first place(since as I said, it's mostly irrelevant). I was nice enough to briefly address it though, and since you seem insistent I'll expand on what I mean. I mostly agree with what Michael Rack said a few posts above. We are not very skilled in mgt of stable chronic medical problems as these other providers, and I think there may be some benefit there in having an expert give it a once over. So that's why I don't think it is an innapropriate consult. And that's all I'll say on the matter since it was never an issue I had an interest in discussing in the first place.

But to answer your initial question- hell yes, they will most definitely fire you if you don't work within their revenue model to that extent. If you're good at what you do and producing value to the organization you'll probably be able to win some smaller battles with administration, the c-suite, etc.....but not ones like that that go right to their revenue model.

 

[SteinUmStein]

But to answer your initial question- hell yes, they will most definitely fire you if you don't work within their revenue model to that extent. If you're good at what you do and producing value to the organization you'll probably be able to win some smaller battles with administration, the c-suite, etc.....but not ones like that that go right to their revenue model.

Do you have anything to back this up? Examples, articles, personal experience, anything? Or is this speculation?

 

[vistaril]

Do you have anything to back this up? Examples, articles, personal experience, anything? Or is this speculation?

I mention a few posts above that I interviewed for a large number of inpatient psychiatry positions in various communities. They made it very clear that this is the way the unit is run, and that your salary(which is admittedly generous and wasn't that far from what medicine hospitalists got) is due to all the contributions leading to revenue you make to their system as a whole and not just those that are the most direct(like your individual billing codes).

Additionally, worked two different inpatient non-academic wkend moonlighting gigs and the pts on bp meds, diabetes meds, cholesterol meds....all ordered by a hospitalist or np affiliated with the hospital group as part of the consult.

Now do I have any evidence that an applicant who deceived during the interview process and said they were a team player(as team player is perceived by the hiring people) would be fired if they then did a 180 with respect to those things? I guess not, just like I don't have any evidence that leaving work at 9am everyday and then turning your pager off would lead lead to getting fired. I didn't ask either question.

It's silly because most people would view high levels of medicine/np/pa inolvement as a positive and selling point.

 

[SteinUmStein]

I can see it both ways - I understand wanting to have someone else take care of the routine medicine stuff on an inpatient unit while you do your job. On the other hand, it would be nice to maintain those skills and not let them atrophy over time with disuse. It's also not that difficult or time-consuming if you do it regularly.

 

[vistaril]

I can see it both ways - I understand wanting to have someone else take care of the routine medicine stuff on an inpatient unit while you do your job. On the other hand, it would be nice to maintain those skills and not let them atrophy over time with disuse. t's also not that difficult or time-consuming if you do it regularly.

if one is so inclined, they could go back and read the note and see the orders of what the np/hospitalist ordered and 'maintain skills' that way. But I don't see what the point would be.

 

[Ceke2002]

Here, at least from my experience/understanding, triage nurses and residents are trained in basic Psych consults. I've only ever overheard a Psych consult being called for either a suspected suicide attempt, or if the patient is floridly psychotic or obviously manic. I would think doing things this way would take some of the pressure off Psych and redirect their efforts towards patients who actually do need a consult. I mean if I come in for a medical issue, and the triage nurse happens to notice self injury scars on my legs that are at least 6 months old I don't think they need to drag a Psychiatrist down for a consult.

 

[Bartelby]

It's silly because most people would view high levels of medicine/np/pa inolvement as a positive and selling point.

Having worked under both models (on child psych all patients had an automatic peds consult managing all general medical issues, on all my other rotations it's on us and medicine is none too happy to stop by) I really liked the high levels of medicine involvement. It lets me focus on their psychiatric presentation instead of spending a big chink of my daily interview time with them discussing their back pain or osteoarthritis or migraines or odd chest pain with negative EKG and workup. When there is an NP with attending support following those things can be deflected to the NP and you can get down to the psychiatric issues (and I get that, for instance, the back pain guy may be opiate seeking and that should be discussed but you don't have to get into all the details of the medical side since someone else is). It also rocks having the NP corral all of the consultants for a complicated patient together while you do the psychiatric work that needs to happen. It also makes it way easier for me to run questions by the team who is already following versus starting up a new consult, which will often get pushback if it is not for a clearly diagnosed and clearly active general medical issue.

I know having medicine involvement can lead to skill atrophy, but honestly most practice settings (outpatient especially) would as well.

As for the original question, I try never to give attitude to or belittle the consulting resident or attending (especially before I have even seen the patient) for what appears to be a poorly thought out or inappropriate consult. I see that all too often in an attempt to duck work or vent frustration and I know from having been on the receiving end how annoying it is. Granted if they have mistakenly consulted me when hospital policies clearly dictate that they should have consulted someone else (for instance a social work consult for a straightforward detox placement) I will let them know that and ask if they still need my involvement, otherwise I will politely and professionally come see the patient. It is also not that hard to just do the consult unless you are absolutely slammed (maybe 1.5 hours work from start to finish). If after seeing the patient it is still obvious that psych involvement is not / was not needed I tactfully relay this in my communication with the team. If the problem persists then I think it is time to get someone higher up than you (like director of the consult service) to discuss this with the ER or medical or surgical or whatever team keeps sending inappropriate consults.