Inpatient Psych

[tr]

I've seen TMS before and I'm very skeptical on the efficacy of the treatment.. But I guess if someone has intractable depression and TMS helps like 10% I guess that's better than nothing.

Is interventional psychiatry becoming a thing? I know there's a lot of research being pumped in the psych world and was wondering if there is a push for such a niche? Perhaps a new fellowship? Thoughts on this anyone?

TMS has similar effect sizes to medication, but seems like it may help a different subpopulation. It is FDA approved for depression and OCD.
It is somewhat less effective than ECT but much better tolerated, without the potential for memory loss that is the major limitation for ECT. Comparative efficacy and acceptability of electroconvulsive therapy versus repetitive transcranial magnetic stimulation for major depression: A systematic review and multiple-treatments meta-analysis - PubMed

I have had good luck with referral to TMS after people fail 3 trials of medication. It is becoming more effective over time as researchers learn how to target symptom-specific circuits more finely.

Interventional psychiatry is already a thing. There is not an ACGME fellowship (yet) but if you want to learn how to do it, target a residency that has a well-developed neurostim program.

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[ObsequiousAplomb]

TMS has similar effect sizes to medication, but seems like it may help a different subpopulation. It is FDA approved for depression and OCD.
It is somewhat less effective than ECT but much better tolerated, without the potential for memory loss that is the major limitation for ECT. Comparative efficacy and acceptability of electroconvulsive therapy versus repetitive transcranial magnetic stimulation for major depression: A systematic review and multiple-treatments meta-analysis - PubMed

I have had good luck with referral to TMS after people fail 3 trials of medication. It is becoming more effective over time as researchers learn how to target symptom-specific circuits more finely.

Interventional psychiatry is already a thing. There is not an ACGME fellowship (yet) but if you want to learn how to do it, target a residency that has a well-developed neurostim program.

Idk if I would say much better tolerated based on that review. Sure, the not very effective R-r TMS (8%) was more likely to be best tolerated (52%) option. But the still not as effective as ECT B-r TMS (25%) was only barely more tolerated than ECT (17%). Compare that to the 65% and 14% for ECT and I would not favor the TMS. I would also not call that somewhat less effective. I would switch the modifiers you used and call TMS much less effective and somewhat better tolerated.

That said, I agree with the rest of what you said. There are some patients who really do respond well to TMS and who don't seem to have any adverse effects. For people who aren't willing to go for ECT it can be a nice alternative. Both should be included in a modern psychiatric residency. If people want to do non-ACGME fellowships like all the psychotherapy fellowships, that would be a nice option to learn more.

 

[tr]

Idk if I would say much better tolerated based on that review. Sure, the not very effective R-r TMS (8%) was more likely to be best tolerated (52%) option. But the still not as effective as ECT B-r TMS (25%) was only barely more tolerated than ECT (17%). Compare that to the 65% and 14% for ECT and I would not favor the TMS. I would also not call that somewhat less effective. I would switch the modifiers you used and call TMS much less effective and somewhat better tolerated.

As I mentioned TMS is a newer technology vs ECT and is being continuously updated. The review I cited contained trials up to 2016, and did not include more recent innovations like theta burst, which further increases tolerability, which may also increase efficacy as people become willing to do longer periods of treatment when visits are less burdensome.

Also the differences in tolerability only increase as you go farther out from treatment (vs the short-term time horizons of the included studies), because memory loss in ECT can be permanent, whereas the most typical side effects of TMS (headache, fatigue) are transient.

 

[painballer27]

If you hate talking to people and your other option was anesthesia, I'd suggest you consider an ECT/TMS specialization. Just place the electrodes/magnet, flip on the switch, and count your money.

How much money are we talking with a specialization in ECT/TMS?

 

[ObsequiousAplomb]

How much money are we talking with a specialization in ECT/TMS?

Usually around $180 per treatment when it comes to ECT. How quickly can you cycle through an ECT case? Depends on the setup. For TMS, how many machines do you want to be / can you manage to have consistently being used all the time? That's the best way to answer the question.

Very wide margin of how many ECT cases people do per hour. The various services I worked on the turnover was between 6 and 20 per hour and was entirely related to the efficiency of the setup. Sometimes all the psychiatrist does is push the button, stare for 30-120 seconds at the EEG, then write a procedure note while anesthesia and nurses do the rest. Other setups the psychiatrist does all the ventilating, placement of EEG, etc. All system dependent.

Those setups I worked on weren't doing it all day though, usually as a quick hour or two in the morning 3 days a week before inpatient or outpatient jobs. I imagine the people who exclusively do ECT would not be going at a breakneck pace 8 hours a day. Plus there's all the consults and workups and state-specific rules on informed consent processes.

 

[Psych19]

Usually around $180 per treatment when it comes to ECT.

Around here the professional service charge is about $100 per treatment for the best-paying commercial insurances. That's also about what Medicare and Medicaid pay. I suppose in the right set-up the hospital might subsidize you out of the facility fee they collect. Or perhaps you're paid based on RVUs and do better because of this.

Very wide margin of how many ECT cases people do per hour. The various services I worked on the turnover was between 6 and 20 per hour and was entirely related to the efficiency of the setup.

20 treatments per hour??? You would have to have multiple machines going and multiple anesthesia teams. It's hard enough to find one anesthesia team who wants to do ECT.

I've never seen more than 3-4 per hour. Anesthesia is not incentivized to go any faster than this, and they're always the rate-limiting step.

In the setups I've seen ECT isn't that much more lucrative than the other things a psychiatrist can do. It is, however, a nice change of pace to do something procedural with often quick clinical results.

 

[ObsequiousAplomb]

Around here the professional service charge is about $100 per treatment for the best-paying commercial insurances. That's also about what Medicare and Medicaid pay. I suppose in the right set-up the hospital might subsidize you out of the facility fee they collect. Or perhaps you're paid based on RVUs and do better because of this.



20 treatments per hour??? You would have to have multiple machines going and multiple anesthesia teams. It's hard enough to find one anesthesia team who wants to do ECT.

I've never seen more than 3-4 per hour. Anesthesia is not incentivized to go any faster than this, and they're always the rate-limiting step.

In the setups I've seen ECT isn't that much more lucrative than the other things a psychiatrist can do. It is, however, a nice change of pace to do something procedural with often quick clinical results.

Yeah, it was ridiculous how quickly the 20/hour team went. It was in the PACU right at the beginning of the surgical day.

There were multiple anesthesia residents and attendings managing alternating patients. Only one machine. The patients were all prepped by the psych resident and med students before the psychiatrist showed up. The psych resident or med student pushed the button while the attending sipped his coffee and ate his morning candy bar. Machine was wheeled to the next bed and plugged into the wires already on the patient. The resident and student had to make sure the settings were adjusted but then the button was pressed again in less than a minute from when the last seizure ended. All the procedure notes were written by the attending who went up to the unit no more than 90 minutes after he started at the PACU.

Of course, it had taken him 10+ years to set it up this efficiently and with that high a patient volume.

The ones that were 6-10 were in special ECT procedure rooms with two anesthesia teams. The psychiatrist walked back and forth between two rooms. Sort of like concurrent surgeries.

 

[Ellomate]

There wasn't a lot of response on violence/assault in Inpatient unit?
I've read numerous stories on residents and attendings being assaulted or even stabbed.
I've seem multiple annoyed pts in the unit as a med student. I heard my attending, a tiny 5'3" skinny woman got choked once in her career.
Sure, you can make the claim that every specialties face this issue, but in truth we are the most vulnerable due to our patient population (EM prob second?).
Stories like people being stabbed, punched to the ground, and pt rushing into the nurses station freaks me out a bit.
I feel like after an altercation and a pt threatening me that he'll find me, I'll be so paranoid walking to my car or my drive home...

Can you shed some light on this?
Anyone face something close or heard stories on fellow colleagues?

Also in outpatient, how do you prevent an opioid user (or any mentally unstable pt) from bringing in a backpack with a knife or a gun inside. Just read a story on someone attempting to stab doc who denies MJ Rx. He hid his knife in his bag.

 

[Taddy Mason]

There wasn't a lot of response on violence/assault in Inpatient unit?
I've read numerous stories on residents and attendings being assaulted or even stabbed.
I've seem multiple annoyed pts in the unit as a med student. I heard my attending, a tiny 5'3" skinny woman got choked once in her career.
Sure, you can make the claim that every specialties face this issue, but in truth we are the most vulnerable due to our patient population (EM prob second?).
Stories like people being stabbed, punched to the ground, and pt rushing into the nurses station freaks me out a bit.
I feel like after an altercation and a pt threatening me that he'll find me, I'll be so paranoid walking to my car or my drive home...

Can you shed some light on this?
Anyone face something close or heard stories on fellow colleagues?

Also in outpatient, how do you prevent an opioid user (or any mentally unstable pt) from bringing in a backpack with a knife or a gun inside. Just read a story on someone attempting to stab doc who denies MJ Rx. He hid his knife in his bag.

Response to this topic one of the last times it popped-up - Dangers of psychiatry- resident stabbed

Honestly, odds of being assaulted while at work are probably greatest in EM and inpatient neuro. I haven’t looked for specific data but I’d lean towards surgeons and OB/Gyn as being “higher” risk for violence from vindictive patients outside of work. Also, there’s fair data suggesting that individuals with severe mental illness are more likely to be victims of violence than perpetrators. Within psych, “assaults” are most likely to occur on inpatient child and adolescent units and geri units, and can honestly probably be avoided >95% of the time with common sense.

Also in outpatient, how do you prevent an opioid user (or any mentally unstable pt) from bringing in a backpack with a knife or a gun inside.

Interesting phrasing and that you immediately went to “opioid user” as an example…

 

[smalltownpsych]

There wasn't a lot of response on violence/assault in Inpatient unit?
I've read numerous stories on residents and attendings being assaulted or even stabbed.
I've seem multiple annoyed pts in the unit as a med student. I heard my attending, a tiny 5'3" skinny woman got choked once in her career.
Sure, you can make the claim that every specialties face this issue, but in truth we are the most vulnerable due to our patient population (EM prob second?).
Stories like people being stabbed, punched to the ground, and pt rushing into the nurses station freaks me out a bit.
I feel like after an altercation and a pt threatening me that he'll find me, I'll be so paranoid walking to my car or my drive home...

Can you shed some light on this?
Anyone face something close or heard stories on fellow colleagues?

Also in outpatient, how do you prevent an opioid user (or any mentally unstable pt) from bringing in a backpack with a knife or a gun inside. Just read a story on someone attempting to stab doc who denies MJ Rx. He hid his knife in his bag.

Using caution, common sense, clinical skills to develop rapport and be able to deescelate effectively, and heavy duty tranquilizers administered by male nurses who enjoy a bit of physical intervention. “Don’t worry doc, we got this guy.” That’s how I have gotten by dealing with potentially dangerous patients. if you aren’t the toughest one on the unit, it’s a good idea to make lots of friends.

 

[hamstergang]

Also, there’s fair data suggesting that individuals with severe mental illness are more likely to be victims of violence than perpetrators.

This stat is misleading when it comes up in conversations like this. That is, if we're wondering what the risk is to psychiatrists of getting assaulted by our patients compared to the risk to other doctors getting assaulted by their patients, how is it relevant how often our patients get assaulted themselves? That patients with SMI are more likely to be victims than perpetrators of violence doesn't tell us how often they are perpetrators of violence.

All that said, I'm a male under 5'5" and I've never really felt in danger with any of my patients in any setting.

 

[Taddy Mason]

This stat is misleading when it comes up in conversations like this. That is, if we're wondering what the risk is to psychiatrists of getting assaulted by our patients compared to the risk to other doctors getting assaulted by their patients, how is it relevant how often our patients get assaulted themselves? That patients with SMI are more likely to be victims than perpetrators of violence doesn't tell us how often they are perpetrators of violence.

All that said, I'm a male under 5'5" and I've never really felt in danger with any of my patients in any setting.

That’s fair and it is basically a straw man. There are other issues with that data and I had rephrased that sentence a few times before posting and thought about cutting it altogether but just left it as is. The broader point I was (poorly) trying to imply is that individuals with primary character pathology v. “Axis I” (for lack of a better descriptor) probably pose a greater risk in regard to violence and the former group, by in large, are ideally kept from the inpatient setting. Obviously, this doesn’t always happen and there are exceptions. Even in the outpatient, forensic, ED, and correctional settings I’ve never been concerned for my safety in happening to interact with these patients in the community; and again common sense goes a long way in dealing with patients in any setting in which there is concern about safety.

 

[comp1]

Persons with SMI are likely to be assaulted than to be assaultive, but are still more likely to be assaultive (and thus assaulted) than the general population. That said, you're going to see patients with SMI everywhere. At least on an inpatient unit, you have some control of the surroundings and environment with expectations of the potential for violence. Not always the case in every PCP office.

 

[ObsequiousAplomb]

A Systematic Review of the Prevalence of Patient Assaults Against Residents

A Systematic Review of the Prevalence of Patient Assaults Against Residents - PMC

The purpose of this study is to systematically review the literature on the prevalence of patient assaults against residents in all specialties, and to identify curricula that address this issue. The authors searched published English-language ...

www.ncbi.nlm.nih.gov

"The prevalence of assaults by patients against psychiatry residents ranged from 25% to 64%. The prevalence of assaults by patients against residents in medicine, surgery, and internal medicine ranged from 26% to 40%, and the prevalence of assaults against residents in pediatrics was 5% to 9%."

Essentially, it's widely variable, and the ranges overlap to the extent that you can say it's roughly equivalent in psychiatry, internal medicine, and surgery residencies.


Anecdotally:
As someone who did residency with more than 50% of my time at a state hospital with primarily forensic patients, only 1/9 of my cohort was ever physically struck by a patient. She turned her back on a catatonic patient who had been seated without moving for 6 hours. He ran 20 feet across the room and punched her in the back of the head. More of us were swung at and dodged, though.

Everyone has a story somewhat like this. A 70+ year old attending was violently beaten in front of me, requiring neurosurgical intervention. The patient was antisocial with no other identifiable psychopathy and was there for murder. The attending was vigilant but the patient was out for blood. In a clearly premeditated and calculated manner he distracted most of the unit staff and snuck up on the attending, who had his back to a wall and a hallway previously cleared by security. Would have happened to any authority figure who was vulnerable and angered the patient, could have very easily been the petite internal medicine doctor instead.

Interestingly, most of the attacks on physicians in that setting were on the internal medicine doctors and not the psychiatrists. The patients almost universally know better than to punch the psychiatrist. 90%+ of the attacks were on the technicians and nursing staff who tend to get within striking distance of those patients. I, for one, never stand or sit near enough to people I assess as being a violence risk that someone could hit me before I manage to run away. That includes staff.

 

[painballer27]

Day to day, pain management can be a nice mix of these 2 specialties by the way

Could you tell us about your path from psychiatry to pain?

Did you know you always know you wanted to do pain when you applied to psych residency? What sorts of things did you do in residency (or before) to make yourself competitive for pain fellowships? Would you choose the same path again?

 

[adiradirim]

Could you tell us about your path from psychiatry to pain?

Did you know you always know you wanted to do pain when you applied to psych residency? What sorts of things did you do in residency (or before) to make yourself competitive for pain fellowships? Would you choose the same path again?

I didn't know! I found out PGY2 that it was a specialty and that I enjoy it while doing my detox rotations.

Ended up doing research, book chapters, rotations, lots of hands on experience, and networking. I set up a psychiatry consult clinic for an outpatient pain rehab program. Basically did everything I could to break in because everyone told me it was impossible.

I wouldn't recommend going through psych into pain unless you were already in psych residency and discovered it late. I thankfully was in a residency that allowed for a lot of exposure. Not every program is like that.

I would definitely pick the same path but I was very lucky. Plus, I couldn't do anesthesia lol.

Feel free to DM me for any specifics