Inventing a Psychiatry Consult forum

[kugel]

I've become interested in creating (or joining) a forum for consulting on real cases where there is no psychiatrist available. For instance, in some foreign countries, even the psychiatric hospitals have no trained psychiatrists. And here in the US there some places where there is no psychiatrist available within several hours drive. Imagine the consternation of a GP (not even FP or IM trained) in a psychiatric hospital in Addis Ababa, Ethiopia, trying to care for hundreds of severely ill psychiatric patients. In such places there are few books, no specialists, no second-generation antipsychotics (SGA's), maybe only a few FGA's and lots of ECT, and maybe a few Tricyclics and MAO-I's - but the supply of most of the available meds is unreliable.

So I'm imagining a forum where non-psychiatrists can present cases, get real consultation suggestions, and go back to care for patients with clear suggestions. This probably has to be on a site where the consultants are vetted for completion of a psychiatry residency and active license in some US state - in order to make sure the consultations are from valid sources. When possible, the presentations should be in the form of formal case presentation: Brief HPI (then get a few responses), Rest of HPI (then get a few responses), PMH and PPH (then get a few responses), MSE and lab/imaging data (then get a few responses), etc. Even though this makes a case take longer and the whole process can become a little tedious, but there is learning that takes place by seeing the responses in sequence and part of the goal of such a forum is to provide these non-psychiatrists with some education which will assist them with all their patients.

If you know of such a forum, please let me know.
If not, how would you go about starting one?
Would you try to get this going on an existing professional medical site (WebMD, MDConsult, etc) or create one de novo?

Thoughts?

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[nitemagi]

Sermo isn't bad. It at least has vetting that the individual must be a physician. I've thought about making a bulletin board (confidential) for discussion of cases that mental health providers could sign up for. But it would likely be a lot of work.

 

[F0nzie]

When possible, the presentations should be in the form of formal case presentation: Brief HPI (then get a few responses), Rest of HPI (then get a few responses), PMH and PPH (then get a few responses), MSE and lab/imaging data (then get a few responses), etc.

This is a cool idea... I've pretty much been using SDN to get clinical opinions outside of my residency program and it's been a tremendous help. We really have some very intelligent folks on here and some of these threads definitely have excellent educational value.

Would you try to get this going on an existing professional medical site (WebMD, MDConsult, etc)

Thoughts?

Sounds like an ideal situation to collaborate with or spark this type of movement with existing reputable organizations. The challenge I see in this is that unless you have some existing connections, it may be difficult to know where to begin or how to navigate to get your proposal to be acknowledged. Making some connections may be a good place to start if you haven't already.

I think SDN could potentially be an adequate platform for this type of proposal as this site already attracts a lot of web traffic from people in our field- not only the physicians browsing the internet for information, but in particular, the minority of physicians who are willing to participate in online discussions. Maybe consider contacting someone on SDN with your proposal to create a more structured platform for presenting clinical vignettes for added educational value. Might not be a bad idea to address the content, logistics, and method of implementation as it may be more helpful than just throwing out the "idea" and letting someone else figure it all out.

or create one de novo?

Thoughts?

Perhaps you already know this but webdesign and maintenance can be very time consuming...once you get html, css, and javascript down, then it's a matter constant troubleshooting and keeping up with the perpetual evolution of the worldwide web. Not to mention all the additional responsibilities required for running a small online organization. If you're very passionate about this type of work, have the time, and sufficiently compelled to get this done, I would go this route.

 

[JMC_MarineCorps]

I've thought about making a bulletin board (confidential) for discussion of cases that mental health providers could sign up for. But it would likely be a lot of work.

I quote the words of the great Dr. Richard Rosner..."If you don't do it, someone worse will."

 

[DD214_DOC]

I quote the words of the great Dr. Richard Rosner..."If you don't do it, someone worse will."

It's really not that much work to setup a BB. In fact, this could present an excellent business opportunity. A website where vetted psychiatrists can provide curbside consults to other physicians with difficult cases or questions who practice in areas with few, if any, psychiatrists. Physicians could buy, "credits" on the website and pay a flat fee based on complexity to have their question/cases answered. The psychiatrist who chooses to answer the question gets a majority percentage of the fee and the website takes the rest for maintenance/upkeep/profit.

I don't know of any such services on the internet. Who knows, this could even extend beyond psych.

In fact, I think it's such a great idea that I already registered a couple domains

With more thought, I think something like this would be better-suited for a subscription-based model, such as a low monthly fee to be part of the network -- at least for the primary care types and people desiring professional information. I'm not sure how to make it an incentive for the shrinks to actually participate.

 

[notdeadyet]

In fact, this could present an excellent business opportunity. A website where vetted psychiatrists can provide curbside consults to other physicians with difficult cases or questions who practice in areas with few, if any, psychiatrists. Physicians could buy, "credits" on the website and pay a flat fee based on complexity to have their question/cases answered. The psychiatrist who chooses to answer the question gets a majority percentage of the fee and the website takes the rest for maintenance/upkeep/profit.

Kugel's idea of a site as an educational endeavor is interesting. Envisioning a for-profit model is a bit dubious.

What physicians would you envision paying a website of psychiatrists for curbsides? PCPs can comfortably handle 90% of the psych issues they encounter. They're not going to pay money (and an HMO certainly isn't) for advice on choosing an SSRI. And for the 10% of things they can't handle, they're going to refer. If this means their patient drives an hour to see a psychiatrist, the patient's going to have to fill up the tank, because it would be a very rare PCP that's going to be managing a case of refractory schizophrenia based on the purchased advice of a psychiatrist they've never met. It's an invitation to litigation. This is why you don't see any sizable transactional advice models for any field in medicine.

Tossing around interesting cases would be educational. It would be an extremely tough sell to make it something folks would pay good money for.

With more thought, I think something like this would be better-suited for a subscription-based model, such as a low monthly fee to be part of the network -- at least for the primary care types and people desiring professional information. I'm not sure how to make it an incentive for the shrinks to actually participate.

You can't charge someone for a service provided for free. If you're going to charge customer for a service, you're also going to have to pay for providers of that service. A PCP asking for specific recommendations regarding their specific patient's care is going to need to get those recommendations from someone who is paid to do so and whose malpractice insurance will cover giving that advice.

And I personally wouldn't want to be on the stand for giving for-profit advice over the internet for a patient I'd never examined or met. In fact, isn't there an APA stance about not diagnosing patients sight unseen?

 

[DD214_DOC]

Don't people curbside all the time without invoking shared liability? Plenty of people pay to subscribe to services such as uptodate, which provides nothing more than information. Providing answers to general questions from PCP does not seem to be any different.

Besides, there is little point in paying to operate something pro-bono. It costs money to run a website, whether it's for educational value or not. The money to operate the forum would need to come from somewhere.

 

[notdeadyet]

Don't people curbside all the time without invoking shared liability?

You don't curbside strangers, you tend to curbside people who also work with you under the same malpractice plan that covers the same patient. And from what I've seen, one of the big differences between a curbside and a consult is that in a curbside it's a casual conversation that doesn't get attributed in documentation.

Plenty of people pay to subscribe to services such as uptodate, which provides nothing more than information. Providing answers to general questions from PCP does not seem to be any different.

Ah, now we're talking two different things. If you envision the site as people posting general questions about the type of things you can find on uptodate and whatnot, you're fine from a liability standpoint. That's the "what's the best SSRI?" question. But who's going to pay for something like that? You're not going to get subscription model going, because the amount of times a physician out there thinks, "Boy, I'd pay out of pocket to have psych's input!" is not going to happen more than once in a rare while.

If you're talking about questions specific to a case, which was the idea originally brought up, it can be done in an educational vein in which ideas are kicked around in the abstract and not meant to be considered specific advice. I could see this flourishing. It makes for some of the better conversation threads on SDN. If you're talking about a business vein where PCP's would pay to contact psychiatrists for expert advice on specific cases, it's a model that's been tried and consistently failed (microtransactions for expert advice) in fields with much lower liability than medicine.

At the end of the day, the sort of case where a PCP is so outside of their comfort zone in managing a psych patient that they would be willing to pay for advice is the one that they will refer out.

Besides, there is little point in paying to operate something pro-bono. It costs money to run a website, whether it's for educational value or not. The money to operate the forum would need to come from somewhere.

Sure. And it's almost always ad-driven revenue. The pay-for-content websites are almost always article-based content.

 

[GoSpursGo]

Sorry, SDN is not here for you to find ideas for your own forum. Thread closed.