I've realized what it is that I hate about being on C/L psychiatry

[MBK2003]

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It's the large number of outpatient psychiatrists (private practice) and mental health clinics who engage in blatant patient abandonment and then I am responsible for finding new intake appointments for psychiatrically complicated but stable patients because the discharge planners are "medical discharge planners" and not responsible for psychiatry follow-up appointments. Why am I spending 3-4 hours calling 20-25 different CBO's to see who has an intake appointment within the next 2 months? Why is it that my hospital's outpatient mental health clinic will only take patients who live within 3 specific zip codes around the hospital and have a certain managed medicaid? Why am I doing it, oh yes, because I the f*&*ing resident on C/L. Not that any of this is relevant to the practice or learning of C/L psychiatry, of course. Thanks for giving me a forum to vent!

MBK2003

 

[Anasazi23]

Wow...I never had to do any of that.

We just get them stable enough and tell them to get their own appointment when they leave - if they didn't want a referral to the clinic.

That would make me hate a rotation too.

 

[Therapist4Chnge]

Wow....what a raw deal. You'd think they'd want you to use your skills for something more appropriate.

-t

 

[billydoc]

It's the large number of outpatient psychiatrists (private practice) and mental health clinics who engage in blatant patient abandonment and then I am responsible for finding new intake appointments for psychiatrically complicated but stable patients because the discharge planners are "medical discharge planners" and not responsible for psychiatry follow-up appointments. Why am I spending 3-4 hours calling 20-25 different CBO's to see who has an intake appointment within the next 2 months? Why is it that my hospital's outpatient mental health clinic will only take patients who live within 3 specific zip codes around the hospital and have a certain managed medicaid? Why am I doing it, oh yes, because I the f*&*ing resident on C/L. Not that any of this is relevant to the practice or learning of C/L psychiatry, of course. Thanks for giving me a forum to vent!

MBK2003

What's the name of your program, if you don't mind my asking?
Thanks

 

[OldPsychDoc]

It's the large number of outpatient psychiatrists (private practice) and mental health clinics who engage in blatant patient abandonment and then I am responsible for finding new intake appointments for psychiatrically complicated but stable patients because the discharge planners are "medical discharge planners" and not responsible for psychiatry follow-up appointments. Why am I spending 3-4 hours calling 20-25 different CBO's to see who has an intake appointment within the next 2 months? Why is it that my hospital's outpatient mental health clinic will only take patients who live within 3 specific zip codes around the hospital and have a certain managed medicaid? Why am I doing it, oh yes, because I the f*&*ing resident on C/L. Not that any of this is relevant to the practice or learning of C/L psychiatry, of course. Thanks for giving me a forum to vent!

MBK2003

Why hire a social worker when you have residents to hone their phone skills on scut? 🙄 🙁

 

[whopper]

Thank the Maker that I don't have to do that Bull.

Does this really make you a better doc? Seems to me that attendings never do this. Any program it seems that makes you do this is just making the residents do scutwork.

The thing I'm hating about C/L at my hospital is that about 50-75% of the consults are bull.

E.g. the IM doctor writes a consult for capacity because he doesn't like the patient. The patient never refused anything, and the doc never explained the benefits of the procedure--no need for a consult.

So I show up, and I can't figure out the reason for the consult, the nurse doesn't know, I got to beep the attending who ordered the consult, then they don't call back for 40 minutes and I got to sit there and can't leave the phone because I beeped the idiot at that number.

 

[MBK2003]

I actually like doing the consults, even the mostly BS "patient is angry" consults. Secretly I'm practicing boards style interviews on most of my consults so that I can get something out of it. I've had several of those bogus consult patients go from "I can't believe they sent in a shrink to see me" to "you are the only the doctor in the hospital who took the time to sit down and get my entire story." I hate having to be a social worker over and over again, hmm... that must be why I chose to get the MD and not the MSW. But unfortunately at my hospital, I'm only slightly more expensive than the MSW, not unionized, and can be abused to tune of 80 hours per week and not just 40 + paid overtime. Two more months and I'm outta here!! YEAH!!!

MBK2003

 

[Big Lebowski]

That's really unfortunate. I'm on C/L right now too and do not have to do any of that. Each unit has their own SW who arranges all appointments/referrals, etc as suggested. Or, the patient is given the information and does it on their own (as required by some of the community MH centers). They're pretty good about not making the resident do a lot of "clerical" work.

I love the rotation and don't mind the "BS" consults. Hey, if they think I'm the "expert" for whatever their question is; so be it. Besides, things like capacity consults can be fun to do. I guess it is good for the profession...

 

[musm2008]

When I was on C/L during my clerkship, we would get consults on people just to put them on an antidepressant. The attending complained that the FP could have handled it. Do psychiatrists like these (or similar) kind of consults because they are an opportunity to bill or are they just annoying?

 

[whopper]

IF its just a simple depression thing I don't mind.

I mind when its BS and they put on something like "capacity" and its just the attending mad at the patient.

Biggest reason why is because I got to waste an hour doing detective work to find out what's really going on.

At best its a waste of my time.

At worst--it can lead to me writing down a consult based on misrepresentation which is uenthical.

 

[Doc Samson]

That's really unfortunate. I'm on C/L right now too and do not have to do any of that. Each unit has their own SW who arranges all appointments/referrals, etc as suggested. Or, the patient is given the information and does it on their own (as required by some of the community MH centers). They're pretty good about not making the resident do a lot of "clerical" work.

I love the rotation and don't mind the "BS" consults. Hey, if they think I'm the "expert" for whatever their question is; so be it. Besides, things like capacity consults can be fun to do. I guess it is good for the profession...

I disagree that taking BS consults is "good for the profession." As long as we maintain this victim mindset, psychiatry is going to remain stigmatized as a specialty. Can you imagine a surgeon taking a BS consult because it's "good for the profession."
A large part of my consult fellowship training has been (in the words of my esteemed mentor) "getting you guys to grow some f@#$ing b@lls." This involves pointing out to consultees that a BS consult, is in fact, BS. What I have found is that when you call them on this, they drop the bogus capacity questions (which I think they like asking because it's a "technical" word that they remember form medical school - although the often call it "competency"), and actually ask a real question like "Ummm, this guy thinks he's on the Titanic and he wants to get off, d'ya think he might be delirious?"

 

[Big Lebowski]

In my experience on C/L, though limited, when I have been asked to "assess for capacity" it has in fact been a genuine consult for capacity, not a question disguised as something else. The services at our hospital have been good about asking for what they want. Of course, there are "BS" consults. Such as asking to assess capacity when a patient is clearly able to assess the issue, but is refusing for whatever reason. There are also "soft" depression consults. However, by being "good for the profession", I meant being valuable to other services. If anything, I think this defuses stigma, rather than foster it. The hospital I am at may just be better about using the C/L service appropriately.

What bothers me, is when people complain about any or all consult requests. Such as "the patient is depressed"....."well, just start an antidepressant." Or, "assess for capacity"......"can't medicine do this?". Another; "assess for suicide risk s/p attempt"....."well, patient is not medically cleared, call me when they are". These have been some of the issues I was referring to. It has made some services think, "what the hell good are the psychiatrists anyway?" Also, it cuts both ways. Such as a psych service calling a medicine consult for treating uncomplicated UTI. Not that I haven't rolled my eyes when receiving a consult request, I'm usually happy to do it because I think I'm helping and I believe the service sees what I'm doing (or the C/L service in general) as valuable to them and the hospital as a whole. This is what I mean by being good for the profession. I guess we just needed to clarify what "BS" means.

 

[Dartos Vader]

"BS" consults happen in every field. I recently finished a month of ID. If it wasn't and HIV patient the consult could have easily been handled by a resident/attending about 70% of the time. I would do rounds every day that typically consisted of: read chart, look at possible source of infection, order C&S, await results, prescribe appropriate antibiotic based on results. The attending didn't mind for two reasons. Number one, he got paid whether it was a stupid consult or not. Number two, a colleague (sp?) asked him to do it. Sometimes what seems easy and obvious to a specialist isn't crystal clear to an outsider.

Of course some people REALLY are just jerks/lazy.

 

[Doc Samson]

"BS" consults happen in every field. I recently finished a month of ID. If it wasn't and HIV patient the consult could have easily been handled by a resident/attending about 70% of the time. I would do rounds every day that typically consisted of: read chart, look at possible source of infection, order C&S, await results, prescribe appropriate antibiotic based on results. The attending didn't mind for two reasons. Number one, he got paid whether it was a stupid consult or not. Number two, a colleague (sp?) asked him to do it. Sometimes what seems easy and obvious to a specialist isn't crystal clear to an outsider.

Of course some people REALLY are just jerks/lazy.

Maybe the fact that other specialties actually get paind for their consults is a reason that we consult psychiatrists tend to need to screen our consults a little more aggressively. A level 5 110 minute+ inpatient psychiatric consult is supposed to be reimbursed at ~$500, HOWEVER most insurances (inclusing Medicare) only end up paying ~$70 for this service. Many insurances do not reimburse AT ALL for any follow-up visits. Consult psychiatry is thus, for the most part, a salaried position that the hospital pays for in order to address the urgent psychiatric issues that can complicate medical care. We are a very limited resource (i.e. we can only see so many patients per day - a reasonable consult takes at least one hour). When we are called for a "BS consult" this impedes our ability to take care of pts who actually need us. There is very little/no downtime on a consult service - being asked to see a pt "who's feeling down and asking to talk to someone" is taking away from seeing the grossly delirious pt who's in danger of pulling out their IABP or the schizophrenic who is so paranoid they won't let nurses draw blood. It's all about distribution of resources.

 

[sga430]

the hospital where i did my externship routinely had seminars by c/l attendings on when to order a consult. lol, usually thise seminars r empty. an ortho seminar draws more people (even with the free food.)

anyhow it is a good idea for a hospital to educate others on when to order a consult.

 

[cleareyedguy]

In a typical hospital, 90% of the people with a psychiatric diagnosis don't get consulted. The few who do get a consultation are outliers.

If the patient and internist are angry at each other, it often reflects the patient's psychiatric issues. Working with the patient (+/- the medical team) can improve medical care.

The consultation is often the only chance for a hospitalized patient to EVER see a psychiatrist and is a GREAT opportunity to make an efficient, effective, compaassionate intervention.

If you are upset about talking to someone about the difficulties of being sick or about seeing a patient who needs an evaluation/treatment for depression, perhaps you should consider another field in which there is less patient contact.

 

[whopper]

If you are upset about talking to someone about the difficulties of being sick or about seeing a patient who needs an evaluation/treatment for depression, perhaps you should consider another field in which there is less patient contact.

I don't know if I'm speaking for most of us here (edited for spelling). I don't mind helping out a patient with a psyche disorder.

I mind getting consulted because some issue that's not psychiatric and the IM (or other hospital floor doc) calls a psyche consult--that was blatantly not psyche.

Worst I've had so far was a patient who was emergency shipped to the hospital because of a potentially fatal finding (I think it was A-fib) and she kept demanding that someone feed her pets at home. She had several and she was demanded to go to the hospital without a means to feed her pets at home.

All the nurses, her docs, the social worker ignored her pleas to have her pets fed and they branded her as psychotic. By day 5 of her stay they called in a psyche consult.

I spent 3 hrs trying to fish through what was really going on. She was not going through anything other than perhaps adjustment disorder. When I wrote down in the consult on her reason for frustration, everyone on the med team was upset with me because it just showed how much they were ignoring her.

The "REAL" reason for the consult was the med team wanted me to OK them giving her haldol to shut her up so they wouldn't have to hear her whine about her worries about her pets starving to death.

 

[Doc Samson]

In a typical hospital, 90% of the people with a psychiatric diagnosis don't get consulted. The few who do get a consultation are outliers.

If the patient and internist are angry at each other, it often reflects the patient's psychiatric issues. Working with the patient (+/- the medical team) can improve medical care.

The consultation is often the only chance for a hospitalized patient to EVER see a psychiatrist and is a GREAT opportunity to make an efficient, effective, compaassionate intervention.

If you are upset about talking to someone about the difficulties of being sick or about seeing a patient who needs an evaluation/treatment for depression, perhaps you should consider another field in which there is less patient contact.

If the patient and internist are angry with each other, it is just as often a reflection of the internist's "psychiatric issues", and there's nothing we can do about that.

I object to the carving out of compassion and "talking to someone about the difficulties of being sick" as the sole dominion of psychiatry. This is the job of all physicians. Sadness is an emotion. Anger is an emotion. Neither is psychopathology. Call me to evaluate and treat psychopathology, don't call me to have the doctor-patient relationship on your behalf.

 

[whopper]

Call me to evaluate and treat psychopathology, don't call me to have the doctor-patient relationship on your behalf.

Exactly.

Perhaps in Clearyeyeguy's neck of the woods its different. However from what I've been seeing from Doc Samson's posts, at least it seems similar in his parts as it is with mine.

Most of my consults have nothing to do with psychopathology but a floor doc's lack of desire to deal with a difficult patient. Of course I acknowledge that a lot of psychiatrists consult medicine for BS reasons too (at least where I am). Patient coughs once--my attending ordered a med consult. No fever, clear lungs, no respiratory complaints. Just a 1 time cough.

Difficult does not = depressed, nor psychotic, nor lack of capacity.

Just had another BS consult. Consult was for "depression". Surgery thought she was depressed because she was intubated. No other reason. I had to fish for 3 hrs again because I'm actually giving them the benefit of the doubt that they aren't idiots and I'm taling to all the staff, the surgery team, her family because I'm thinking maybe there really was depression (Which the patient is denying).

Nope, they thought she was depressed just because she was intubated.

3 hrs of waste. IF I charged by the hour--I guess I wouldn't mind it as much.

 

[Anasazi23]

If the patient and internist are angry with each other, it is just as often a reflection of the internist's "psychiatric issues", and there's nothing we can do about that.

I object to the carving out of compassion and "talking to someone about the difficulties of being sick" as the sole dominion of psychiatry. This is the job of all physicians. Sadness is an emotion. Anger is an emotion. Neither is psychopathology. Call me to evaluate and treat psychopathology, don't call me to have the doctor-patient relationship on your behalf.

This is all true. Nobody likes to be sick - and factitious patients notwithstanding, it isn't psychiatry's job to walk around the hospital spreading good cheer. There are sick patients with with real psychopathology that take time to treat. Unless there is a good reason to pull a busy psychiatrist from this patient care, then it shouldn't be done.

One of my favorites is, "Patient wants to see a psychiatrist."

I absolutely refuse to entertain a consult like this. I've got somewhat nasty on the phone saying. Yes, my patient wants to see a cardiologist too, find one and bring him here.

I know there is an inherent difference between these fields of medicine, but I think adjustment counseling and "just wanting to talk" is best left to other ancillary disciplines, if it's needed at all.

 

[MBK2003]

I think adjustment counseling and "just wanting to talk" is best left to other ancillary disciplines, if it's needed at all.

This is one of my biggest beefs on our C/L rotation (aside the primary social work/discharge planning I have to do). There's a big difference in the consult calls between the IM and the FP people. In my experience, FP residents are much more willing to call the pt's family and ask them to come in and provide support to the patient, long before they will call psychiatry.
I hate having to say over and over again, "sadness is not clinical depression and is a normal response" (thinking to myself, "call me when you've documented two weeks of 5/9 criteria with impairment, then we'll talk about me coming to see the patient"). It's why I hate getting that dreaded consult from the oncology service - "sad, I mean depressed, about his/her diagnosis of terminal cancer, please evaluate and start psychotherapy." Come on, I treat psychopathology not normal grief, and if you think I have time on C/L to do psychotherapy, I'd like some of what you've been smoking. Hmmm... just 58 days of C/L left 😱

MBK2003

 

[maranatha]

This is an interesting thread....You guys make it seem like C&L is quite often a pain in the a@%.

So why is it such a popular specialty???

 

[whopper]

I think it probably varies per hospital.

In my own hospital, the program director at my specific hospital (my program has 2 program directors depending on the hospital) is also the department head and a big person in the administration. She's got too much on her plate so she doesn't do much in terms of in services to inform floor docs on what is and what isn't a proper consult.

Same program--different hospital Cooper Hospital-the doctor in charge of C/L does have regular contact with the floor docs and there's fewer BS consults.

I think if a hospital allows for good communication between the C/L psychiatrist and the floor staff, this can cut down on BS consults.


Also remember that some of the most fascinating med-psyche cases will probably be seen on C/L.

I actually like C/L when I'm doing real C/L, not the BS cases. The BS cases waste my time because I have to assume it might be real until proven otherwise and I waste lots of time fishing through BS only to find it wasn't a justified consult.

 

[MBK2003]

Also remember that some of the most fascinating med-psyche cases will probably be seen on C/L.

For me as well, the "Fascinomas" keep me coming back the next morning (although not to the extent that I'd consider a C/L fellowship). You can get a great case on C/L and be talking about it with colleagues and supervisors for days, much more so than the psych ER. I can see the appeal, through the fog of sh&t, of course.

MBK2003

 

[whopper]

If I got to charge per hour and demand that I can direct in services between the psyche and the medical floor team, I think I'd actually love C/L.

If I got to charge per hour, then it'll probably make the hospital push to keep floor docs from ordering BS consults, and if they didn't--well that's just more money for me. Not that money is the most important thing but at least I'd be getting something for my wasted time.

 

[Anasazi23]

I think it also depends on the biological savvy and orientation of the consult service too. Medicine heavy services will almost universally not be providing psychotherapy and are very highly valued for their ability to pick up zebras and almost act as a diagnostic specialty service in some ways.

 

[maranatha]

I may consider a psychosomatic fellowship b/c i'm interested in psycho-oncology and palliative care. But based on what has been written on this thread (i'll take it with a grain-of-salt until i've actually done C&L of course), i'd have no problem leaving the C&L portion out of the fellowship....

 

[OldPsychDoc]

I may consider a psychosomatic fellowship b/c i'm interested in psycho-oncology and palliative care. But based on what has been written on this thread (i'll take it with a grain-of-salt until i've actually done C&L of course), i'd have no problem leaving the C&L portion out of the fellowship....

Where you're going, maranatha, C/L is very low on the BS and high on the hospital respect-o-meter. But that's b/c you'll have AWESOME attendings.😍

 

[Big Lebowski]

It must vary by hospital and depends what they expect. The supervising C/L MD at the hospital I'm rotating at is respected and well-liked by the other services. Plus, she has been doing this for 20 years. As a result, it seems they know when it is appropriate to call a consult and are always very appreciative for our input. I must have gotten lucky in my assignment.

 

[Dramkinola]

Addressing some of the "negatives" above that I skimmed through...
At the hospital I am doing my C/L service, the medicine department prides itself on trying to handle everything from uncomplicated depression to mild anxiety and ETOH detox... but the consult load is STILL heavy enough to warrant a separate Addiction and General Psychiatry consult services...
Of course every service has it's share of "stupid" consults... particularly from surgeons and the ER... but maybe it differs at my program as we do our medicine internship at the same hospital, which allows us to build personal relationships with the medicine attendings and residents... these personal relationships allow us to call the medicine team and question, "are you serious?" which often times leads to a "sorry, we just weren't sure, can we just curbside you instead..."

As for the "acting like" a social worker, New Orleans (Louisiana, in general) has a system of State run Mental Health Clinics which are free and walk-in, providing free medicines for those in need... is this not the case in other cities?

For anyone WITH insurance, we can refer to Ochsner's outpatient psych service (which post-katrina is WAY backed up) or LSU's Behavioral Health Science center outpatient clinic, both of which have their bevy of residents, as well as clinical social workers, nurse practitioners, and psychologists...

Even with our dire shortage of mental health professionals, we get patients in somewhere... with a max of two phone calls... it helps that our last Chief resident compiled a comprehensive list of mental health/substance-abuse rehab facilities that each one of us carries...

As for little things like paging doctors and waiting, fortunately we have Spectra-links that we carry, eliminating that pain in the butt...

just my 2 cents...

 

[cleareyedguy]

I find this thread depressing.

It sounds like quite a few trainees don't think that cl psychiatrists should be called in to handle the difficult patient, the sad patient, and the capacity consult. They aren't supposed to help with family or social issues. They aren't supposed to tease out the tricky patients who fall on the border between adjustment disorder and major depression and illness behavior. They aren't supposed to talk to patients who confuse the internists. It sounds like the evaluation of an intubated patient takes 3 hours (?!?), though I'm not sure why such a consult would take more than 45 minutes, including chart reading, family contact, a brief talk with the presumably ill patient, and the chart note. It sounds like people want to be called in only to see a patient with an obvious major depression without axis II so that lexapro can be neatly suggested, which strikes me as the dream of the insurance companies but which would lead psychiatry to a dry, barren corner of the medical world. Further, it ignores the fact that lexapro by itself would not be the treatment of choice. Finally, I still don't buy the apparent ubiquity of BS consults. Yes, there are situations in which medicine asks for a consult in which the answer should be obvious, but if a patient wants to see a psychiatrist, I consider self-referral an excellent reason for a consult (who do you think you are going to treat after residency?), and I also think adjustment to illness is an excellent reason for a consult (being in the hospital is a stress, and we are supposed to try to relieve suffering, and brief psychotherapy can help).

If you approach a rotation with the attitude that 80% of the consults could be handled by an internist if only s/he had the focus and training of a psychiatrist, then you are going to get quickly bitter. If you approach it by saying that you are only seeing 2-3% of the patients in a typical hospital, and that by definition that person has been selected by some sort of criteria that renders them extraordinary, then you can get in there and help without feeling aggrieved (you could also practice getting faster--no need to spend 3 hours on a typical consult).

 

[Anasazi23]

I think some of this depends on individual experiences on C/L services in particular hospitals. Sloan, for example, spends a tremendous amount of time copiously going through the medical complexities of each case, and is renowned for their thorough evaluation of such things as pain management and medication recommendation based on diagnosis and chemothreaptutic agents. If they took each consult equally to see every "sad patient," stuff just wouldn't get done, and the more emergent consults would suffer in quality.

I don't think the hospital is a spa. With pathological exceptions, nobody enjoys being here, and their mood lowers. This does not, in my opinion, warrant a psychiatric consult. Simply because a patient is bored, and staring at the ceiling all day, it isn't the right time for them to self-refer to a psychiatrist so that they can entertain themselves by telling their life story and elicit adjustment issues that are not affecting them to a significant degree.

There's a big difference between the inpatient hospital medicine patient self referral and the outpatient private practice referral, and I hate to put it bluntly, but; outpatient self-referral implies a paid-for service that is provided. Inpatient self-referral takes the C/L psychiatrist away from more pressing cases. I'm not saying that hospital self-referrals cannot be legitimate or urgent. But I tend to dislike when psychiatry is separated from other medical disciplines in this regard. Like I said earlier, no intern or attending gets on the phone with a nephrologist because the patient "wanted to see a nephrologist." I just think it's hospital protocol that a preliminary evaluation be done by whatever team is covering the patient, and a proper referral made. It burned me to no end to get on the phone after being paged only to hear from the intern, "...the patients wants to see a psychiatrist." Perhaps others disagree with me.

Anyway, these are just my opinions.

 

[Doc Samson]

I entirely agree Sazi. Major urban medical centers such as where I trained/practice have so many patients requiring urgent/emergent psychiatric attention, that consultation services simply do not have time to address non-urgent/emergent issues. This is not the time to address chronic dysthymia or family dynamics. You cannot reasonably "do" psychotherapy in the general hospital setting for a variety of issues (not least of which is the fact that most patients have a room-mate, which kinda puts a limit on how honest the patient is going to be with you vs. seeing you in a private office). Consultation Psychiatry (or Psychosomatic Medicine) is a board certified subspecialty precisely because it is not just the practice of adult psychiatry in the general hospital setting - it requires an entirely different set of skills, rules, and boundaries.

Regarding feeling embittered - anger and embitterment are two very different things. I am not bitter, but I am frequently angry. This is not because of a "****, now I have to do more work" dynamic, rather it is because of the cavalier use of psychiatric illness as a dumping ground for anything that the primary treater is unable to/cannot be bothered to explain. At least twice a day, I am asked to see a pt for "depression" when in fact they are frankly delirious because of some underlying untreated medical issue. When I bring this to the attention of the consultee, they often try to deny the existence of the delirium (usually claiming "it's probably their baseline"), and 8 times out of 10 stall in starting the IV Haldol I recommend - sometimes even starting Prozac instead despite my evaluation. It's easy for them to blame it on mental illness, because then it's less work for them. Anyone with the word "alcohol" in their medical history will always get started on IV Ativan if they appear confused/agitated - no matter how big the SDH, pleural effusion, or drop in HCT. Again, "it's alcohol withdrawal, call psych" is a whole lot easier than developing your own differential for agitation.

I do not see my anger as a problem - as I've said before, it's what keeps me coming back to work every day. When I was interviewing for consultation fellowships and I was asked what my motivation for a career in this field was, one of my answers was "to protect the mentally ill from mistreatment in the general hospital." This remains true - I'm just p!ssed that I have to do it so often.

 

[whopper]

The Psyche attendings at my hospital and the hospitalists (the group of IM doctors that handle patients that didn't have an IM doctor before admission-and these guys are responsible for doing the med consults to the psyche floor) had a meeting becuase the hospitalists felt the psyche attendings were ordering too many BS consults.

I agree with the hospitalists. As I mentioned above--one cough, no fever, no rales, no wheezing, O2 sat 99%---MED CONSULT!

The psyche attendings all mentioned they'll try to cut down on the BS consults, but the reality was nothing was done. There's still just as many BS consults.

Its a shame,--and as a psychiatry resident it kind of makes me feel ashamed to see these docs ignore their nonpsychiatric medical skills. I of course realize that we're not supposed to know as much as an IM doc, but heck, the amount of stupid consults--a medstudent would be able to see they're BS.

Same's going on with psychiatry consults. However I don't blame the hospitalists on this one because they're only a small fraction of the floor docs and they usually don't order BS psyche consults.

The bottom line I think is in this type of situation, the departments and the administration need to come up with better ways to prevent these things from happening. In my hospital, its not happening. (My program spans 3 hospitals. 1 hospital--the C/L is very well organized, in the 2 others, its not). Yeah-the 2 groups of docs met, but the psyche attendings just gave a social smile with no seemingly real intention to make any changes.

The only good thing about is as a resident I only have to deal with this for a few months, and seeing BS consults does help you learn to spot what is real vs BS. However if this were a full time job--I'd quit at first oppurtunity.

Not every hospital is going to have these BS consults. Again, its going to depend on political factors in the hospital. Also even if the hospital is bad in this area--if you charge per consult or per hr, at least you're getting compensated for the bull. Also if you do get a C/L position, psychiatrists are in high demand and if you don't like the bull, you may have enough clout (due to the high demand) to demand improvements to cut down on the bull.

One of the residents from my program who graduated is doing C/L. She told her hospital that she wanted to organize lectures & in-services on appropriate use of the consult service, and now the BS consults have greatly diminished.

 

[MBK2003]

When I was interviewing for consultation fellowships and I was asked what my motivation for a career in this field was, one of my answers was "to protect the mentally ill from mistreatment in the general hospital." This remains true - I'm just p!ssed that I have to do it so often.

This plays a role in my latest "IM resident management scheme" based upon the behavior modification with children - reward good behavior, ignore the things that you can ignore, and punish really bad behavior with time outs.
I had a consult from an IM resident who was really interested in working up this very delusional patient's medical problem, including coaxing and bribing him into a rectal exam. She called the consult to see if we had recs on his meds and ideas about dispo, but had already done a huge amount of work getting parallel from this very chronic SPMI patient's multiple caregivers. She even went as far to say "I know it's an outpatient work-up, but we have him here in the hospital, so we might as well make use of the time and available resources." My heart melted! 😍 So I sent off a long email to the medicine chiefs about my very positive experience with this resident.
When another IM resident started literally screaming at me a few days ago, I did the "I can't talk to you when you are screaming, please take a few minutes and call me when you are ready to speak in a calm, professional tone. (Click)" If it works on 8 year olds with DBD, why can't it work with housestaff?

MBK2003

 

[Demosthenes]

Does this really make you a better doc? Seems to me that attendings never do this. Any program it seems that makes you do this is just making the residents do scutwork.

While you're very likely right about why a resident is doing this, I think it may make for better doctors. Around here, at least, MH is so underfunded that most pts without fairly good private insurance are essentially untreated. According to the newspapers, it's about to get worse, with nearly half of those currently receiving care being dropped from tx. I like the idea that residents are learning something about how hard it can be to get MH tx, which I really do think will make for a better doctor down the line.

My background is in NPOs, and I admit a bias, but I've also seen too many doctors ask pts why they didn't just see a doctor sooner? For the uninsured in my area, at least, it's because county health has a three week wait for urgent care appointments, and 12 to 16 weeks for anything else. And the MH appointments -- well, frankly, many MH pts would be better off breaking store windows to get into the jail, because they'll get treatment much sooner that way.

Still, I hope the OP is getting some more relevant experience, too.

 

[Demosthenes]

I object to the carving out of compassion and "talking to someone about the difficulties of being sick" as the sole dominion of psychiatry. This is the job of all physicians. Sadness is an emotion. Anger is an emotion. Neither is psychopathology. Call me to evaluate and treat psychopathology, don't call me to have the doctor-patient relationship on your behalf.

Oh, so well said!

Story from my own life: at 19, an ortho looked at some films of my leg, and started saying something about the "great things being done with prosthetics nowadays..." And then started discussing referrals to a psychiatrist because I was so upset. Hello? 19? Prosthetic leg talk is *supposed* to upset me! (Thank God for second opinions, right? I'm happy to say that my leg is still attached in middle age.) Sure makes me wonder, though -- this guy was so enthusiastic, and I can understand that, but how clueless do you have to be not to see a pt in that situation?

Thanks, Doc Sampson. You have a way of providing perspective on a lot of this.

 

[cleareyedguy]

I object to the carving out of compassion and "talking to someone about the difficulties of being sick" as the sole dominion of psychiatry. This is the job of all physicians. Sadness is an emotion. Anger is an emotion. Neither is psychopathology. Call me to evaluate and treat psychopathology, don't call me to have the doctor-patient relationship on your behalf.

I strongly agree with the straw man (of course doctors shouldn't opt out of being a doctor), but I have trouble with being proud about getting angry about seeing patients who are having an especially hard time with their illness and about getting involved in the occasional dr-pt conflict. These latter problems are relatively rare--perhaps 1% of the patients in the hospital--but they cause a lot of suffering in those we would like to help. They may not have an acute psychotic disorder or whatever you consider "psychopathology," but, if you go once a day to make things easier for patients or peers, I don't see that as a problem.

I'm polarizing the discussion a little bit to make a point, but it seems likely that a perpetual antagonism towards so-called "BS consults" is likely to lead to antagonism and a reduced likelihood that your peers will pay attention to your suggestions about interventions or consultation criteria.

 

[Psychintern2006]

Thats a lot of abuse......thought only my program sucked !!

what / where are you? coast/state/city/program~

I was considering a transfer..hope I do not land in your program!