Newly minted attendings!

[dynamite]

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Hey everyone,

So I've officially been an Attending at an academic hospital for all of 3 days (took a while to finish credentialing)!

I've taken on a variety of duties (inpatient including a busy ECT service, oupatient at resident's clinic including supervision, outpatient at a private practice group, community clinic). Anyway, rounded on 4 patients on Saturday and saw 5 private outpatients, and it literally took me like 8 hours!!! Rounding as a fresh Attending is like 10 times as long as when I was a resident!

Anyway, just wondering if any new Attendings out there can commensurate. (Or an old Attendings can encourage).

 

[whopper]

Advice: you are the head guy on the unit. In that role, you should show leadership to staff members.

If you have residents or medstudents, you have a duty to teach them.

 

[Manicsleep]

One huge advantage you have is that you are in an academic institution. Its basically like extended residency. Build a good foundation, learn your support system: secretaries, nurses, social workers/psychologists, residents, fellows and other attendings. Get a couple of mentors, formal and informal. Try to get some in different phases of their careers.

The early overcautious attitude is not a bad thing. Especially if you are at a new place. Be confident in your decisions.

 

[whopper]

The only thing I really haven't liked about being an attending in general is that once you're in job, you're job is very fixed. In residency, every few weeks to months, you got into a new rotation. Things changed, fresh start at a new thing etc.

I've seen attendings do the same job for decades. The longer they do it, the less they remember medical knowledge commonly seen outside that scenario. E.g. in a long term unit, acute drug withdrawal is rarely seen because in these units, patients are often there for several weeks to years. In the ER, doctors often forget how to do long term psychotherapy. My advice is no matter what job you take, try to keep going with your education, and see if you can get into a gig where you work in multiple clinical settings.

A few months in my first attending position, a guy came in with acute alcohol withdrawal. The attendings that worked at the place for years didn't know how to treat it. I came on the scene, ordered librium and thiamine. The administration called me in and were shocked that I treated him, thinking it was a non-psychiatric medical condition.

In several places there's no continuing education. I've seen several psychiatrists not incorporate much information past residency. I've, for example, seen doctors still giving tricylics, not because they knew something we didn't. It was because they were still stuck with the same prescription practices from decades ago.

I've seen several attendings not manage staff in a leadership manner. While most units have nurse managers, attendings should still listen to the needs of staff, attend to them, and keep in contact with the nurse manager if they need to be kept in line. Staff members are trapped in a situation where if the attending is doing poor quality work, they're stuck because psychiatrists are in high demand and hospitals have a hard time replacing them.

Do not use your position to exploit residents or medical students.

Do a good job. If you do so, your rep will grow in the local community.

 

[tkim]

In the ER, doctors often forget how to do long term psychotherapy.

Why would we, in the ER, do long-term psychotherapy? That makes no sense.

 

[whopper]

Why would we, in the ER, do long-term psychotherapy? That makes no sense.

It makes perfect sense. I'm not saying you should do it. I'm saying that if you do psychiatry in the ER or in a crisis center attached to the ER, and that's your main 9-5 job, then because you don't have to do it for some time, after awhile you'll get rusty on it.

Several attendings have been doing their job in their specific clinical scenario for years, even decades. They forget how to do several things outside of that clinical scenario, and some of these things may still be needed in a psychiatrist's palette of knowledge to practice good psychiatry.

Just as I mentioned that in a long term unit, rarely someone came in with acute alcohol withdrawal, there will be situations where a psychiatrist in the ER forgetting the basics of long term therapy might miss details that could have assisted in the patient's care.

At one of the places I work now, most (over 95%) of the patients are there either because they have a form of psychosis, mania, or MR. Most of them have a comorbid substance abuse problem. Despite the comorbid substance abuse, we usually get people after they've been in jail at least a few weeks, so they are hardly ever in acute withdrawal. We rarely get someone with an anxiety disorder, depression, a somatoform disorder, or someone with a complex medical condition.

Most of the doctors at this location who worked there for years have forgotten how to treat several disorders such as depression, GAD, or OCD. There was a patient who had OCD and the attending couldn't figure out what this person had. The attending had to present the case, and within minutes the newer attendings, and the psychologists were all wondering if OCD was considered. The presenting attending didn't even remember what to look for with OCD, and said no to most of the questions when people asked "did you notice if this person did x?" She then chalked up all of the person's compulsive behavior as psychosis. The institution finally got an outside consultant (one of the country's best doctors) to examine the patient and within just a few minutes, he was able to tell the patient just simply had OCD.

While it always is a great learning experience whenever this guy comes to the hospital and presents (he does so about 1-5x per year), this time I felt it really was a waste of his time. A first year resident could've spotted the OCD.

 

[tkim]

It makes perfect sense. I'm not saying you should do it. I'm saying that if you do psychiatry in the ER or in a crisis center attached to the ER, and that's your main 9-5 job, then because you don't have to do it for some time, after awhile you'll get rusty on it.

Still not clear on what 'long-term psychotherapy' means to you versus me. I check for psychiatric versus organic illness, SI/HI, then refer if necessary. I wouldn't start anyone on psych meds as I couldn't follow up with them.

 

[whopper]

Psychotherapy that's going to go over the course of at least several weeks, if not months, if not years.

 

[tkim]

Psychotherapy that's going to go over the course of at least several weeks, if not months, if not years.

Okay, so what long-term psychotherapy is okay for me, as the ER guy, to initiate for a person that I probably will never see again?

 

[OldPsychDoc]

Okay, so what long-term psychotherapy is okay for me, as the ER guy, to initiate for a person that I probably will never see again?

I *think* the point was that if you're specializing in the ER that you aren't going to be keeping up your long-term psychotherapy skills, just as if you're doing outpatient therapy-oriented practice, you're probably going to lose your comfort with wielding ECT paddles. I don't think that whopper was saying that you "should" be doing long term therapy.

To get back to the intent (again, I *think* the intent) of the OP--there is a HUGE learning curve in the first year as an attending. Seek mentoring, listen to your nurses and other staff, try to be kind to yourself.

 

[pingouin]

Correct me if I'm wrong, but I think that whopper was speaking of psychiatrists who specialize in emergency pscyhiatry, not emergency medicine physicians (like tkim) doing long-term psychotherapy.

 

[whopper]

I don't mind you two writing for what you thought I meant because you are both correct and I clarified these points several times.

Thanks.

 

[tkim]

Ah, I see - psych 'ER'. Okay.

 

[Suenya]

Ah, I see - psych 'ER'. Okay.

Random misunderstandings aside, my location is the opposite of yours and I just thought that was funny.

 

[zihuatanejo]

Random misunderstandings aside, my location is the opposite of yours and I just thought that was funny.

I also thought it funny that tkim vociferously believed that a discussion about psychiatrists practicing emergency psychiatry somehow referred to him as an EM physician. I got a good chuckle out of his repeated good-natured protestations that he did not need to keep up with his psychotherapy skills as if EM physicians were ever trained or needed to be trained in psychotherapy in the first place. I would like to know the name of the EM department that trains its residents to become psychotherapists just in case they get bored with EM.

 

[tkim]

I also thought it funny that tkim vociferously believed that a discussion about psychiatrists practicing emergency psychiatry somehow referred to him as an EM physician. I got a good chuckle out of his repeated good-natured protestations that he did not need to keep up with his psychotherapy skills as if EM physicians were ever trained or needed to be trained in psychotherapy in the first place. I would like to know the name of the EM department that trains its residents to become psychotherapists just in case they get bored with EM.

It's just the use of term "ER" that threw me. I figured that when ER is mentioned, it's the medical ER. I know that there are psych 'ER's - my residency had one, but we never called it that.

 

[Doc Samson]

I also thought it funny that tkim vociferously believed that a discussion about psychiatrists practicing emergency psychiatry somehow referred to him as an EM physician. I got a good chuckle out of his repeated good-natured protestations that he did not need to keep up with his psychotherapy skills as if EM physicians were ever trained or needed to be trained in psychotherapy in the first place. I would like to know the name of the EM department that trains its residents to become psychotherapists just in case they get bored with EM.

This reminds me of the Boston Med episode last week where the ED attending attempted a psychiatric interview with a patient which would likey have only been limited to "we need a psych consult" had the TV cameras not been there.

 

[nancysinatra]

I also thought it funny that tkim vociferously believed that a discussion about psychiatrists practicing emergency psychiatry somehow referred to him as an EM physician. I got a good chuckle out of his repeated good-natured protestations that he did not need to keep up with his psychotherapy skills as if EM physicians were ever trained or needed to be trained in psychotherapy in the first place. I would like to know the name of the EM department that trains its residents to become psychotherapists just in case they get bored with EM.

Yeah, I thought this was funny too. I didn't know tkim was an EM doc but I knew there was something funny from his first post... When was the last time you heard a psych attending be this blunt:

"Why would we, in the ER, do long-term psychotherapy? That makes no sense."

Hee hee. I like the idea of the kindly ER doc referring patients out for years of helpful psychoanalysis. ;-) I also like how the conversation veered into an actual debate about the length of the hypothetical psychotherapy that might occur in the ER.

 

[whopper]

It's just the use of term "ER" that threw me.

Makes sense to me, and I apologize for my end. We almost got into an Abbott and Costello 1st base sketch in text format.

This year I'm doing forensic psychiatry inpatient, forensic psychiatry consulting, research on the psychological autopsy, and private practice. I've done ER psychiatry for 4 years straight (we were always on call in the ER crisis center at my program), and I think my skills there will stay sharp since I've done about 15 forensic evaluations a year which have a lot of parallels (e.g. you have to see someone in a limited amount of time and make a diagnosis and recommendation).

So I do think I'm keeping most of my ends covered, and I hope to not get rusty. The one area I'm afraid I may be getting rusty on is consult liason psychiatry.

I was asked to take a job at the university hospital doing ER psychiatry and some consult psychiatry in addition to being active with the forensic section of the department. I turned down the job, but I may take it up in the future.

A buddy of mine was doing consult liason at the area university hospital, and what he's been asked for consultation is way ahead of what I learned in my own program, and I haven't done CL for 2 years. For example, he was asked to give recommendations on predicting if a patient would adhere to the immunosuppressant medications after a transplant surgery. Where I did my residency training, we were never asked to handle that, and from my understanding there is little research in this area (Doc Samson, care to enlighten me?)

I got a feeling if I take the job sometime down the road, the first month will be a very rude awakening.

 

[Faebinder]

Makes sense to me, and I apologize for my end. We almost got into an Abbott and Costello 1st base sketch in text format.

This year I'm doing forensic psychiatry inpatient, forensic psychiatry consulting, research on the psychological autopsy, and private practice. I've done ER psychiatry for 4 years straight (we were always on call in the ER crisis center at my program), and I think my skills there will stay sharp since I've done about 15 forensic evaluations a year which have a lot of parallels (e.g. you have to see someone in a limited amount of time and make a diagnosis and recommendation).

So I do think I'm keeping most of my ends covered, and I hope to not get rusty. The one area I'm afraid I may be getting rusty on is consult liason psychiatry.

I was asked to take a job at the university hospital doing ER psychiatry and some consult psychiatry in addition to being active with the forensic section of the department. I turned down the job, but I may take it up in the future.

A buddy of mine was doing consult liason at the area university hospital, and what he's been asked for consultation is way ahead of what I learned in my own program, and I haven't done CL for 2 years. For example, he was asked to give recommendations on predicting if a patient would adhere to the immunosuppressant medications after a transplant surgery. Where I did my residency training, we were never asked to handle that, and from my understanding there is little research in this area (Doc Samson, care to enlighten me?)

I got a feeling if I take the job sometime down the road, the first month will be a very rude awakening.

Did you tell them they need a soothsayer not a psychiatrist?

 

[billypilgrim37]

For example, he was asked to give recommendations on predicting if a patient would adhere to the immunosuppressant medications after a transplant surgery. Where I did my residency training, we were never asked to handle that, and from my understanding there is little research in this area (Doc Samson, care to enlighten me?)

You mean your didactics didn't include Magic 8 Ball Training?

 

[Doc Samson]

Agree to some extent with FB and BP... my line in these cases tends to be "When you order a psych consult, you know that's for a psychiatrist and not a psychic, right?"

Nonetheless, what we can do is assemble a pro/con type list of indications that the patient will/will not be a good custodian of a transplanted organ. As with most things in psychiatry, past behavior is the best predictor of future behavior, so you could comment on whether they've managed to adhere to their pre-op med regimen, whether they've maintained abstinence from tobacco/alcohol/illicits, whether they show up to their appointments, whether they are able/willing to access a reasonable support network for help when they're sick etc.

 

[whopper]

Did you tell them they need a soothsayer not a psychiatrist?

Which is what I was thinking. Clearly another example of an inappropriate consult. I figured maybe I was missing something.

I did look it up in pubmed. It turns out the Cleveland Clinic is doing research on this area.

I believe, however, that they'll likely not be able to get very far. The PD of my fellowship advanced the science of predicting future violence to it's current state, in fact he's even advanced some areas in the field of statistics (in addition to winning a Guttmacher award, being named one of the top medical doctors in the country etc.). He was only able to advance it to the degree where it was a little over 50%. If that's all he was able to advance it, I find it unlikely the Cleveland Clinic could do better in an area with similar if not the same problems.

 

[OldPsychDoc]

Agree to some extent with FB and BP... my line in these cases tends to be "When you order a psych consult, you know that's for a psychiatrist and not a psychic, right?"

Nonetheless, what we can do is assemble a pro/con type list of indications that the patient will/will not be a good custodian of a transplanted organ. As with most things in psychiatry, past behavior is the best predictor of future behavior, so you could comment on whether they've managed to adhere to their pre-op med regimen, whether they've maintained abstinence from tobacco/alcohol/illicits, whether they show up to their appointments, whether they are able/willing to access a reasonable support network for help when they're sick etc.

A list which they, of course, could possibly develop on their own if they actually talked to the patient and asked questions... 🙄

 

[Regnvejr]

...A buddy of mine was doing consult liason at the area university hospital, and what he's been asked for consultation is way ahead of what I learned in my own program, and I haven't done CL for 2 years. For example, he was asked to give recommendations on predicting if a patient would adhere to the immunosuppressant medications after a transplant surgery. Where I did my residency training, we were never asked to handle that, and from my understanding there is little research in this area (Doc Samson, care to enlighten me?)

I got a feeling if I take the job sometime down the road, the first month will be a very rude awakening.

Essentially, these are competency evaluations with "motivational interviewing" included.

But nobody can predict the future

(Which is what gets psychiatrists off the hook on the lawsuits from families of suicided patients.)

 

[whopper]

A list which they, of course, could possibly develop on their own if they actually talked to the patient and asked questions...

\

Exactly. I remember several times as a resident while doing C&L, that I wanted to write something to the effect of...

"What you are asking is not within the scope of psychiatry. You are likely to have more skill in determining the answer to this question than we are."

I would, of course, get an attending who didn't spend 2 hours trying to figure out WTF was going on and tell me not to write the comment.

The situation being that about 50%-100% of the consults I got were asking me perform things that should've been done by the medical doctor or surgeon and not psychiatry. I'd have to spend 2 hours figuring out what was really going on per consult, and then an attending would just spend 5 mintues per consult signing it, and not seem to be interested in the gap of communication and the lack of understanding.....

So I asked the department if I could do a presentation to the other departments on examples of inappropriate consult requests, and what exactly psychiatry could do with consults to bridge the gap. I was told no.

Hey, I'm an attending now. I don't have to deal with that BS anymore.

 

[OldPsychDoc]

\

Exactly. I remember several times as a resident while doing C&L, that I wanted to write something to the effect of...

"What you are asking is not within the scope of psychiatry. You are likely to have more skill in determining the answer to this question than we are."

I would, of course, get an attending who didn't spend 2 hours trying to figure out WTF was going on and tell me not to write the comment.

The situation being that about 50%-100% of the consults I got were asking me perform things that should've been done by the medical doctor or surgeon and not psychiatry. I'd have to spend 2 hours figuring out what was really going on per consult, and then an attending would just spend 5 mintues per consult signing it, and not seem to be interested in the gap of communication and the lack of understanding.....

So I asked the department if I could do a presentation to the other departments on examples of inappropriate consult requests, and what exactly psychiatry could do with consults to bridge the gap. I was told no.

Hey, I'm an attending now. I don't have to deal with that BS anymore.

My beloved C/L attending would remind us that that was the "Liason" part of "Consult/Liason"...

 

[Manicsleep]

My beloved C/L attending would remind us that that was the "Liason" part of "Consult/Liason"...

👍

 

[Faebinder]

My beloved C/L attending would remind us that that was the "Liason" part of "Consult/Liason"...

It's called psychosomatic medicine now. Maybe the liason part was a pain? 🤣