Pediatric/CAP - consult liaison psych?

[PuffBlueCat]

Are there any CAP fellowships or triple board programs that have a big consult-liaison component to them? Is this even a thing? I can’t imagine there is a large pediatric psych population with comorbid medical issues…

Would love to hear everyone’s thoughts and perspectives. Thanks in advance!!

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[trophyhusband]

Are there any CAP fellowships or triple board programs that have a big consult-liaison component to them? Is this even a thing? I can’t imagine there is a large pediatric psych population with comorbid medical issues…

Would love to hear everyone’s thoughts and perspectives. Thanks in advance!!

My wife did quite a bit at the University of Utah program in her CAP fellowship and it was run by a couple of the triple boarders who graduated from the program. She hated CL though.

Now that she's an attending she's the Psychiatric Emergency Services Medical Director... and she does IP/OP CL 🤣.

 

[clozareal]

Look for big children's hospitals with CAP fellowships, especially if there's an emergency room. I see these children's hospital affiliated CAP fellowship programs at AACAP every year: Boston Children's, CHOP, Cincinnati Children's, Children's National, Baylor (Texas Children's), UCLA, Stanford, Seattle Children's, Children's Hospital Colorado (CHCO), Nationwide Children's Hospital.

My C-L program at the children's hospital had way more consults than we could see in a day so yes, there's a huge component. There are even embedded child psychiatrists in the neurology, oncology, and pediatrics clinics.

 

[shoomer]

I can’t imagine there is a large pediatric psych population with comorbid medical issues…

Oh sweet summer child...

 

[Merovinge]

Just take a look at the top 20 ranked children's hospitals in the country and that would be (basically) the list of best programs for CAP C/L. Of course the work is almost exclusively also going to be at those very same institutions so only something to pursue if you want to be in an academic arena doing that. The list above by Clozareal is a good start although there are certainly a handful more that are very good as well.

 

[PuffBlueCat]

My wife did quite a bit at the University of Utah program in her CAP fellowship and it was run by a couple of the triple boarders who graduated from the program. She hated CL though.

Now that she's an attending she's the Psychiatric Emergency Services Medical Director... and she does IP/OP CL 🤣.

Gotcha! Thank you for sharing her experience. That sounds like an interesting path she took. It sounds like triple boarding isn’t necessarily a requirement to go that route?

What’s crazy is that I am currently in the CICU with my infant son who just had heart surgery here at Primary Children’s in SLC. I plan on applying psych, and all this has me thinking about pediatric CL.

 

[PuffBlueCat]

Look for big children's hospitals with CAP fellowships, especially if there's an emergency room. I see these children's hospital affiliated CAP fellowship programs at AACAP every year: Boston Children's, CHOP, Cincinnati Children's, Children's National, Baylor (Texas Children's), UCLA, Stanford, Seattle Children's, Children's Hospital Colorado (CHCO), Nationwide Children's Hospital.

My C-L program at the children's hospital had way more consults than we could see in a day so yes, there's a huge component. There are even embedded child psychiatrists in the neurology, oncology, and pediatrics clinics.

Thank you for the guidance. I’m going to look into those programs more. Given that a lot of these are big academic centers, can you speak at all to how DO-friendly they may be?

I think this type of work would really be interesting, and from what you’re saying it sounds like there’s a much greater need than I imagined.

 

[PuffBlueCat]

Oh sweet summer child...

Please forgive my naivety 😂

 

[Merovinge]

Thank you for the guidance. I’m going to look into those programs more. Given that a lot of these are big academic centers, can you speak at all to how DO-friendly they may be?

I think this type of work would really be interesting, and from what you’re saying it sounds like there’s a much greater need than I imagined.

All of CL is a tiny portion of psychiatry. Peds Psych CL is a tiny portion of Peds psych. It certainly is a great way to learn and I know someone who made a career from it, they lasted about a decade doing 100% pure CAP CL before moving onto greener pastures. This is definitely an area where being triple boarded would be reasonable (but far from required). These will be somewhat more competitive CAP fellowships (at the top #20 children's hospitals) in general, but it's still CAP and largely noncompetitive. If you do a good job and get into a decent adult residency you would certainly have a good chance with broad applications.

 

[clozareal]

Thank you for the guidance. I’m going to look into those programs more. Given that a lot of these are big academic centers, can you speak at all to how DO-friendly they may be?

No sorry. Look at their current fellow list and see if they have any D.O.s

 

[TexasPhysician]

Just take a look at the top 20 ranked children's hospitals in the country and that would be (basically) the list of best programs for CAP C/L. Of course the work is almost exclusively also going to be at those very same institutions so only something to pursue if you want to be in an academic arena doing that. The list above by Clozareal is a good start although there are certainly a handful more that are very good as well.

I’d take it a step further and aim for a top 5 children’s hospital CAP fellowship. Child C&L is a tiny field. There is minimal exposure in most CAP programs.

 

[Merovinge]

I’d take it a step further and aim for a top 5 children’s hospital CAP fellowship. Child C&L is a tiny field. There is minimal exposure in most CAP programs.

Respectfully agree to disagree, I know people who have trained or worked at programs that are consistently 5-15 (maybe 20ish depending on the year) and get excellent CAP C/L exposure. If you are training at a program that is pulling in kids from a several million population area and is the place that doctor's would send their own kids, you are likely going to get good CAP C/L training.

 

[CAPapplicant2223]

I'm at a relatively small CAP fellowship and there's no shortage of CAP CL cases at our medical center. Might vary how much time your program has you rotate on CL but doesn't seem like a small field based on my experience

 

[TexasPhysician]

I'm at a relatively small CAP fellowship and there's no shortage of CAP CL cases at our medical center. Might vary how much time your program has you rotate on CL but doesn't seem like a small field based on my experience

After finishing CAP, I feel like 98% of CAP cases are relatively easy to diagnose and establish a reasonable plan. I’m not saying change, remission, or the overall job is easy. It was certainly worth the fellowship, and the field can test you.

What I’m trying to say (about to go to bed so may not be eloquent) is that a good C&L program is going to require a much larger geographical pull than the average residency program. You want to see the zebras. A good CAP C&L training will attract children from across the nation and maybe well beyond. My guesstimated 2% of cases being unusual is significantly higher at limited places in our country. That is where you want to be if CAP C&L is your career focus.

Is that 5 total programs, 15, or whatever? I’ve never done a study to evaluate this. My CAP training adequately prepared me for CAP C&L at average local hospital with its limited PT needs. I absolutely would not want to manage the CAP C&L service at MGH. I’d almost wager that Harvard programs have dedicated clinics for different unusual conditions that the average CAP doesn’t see in a year.

 

[calvnandhobbs68]

After finishing CAP, I feel like 98% of CAP cases are relatively easy to diagnose and establish a reasonable plan. I’m not saying change, remission, or the overall job is easy. It was certainly worth the fellowship, and the field can test you.

What I’m trying to say (about to go to bed so may not be eloquent) is that a good C&L program is going to require a much larger geographical pull than the average residency program. You want to see the zebras. A good CAP C&L training will attract children from across the nation and maybe well beyond. My guesstimated 2% of cases being unusual is significantly higher at limited places in our country. That is where you want to be if CAP C&L is your career focus.

Is that 5 total programs, 15, or whatever? I’ve never done a study to evaluate this. My CAP training adequately prepared me for CAP C&L at average local hospital with its limited PT needs. I absolutely would not want to manage the CAP C&L service at MGH. I’d almost wager that Harvard programs have dedicated clinics for different unusual conditions that the average CAP doesn’t see in a year.

Purely by virtue of if you're looking for "weird" medical complexity stuff, you primarily want a children's hospital that's the major regional hospital with a good catchment area. That would apply to basically your main referral center children's hospital in every state. So like yeah CHOP, Boston Childrens, Johns Hopkins and Children's National are all top end children's hospitals but that doesn't always necessarily mean they're seeing way more complex pathology than Seattle Childrens or Childrens Hospital Colorado or Cincinnati. I can probably name at least 5-7 more hospitals that are major referral centers for their regions, even if they aren't on the "top 10 children's hospitals" or whatever.

The unusual infectious stuff is also geographically based as well so it can matter if you're in a southern vs southwest vs midwest hospital. Not much Coccidioidomycosis up at Boston Children's for instance and not much Borrelia in Texas (so far).

 

[clozareal]

What I’m trying to say (about to go to bed so may not be eloquent) is that a good C&L program is going to require a much larger geographical pull than the average residency program. You want to see the zebras. A good CAP C&L training will attract children from across the nation and maybe well beyond. My guesstimated 2% of cases being unusual is significantly higher at limited places in our country. That is where you want to be if CAP C&L is your career focus.

You want to see the zebras but you also need attendings who can recognize those zebras, do a good job with the evaluation, know how to treat these patients, AND do a good job teaching it to fellows. It's necessary but not sufficient to have just a top children's hospital. I'm shocked at how many CAP attendings at my fellowship program have said they never seen/treated catatonia which we saw with regularity in our peds CL service.

 

[Monocles]

I want to give a plug for pediatric psych CL models and say that it's great for psychiatrists that want to be part-time. When I was in fellowship nearly all of my attendings were 2-3 days/week max on the CL service.

It doesn't have to be inpatient hospital/medically complex patients either. Outpatient collaborative care model is becoming more of a thing. 90% of the consult questions will be about simple SSRI dosing or fine-tuning ADHD regimens so it's a great gig for people who are winding down in their careers. If a weird zebra case does come up (ex: suspected PANDAS, NMDA encephalitis, Wilson's disease, pheochromocytomas etc) you can always shrug and refer to the big academic centres

 

[comp1]

I feel like residencies don't train a lot in real time consulting in the outpatient setting, but it is becoming more common. It's definitely not for me (nor is anything outpatient), but it is becoming more common as it's very cost effective.

 

[Merovinge]

I feel like residencies don't train a lot in real time consulting in the outpatient setting, but it is becoming more common. It's definitely not for me (nor is anything outpatient), but it is becoming more common as it's very cost effective.

There have been significant efforts to push outpatient c/l work/models but it just feels completely alien to how our healthcare system works and medicine changes at a glacial pace. I trained somewhere this was a big deal but even with grant funding it saw relatively little use. Every time I hear older CAP talk they always harp on this being a better model than rapid NP expansion (to which I would agree), but I never see any data showing increased adoption.

As an aside for any resident interested in doing this work, it's wildly different than inpatient CL, make sure you find a fellowship that has a significant emphasis on this work if you want to spend a significant chunk of your career in it.

 

[comp1]

Yeah I was also thinking the outpatient consult concept has very little to do with inpatient CL (much like inpatient psych in general has little to do with outpatient psych in general). If people are interested in it though, all VAs are mandated to have it (called PCMHI) and so any VA heavy residency should offer it at the very least as an elective pretty easily. Not that this helps with CAP...

 

[PuffBlueCat]

I’m glad to see the discussion this has generated. Aside from the obvious C/L psych, CAP, and inpatient peds, does anyone have suggestions for any other elective rotations I should/could do in my 4th year that would be helpful to explore these interests?

 

[Merovinge]

The typical answer is things you won't get exposure to in residency/fellowship. That would largely be any peds subspecialties (other than neuro which you will get a lot of). I think peds child abuse (if you can stomach it, it haunts me 15 years later and was also one of the best rotations I did), peds derm, peds surgery, and peds EM would be pretty helpful in the peds CL space. Can't go wrong with any medical peds subspecialty either.

 

[clozareal]

I did a peds surgery rotation and it was pretty useless. My neurosurgery elective was much more useful but even then, I don't care about surgical technique. Derm would be extremely helpful. I did a peds cardio rotation which I thought would be helpful but ended up being too esoteric.

I think sleep medicine, endocrinology, gastroenterology, rheumatology, pain medicine (there was a pain rehabilitation center where I went to medical school), and palliative medicine were extremely helpful electives for me to do.

 

[Merovinge]

I did a peds surgery rotation and it was pretty useless. My neurosurgery elective was much more useful but even then, I don't care about surgical technique. Derm would be extremely helpful. I did a peds cardio rotation which I thought would be helpful but ended up being too esoteric.

I think sleep medicine, endocrinology, gastroenterology, rheumatology, pain medicine (there was a pain rehabilitation center where I went to medical school), and palliative medicine were extremely helpful electives for me to do.

Now that I think about it, I would try and see upfront if you can spend your time with them in clinic/ED/IP and stay entirely out of the OR. If you could do that I think it would be helpful, if you spend a bunch of time in the OR it would be useless. I did my M3 required surgery rotation as the last of the year and they would ask me if I wanted to go to the OR, like a good anti-gunner I would just say "no thanks" and leave 🤣. Kinda wishing I had gone now, not because it matters at all for my job, but because I ended up marrying a surgeon.

 

[Stagg737]

There have been significant efforts to push outpatient c/l work/models but it just feels completely alien to how our healthcare system works and medicine changes at a glacial pace. I trained somewhere this was a big deal but even with grant funding it saw relatively little use. Every time I hear older CAP talk they always harp on this being a better model than rapid NP expansion (to which I would agree), but I never see any data showing increased adoption.

As an aside for any resident interested in doing this work, it's wildly different than inpatient CL, make sure you find a fellowship that has a significant emphasis on this work if you want to spend a significant chunk of your career in it.

Imo as an outpatient consult doc there's several reasons for this:

1. PCPs don't want to be the ones managing these patients. They want a specialist they can refer to who can take over caring for the tough cases that take more time and effort with no increased pay when they're not sure how to manage it long term anyway.

2. Patients and their families don't want the PCPs managing them. I cannot tell you how many times I've had my consult patients ask "Why can't I keep seeing you?" Sometimes because they just like that I take the time to listen and work with them, but often because I actually know the meds better and the PCPs have told the patients that they don't feel comfortable prescribing certain meds.

3. It's relatively cheap and a decent moneymaker to hire an NP to act as someone that can appear to meet the above 2 points and treat patients longitudinally vs paying a psychiatrist to do a one-off or short term care.

My clinic was funded by a grant that ran out in 2022 and now the university basically eats the cost of having me see these patients to reach half of a state and get patients "in-system" to increase their presence and visibility.

 

[Stagg737]

I’m glad to see the discussion this has generated. Aside from the obvious C/L psych, CAP, and inpatient peds, does anyone have suggestions for any other elective rotations I should/could do in my 4th year that would be helpful to explore these interests?

If you can do a rotation with a good child psychologist who can get you some early exposure in direct 1-on-1 therapy as well as family therapy I think that will help immensely with navigating the dynamics of these encounters much easier from the start. It will also give you a better idea if this is really a field you want to go into as I was CAP track in residency and managing those dynamics played a role in why I dropped that path.

 

[Merovinge]

Imo as an outpatient consult doc there's several reasons for this:

1. PCPs don't want to be the ones managing these patients. They want a specialist they can refer to who can take over caring for the tough cases that take more time and effort with no increased pay when they're not sure how to manage it long term anyway.

2. Patients and their families don't want the PCPs managing them. I cannot tell you how many times I've had my consult patients ask "Why can't I keep seeing you?" Sometimes because they just like that I take the time to listen and work with them, but often because I actually know the meds better and the PCPs have told the patients that they don't feel comfortable prescribing certain meds.

3. It's relatively cheap and a decent moneymaker to hire an NP to act as someone that can appear to meet the above 2 points and treat patients longitudinally vs paying a psychiatrist to do a one-off or short term care.

My clinic was funded by a grant that ran out in 2022 and now the university basically eats the cost of having me see these patients to reach half of a state and get patients "in-system" to increase their presence and visibility.

I completely agree, I guess my point was more, what can be done about it? I continue to hear people push so hard for the model but I don't see how it overcomes points 1 and 2. The only thing I can imagine is really financially incentivizing PCPs to do, but how can anyone get that type of funding when you can just hire an NP to see the patient.

 

[Stagg737]

I completely agree, I guess my point was more, what can be done about it? I continue to hear people push so hard for the model but I don't see how it overcomes points 1 and 2. The only thing I can imagine is really financially incentivizing PCPs to do, but how can anyone get that type of funding when you can just hire an NP to see the patient.

Idk that there is anything to do about it. I think the better solution is to make collaborative models more feasible with psychiatrists either embedded or directly associated with clinics where we are more directly available like the setup I’m in. This should have been much easier to implement with telehealth, but idk that systems have taken advantage of this.

 

[PuffBlueCat]

The typical answer is things you won't get exposure to in residency/fellowship. That would largely be any peds subspecialties (other than neuro which you will get a lot of). I think peds child abuse (if you can stomach it, it haunts me 15 years later and was also one of the best rotations I did), peds derm, peds surgery, and peds EM would be pretty helpful in the peds CL space. Can't go wrong with any medical peds subspecialty either.

I did a peds surgery rotation and it was pretty useless. My neurosurgery elective was much more useful but even then, I don't care about surgical technique. Derm would be extremely helpful. I did a peds cardio rotation which I thought would be helpful but ended up being too esoteric.

I think sleep medicine, endocrinology, gastroenterology, rheumatology, pain medicine (there was a pain rehabilitation center where I went to medical school), and palliative medicine were extremely helpful electives for me to do.

Thank you for the recommendations. I already have rheum and pain scheduled - sleep, GI and palliative are on my short list also. I'd love to find a neurosurgery rotation, but we'll see.

I'll definitely be adding more pediatric subspecialty electives as well.

 

[PuffBlueCat]

If you can do a rotation with a good child psychologist who can get you some early exposure in direct 1-on-1 therapy as well as family therapy I think that will help immensely with navigating the dynamics of these encounters much easier from the start. It will also give you a better idea if this is really a field you want to go into as I was CAP track in residency and managing those dynamics played a role in why I dropped that path.

This is a great idea I hadn't considered. I will look into this further!!