Programs for someone with interest in psychiatric emergencies

[watermanMD]

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As the title implies, just wondering if there are any EM programs that place a stronger emphasis on psychiatric education/ training in their curriculum? Or perhaps with strong psych emergency or addiction electives? Seems to me that most programs don't provide much psych training even though psych seems to permeate the ED. It looks like Kaiser offers an Emergency Psychiatry fellowship that is open to EM physicians, however, it appears to be in a period of flex/redevelopment. I was interested in psychiatry before EM and wouldn't mind carving out a niche for myself, as I enjoy these patients (granted, I recognize that as a student I have much more time to spend with said patients than my attending's do). Also, ever heard of an EM physician working some shifts in a dedicated psych ED/ PES?

 

[RustedFox]

 

[GonnaBeADoc2222]

Give it a week of internship...You will no longer be interested in psychiatric emergencies.

 

[Pons Asinorum]

Any program near any type of population center will have more than enough exposure to psych EM to slake your thirst. Quickly.

 

[askamsky51]

I'm trying to remember the interview cycle, forgive me if I'm wrong...

Lots of programs have locked psych units attached to the ED. However I think mayo had a dedicated psych month? Only one I heard of.

 

[EMDOC17]

If you really like managing and treating psych patients I think EM will be hard for you. We have a lot of psych but I feel my decision making/education is very rudementary. Do they need admission? Yes/No. are they agitated and or aggressive? Yes: 5 mg of haldol/zyprexa +/- Ativan and Benadryl. Sign out to my partner taking over for me. When I show up I take them back on my patient load. Rinse and repeat.

I have little to offer for the psych patient. I don’t start mood stabilizers, SSRI’s, and absolutely don’t start or refill benzo’s. So what do I do? I make a decision to admit or not and sedate or not. Just typing this makes my skin crawl.

I again have little to offer the psych patient. In my town outpatient psych follow up is two months away. Inpatient psych is often two days away. In the meantime I’m keeping them in a room with a security guard posted and no access to windows. If you weren’t depressed or psychotic before this, you will be after.

It would be great if we actually could be efficient on starting CBT, SSRIs, mood stabilizers in the ED. We can’t. Same with the fact that I would love to be able to cath the patient after a Vfib arrest, or do the endo at 2 am when GI refuses.

My point is EM is EM. Love it for what it is. If you live psych this isn’t the place for you.

 

[miacomet]

Have you considered psychiatry? There is mad money out there for psychiatrists who are interested in working in CPEPs and admitting psych emergencies.

 

[DrDrummer]

Come visit the Bay Area. We have several dual diagnosis centers of excellence to train at and have one of the highest concentrations of citizens with decompensated mental illness that you will ever see. If you want to see the intersection of substance abuse and psychopathology I don't think there is a better place to train. (Possibly Florida based on what I read in the news, but that all might just be bath salts.) There is also a lot of emphasis here on substance use disorders specifically and treating these / harm reduction. (For everyone else less interested in these particular things I'll just mention there's a lot of nice things about the area too, cost of living aside. 🙂)

If you are that interested in psychiatry, as an above poster mentioned, there are tons of jobs for people willing to do this and if you want psychiatric-focused training you should pursue that as a specialty. That said, there is a lot of room for emergency physicians to continue doing research in these areas and it is certainly the location in which many patients with psychiatric illness receive much of their medical care (psychiatric and otherwise).

You might be interested in this guy's work: Leslie S. Zun, MD, MBA -- you could e-mail him and ask where he thinks the best training programs are. He is an EP who is the current president of the American Association of Emergency Psychiatry and I believe is working towards trying to develop a sub-specialization in emergency psychiatry for emergency physicians.

 

[hundreddaysoff]

If you primarily want EM but are also interested to experience a bunch of psych pts in their total diversity, I think the main thing you want is to train in as big a city as possible. No idea if county shops generally see more psych vs others. But if a place is big enough to have a separate psych ER staffed by psychiatrists that you get to rotate in, you'll definitely be able to learn a lot more in-depth about their illnesses and subsequent management after the ER.

I was a med stud at a huge county place w/ a psych ER and definitely saw a lot more psych there than the smaller academic shop where I did residency. Also did much more in-depth psych intake interviews. I do agree w/ the above replies that advanced psych management skills are not required or often even allowed in most attending ER jobs, and most ER docs probably prefer it that way.

I'm somewhat interested in addiction medicine as a future side gig. One other thing (of only a very few) I regret about my residency is we didn't have resources to start our ER pts on suboxone as we had no follow-up clinic. Just got my X number as an attending and am thinking about how to actually make suboxone work on the ground now w/o prior experience. Consider that angle as well when you're shopping programs.

 

[enalli]

If you want to make meaningful, long-lasting contributions to the lives of your psychiatric patients, you have to look elsewhere. In the low-volume EDs where you have enough time to talk to people, you won't have many interesting psych patients. In the high-volume EDs where you have the most interesting psych patients, you won't have the time to talk to them (and you will be busy trying to keep other people alive).

 

[Gastrapathy]

Is the B-52 still a thing?

 

[hundreddaysoff]

Is the B-52 still a thing?

At my big county med stud shop it was. In residency, most of my attendings discouraged polypharmacy and made us stick w/ one of either Haldol, Zyprexa, or benzos. Usually monopharmacy was enough +/- intubation in extreme cases. Haven't had a sick enough psych pt to break out the B52 as an attending yet, but wouldn't hesitate to do it if needed... beats intubation.

 

[gro2001]

As the title implies, just wondering if there are any EM programs that place a stronger emphasis on psychiatric education/ training in their curriculum? Or perhaps with strong psych emergency or addiction electives? Seems to me that most programs don't provide much psych training even though psych seems to permeate the ED. It looks like Kaiser offers an Emergency Psychiatry fellowship that is open to EM physicians, however, it appears to be in a period of flex/redevelopment. I was interested in psychiatry before EM and wouldn't mind carving out a niche for myself, as I enjoy these patients (granted, I recognize that as a student I have much more time to spend with said patients than my attending's do). Also, ever heard of an EM physician working some shifts in a dedicated psych ED/ PES?

As the others have mentioned, there is not going to be enough of a psych component to any EM residency's education to really satisfy a deep interest in psych emergencies. I have seen one curriculum out there that had a 2 week psych rotation as part of residency, but that's about it. Even then, the daily practice of EM is just not that heavy in the kind of psychiatric care that you are looking for. While it is true that a lot of ER patients will have psychiatric issues, most of the psych care you provide will be limited to one of the following scenarios:

1) Screening for suicidal ideation, homicidal ideation, or command auditory hallucinations
2) Sedating acutely agitated individuals, sometimes agitated as part of their mania or psychosis

So if you are really interested in making psych a major part of your clinical care, EM is not the best option. However, perhaps the way to make this your niche in EM is through research and education. There is an attending at Columbia who is one of the very few EM R01 funded researchers, and his focus is in psychiatry. His clinical practice isn't really different from that of any other ER doc, but that is what has been the focus of his research and educational endeavors. So if you are set on EM and this sounds like a pathway you would be interested in, I would recommend looking for an ER program that has faculty whose research is in psych/behavioral topics.