Psych residents doing social work

[bunbury]

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Just wondering how many psych residents out there are responsible for patients' social work issues...

In my program, our short calls consist of seeing consults in the Emergency Department. Our psychiatric hospital is a free standing facility separate from the general hospital. If the patient needs to go inpatient psych, the residents have to arrange everything - we call the insurance companies, get patients assigned to insurance networks, call around to the psych hospitals and find available beds... in short, we do everything a social worker does, without the social work training.

This not only goes for short calls in the ED, but also for all floor consults in the general hospital. For some reason, the social workers on the floors arrange nursing home placement, etc., but do not take care of transfers to psychiatric facilities, so residents on the consult service have to take care of all the paperwork, phone calls, and arguments with insurance companies. To top it all off, our night float "emergency psychiatry" month is entirely social work in the ED.

Not only is this extremely time consuming and confusing when you are alone on call and your phone is ringing non-stop with consults, it is beyond the scope of what a resident should be doing and has little educational value.

Oddly enough, other than this issue, the residency program is actually quite good and offers excellent training and teaching. However, the program figures if they can get residents to do the social work for free, why hire a social worker. It has been this way for years, despite numerous complaints from residents. I understand that all residencies involve doing crappy scutwork to some degree, but this seems ridiculous.

Do any other programs make their residents do this??

 

[JMC_MarineCorps]

Sounds like a bad deal...seriously as if that sort of scutwork is remotely useful. Just another way for the man to squeeze blood from a turnip.

Don't worry, I got my complaints too....plenty of them. Just mention the VA and watch me go off.

 

[kugel]

If the patient needs to go inpatient psych, the residents have to arrange everything - we call the insurance companies, get patients assigned to insurance networks, call around to the psych hospitals and find available beds... in short, we do everything a social worker does, without the social work training.

I would seriously consider getting a group together and telling your Prog Director that you are going to the Dean of Graduate Medical Education (or equiv at your location) unless the PD can remedy this without such action.
Your arguments:
- You are not properly trained for such tasks.
- You do not have licensure for Social work.
- The hospital has not credentialed you for social work.
- When you make a mistake, the hospital will have trouble explaining to the State/Feds or the plaintiff's lawyer why they had someone without proper training or license doing this work.
- It has no legitimate graduate medical education value, as evidenced by the fact that there are no RRC requirements for this and there is no recognized standard for these activities among psych residencies. (If it did have GME value, they would have residents from every discipline doing this for all patients)
- If SWs at your facility are unionized, then there is very likely a serious labor law issue.

 

[Doc Samson]

Did this all through residency - successfully petitioned the administration to change this when I was chief resident. Now my former program has a 24H bed-finding service in the ED. A few words of advice:

Stop calling this social work. Social workers do more than find beds, calling bed-finding social work will only make you enemies.

Don't make the argument that there's no educational benefit to this. There is something to be learned on a health-systems level from placement and insurance pre-certification.

Frame this as an efficiency issue for the hospital. Point out that the time you spend on the phone is time away from seeing patients, thus contributing to the back log of patients that occurs in every ED we work in.

My approach was to pull data from a month of residents doing bed-finding, convince my PD and chair to fund a month of 24H bedfinding and pull the same data, then compare the two. It showed a massive reduction in ED wait time. Even casually mentioning this to the ED chair will generate enough excitement (and potentially funding) to carry your position through.

Finally - don't threaten anyone in a supervisory position with anything ever. Really won't help.

 

[whopper]

Where I did residency, my program was split between 2 hospitals. At one hospital, you had to do this type of work, at another you did not.

The residents that had to do the work hated it, for all the reasons you mentioned. It didn't advance their knowledge of psychiatry, didn't help them on their board exam, etc, yet the work was very frustrating. I've yet to see a psychiatric job where the doctor had to do social work except for psychiatrists in private practice who choose to run the show completely by themselves (e.g. they do the secretarial work, the social work, the billing work etc.)

Is there a benefit to doing this type of work? Yes, because it helps you to see how partners in your treatment team work. However using that same argument, there's a benefit to you doing nursing, occupational therapy, hey possibly even janitorial work because it'll help you to understand everyone working on your unit in the hospital. For that matter, if your patient is a construction worker, why not work in construction so you can understand him better?

The residents at the hospital where they had to to this work complained big time. The PD mentioned she was going to try to get rid of it, but this happened right as I was leaving. I don't know if any changes were made.

IMHO this really is a waste, and it can be filled with better things for a resident to do that are actually more cost effective for a hospital. Social workers don't make much, and residents take up the work that several attending doctors would have otherwise done (though of course those attendings are supposed to supervise and make sure its done right.)

When this type of thing goes on, it makes me wonder if the program can't get the residents to do more work that would be more cost and learning effective, so they decide to just dump some social work on them to save money.

My approach was to pull data from a month of residents doing bed-finding, convince my PD and chair to fund a month of 24H bedfinding and pull the same data, then compare the two. It showed a massive reduction in ED wait time. Even casually mentioning this to the ED chair will generate enough excitement (and potentially funding) to carry your position through.

Which was a similar if not the same argument used by the residents. If those residents could just do psychiatry and not social work, they would be able to get the work faster and better, and it could actually be more cost effective for the hospital despite that they'd have to get another social worker.

- You do not have licensure for Social work.
- The hospital has not credentialed you for social work.

Very good points. Just how qualified is a resident to do this type of work? I don't recall any social worker training in medical school, and if an attending is supposed to supervise the resident, that attending most likely does not have social worker training or credentials.

I'm wondering what an insurance company would think of the coverage of a practicing doctor that did social work, or the legal implications of this. Another question is what are the ACGME implications? I've been out of resident just over a year, and don't have the ACGME guidelines in front of me, but I wouldn't be surprised if there was a section saying something to the effect that a resident in a training program is not supposed to do work outside their field of training. E.g. it would be absurd for a resident to be made to mow a doctor's lawn as part of the curriculum. Perhaps social work can be put into this category.

 

[cleareyedguy]

Did this all through residency - successfully petitioned the administration to change this when I was chief resident. Now my former program has a 24H bed-finding service in the ED. A few words of advice:

Stop calling this social work. Social workers do more than find beds, calling bed-finding social work will only make you enemies.

Don't make the argument that there's no educational benefit to this. There is something to be learned on a health-systems level from placement and insurance pre-certification.

Frame this as an efficiency issue for the hospital. Point out that the time you spend on the phone is time away from seeing patients, thus contributing to the back log of patients that occurs in every ED we work in.

My approach was to pull data from a month of residents doing bed-finding, convince my PD and chair to fund a month of 24H bedfinding and pull the same data, then compare the two. It showed a massive reduction in ED wait time. Even casually mentioning this to the ED chair will generate enough excitement (and potentially funding) to carry your position through.

Finally - don't threaten anyone in a supervisory position with anything ever. Really won't help.

If I were in training, I'd tape the above to my computer screen, and whenever I got frustrated, I'd use it.

Administrators (who will be you soon enough) do NOT want to hear whining. They want data and they want empathy. Empathy, as in, a reflection that you understand their perspective well enough to change that perspective through creative and effective solutions. A fundamental error in organizations is to complain without a focus and without a solution; in other words, if you're going to engage in administration, you gotta use their language.

 

[Doc Samson]

Administrators (who will be you soon enough) do NOT want to hear whining. They want data and they want empathy. Empathy, as in, a reflection that you understand their perspective well enough to change that perspective through creative and effective solutions. A fundamental error in organizations is to complain without a focus and without a solution; in other words, if you're going to engage in administration, you gotta use their language.

Right - early in residency I was (as the quote goes) "full of sound and fury signifying nothing." At some point in PGY-3 I realized that righteous indignation doesn't get you very far - you do much better by presenting yourself as the most reasonble person in the room (even if just below the surface you dream about smashing furniture in the ED).

 

[masterofmonkeys]

Right - early in residency I was (as the quote goes) "full of sound and fury signifying nothing." At some point in PGY-3 I realized that righteous indignation doesn't get you very far - you do much better by presenting yourself as the most reasonble person in the room (even if just below the surface you dream about smashing furniture in the ED).

Currently being in a similar situation myself, I am full of sound and fury, and desperately trying to come up with ways to take care of the problem without looking like a whiner. I'm full of solutions, just worry how they might come off.

 

[billypilgrim37]

I am learning that the phrases "delay in patient care" and "unsafe patient care conditions" can never be peppered in an email too much.

 

[pingouin]

Stop calling this social work. Social workers do more than find beds, calling bed-finding social work will only make you enemies.

Don't make the argument that there's no educational benefit to this. There is something to be learned on a health-systems level from placement and insurance pre-certification.

Thanks for saying that, Doc S. I'm currently an M2, however I hold a BSSW, a MSW, worked for 10 years post-masters, and have been independently licensed as a LCSW for almost 9 years now. I've worked in a SW capacity on pretty much every angle covered in this thread:

• psych/CD intake assessor for a community hospital network that does not have psychiatry residents
• intake case manager for a national managed behavioral healthcare company (I was the one you talked to from the ED)
• ED social worker at a Level 1 pediatric trauma center that (don't ask) has no inpatient psychiatric services so every psych case had to be transferred out

I would never tell anyone that it's the most efficient use of a resident's time and skills to do certs, placements, and transfers, however I object strongly to the notion that all the scutwork for that stuff should automatically fall on a social worker's shoulders.

First, none of the tasks listed in the original post are the exclusive domain of a social worker. They're not part of the bachelors- or masters-level curriculum, although some may learn how to do them during a practicum. Most will not. In the non-academic world, intake positions are held by MSWs, MAs, PhD/PsyDs, and perhaps (and unfortunately) in some rural areas, even bachelors-level persons. In small hospitals with no psychiatric services intakes are often called in by the attending emergency physician. Most of us at any level of education learned to do it by muddling through the first few times and getting better with practice.

Do not make the mistake of assuming that all social workers are knowledgable about the mental health system. Of the 12 social workers in our ED, only two of us had mental health backgrounds. Social work is like medicine in that many have subspecialized (health, mental health, children and families, administration, school, community, etc.) and many hospital social workers have never worked in mental health, which uses a completely different set of resources. (Although the OP seems to work in a free-standing psych hospital, where they should all have a MH background.)

It might be good to find out what the ED social workers' responsibilities are and whose budget pays them. Where I worked, our priority was dictated by the ED physicians- responding to all traumas, deaths, and performing forensic child physical/sexual abuse interviews took priority over any other pages we got, and all of those are very time-consuming tasks. (My record was 6 forensic cases in one 12 hour shift, with at least 2 interviews per case + a hotline call on all 6 + a 4-page writeup on each.) Fitting "psych placements" into our job description was not something the ED wanted to do given we were already stretched to the limit. It was when the child psychiatry department contracted with a local crisis line to do it that the child fellows were no longer responsible for the "scut" part.

From my managed care experience, receiving the clinical information from the person who did the assessment expedites the process in most cases by being able to answer all questions in one phone call. Otherwise it's often a game of "Hold on, let me call the doctor" by whoever's calling it in. It allows the resident to advocate for the patient's needs when, for example, the insurance tries to argue for partial hospitalization instead of inpatient. In the big picture, all of this really is better for the patient as it really does move them faster out of the ED and into a safer environment.

I fully recognize that no matter what the entire process sucks, and don't get me wrong- I hope that wherever I train has someone to do it for us. But it does give residents a taste of how the system actually works (or doesn't) which is always a valuable lesson.

 

[whopper]

But it does give residents a taste of how the system actually works (or doesn't) which is always a valuable lesson.

I'd agree there, but is it useful to be doing it for 4 years? To get a taste? That was the situation in the other half of the residency program. IMHO they were getting a useful enough taste after 1-3 months of this type of work. To do it for 4 years makes me question if the time spent on this turns what was valuable lesson at 3 months into lost oppurtunities to learn more in other areas to the extreme where the negative strongly outweighs the positive.

From my managed care experience, receiving the clinical information from the person who did the assessment expedites the process in most cases by being able to answer all questions in one phone call. Otherwise it's often a game of "Hold on, let me call the doctor" by whoever's calling it in. It allows the resident to advocate for the patient's needs when, for example, the insurance tries to argue for partial hospitalization instead of inpatient. In the big picture, all of this really is better for the patient as it really does move them faster out of the ED and into a safer environment.

That's a very good point.

 

[kugel]

I'm a huge fan of cross-training. I've always been one to get very involved in "how the system works" and so tend to get my hands in these kinds of issues wherever I work. But that seems to be fairly unusual among docs I've known, and I've been criticized for it ("You need to stick to what we pay you for").

It's true, "bed finding" is not really a SW issue, and it's not why most of them entered graduate school - it's clerical. It's knowing how to read the insur info, how to call hospitals and insur companies, keeping track of lists of which hospitals have which services avail., etc. And it's about persistence; calling them back every 45 min, reminding them that other hospitals are considering accepting this pt, asking who in particular now has the referral, telling their intake director what a good job their staff does and why we often call his hospital first, etc. And it varies so much from system to system and region to region, that "training" often does not translate that well to another setting. Having done this in several settings, I would say that doing it for 10-15 cases is enough to understand the basics of how a pt gets from one facility to another - if that matters to your psychiatric residency training. Calif. is a different animal than any place else I've worked, and it's done quite differently where I am now in CA than where I was in CA 3 yrs ago. To truly completely understand the system would require doing it every day for a year or more - but to what end?

It's also true that the clinical info is best obtained from the person who did the evaluation. "When the receiving physician is ready to ask about the case, give me the number to call," (or have the MD call my pager) works fine. I'm happy to respond quickly, give a bullet presentation of the case, and answer any questions. In the mean time, I can go on treating patients.

 

[whopper]

If you're running an inpatient treatment team, or an outpatient (P)ACT team, knowing the stresses and routines your team must work in helps you to make better decisions that can more realistically be implemented.

I've seen plenty of cases where residents and attendings were not listening to their staff, and putting staff in a position where they simply had to deal with it.

E.g. I've seen cases where the patients were cheeking meds, the nurse mentions in the treatment team meeting, and the psychiatrist who could've started a depot, a dissolvable med, a liquid med just keeps the same medication going. Then the doctor doesn't even address the issue with the patient. The patient for example could've not been taking the medication because the pill was too large, and then the doctor just continues the same medication. Classic case of the fly hitting the glass window over and over and over again.

If the doctor spent some time to see what the nurse is going through when giving the pill, that would give the doctor more insight. I've seen several doctors ignore this type of human resources perspective with their staff. A doctor that was mindful to begin with would have at some time simply spent the time to talk to their staff, but like I said, a lot of doctors don't do that, nor is that type of behavior rewarded. It won't get you to pass an exam, it won't earn you points with attendings (though it may with a nurse manager), its not going to be something you can put on your CV.

The medical education process often does not recognize this type of skill. For example if one was a manager of a construction crew, and did a very good job at it, it makes one more likely to have this type of skill, or in other positions such as a manager in a business, etc. The main thing it seems everyone is interested in is grades and test scores, on an extreme where this appears more important than anything else by an order of more than 10 to 1. I've seen some very academically brilliant people make some mistakes such as ignoring their treatment team because they attacked every problem as if it were academic. They didn't seem to have a human resources grasp of the situation.

However there is an issue of how much of this type of experience should be imposed on a resident. For example, it may help a resident in training actually give out meds like a nurse does for a few days, maybe a few weeks, but to make them do it for 4 years, that is big time overkill. If it had to come down to none of this type of training or 4 years of it, I'd argue against it completely because IMHO its worse to make someone do something for that duration when the benefit peaks after a much shorter duration.

It seems though that at least in relation to the bed-finding component, its either all or none--do it for years, or not do it at all.

 

[CaMD]

Back from the grave! Bunbury, how did this end up working out at your program? May I inquire from other residents (or attendings) how many of you are required to do these insurance pre-authorizations and arrange transfers, etc?

My program has some aspects of this and is slowly making some changes, but I was hoping gathering some data about the prevalence of these practices and how it's handled elsewhere might be helpful.

 

[hippiedoc13]

Back from the grave! Bunbury, how did this end up working out at your program? May I inquire from other residents (or attendings) how many of you are required to do these insurance pre-authorizations and arrange transfers, etc?

My program has some aspects of this and is slowly making some changes, but I was hoping gathering some data about the prevalence of these practices and how it's handled elsewhere might be helpful.

We've had similar issues at my program, and changes were in progress when I started in the residency, and now we are also in that stage of slowly making changes and trying to solidify our gains. I really have to thank the resident classes 2 or 3 years ahead of me for taking this on.

Our program covers 2 hospitals, and when we are on call, the resident is the only psychiatrist in the hospital. We are responsible for doing all the admissions to our inpatient unit, as well as all consults in the ED and any urgent consults on the med & surg services that can't wait till morning. Obviously we are very busy and there's a lot of actual psychiatry to be done.

In the past, the psych resident was responsible for pretty much all of the clerical work described in the above posts (note that I call this 'clerical work' and not 'social work', as most of it truly is clerical). This included verifying insurance, calling for authorizations, calling around to find a bed for transfer if our unit was full, faxing all sorts of forms. Extremely time-consuming and it really did affect timeliness of patient care. We were also being held responsible for arranging disposition of pts from the ED (ie, to detox, to crisis center, etc). Not just determining appropriate level of dispo (which of course IS our job), but actually arranging the dispo ourselves--basically the ED was de facto making us the primary service for anyone labeled "psych," instead of retaining responsibility as the primary service with us as the consultants.

The residents took this up with the psych dept, and then with the ED. By making the argument about the effect on patient care and flow, some good changes were made. We clarified our relationship with the ED as consultants whose role it is to evaluate and offer a medical & psychiatric opinion and recommendations, but if the pt is in the ED, then the ED retains primary responsibility for the pt until such time as we admit the pt to our service. Also, we demonstrated how much time was consumed with clerical work--time that could not be spent seeing patients. Now many clerical responsibilities have been shifted to the clerk in the ED: verifying insurance, locating available beds for transfer, faxing paperwork. Unfortunately our residents are still responsible for calling to get insurance authorization--which is incredibly annoying, but I can see how this is something that does need to be done by a clinician who has actually evaluated the patient, because I often find myself arguing with the insurance person on the phone to get them to authorize the level of care the pt needs, and a non-physician who hasn't seen the patient can't possibly be expected to do it as effectively.

There are still hiccups in the system from time to time. A couple years back, when the new division of labor was still very new, our psych residents frequently got a lot of "attitude" from the ED clerk who would try to tell us "that's not my job, it's yours" and refuse to do it. I recall a particular incident when the clerk complained to the charge nurse, who tried to harangue me into faxing transfer forms and calling around for a bed, and when I politely stood my ground, the charge nurse went and complained about me to the senior ED doc who was in charge that shift. The ED doc started in on me then. I smiled and reminded him of the new system. And then I said very calmly: "I'll tell you what. It's a weekend and I am the only psychiatrist in this hospital. I already have 3 pending consults from your ED. I am the only person in this hospital who can lift holds. I can either stand next to the fax machine, or I can see patients, but I can't do both simultaneously. So why don't you decide how we can most effectively use my time and our resources, and that's what we'll do."
Not surprisingly, I didn't end up doing those phone calls or faxing...

 

[CaMD]

Thanks for the info, hippiedoc. Your program setup sounds similar to mine.

I'm definitely indebted to the residents in the years above me who started getting much of this clerical stuff off of our plate. My understanding is it's way better than it was before. ie, we no longer have to actually call around for beds for patients, though we do have to be the ones getting all the paperwork together and faxing it to the place that looks for beds. And we still have to do pre-auths.

A lot of my frustration stems from the fact that no other services in the hospital have to do this. If the medicine floors are full the medicine resident is not spending their time gathering insurance info and printing out labs etc.

And as far as pre-authorizations, is that something specific to mental health care? If someone comes into the hospital with chest pain, does their insurance not require a pre-authorization? Is it that insurance being stricter with mental health or if its that every other service has someone do it for them?

 

[jettavr6]

Although it is a good idea to learn how to obtain pre-authorizations and beds, I believe that this should be limited to a finite amount of patients. The sheer number of patients that need to be seen in the ER is a challenge even for the most experiened of psychiatrists. A resident simply does not have the time to spend upwards of 45 minutes on the telephone. A social worker is much more experienced and often has established social contacts which can help in the disposition of patients. And in the rare event that the resident has a free 45 minutes, I would rather that they go eat, sleep, or destress for a little while before resuming their 24 hour call.

 

[Ibid]

It Is hell out there. I have started a new thread inspired by this one. Management Training for Doctors

 

[jettavr6]

Finally - don't threaten anyone in a supervisory position with anything ever. Really won't help.

This is an interesting topic, and I agree with Doc Samson in theory. Taking it a little further, I don't believe you can really achieve much in life by making any kind of threats. That said, many people in supervisory positions end up feeling threatened by even the most benign of comments.

Times have changed since many of us went to medical school, trained, etc. I've been a resident, then an attending, and now a fellow. It's my strong belief that residents who feel that they are being abused or treated unfairly, should speak up and let people know. Any good supervisor will not view this as a threat, and will not retaliate.

From my experience observing different departments/specialties, I think that we in the field of Psychiatry have a long way to go in improving how we treat residents.

 

[Doc Samson]

This is an interesting topic, and I agree with Doc Samson in theory. Taking it a little further, I don't believe you can really achieve much in life by making any kind of threats. That said, many people in supervisory positions end up feeling threatened by even the most benign of comments.

Times have changed since many of us went to medical school, trained, etc. I've been a resident, then an attending, and now a fellow. It's my strong belief that residents who feel that they are being abused or treated unfairly, should speak up and let people know. Any good supervisor will not view this as a threat, and will not retaliate.

From my experience observing different departments/specialties, I think that we in the field of Psychiatry have a long way to go in improving how we treat residents.

People who are being abused should speak up - they jsut shouldn't threaten to speak up. In the setting of the example I was originally responded to, telling your PD "Fix this or I'm going to the Dean" is just poor strategy. Ask the PD to fix it - if they don't, then go to the Dean.

 

[jettavr6]

People who are being abused should speak up - they jsut shouldn't threaten to speak up. In the setting of the example I was originally responded to, telling your PD "Fix this or I'm going to the Dean" is just poor strategy. Ask the PD to fix it - if they don't, then go to the Dean.

Agreed. But when a resident does speak up in the manner that you've suggested, I've observed many supervisors perceive this as a threat. And once a person does go above a PD, retaliation mode often sets in. However, I am seeing a change these days for the better.

Another current thread here speaks about management training which is something that I encourage all residents to pursue. I'm proud of all current medical students who are in joint MD/MBA programs and feel that things can only get better in terms of management for the future.

 

[beezley]

I'm a PG-2, this is the year where we do our overnight ER call. I do dispo, what most would call 'SW' all the time. The ER SW stands over me and says, 'maybe you should calling X, Y, or Z. I'm too tired to fight it. I just do it. Whatever. I have dreams of (if it is a really busy night) photocopying my disposition possibilities from my notebook and handing to the ER SW and saying, 'call me when you have an accepting facility'.

If it ever happens I'll let you know how that goes. I have a good guess.

It sucks, but it is only a year in our program. I keep telling myself that it is good for me, but I hate it.
😡

 

[beezley]

I think I should add that if it was not for the crappy dispo phone call/SW stuff I would really like ER psychiatry.

I want to think about the medicine, not butt heads with the community mental health or other facilities trying to get people tucked away. I guess that is part of the usual disillusionment that happens in residency.