Question about moonlighting and medical management issue

[leonazul25]

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3rd year resident here. Got my first moonlighting gig at an outpatient mental health facility and have some questions. The majority of the patients at the facility are involuntary brought in by police for an examination. A healthy mix of substance abuse/withdrawl, acutely psychotic, suicidal ideation, and some behavioral issues secondary to dementia.

I am working there on the weekends seeing only the new admits. After I'm done, I leave and am on phone call through the rest of the day/night. I also do a physical exam during the eval. The patients are supposed to have been medically cleared by the RN before admission. There is no lab on site, so labs are not available. There are RNs and techs/staff on site there 24 hours, place is across the street from major hospital.

What I did not anticipate are the medical phone calls. Issues concerning blood pressure medication, insulin, abnormal vitals, making decisions to transfer them to the local ER. It is like being on call when I was on medicine 2 years ago.

I realized after working this weekend that I am also medically responsible for these patients, about 30 people or so. Which is kind of scary. Is this a normal situation for a small outpatient receiving facility, the psychiatrist doing some medical management? Have any of you guys had to do this, and how did you handle it?

Thanks.

 

[Shikima]

Eyes wide shut. What I mean is, you learned a good lesson to find out all details prior to finding your first gig after residency. See if there is anyone you can talk with at your facility to help mentor you through the process and see what you're able to stomach vs throwing the towel in.

 

[leonazul25]

Eyes wide shut. What I mean is, you learned a good lesson to find out all details prior to finding your first gig after residency. See if there is anyone you can talk with at your facility to help mentor you through the process and see what you're able to stomach vs throwing the towel in.

Thank you for the post but this did not answer any of my questions. Can any one chime in from personal experience?

 

[OldPsychDoc]

😕I'm a little confused--you refer to this as outpatient, yet you're doing "admits", and responsible for continuing care...

 

[leonazul25]

😕I'm a little confused--you refer to this as outpatient, yet you're doing "admits", and responsible for continuing care...

you're right. It's not outpatient, not sure why I wrote that.

 

[Psychobabbling]

What you are describing is a CPEP thrown out away from the hospital. If you have no meds on site and are dealing with medical issues. Punt to ED for issues to be taken care of, if not admitted, and see them when/if they come back

 

[leonazul25]

What you are describing is a CPEP thrown out away from the hospital. If you have no meds on site and are dealing with medical issues. Punt to ED for issues to be taken care of, if not admitted, and see them when/if they come back

Just did a bit of reading and the structure looks quite similar. I have medical meds on site. ED is across the street and nurse would have to call 911 to transport patient. So, I am the one managing the medical meds as well. I am bit paranoid because at my hospital, I am used to having cbc,bmp, ids, etoh level and medicine residents handle inpatient med issues instead of psych residents. I guess I should buy a book on emergency psychiatry and review on call guidelines for medicine. My questions still remains though, concerning if it is standard that psych docs are doing the medical management here?

Thanks

 

[TexasPhysician]

At most facilities, you can consult IM. Otherwise I keep things basic. If the patient/family know their meds, I continue them. Punt anything severe to the ED. Sliding scale for glucose control.

As a physician, I have no qualms handling basic med issues or advising the patient to have it evaluated outpatiently.

 

[heyjack70]

The RN doing the medical clearance raises a huge red flag for me. That is a doctor's job, or at the very least an ARNP. Are these patient's being admitted from an outside ED? If so they should have labs/medical clearance done there prior to ever being sent.

Without IM consultation, I would have a fairly low threshold for sending patients to the ED for any remotely urgent/emergent medical issues.

 

[vistaril]

3rd year resident here. Got my first moonlighting gig at an outpatient mental health facility and have some questions. The majority of the patients at the facility are involuntary brought in by police for an examination. A healthy mix of substance abuse/withdrawl, acutely psychotic, suicidal ideation, and some behavioral issues secondary to dementia.

I am working there on the weekends seeing only the new admits. After I'm done, I leave and am on phone call through the rest of the day/night. I also do a physical exam during the eval. The patients are supposed to have been medically cleared by the RN before admission. There is no lab on site, so labs are not available. There are RNs and techs/staff on site there 24 hours, place is across the street from major hospital.

What I did not anticipate are the medical phone calls. Issues concerning blood pressure medication, insulin, abnormal vitals, making decisions to transfer them to the local ER. It is like being on call when I was on medicine 2 years ago.

I realized after working this weekend that I am also medically responsible for these patients, about 30 people or so. Which is kind of scary. Is this a normal situation for a small outpatient receiving facility, the psychiatrist doing some medical management? Have any of you guys had to do this, and how did you handle it?

Thanks.

wow, all that seems crazy.

One of the things I've noticed in talking to people about inpatient positions is that at most non-academic inpatient places you do *no* medicine stuff. By this I mean none at all. For example, every single admit that is on any 'medical' medication gets a medicine consult. Pt could be on Amlodipine 2.5mg daily as their only medication they have been on for 4 years. BP on admission is 120/78. And medicine is an auto consult. medicine happily comes by, puts their consult note in, puts the order for amlodipine 2.5mg daily in, etc..and then they may even come by and do daily f/u notes.......I think at many places there is an auto medicine consult even for patients who have no pmh at all and are on no medical meds.

Very different from many academic places where you would be expected to know/do 'a little basic medicine'......I guess that's a good or bad thing depending on what you want to do.

 

[whopper]

I just posted in the thread about private practice in residency before I saw this and it's almost the same thing.

You don't go into a job unless you know what you're going into. PP demands more responsibility from a doctor than other forms of care because you're the guy running the clinical and the business end, not just the clinical.

But getting to what you just wrote...

I realized after working this weekend that I am also medically responsible for these patients, about 30 people or so. Which is kind of scary. Is this a normal situation for a small outpatient receiving facility, the psychiatrist doing some medical management? Have any of you guys had to do this, and how did you handle it?

There are "stand-alone" psychiatric faclities with limited medical support. I've worked in a few. Any state psychiatric facility (I've worked in two), a private high end facility with some of the world's top psychiatrists (The Lindner Center), and in facilities like this you don't have medical response what you'd like it to be.

E.g. You order a lab and you don't get it for 3 days, no CT scans, you want a consult they may only show up once a month if at all.

Legally, you are the doc and you are medically responsible. Is it scary? Hell yeah.

Here's the strategy each of these places employ.

1) If you even suspect there's a serious medical problem you don't admit. You have them sent to the ER. The police bring someone and their head's bleeding? You tell them to send the person to the ER. BP at 210/130 and a headache, you send them to the ER. You don't admit ANYONE unless you can handle them as an inpatient.

2) Once an inpatient, you have a very low threshold to send them out to the hospital. E.g. while at the Lindner Center, one of the nation's top psychiatrists was working with me as the other doctor on the unit. A patient was what I believed to be sleep-walking during the daytime. He was just started on Ambien the night before and I attributed it to the Ambien. That psychiatrist had the guy sent to the local hospital. His thought-process was that the facility was a stand-alone psych facility and he couldn't take the chance. Hey, if one of the nation's top doctors tells me that, that's good enough for me.

All of these things entail that you have a very good relationship with the hospital across the street so when you need to send them over, the other side understands you and sees you as a team player.

At the Lindner Center, the local hospital was very cooperative with transfers. At some institutions, they'll play turf war and refuse to take a patient that needs to be taken.

If the other hospital plays turf war, I'd consider getting out of that moonlighting job. From personal experience, when this happens after a few months there will be a bad outcome, and you don't want your name on such a case.

At University Hospital in Cincinnati, we have an IM doctor available to see any patient that comes in, but only if we request. It's automatic if the patient is 55 or over. The IM doctors work well with us and also have a low threshold. As of right now but this will change in about 1.5 years, the psych unit was changed to a stand-alone sight, but we can get labs done quickly becuase they're sent to the main hospital.