[Residency Advice] Does it matter much how the program admits patients to the psych wards?

[rhondabear]

I’ve been on some interviews and talked with others about their interviews, and I’ve been kind of shocked at the variety of how patients are admitted.
(What’s normal to me is that a resident goes down to the hospital ED to assess the patient.)

Here are the other scenarios I’ve seen or heard:
- Redidents never/rarely admit themselves, instead there are NPs/PAs who do assessments all day and all night.
-Residents never/rarely admit themselves, instead there are social workers (???) and therapists assess the patient

It seems kind of odd/wrong to me that social workers are the ones doing assessment

Some other new/perplexing methods I am unfamiliar with are “crisis” units and “psych EDs” that are run by mostly by residents and then they transfer patients to a psych ward

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[MBBSMOM]

What is the question you are asking? Each hospital has its own flow. Most residencies will use residents in the ER for cheap labor. Attendings unless an absolute emergency never set foot in the ER. I haven’t set foot in an ER in years. My shop is staffed by social workers/LPC and when I’m on call they call me to discuss the pt. I make a recommendation on the level of care based on the SW/LPC assessment. Most hospitals outside of academia have SW/LPcs doing initial ER assessments.

 

[Sushirolls]

You are over thinking this. Simplify your thinking.
Admit / Observation [if available to an ED] / Discharge
Those are the three choices for an ED presentation of mental health.
Making that basic assessment can be done by ED / MSW / Psychologist in an okay fashion. Are they perfect? No, but that's where the evaluation on the inpatient unit by an actual Psychiatrist or Resident Psychiatrist allows for a more in depth assessment and even discharge. In residency there was a fair amount of 1 day discharges.

In general a psychiatrist in the ED is a waste of resources unless they have an observation unit or a true Psych ED adjacent to the regular ED.

Don't get too concerned if you aren't spending the time in the ED. Even if you did, and you wanted to discharge, chances are your attending will say admit. That's a long story. And once you become an attending and patient care falls on your head/license, you too will likely say admit.

 

[reca]

Idk, I think PES/CPEP experience is invaluable. It’s more than just admit/no admit, especially if you’re doing it well.

 

[rhondabear]

Thanks for all the replies.

I just wanted to make sure I’m not missing out at a place that doesn’t use residents in the ED, concerned that my ability to assess quickly/correctly would be lacking

 

[wolfvgang22]

Idk, I think PES/CPEP experience is invaluable. It’s more than just admit/no admit, especially if you’re doing it well.

You're right. It's also whether the admit is voluntary or involuntary.
Seriously, though, the more different settings a resident can experience the better. There is more than one way that can be effective.

 

[Fabio001]

Trust me when I say that a call shift, where doing safety evaluations is a primary task, will start to feel like busy work in short order, (personally, I'd avoid a program where doing safety evaluations is a majority component of any rotation or call shift). The decision on whether or not to admit a patient is one you'll get plenty of experience with on your consult rotations and in the outpatient setting.

As has been already stated, a resident or attending will often be on call for consultations with the crisis team on challenging cases, which is exactly as it should be. Otherwise, let the social workers handle the bread and butter so you can work at the top of your license.

 

[FlowRate]

Don't get too concerned if you aren't spending the time in the ED. Even if you did, and you wanted to discharge, chances are your attending will say admit. That's a long story. And once you become an attending and patient care falls on your head/license, you too will likely say admit.

While the attendings at one of our shops tend to be more conservative than at the other, we do a lot of discharging. It helps that we have a fourth option (unlocked crisis unit) and a "fifth" option that make makes people feel better even though it's still just discharge (partial hospital.)

 

[calvnandhobbs68]

There’s not some magical ability we suddenly obtain when we get a medical degree to assess risk more adequately than everyone else. Risk assessments are part training and part personal preference/risk tolerance anyway with pretty terrible inter rater reliability on who should be admitted or not when self harm risk is concerned (And all parts BS since we’re all as good as chance at predicting who is actually going to commit suicide anyway). Social workers can certainly be trained to perform risk assessments and perform these in many hospitals all over the country.

I do agree with the poster above that being exposed to as many different settings as possible during residency is beneficial. However, there’s a difference between being used as cheap labor (hospital uses you instead of other staff so they don’t have to hire social workers/NPs for that position) and having an educational experience. You could probably pretty easily do an elective at some point where you do a month or half days spread throughout the year of ED assessments if you wanted to see if you like that setting or feel you need that experience.

I also agree with the Fabio that unless you really love that setting, you’re gonna get sick of doing ED risk assessments pretty fast and it’s gonna feel like busywork. It doesn’t take long to realize you don’t need a medical degree to do risk evaluations....

 

[downwithDTB]

I would argue that it matters quite a lot; however, having lots of non-mds in the ED can be great or terrible. 1) getting comfortable with discharging lots of patients from the ed is an important skill in psychiatry as is learning to evaluate fresh presentations closely for the need for urgent additional medical work up. 2) I'd say I've discharged 90-95% of ED presentations in residency with the blessing of attendings. If you're too risk averse to discharge someone from the ED, you're putting that risk onto the inpatient attending which is cowardly. Short term hospitalizations don't alter risk for most people who come to the ED. 3) do you really trust someone with zero medical background or a busy ed provider who doesn't care about psych pts to identify a medical illness in a psychotic patient who isn't verbalizing a chief complaint? 4) do you want to be a resident in a program with a boatload of 1 day admissions? That's sounds like a terrible training experience and a boatload of paper work.

On the otherhand... If you're doing *all* of the work in the ED that isn't great either. A good SW and admin staff can screen patients who clearly aren't emergencies "I want a sandwich" "can I get an appointment?" help with dispo and referrals, work the shelter system, provide emotional support, do UR, call collateral, ect. The best ED has lots of support but lets psychiatists call the shots and only admits patients that will really likely benefit from the admission. Lots of patients are harmed by the reinforcement of maladaptive coping by excessive hospitalization that they don't follow up to the great expense of the taxpayer and patient. I would think that that ED setup would be a major impact on the quality of the experience for PGY1/2 and call as well as for referring to/from the ED in later years.

Also, it's really nice when you know showing up in the morning that any psychotic and potentially violent patient admitted overnight will have been treated appropriately so you don't want into a storm in the morning. I hate ED call but would hate a program without a psychiatist in the ED even more.

 

[Sushirolls]

Idk, I think PES/CPEP experience is invaluable. It’s more than just admit/no admit, especially if you’re doing it well.

Yes, Psychiatric EDs are a fantastic experience, a 1 month rotation, or better yet a moonlighting experience if people have access to them. But these units have the ability to observe patients, too.

The OP is talking about general residency exposure to general ED C/L work. That gets old real quick.

 

[psycharmed]

I’m just 3 months into residency but my 4 weeks of CPEP rotation have been the best. You get to see patients when they are the most sick and learn how to manage them, make a primary diagnosis and decide the dispo (re-eval, extended observation, admit, discharge). It’s one resident, one attending and one social worker along with nursing staff and the resident runs the show. Most attendings work collaboratively to hear your opinion on the dispo planning for the patient which allows for a good learning experience. I prefer it to inpatient because it’s shift work (8 am to 5 pm and sign out the remaining work to the on call resident) and you evaluate a patient cross sectionally rather than carrying them longitudinally.

 

[clausewitz2]

You're right. It's also whether the admit is voluntary or involuntary.
Seriously, though, the more different settings a resident can experience the better. There is more than one way that can be effective.

Hey now, there's more to it than all that.

You also have to decide whether they go up with IM Zyprexa or IM Haldol as their agitation PRN. Clearly a choice calling upon all four years of medical school training.

 

[clausewitz2]

I’m just 3 months into residency but my 4 weeks of CPEP rotation have been the best. You get to see patients when they are the most sick and learn how to manage them, make a primary diagnosis and decide the dispo (re-eval, extended observation, admit, discharge). It’s one resident, one attending and one social worker along with nursing staff and the resident runs the show. Most attendings work collaboratively to hear your opinion on the dispo planning for the patient which allows for a good learning experience. I prefer it to inpatient because it’s shift work (8 am to 5 pm and sign out the remaining work to the on call resident) and you evaluate a patient cross sectionally rather than carrying them longitudinally.

Hate to break it to you, but the typical inpatient stay is still pretty much a cross-sectional assessment.

 

[thoffen]

I think it matters. The fewer the handoffs, the better the care. That is pretty well known. That said, working interdisciplinary and combining assessments is also important for good care.

Most likely, the practical and business aspects of this are driving things away from that ideal. Exposure to this system and understanding its good and bad are also important. Outside of academics, there is a high likelihood that a lower level assessor will be handing off patients to you, and you will have to learn to budget your time wisely in this setting.

For best training? Perhaps a residency with multiple different systems so you can learn from each.

 

[Sushirolls]

There are also more nuances to this issue of admission in the usual ED setting.

Some EDs just lack the clinical SW presence to assist in discharge planning for patients. The other issue is patients show up during "psych time" which is noon to midnight, and discharge happens several hours later, ~3PM-3AM. This means calling to get appointments, calling to get collateral, calling to request gun removal, etc likely won't happen because its outside of business hours. And, well, can't reach Auntie Lakshmi, Uncle Billy Bob, or Cousin Nguyen because they don't answer their phone due to robo-calls. Thus, the scales tip in favor of admission.

 

[wolfvgang22]

I think it matters. The fewer the handoffs, the better the care. That is pretty well known.

Lies from biased research in the name of continuing resident labor exploitation. Other, more recent evidence is equivocal about this.

 

[thoffen]

Lies from biased research in the name of continuing resident labor exploitation. Other, more recent evidence is equivocal about this.

Oh? That's news to me.

 

[downwithDTB]

I don't think that there is any doubt that handoffs are bad. The outstanding question is what are you doing to reduce the number of handoffs... the research was conducted in a highly biased way to justify keeping 24 hr shifts. My read on it is that 2 handoffs are probably better than sleep deprivation but the studies were not designed to show that.

One can imagine scenarios for ED psych that reduce handoffs without tired doctors and some that increase handoffs without decreasing the tiredness of the docs.

 

[hallowmann]

I prefer admitting the patients I'm going to be taking care of. I think there is some value doing the ED assessments, but I also like getting all the information first, as it tends to help with planning the remainder of their admission. That said, my work rarely involves deciding if the patient needs admission. It has already been decided that they need admission, that's why I'm going to see them. That decision is made either by an ED physician or a PA, NP, social worker, or believe it or not an attending psychiatrist on the ED service. The only other times I have to evaluate ED patients is on-call when its an unclear disposition plan or when they are being admitted to the Obs crisis/Psych ED unit.

Things have shifted a bit since I first started now that we have the crisis unit/Psych ED, so a lot of the H&Ps are done either by the on call resident or the NP/PA staffing that unit. We still do a formal interview upon admission to the unit, gather collateral, etc., but the documentation burden is a bit less (although realistically the H&Ps done for that unit are quite variable in quality).

Whether or not you go down to assess the patient in the ED doesn't seem all that important to me, but ideally you should be the one evaluating the patient when they get to the floor and making the final decision in terms of medications to continue or start.

 

[NickNaylor]

Our PES experience (at the county hospital) was very educational, however we have an extremely busy service with a separate PED that is staffed 24/7 by attendings. Residents don't "staff" the ED solo or with attending-on-the-phone back-up. I think it can be useful to work in PED as you can see and get very comfortable with things like acute agitation, drug intoxication, etc. that you may not see as frequently on inpatient units (since they presumably won't make it to an inpatient unit). I would be less thrilled about an experience where you're simply "covering" the ED without an actual supervision... there's only so much learning/teaching that can occur in that type of setup, and the line between educational and service obligations quickly becomes blurred.

Having something like a LCSWs/LPCs assess patients in the ED to determine if they meet inpatient criteria and to provide referrals if they are going to be discharged isn't unusual. Our university hospital only has LCSWs overnight, and the C/L service will typically only see patients if there is an acute safety concern or the patient needs to be involuntarily admitted. The ED docs can admit to our inpatient unit after they meet with the LCSW without the patient ever seeing psychiatry, though we try to prevent that by having voluntary patients directly admit to our inpatient unit rather than going through the ED. Many private hospitals in the area seem to work this way.