So how long do you think a consult should take?

[Doctor Bagel]

---

Members do not see this ad.

So I'm relatively new to the non-academic world and have been a bit surprised by how consults are treated. In my job, we carry the pager about once a week which means we do orders for admits and cover consults as they arise on top of whatever our regular work load would be. Consults are relatively rare, but I feel like when they do pop up, there's an expectation that we can provide meaningful consults in really little amounts of time.

Case in point -- I received a consult request from the ED today later in the afternoon regarding a man with dementia and behavioral disturbances who appeared to be pretty much at baseline. His facility was requesting a psychiatric consultation with recommendations for PRNs prior to him returning to his facility. Of note, this guy already has a psychiatrist. So my thought is that to actually do a quality consult that would provide value to a geriatric patient with dementia, multiple medical concerns and behavioral disturbances would honestly take 2 to 3 hours including interviewing the patient, his doctor, care givers, reviewing the (quite extensive) chart and lastly writing your note. That was not remotely feasible for my work flow for the day, and I wound up briefly talking to this guy, reviewing his MAR for totally inappropriate stuff (which btw wasn't there) and doing a quick chart review for obvious things. That took an hour and provided I thought about zero value.

I feel pretty comfortable doing admissions more quickly because you have more time with people and can figure out things as you go along. These one time consults, though, with patients where you won't do follow up are hard. Am I being entirely unreasonable in thinking it's unrealistic to expect psychiatric consults in short periods of time?

 

[nexus73]

An hour is reasonable. But it's a crap consult to begin with IMO. I assume this was less of a request for psych consult from the facility and more of a demand, as in they won't accept patient back without a psych consult. The facility is in CYA mode and wants a psychiatrist to carry any potential short term liability following whatever behaviors led him to the ED... until the patient can be seen by his main psychiatrist as an outpatient.

Evaluating the meds is probably most important to minimize typical deliriogenic substances. Beyond that, contacting the facility to look into the precipitant of the behavior problem would be useful in an ideal world, but in my experience you're unlikely to get them to change anything unless the patient has some type of case management as an outpatient to advocate for him and help either improve staffing or switching facilities. I've had patients where behavior problems were totally caused by staff being a bad match for the patient. For example, a racist army vet with dementia in an adult family home run by predominantly Vietnamese staff. Moving him to a different facility with caucasian staffing completely changed his behavior. You're unlikely to get a change like this accomplished out of the ED. I was able to do this from an outpatient office with highly involved case management specifically providing geri psych care through the county.

If your patient was on a medicine service and you had a few days you might be able to make more meaningful med adjustments.

 

[keifernny2]

I usually don't spend more than 45-60 mins per consult. Anything that requires more than that will often benefit from admission to sort out the issues.


Sent from my iPad using Tapatalk

 

[smalltownpsych]

My consults typically include the recommendation for what the patient needs as I won't be providing it given the limitations of the situation. For a case where they are trying to kick the liability can to me, I just kick it right back. For a case of danger to self or others, I comment directly on what I can observe and only that. I then recommend that the people who made the referral continue to monitor and take steps to ensure safety, provide treatment, and they can always bring em back if they deem necessary. In the middle of it all, if I can provide one useful tip or insight that will help, then I feel it was a good consult. Everyone is too busy to remember much more that one key point anyway so I try to stay focused on that.

Also, you should really read House of God as it has great advice on how to deal with patients and situations like this. 🙂

 

[sunlioness]

I remember those consults. They were frustrating. They bring in grandpa for grab assing the pretty nurse's aid. Won't take him back until I clear him and comment on what meds he needs so he won't grab ass anymore. I write a note saying grandpa's fine, you need to train your staff.


Sent from my iPad using Tapatalk

 

[Doctor Bagel]

I did pretty much leave it like you need to work with this patient's psychiatrist and pcp on making medication adjustments. I felt a bit exploited. Maybe if I got paid for work instead of a straight salary, it would be less annoying. Also, I hate geriatric psychiatry...

Lots of these patients probably would benefit from someone actually having the time to look at their charts, talk with people and possibly make meaningful recommendations, but who has the time (or gets paid for taking the time). Of course that's a bigger comment on medicine in general. Reminds of my community psych job where people would show up with their residents from their care facilities who had significant impairments (often profound MR) and train wreck medications just to sedate them 25 minutes into a 30 minute appointment and want me renew their prescriptions.

 

[Doctor Bagel]

An hour is reasonable. But it's a crap consult to begin with IMO. I assume this was less of a request for psych consult from the facility and more of a demand, as in they won't accept patient back without a psych consult. The facility is in CYA mode and wants a psychiatrist to carry any potential short term liability following whatever behaviors led him to the ED... until the patient can be seen by his main psychiatrist as an outpatient.

Evaluating the meds is probably most important to minimize typical deliriogenic substances. Beyond that, contacting the facility to look into the precipitant of the behavior problem would be useful in an ideal world, but in my experience you're unlikely to get them to change anything unless the patient has some type of case management as an outpatient to advocate for him and help either improve staffing or switching facilities. I've had patients where behavior problems were totally caused by staff being a bad match for the patient. For example, a racist army vet with dementia in an adult family home run by predominantly Vietnamese staff. Moving him to a different facility with caucasian staffing completely changed his behavior. You're unlikely to get a change like this accomplished out of the ED. I was able to do this from an outpatient office with highly involved case management specifically providing geri psych care through the county.

If your patient was on a medicine service and you had a few days you might be able to make more meaningful med adjustments.

Basically they wanted to d/c him as soon as I saw him, so no chance to make any changes and monitor for efficacy. I think they didn't want to take him back and were hoping he'd get admitted with new housing found for him. It was a crap consult -- actually devoting an hour to it meant I got home even later after an already long day.

 

[wolfvgang22]

I get consults like this all the time also. I spend about 45 minutes to 1.5 hours on them depending on complexity. If it's a guy with dementia pinching nurses, that takes 45 minutes or less usually. They often want me to "talk" to the poor guy with advanced Alzheimer's and shame him into not pinching nurses and sedate him somehow. I don't do that. I recommend Behavioral interventions, staff training. Sometimes the patient gets passed around the nursing facility carousel sometimes, like a hot potato. It stinks.
I often wonder if one day I'll be that 88 year old guy...

 

[smalltownpsych]

Basically they wanted to d/c him as soon as I saw him, so no chance to make any changes and monitor for efficacy. I think they didn't want to take him back and were hoping he'd get admitted with new housing found for him. It was a crap consult -- actually devoting an hour to it meant I got home even later after an already long day.

Rule from House of God: Placement comes first. Have the nurse contact the social worker to get on it right away 'cause nothing our consult does will change that fact.

I get consults like this all the time also. I spend about 45 minutes to 1.5 hours on them depending on complexity. If it's a guy with dementia pinching nurses, that takes 45 minutes or less usually. They often want me to "talk" to the poor guy with advanced Alzheimer's and shame him into not pinching nurses and sedate him somehow. I don't do that. I recommend Behavioral interventions, staff training. Sometimes the patient gets passed around the nursing facility carousel sometimes, like a hot potato. It stinks.
I often wonder if one day I'll be that 88 year old guy...

Whenever I do end up in the nursing home, I'm sure that I will be that guy. It's like a free pass to touch the girls. "I can't help it, I'm old and feeble-minded". 😏

 

[sunlioness]

I kinda want to be the feisty old lady. Somehow the guy employees never seem to mind as much. Perhaps I'll get more action than I do now.


Sent from my iPhone using Tapatalk

 

[SourceOfDenial]

We have a dedicated psych ER so these folks come in all the time. Usually takes about an hour, and rarely do we admit--if they do get admitted its because we find something medical. Most of the time the nursing home psychiatrist comes by rarely. Lots of poor medication choices, redundancy, benzos, anticholinergics, etc.

Seems like often it's someone who is frustrated, staff tells them they can't do something and then try and stop them physically when the do, so staff gets pushed, yelled at, hit. And then calling and getting the person on the phone who was there is always difficult.

The whole experience has made me realize if Im heading to a nursing home, I'm going to make sure my family knows to off me instead.

 

[nexus73]

Basically they wanted to d/c him as soon as I saw him, so no chance to make any changes and monitor for efficacy. I think they didn't want to take him back and were hoping he'd get admitted with new housing found for him. It was a crap consult -- actually devoting an hour to it meant I got home even later after an already long day.

I highly recommend pursuing salary by wRVU. If enough psychiatrists band together it could happen at your institution.

 

[nexus73]

Mount Misery as the sequel to House of God is worth a read for psychiatrists (set at fictionalized Mclean Hospital outside Boston).

 

[Doctor Bagel]

Mount Misery as the sequel to House of God is worth a read for psychiatrists (set at fictionalized Mclean Hospital outside Boston).

I had been hesitant to read it because the first half of House of God was pretty awesome, but it kinda fell apart partway through. I was worried Mount Misery might be more of the same. The rules of the House of God are pretty spot on, though. They can always hurt you more.

 

[nexus73]

I had been hesitant to read it because the first half of House of God was pretty awesome, but it kinda fell apart partway through. I was worried Mount Misery might be more of the same. The rules of the House of God are pretty spot on, though. They can always hurt you more.

Similar pattern with MM; falls off a bit at the end.

 

[splik]

I look at consults the way a freudian would analyze a dream: there's the latent consult and the manifest consult.

no one ever consults psychiatry for delirium recs, or to diagnose a patient with mental disorder, or to look for other causes of their psychiatric distress. And this is where understanding what the latent content of the consult is comes in as the real reason for the consult

Examples

Manifest consult: "We think this patient has schizophrenia and appreciate your recs"
Latent consult: "We want to turf this patient to your service because we're not doing anything for him and he's being a nuisance"
Phatansy/defense: disavowal
What actually happens: patient has delirium. make recs for behavioral management and prn haldol with advice look for underlying medical cause. ortho discharges patient anyway

Manifest consult: "This patient has borderline personality disorder, we'd appreciate your recs for management of her non-compliance with insulin"
Latent consult: "We're pissed off because she won't do what she's told. Please make her do what she's told!"
Phantasy/defense: wishful thinking, magical thinking
What actually happens: patient feels helpless in hospital, regresses, non-compliance only way of asserting control. but you can't make her do what they want because they won't listen to her. Consulting service angry at you for not being magically able to make her comply

Manifest consult: "This patient said she was suicidal, please come and do a safety assessment"
Latent consult: "please come and take this patient off our service"
Phantasy/defense: passive aggression, disavowal
What actually happens: patient has hypoactive delirium, doesn't know what she's doing. recommend look for underlying cause and behavioral mx.

Manifest consult: "Please come and assess capacity to refuse placement"
Latent consult: Please help us force this patient into placement
Phantasy/defense: disavowal, wishful thinking, intellectualization
What actually happens: patient has capacity to refuse placement. even if she didn't you couldn't force them into a SNF. consulting service displaces hostility onto psychiatric consultant

Manifest consult: "Please come and assess capacity to refuse surgery"
Latent consult: "please consent thing patient for surgery and explain procedure to them because I wasn't able to explain this to them effectively"
Phantasy/defense: intellectualization
What actually happens: they need to actually explain procedure to patient. you can help assess capacity if relevant while consenting patient.

Manifest consult: "patient is violent, please come and assess"
Latent consult: "I'm having murderous thoughts about this patient, and they are becoming increasingly agitated, please admit to your service"
Phantasy/defense: projective identification
What actually happens: patient is frustrated about how they are treated in the hospital and feel better when has chance to vent about it but ultimately leaves AMA

I enjoy seeing consults but let's face it, most of it is pretty basic stuff. I don't think it would make a difference in the majority of cases if you spent 2-3 hours vs. 45 mins if the consult is BS in the first place. At any rate, even if you had wonderful recs they probably wouldn't listen to them anyway because that wasn't what they wanted. I think about 50% consults I could make recs without even seeing the patient and most of the time you can figure it out in 20 mins of so. 10-20% of the time there is something a bit more challenging to tease apart.

I wouldn't write more than a paragraph for the simple ones. no one wants to read more than that and it's not necessary for billing as should be on time and >50% counseling and coordination of care.

 

[Doctor Bagel]

I enjoy seeing consults but let's face it, most of it is pretty basic stuff. I don't think it would make a difference in the majority of cases if you spent 2-3 hours vs. 45 mins if the consult is BS in the first place. At any rate, even if you had wonderful recs they probably wouldn't listen to them anyway because that wasn't what they wanted. I think about 50% consults I could make recs without even seeing the patient and most of the time you can figure it out in 20 mins of so. 10-20% of the time there is something a bit more challenging to tease apart.

I wouldn't write more than a paragraph for the simple ones. no one wants to read more than that and it's not necessary for billing as should be on time and >50% counseling and coordination of care.

Yeah, that's the thing. 2 hours of a geriatric consult gathering all the data I needed to gather would be wasted. I'd probably be doing it more for a sense of pride in my own work than for any actual good. I don't enjoy consults -- I especially don't enjoy the aspect of losing control of my time for something of so little value. Actually regardless of value, I don't enjoy losing control of my time. I could have gone for a run or had an extra hour to spend at dinner with my husband.

OK, so on an actual clinical note -- would anybody recommend prn's for a patient who is going back to a facility, and you'll have no opportunity to see if anything works? Am I insane in thinking that's an insane question?

 

[doctorpilgrim]

Splik has explained it well. One of the more helpful things I do in a consult is helping formulate the question or latent/real intent of consult as usually this is what leads to an effective resolution. If the question was delirium or capacity or an obvious one then usually up to date is consulted instead of me.
Once the real question is identified it becomes a focused consult.

 

[st2205]

The whole delirium consult baffles me. The things we emphasize on clerkship, at least for the test, are on the worthless nuances of different psychotic/mood disorders or knowing the time frame of brief psychotic / schizophreniform / schizophrenia, etc. Amazingly, no med student walks away from their psychiatry rotation knowing what delirium is, what it looks like clinically, and why it's not psychosis. But, damnit, we know the difference between schizoaffective disorder bipolar type and bipolar disorder with psychotic features... at least on paper!

 

[wolfvgang22]

Yup. I learned all about delirium in residency on consult rotations, as well as the nuances of the Turf.

 

[smalltownpsych]

Love the Freudian conceptualizing. I had a consult tonight for a patient with borderline intellectual functioning and type 1 diabetes who yells a lot and has been arguing and becoming increasingly hostile with nurses about his insulin dosages and blood sugar levels. Manifest content was capacity but latent content was can you make him nicer or if not at least we can get some empathy as we deal with this difficult patient. A lot of the time the "treatment" is for the people requesting the consult. I spent 45 minutes calming patient, 20 minutes calming nurses, and ten minutes calming the medical doc on call. By the time I left they were no longer all threatening each other. Reminded me of some family sessions I have done. No real complex diagnosis/conceptualizing or strategy to fix anything other than if you all stop being so damn angry with each other things might go a lot better for everyone. Kind of like my dad when us kids would fight in the back of the car. He didn't care who started it, he just wanted it to stop - or else. 😱

 

[Doctor Bagel]

The whole delirium consult baffles me. The things we emphasize on clerkship, at least for the test, are on the worthless nuances of different psychotic/mood disorders or knowing the time frame of brief psychotic / schizophreniform / schizophrenia, etc. Amazingly, no med student walks away from their psychiatry rotation knowing what delirium is, what it looks like clinically, and why it's not psychosis. But, damnit, we know the difference between schizoaffective disorder bipolar type and bipolar disorder with psychotic features... at least on paper!

That's a good point. At my medical school, we all spent 2 weeks on the consult service so we saw a lot of delirium. I forget that having consult experience isn't a normal part of most medical students rotations. It's also not emphasized on their shelf.

 

[Doctor Bagel]

Love the Freudian conceptualizing. I had a consult tonight for a patient with borderline intellectual functioning and type 1 diabetes who yells a lot and has been arguing and becoming increasingly hostile with nurses about his insulin dosages and blood sugar levels. Manifest content was capacity but latent content was can you make him nicer or if not at least we can get some empathy as we deal with this difficult patient. A lot of the time the "treatment" is for the people requesting the consult. I spent 45 minutes calming patient, 20 minutes calming nurses, and ten minutes calming the medical doc on call. By the time I left they were no longer all threatening each other. Reminded me of some family sessions I have done. No real complex diagnosis/conceptualizing or strategy to fix anything other than if you all stop being so damn angry with each other things might go a lot better for everyone. Kind of like my dad when us kids would fight in the back of the car. He didn't care who started it, he just wanted it to stop - or else. 😱

This reminds me of one time in residency where I was on backup call and got called in for a consult that really boiled down to a turf war between palliative care and a surgical service. Might have been fine during the day but I didn't appreciate having to come in after hours to deal with it. It wasn't helped by my program's rule that we see all consults when they come in rather than sometimes (appropriately) delay them to the next day. So, ugh, hate consults due to my own manifest content of powerlessness.

 

[splik]

The whole delirium consult baffles me. !

well my point was no one consults psychiatry for delirium...they would consult internal medicine. we may diagnose delirium but that's not the reason for the consult.

 

[sunlioness]

I always hate it when I get delirium consults. It's like you're an intensivist. You see delirium all the time. I'm an outpatient psychiatrist covering a service. What could I possibly add to the treatment of delirium that you don't already know. 🙁

It makes me a little less annoyed when I get the "we will consult psych to restart home meds" consults. Because I figure as pointless as that is .... At least I can do it.


Sent from my iPad using Tapatalk

 

[Shikima]

What's the reimbursement on consults anyways for the amount of time and energy spent on them?

 

[FlowRate]

That's a good point. At my medical school, we all spent 2 weeks on the consult service so we saw a lot of delirium. I forget that having consult experience isn't a normal part of most medical students rotations. It's also not emphasized on their shelf.

Funny enough, the "common knowledge" at my school is that the CL rotation (we had choice of CL or inpatient) will be better preparation for the shelf, because specialty shelf (at least psych and neuro) exams seem weighted toward what the average internist should know, plus occasional basic science of the field questsions, so lots of med interactions, some genetics, and then standard diagnostic criteria questions.