State of telepsych and warning

[nomadlexus]

My inpatient job terminated the psychiatrists recently and replaced with telepsych np's overseen by MD "medical director" who is also remote. The change began slowly, but looking back the writing was on the wall the last 1-2 years. We had long standing tension with hospital admin about psych services being inadequate, despite no objective evidence this was true. Really admin wanted psych to be run like hospital medicine with 24 hour coverage, but run by a small group of psychiatrists that work days, no nocturnist. The initial push was to get telepsych into the ED for overnight consults. This transitioned to telepsych screening and accepting patients for admission overnight. Then we lost 2 docs and admin said they would not be replaced, and then expanded telepsych to covering ED all hours and supplementing the consult service with telepsych. Then telepsych expanded to covering all ED and med floor consults with inpatient being the last service covered by in person doctors. Then the hammer fell and the in person team was let go.

I guess the point of my post is to serve as some kind of warning to others about the insidious shift to telepsych and looking back my advice would have been to refuse any telepsych presence at all. I also regret not more aggressively pushing for peer review of bad telepsych consults (which were frequent), and documenting in emails my concerns, as this could have been helpful for post termination lawsuit potentially.

Also, I'm curious what others are seeing in the realm of telepsych services in the hospital. I certainly see the benefit of telepsych in hospitals that cannot hire an in person team. But our hospital had in person doctors and was replaced anyways. I assume it was a cost cutting measure, but of course when you get let go they will never tell you that.

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[smalltownpsych]

They did this exact same thing at our local hospitals psych unit and the neighboring city fired all of their psychiatrists and replaced with NPs. It is like a race to the bottom with hospital based psychiatric services. Telepsych devalues what we do both as psychiatrists and psychologists. Sure it can make sense in some situations but in my mind because of how it threatens our field, we should all fight it.

 

[Jules A]

The two hospitals where I worked that brought in telepsych quickly did away with it because they were terrible. The ED coverage was lame and consults were horrendous.

 

[Wheatbread]

That’s terrible. How big is the inpatient unit?

 

[finalpsychyear]

NPs are coming and soon most states will be autonomous. I thought we had 10 years but its coming sooner. This idea has always kept me working harder and extra since i felt it was a legit threat. Still sorry to hear this.

 

[nomadlexus]

The two hospitals where I worked that brought in telepsych quickly did away with it because they were terrible. The ED coverage was lame and consults were horrendous.

The consults were consistently bad for us too, bad diagnosis, missing delirium, missing catatonia, never available for follow up questions, different docs each day making weird med changes that made no sense, no concept of safety planning--everyone needs psych admission, admitting patients with dementia, severe intellectual disability and autism brought in due to an outburst at the group home but had been calm in the ED for 12+ hours need admission, just all around bad psychiatry

The new job I'm at seems more like your experience, where telepsych is bad and the ED and hospitalists recognize it and don't like it, it's been only a stop gap when in person wasn't available, with goal of the hospital to not need telepsych

I think if someone is facing telepsych moving in, rallying support from the ED and hospitalists is key so they can push back together on bad care

 

[jbomba]

Are these private hospitals? I work county facilities and jail, and I haven't seen any talk of being replaced. We also have no NPs seeing any patients, it's only psychiatrists. I'm wondering if out here in CA there is some sort of regulation that patients need to be seen by a physician in these publicly funded facilities.

 

[mistafab]

everyone needs psych admission, admitting patients with dementia, severe intellectual disability and autism brought in due to an outburst at the group home but had been calm in the ED for 12+ hours need admission, just all around bad psychiatry

The problem is you weren't trained right - and these midlevels and overnight consultants were. Someone who has a chart diagnosis of dementia or severe ID/autism and is non-verbal is actually a new diagnosis of schizophrenia at age 84. They need to be on quetiapine, risperidone, and rexulti. Low doses on all of them, plus atarax 50 mg q 6 hr. Why do they keep getting agitated? Start clonazepam 1 mg TID as well. Plus on discharge you need to give them bipolar disorder as well because "they were agitated, which is more likley bipolar."

Bonus points if you discharge on the date that insurance pulls coverage.

 

[thelastpsych]

The problem is you weren't trained right - and these midlevels and overnight consultants were. Someone who has a chart diagnosis of dementia or severe ID/autism and is non-verbal is actually a new diagnosis of schizophrenia at age 84. They need to be on quetiapine, risperidone, and rexulti. Low doses on all of them, plus atarax 50 mg q 6 hr. Why do they keep getting agitated? Start clonazepam 1 mg TID as well. Plus on discharge you need to give them bipolar disorder as well because "they were agitated, which is more likley bipolar."

Bonus points if you discharge on the date that insurance pulls coverage.

As a side note, any and all emotional disregulation is called bipolar for some provoders. Even clear cases of BPD, or patients with delirium. They start the mood stabilizer, and you are the bad guy for reviewing the diagnsosis and pulling out valproate/lithium etc, even if such drugs only accumulate side effects.

 

[Sushirolls]

My experiences with Big Box shops is quite simple. A place is either really supportive of psych and shows it.

Or they are merely tolerating psych and ignoring it, which means nothing will change for the better.

Or they are on path to get ridding of everything psych.

These decisions are not made at physician leadership level but the admin folks above. You won't ever be privy to their thoughts, but you can judge their actions. If you are on the positive track - which is rare - consider yourself blessed. The other two tracks, you should already be preparing for plan B.

Currently in my new middle of nowhere location I already witnessed a tiny hospital implode and gut their whole psych department. One closer to me might actually be a good one and worthy of helping to build theirs up - but having rode the hospital political goat before - a mere leadership change is all it takes to implode.

I'm sticking with solo private practice.

 

[Sushirolls]

@nomadlexus
Congratulations. This is a hard career lesson to learn, to be slapped by, but you are free.
You are now free to decide your career trajectory, "unburdened by what has been."

 

[lobstar]

My hypothesis is that this happens mainly due to the cost of midlevel vs doc and also that outcomes and quality in psychiatry are nearly irrelevant for the business side of medicine. Even if a midlevel (or a doc for that matter) makes bad treatment decisions, the diagnosis is somewhat nebulous anyway (bipolar vs schizophrenia vs weird vs drugs) and 10 psychs will have 3 different opinions. We've all read the charts where the first line is pt has a history of 8 diagnoses and everyone knows its all nonsense garbage, but the notes has looked like that for years over numerous docs or midlevels. Someone says bipolar, I say BPD, either way the financial picture is they discharged on day 8.

Add in suicide being very rare, can't really sue over weight gain since you can't pin it on the meds in a strict liability sense, tardive dyskinesia mostly happening on people without the cognitive ability/organization to get a lawyer, and a population that's hard to study at baseline due to consent, follow-up, etc and you're left with admins moving us interchangeably or just gutting the entire department since it doesn't make much money anyway and the liability is exceedingly low.

 

[FN9]

My hypothesis is that this happens mainly due to the cost of midlevel vs doc and also that outcomes and quality in psychiatry are nearly irrelevant for the business side of medicine. Even if a midlevel (or a doc for that matter) makes bad treatment decisions, the diagnosis is somewhat nebulous anyway (bipolar vs schizophrenia vs weird vs drugs) and 10 psychs will have 3 different opinions. We've all read the charts where the first line is pt has a history of 8 diagnoses and everyone knows its all nonsense garbage, but the notes has looked like that for years over numerous docs or midlevels. Someone says bipolar, I say BPD, either way the financial picture is they discharged on day 8.

suicide is rare when competent treatment is provided, start missing obvious signs, making poor decisions regarding medications and commitment and all of the sudden you will have a law suit or two plus admitting everyone is a recipe for pissing off admin due to financial reason, so it works short term but what I have seen is you cant replace the whole team of MDs with NPs, just doesnt work, a few NPs sprinkled in there and maybe life goes on.

 

[comp1]

Name and shame. Definitely not seeing this where I am. Hospital leadership would rather an inpatient position just remain empty forever.

 

[Candidate2017]

suicide is rare when competent treatment is provided, start missing obvious signs, making poor decisions regarding medications and commitment and all of the sudden you will have a law suit or two plus admitting everyone is a recipe for pissing off admin due to financial reason, so it works short term but what I have seen is you cant replace the whole team of MDs with NPs, just doesnt work, a few NPs sprinkled in there and maybe life goes on.

A hospital/business doesn't need to replace all doctors, just most of them, and the remaining docs are pressured to "supervise" NPs. Even better, some of the docs join the dark side and become admin. If the doctors leave, the business hires locums until the new crop of grads with 6-figure loans sign on for a paycheck. Rinse and repeat. There's a reason only 10% of psychiatrists do inpatient.

And The Man doesn't care about malpractice deaths, as malpractice only falls on physicians and NPs. It doesn't cost the hospital anything. $1 mil from the physician's malpractice + $ 1mil from NP's malpractice + their personal assets + whatever business liability insurance the hospital carries is more than enough to compensate a wrongful death (if there is a wrongful death, not just malpractice). Worse case scenario, a bankruptcy filing means lawsuit judgments will never get paid. Plaintiffs' lawyers know this. Whatever record breaking jury award you hear in the news against a hospital is settled for much less.

 

[calvnandhobbs68]

A hospital/business doesn't need to replace all doctors, just most of them, and the remaining docs are pressured to "supervise" NPs. Even better, some of the docs join the dark side and become admin. If the doctors leave, the business hires locums until the new crop of grads with 6-figure loans sign on for a paycheck. Rinse and repeat. There's a reason only 10% of psychiatrists do inpatient.

And The Man doesn't care about malpractice deaths, as malpractice only falls on physicians and NPs. It doesn't cost the hospital anything. $1 mil from the physician's malpractice + $ 1mil from NP's malpractice + their personal assets + whatever business liability insurance the hospital carries is more than enough to compensate a wrongful death (if there is a wrongful death, not just malpractice). Worse case scenario, a bankruptcy filing means lawsuit judgments will never get paid. Plaintiffs' lawyers know this. Whatever record breaking jury award you hear in the news against a hospital is settled for much less.

In general, very rarely does anyone have to do anything in terms of personal assets for malpractice suits. Especially in psychiatry, judgements are dropped down to limits or settled for way under limits. Much more likely for the hospital to have to pay out multiple millions of dollars before anyone goes after a physicians personal assets.

 

[Sanman]

Not surprised by this at all other than it happening so quickly/abruptly. The ironic part for me is that my hospital is struggling to find in person psychiatry or specialty psychology. From a cost perspective, I only see this worsening. I imagine that more and more psychiatry will be cash only. Seeing the same thing for PCPs in my area as well. Concierge medicine is becoming more and more common is you don't want to see an NP at the local in-network hospital-affiliated group practice. Every physician who leaves seems to be replaced with an NP.

 

[Celexa]

Economic incentives almost never line up with quality care in psych, but everywhere I've been they HAVE lined up towards the hospital wanting patient throughput and therefore discharged. Much unhappiness if psych pts are tying up ED beds. And my understanding has been that telepsych is less risk tolerant (and also isolated from the social pressures of, say, irritated ED and medicine colleagues) so they admit more people. Seems like that's a decision which will rapidly bite the hospital on the ass unless they're in one of those perverse situations where admitting and holding the pt for all insurance days is incentivized, like in those recent articles about the for profit chain in Florida. In which case it seems like a disaster waiting to happen and better to flee now anyway.

There has been a push at my (academic) institution for us to provide coverage to our newly acquired remote sites with telepsych coverage (these are places without psych), but no discussion of replacing us. I'm sure part of that is due to the academic setting but also, as I said, they need people discharged and our leadership seems aware that random tele will not help them with throughput.

 

[zolof]

My inpatient job terminated the psychiatrists recently and replaced with telepsych np's overseen by MD "medical director" who is also remote. The change began slowly, but looking back the writing was on the wall the last 1-2 years. We had long standing tension with hospital admin about psych services being inadequate, despite no objective evidence this was true. Really admin wanted psych to be run like hospital medicine with 24 hour coverage, but run by a small group of psychiatrists that work days, no nocturnist. The initial push was to get telepsych into the ED for overnight consults. This transitioned to telepsych screening and accepting patients for admission overnight. Then we lost 2 docs and admin said they would not be replaced, and then expanded telepsych to covering ED all hours and supplementing the consult service with telepsych. Then telepsych expanded to covering all ED and med floor consults with inpatient being the last service covered by in person doctors. Then the hammer fell and the in person team was let go.

I guess the point of my post is to serve as some kind of warning to others about the insidious shift to telepsych and looking back my advice would have been to refuse any telepsych presence at all. I also regret not more aggressively pushing for peer review of bad telepsych consults (which were frequent), and documenting in emails my concerns, as this could have been helpful for post termination lawsuit potentially.

Also, I'm curious what others are seeing in the realm of telepsych services in the hospital. I certainly see the benefit of telepsych in hospitals that cannot hire an in person team. But our hospital had in person doctors and was replaced anyways. I assume it was a cost cutting measure, but of course when you get let go they will never tell you that.

darn thats too bad
what area of the country if you dont mind? doesnt have to be specific just southwest, southeast, etc. so I can avoid that area for inpatient. I havent seen this happening in the north and southeast where I have worked, however I would not be surprised if it did.

 

[ridethecliche]

Having telepsych NP coverage for inpatient coverage is freaking criminal. Holy moly that's W.I.L.D.!

I do a bit of telepsych overnight ED coverage at the main hospital I'm at but don't love it. I'm starting to look for a job and hoping I can push to get some time to do overnight in person coverage. I think it's embarrassing for us to have tele overnight as the baseline. I like the psychiatrists who do that here full time, but I really don't get it.