Telepsychiatry in the ED and liability

[1edyfirel]

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Considering a 1099 telepsych ED job--pay is good, workload seems reasonable. However, from looking at threads here there are a couple posters who are very adamant this is high liability, bad medicine, and they would never do it. Would like to hear more, or hear from people who have actually done telepsych in the ED. I like ED/CL work and still do a decent amount now (in person). Wondering why the liability is so much higher for tele vs in-person (assuming pt has had med workup/clearance before I eval, similar to in-person). Thanks!

 

[reca]

What do you consider "good pay"?

 

[1edyfirel]

What do you consider "good pay"?

$200/hr, though I’m not asking the message board for their thoughts on the offer. I’ve done a ton of interviewing and comparison of offers, and I am certainly aware of the garbage rates being offered.

I also don’t know why that is your contribution to my question. Super helpful ...

 

[reca]

Calm down. You asked a question and are now getting fired up the second you're asked about more details. If you consider that "good pay" for ER work, jump on it.

For others reading the thread, I wouldn't recommend the liability of telepsychiatry in the ED at such a low rate.

 

[robellis]

Calm down. You asked a question and are now getting fired up the second you're asked about more details. If you consider that "good pay" for ER work, jump on it.

For others reading the thread, I wouldn't recommend the liability of telepsychiatry in the ED at such a low rate.

I agree with this, telepsych ED work is probably the highest liability because you’re essentially a liability blanket for the hospital so the pay better be commensurate with that risk and 200/hr is something you can get many settings

 

[1edyfirel]

So my question isn’t actually about what amount is enough for the liability risk. I’m curious about others experience doing this work and why some doctors say they would never do tele psych ED work. If this is ****ty medicine with a high liability risk, there’s no dollar amount I would do that for. I’m just trying to be as informed as possible into the nature of the work.

 

[nexus73]

I’d guess the liability is if you recommend discharge and something bad happens. The ED doc is going to side step that responsibility as fast as possible.

For this reason I assume telpsychiatrists are pretty conservative and recommend a lot of admissions that would typically be unnecessary. And why wouldn’t they? They don’t know the local resources. They have no loyalty to the hospital or concern about use of resources. And who wants to get sued in Wyoming when you live in Virginia (you get to go to Wyoming for the deposition).

 

[psychacad]

Since when $200/hr is 'such a low rate'? That is much higher than average for telepsych, and even higher than average for regular ER work at least in metro areas.

Not to further derail this thread with more nonsense, cause the point was clearly not about the pay.

I'd be interested if someone has direct experience as well. Thing is, at the end of the day, you have to follow your instinct/judgement, and you have the option to err on the safe side (hold for observation) if you don't feel the evaluation is good enough. I feel like if you cross your t's and dot your i's and do good work like in a regular ED, you should be fine. i.e: try to always get collateral, especially if the pt was sent by someone else or there's concern about SI, have a solid discharge plan in place (outpatient referral, observation with family if needed...etc) and most importantly document well with a well reasoned risk assessment. If you do this, imo it should be OK even if something bad happens. Another thing to know is the availability/quality of staff. Are you working with psychologists vs SWs vs NPs? (psychologists tend to do a much better job, imo).

 

[splik]

I am one of the voices who warns of the liability of this kind of work, but I am going to give you a balanced perspective here. I still recommend avoiding this work. I do some inpatient C-L telepsych. I do not and will not do ER telepsych. We explored this for our own service during the early days of COVID and I prohibited it. I have colleagues who do telepsych malpractice cases. I've also heard the companies like Vituity that push this model make the case against it being high liability.

Here are my concerns:
- the standard of care is at least the same for telepsych as it is for in person care. Some have argued that the standard of care for telepsych is higher than for in person care. This is an evolving area. No one (not least the lawyers) are arguing the standard is lower.
- I have a lot of experience evaluating acute presentations via telepsych. That's fine in the hospital setting (they're already admitted). Not so in a busy, noisy ER where the pressure is to get the patients out. You miss a lot via tele in terms of non verbal cues, picking up subtle psychosis, subtle cognitive dysfunction, and limited in terms of your physical exam of the patient
- You are reliant on staff in the ED to help in your assessment. Typically it is PAs or NPs who are dealing with these patients, not physicians. You also have to rely on RNs who may not have any interest in dealing with psych patients.
- even in person (I work at a great hospital with excellent physicians) and they still try to pass of patients in DKA, who are sepsis, in acute liver failure, in DTs and so on as "medically clear". Try figuring that out via telemedicine.
- the ER is already the highest liability area for psychiatrists to practice in. Try doing that via telepsych considering the concerns mentioned above and you will see where it becomes even higher liability. Now, it's not OB or spinal surgeon, but it does create a problem for the uninitiated
- it requires a special skill set, experience, and body of knowledge. The malpractice attorneys are already arguing that telepsychiatry is a subspecialty of psychiatry that requires specific education, training and experience. And there are people willing to testify to that effect.
- I have met several expert witnesses who are eager to throw their colleagues under the bus and ultimately it is expert testimony that sets the standard of care in these cases in the absence of clear guidance

Here the arguments against:
- for years people were arguing that doing telepsych to patients homes instead of in a clinical setting was a recipe for disaster and over the past yr it has become the de facto way of receving mental healthcare with little fanfare
- the malpractice insurance companies do not charge more for telepsych work because their actuarial calculations don't indicate that it is higher liability
- you are a consultant, and thus the in person docs are the ones on the hook (though consultants in person are sued all the time)
- you are just providing an opinion to the primary physician (ahem, PA/NP) who is seeing the patient on the ED, it's on them to decide what to do
- if you weren't seeing them via telemed, they wouldn't be seem by psych at all
- psychiatrists are still the least likely to be sued of any physicians and that has not changed with telepsychiatry

I don't consider these, except maybe the first two, particularly persuasive. This is new terrain and its usually several years after the incident that the malpractice claim is filed. But it is definitely true people were hysterical about doing telepsych to patients' homes and now that is the standard.

If you're interested, the kinds of cases that have resulted in a negligence case are failure to recognize another medical condition (yes, the telepsychiatric consultation will be named a defendant in these cases), negligent discharge, wrongful diagnosis, failure to hospitalize, failure to accurately assess suicide risk. I've also heard colleagues who should know better claim that you can do just as good a job of evaluating catatonia and delirium via telepsych. There is a lot that you can do over telepsychiatry that is almost as good as in person, but in my experience there are certain things you will certainly miss via telemedicine in an ER situation and if you don't have reliable staff on the ground to help you out with filling in the blanks you are asking for trouble.

 

[psychacad]

I am one of the voices who warns of the liability of this kind of work, but I am going to give you a balanced perspective here. I still recommend avoiding this work. I do some inpatient C-L telepsych. I do not and will not do ER telepsych. We explored this for our own service during the early days of COVID and I prohibited it. I have colleagues who do telepsych malpractice cases. I've also heard the companies like Vituity that push this model make the case against it being high liability.

Here are my concerns:
- the standard of care is at least the same for telepsych as it is for in person care. Some have argued that the standard of care for telepsych is higher than for in person care. This is an evolving area. No one (not least the lawyers) are arguing the standard is lower.
- I have a lot of experience evaluating acute presentations via telepsych. That's fine in the hospital setting (they're already admitted). Not so in a busy, noisy ER where the pressure is to get the patients out. You miss a lot via tele in terms of non verbal cues, picking up subtle psychosis, subtle cognitive dysfunction, and limited in terms of your physical exam of the patient
- You are reliant on staff in the ED to help in your assessment. Typically it is PAs or NPs who are dealing with these patients, not physicians. You also have to rely on RNs who may not have any interest in dealing with psych patients.
- even in person (I work at a great hospital with excellent physicians) and they still try to pass of patients in DKA, who are sepsis, in acute liver failure, in DTs and so on as "medically clear". Try figuring that out via telemedicine.
- the ER is already the highest liability area for psychiatrists to practice in. Try doing that via telepsych considering the concerns mentioned above and you will see where it becomes even higher liability. Now, it's not OB or spinal surgeon, but it does create a problem for the uninitiated
- it requires a special skill set, experience, and body of knowledge. The malpractice attorneys are already arguing that telepsychiatry is a subspecialty of psychiatry that requires specific education, training and experience. And there are people willing to testify to that effect.
- I have met several expert witnesses who are eager to throw their colleagues under the bus and ultimately it is expert testimony that sets the standard of care in these cases in the absence of clear guidance

Here the arguments against:
- for years people were arguing that doing telepsych to patients homes instead of in a clinical setting was a recipe for disaster and over the past yr it has become the de facto way of receving mental healthcare with little fanfare
- the malpractice insurance companies do not charge more for telepsych work because their actuarial calculations don't indicate that it is higher liability
- you are a consultant, and thus the in person docs are the ones on the hook (though consultants in person are sued all the time)
- you are just providing an opinion to the primary physician (ahem, PA/NP) who is seeing the patient on the ED, it's on them to decide what to do
- if you weren't seeing them via telemed, they wouldn't be seem by psych at all
- psychiatrists are still the least likely to be sued of any physicians and that has not changed with telepsychiatry

I don't consider these, except maybe the first two, particularly persuasive. This is new terrain and its usually several years after the incident that the malpractice claim is filed. But it is definitely true people were hysterical about doing telepsych to patients' homes and now that is the standard.

If you're interested, the kinds of cases that have resulted in a negligence case are failure to recognize another medical condition (yes, the telepsychiatric consultation will be named a defendant in these cases), negligent discharge, wrongful diagnosis, failure to hospitalize, failure to accurately assess suicide risk. I've also heard colleagues who should know better claim that you can do just as good a job of evaluating catatonia and delirium via telepsych. There is a lot that you can do over telepsychiatry that is almost as good as in person, but in my experience there are certain things you will certainly miss via telemedicine in an ER situation and if you don't have reliable staff on the ground to help you out with filling in the blanks you are asking for trouble.

Thanks for the detailed explanation.

One argument I have against (perhaps a minor one), is that large systems with a good reputation like Northwell have systematized this for a few years now and are touting very good outcomes (mainly claiming less waiting times). Northwell harnesses telepsychiatry to reach patients in crisis

I think one might fare better if they are doing this in a good structured environment, rather than unknown hospital in the middle of nowhere contracting with x telepsych company. It's still all new though. Would be interesting to see where this goes in a few years.
But talking about liability, I've had some offers of providing consultation over the phone for admit/discharge decisions. LOL.

 

[Merovinge]

Have you worked in rural/underserved EDs seeing psychiatric consults before (you say you do ED work but I'm wondering if the ED(s) you consult to are going to be typical of where you will take telepsych consults from)? Your service is not to help or diagnose patients but to get undesirable patients out of their ED. If you recommend admission and there are not beds available, get ready to spend your time dealing with passive-aggressive pushback. Even worse if it's an involuntary case or they need med-psych placement. Medical "clearance" is ordering a CBC/chem panel and eye balling the patient.

I do this work right now in person and it is miserable. I loved ED work as a resident, however I would rather not practice psychiatry then continue at my current position (2 months to go!) doing this work. It is the only thing I have done as an attending that has made me dislike medicine.

 

[nexus73]

Have you worked in rural/underserved EDs seeing psychiatric consults before (you say you do ED work but I'm wondering if the ED(s) you consult to are going to be typical of where you will take telepsych consults from)? Your service is not to help or diagnose patients but to get undesirable patients out of their ED. If you recommend admission and there are not beds available, get ready to spend your time dealing with passive-aggressive pushback. Even worse if it's an involuntary case or they need med-psych placement. Medical "clearance" is ordering a CBC/chem panel and eye balling the patient.

I do this work right now in person and it is miserable. I loved ED work as a resident, however I would rather not practice psychiatry then continue at my current position (2 months to go!) doing this work. It is the only thing I have done as an attending that has made me dislike medicine.

My hospital looked into telepsych options for the ED as psychiatry is not available at all hours like they wanted. My experience was ED doctors basically want telepsych to take over any and all psych patients once deemed medically clear, not just a consult. Of course no telepsych is setup to be a remote attending (not that I'm aware of) of boarded ED patients. The ED was not impressed. They clearly just didn't want anything to do with psych patients even though they were in their ED. This went for ED nurses as well. I'd anticipate being the target of that frustration from the ED staff, whether it's conscious or not. There is a very real feeling from the ED that "these are not our patients, these are your psych patients."

 

[1edyfirel]

Thanks, everyone--your thoughts are so helpful. Merovinge, I trained in a county hospital and work in one now, so I'm sadly very aware of the pressures and those angry ED charge nurses, and (as nexus73 mentions) I do not want to be the constant target of their frustration with the system b/c that will burn me out quickly. I have a few phone calls set up with psychiatrists currently working for this group, and will be using feedback from here to tailor some of my questions.

 

[the5thelement]

You know how these "telepsych provider companies" sell themselves to the hospital admin to get the contracts? Their selling point is "Our psychiatrists will increase the amount of discharges from the ED (and not admit everyone who walks in). " The pressure is on the psychiatrist to discharge the patient and take on the risk if something untoward happens. Tread lightly.

 

[Merovinge]

My hospital looked into telepsych options for the ED as psychiatry is not available at all hours like they wanted. My experience was ED doctors basically want telepsych to take over any and all psych patients once deemed medically clear, not just a consult. Of course no telepsych is setup to be a remote attending (not that I'm aware of) of boarded ED patients. The ED was not impressed. They clearly just didn't want anything to do with psych patients even though they were in their ED. This went for ED nurses as well. I'd anticipate being the target of that frustration from the ED staff, whether it's conscious or not. There is a very real feeling from the ED that "these are not our patients, these are your psych patients."

Exactly my current experience and absolutely the worst way to practice psychiatry. I would rather take care of BPD patients all day then deal with ED doctors who feel the revenue they generate is much more important than human lives and have financial incentives for how long patients sit in their ED which only brings more vitriol to people with psychiatric complaints.

 

[Stagg737]

I don't think I could do ED telepsych. My personal opinion is that if you're not capable of doing a physical exam on a patient then you're not going to meet the standard of care for some patients. Also agree with Splik's point that smaller things or sometimes even larger things can be missed via telehealth.

One of my attendings gave me an example of this where they saw a patient via telehealth who was able to verbally keep it together and kept the camera close to her face. Family brought her in to the ER the following day and she was hiding in the corner of the room, extremely paranoid, had written all over her walls, etc. I realize the telehealth portion was when the patient was at home, but signs which would have been very obvious in person were completely missed via telepsych. I've also been burned once or twice by trusting the report from the ER docs who medically "cleared" the patient only to find them needing to be transferred back to our hospital once seen in-person.

 

[comp1]

This is done all over the country all of the time. It's definitely considered meeting the standard of care for the vast majority of communities, if not all. I think a lot of the above issues are going to be the same whether you're in person or not. The ED is not going to be pleased if you put someone on a hold, particularly a medically complex person. There will be pressure to discharge people. If you don't discharge the person, they're going to want you to "reassess" the next day when they're still there and it will likely involve some passive aggression. The medical clearances are going to be occasionally...limited. There's going to be cases who don't meet strict hold criteria for self harm, but that you're still really worried about and have to document the heck out of to discharge. The thing is, all of this is the same in person. I've done both and other than telepsych often being a lot slower because you have to get everything set up (not counting a commute of course), it's not really that different. I trust that the malpractice insurance adjusters know their business and the risk is not actually greater. I think the bigger question, and it seems to be one for a lot of commenters above too, is whether you want to do ED consults, telepsych or otherwise.

 

[capsychiatrist]

Some people have mentioned Vituity on here. I'm curious if anyone has more information about this company or has considered taking a job with them? It looks like most of the positions are for telepsychiatry, but some are in person.

 

[reca]

Some people have mentioned Vituity on here. I'm curious if anyone has more information about this company or has considered taking a job with them? It looks like most of the positions are for telepsychiatry, but some are in person.

I considered it but ended up deciding not to as the pay was way too low for the work. It was $165/hour for high acuity telepsychiatry. Considering you can find low liability outpatient telepsychiatry paying around that or even better, didn't make sense to go into a high risk area. Also, vituity is a rebranding of CEP America. Considering the havoc these groups have wrecked in the emergency medicine world, I'm not sure it's a good idea for us to embrace them in psychiatry. I could easily see 20 years from now groups like Vituity controlling almost all inpatient and emergency psychiatry markets outside of academic centers.

 

[Dave1980]

Thanks, everyone--your thoughts are so helpful. Merovinge, I trained in a county hospital and work in one now, so I'm sadly very aware of the pressures and those angry ED charge nurses, and (as nexus73 mentions) I do not want to be the constant target of their frustration with the system b/c that will burn me out quickly. I have a few phone calls set up with psychiatrists currently working for this group, and will be using feedback from here to tailor some of my questions.

Burn out because of tele psych!?!

lol

sorry

carry on