Transplant evaluations by psych residents in Clinic?

[frogly]

Question, genuinely have no idea. Is it a appropriate for a resident in an outpatient setting to perform transplant evaluations and clear patients for transplants? To be clear, this is the full SIPAT stuff I am talking about, not just capacity.
We do not have a transplant unit at our hospital, or transplant team. I believe the evals are for patients in another hospital, possible even one out of town that is owned by the organization. We are a little short on the details ourself, even though patients are already booked on our schedule. We have a SW who does plenty already in the clinic. No psychologists in the clinic, nor in the hospital either, we have to refer everyone out. No specific training, no chance to observe anyone doing it, and the clinic has already told us it is impossible to book any appointment slot longer than an hour, so we already have to conduct child patient h&p’s in 2 separate hour long appointments sometimes weeks apart. We can check out to an attending at the end but no direct supervision. No CL fellowships at this hospital either.
All the residents are very concerned with this, but I just wanted to get perspective

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[robellis]

I’m an attending and have no clue how to do this..not sure how you would know either without a lot of research or being taught how to do it

 

[erg923]

Question, genuinely have no idea. Is it a appropriate for a resident in an outpatient setting to perform transplant evaluations and clear patients for transplants? To be clear, this is the full SIPAT stuff I am talking about, not just capacity.
We do not have a transplant unit at our hospital, or transplant team. I believe the evals are for patients in another hospital, possible even one out of town that is owned by the organization. We are a little short on the details ourself, even though patients are already booked on our schedule. We have a SW who does plenty already in the clinic. No psychologists in the clinic, nor in the hospital either, we have to refer everyone out. No specific training, no chance to observe anyone doing it, and the clinic has already told us it is impossible to book any appointment slot longer than an hour, so we already have to conduct child patient h&p’s in 2 separate hour long appointments sometimes weeks apart. We can check out to an attending at the end but no direct supervision. No CL fellowships at this hospital either.
All the residents are very concerned with this, but I just wanted to get perspective

A successful transplantation requires a multistaged, multidisciplinary psychosocial and psychological evaluation. There are readily available best practice guidelines for how this should be done by at least 2 medical societies and the American Psychological Association. I've actually never seen a single, hour of less evaluation clear a patient for such a serious/high impact procedure. My portion of the evaluation alone when i did these in the VA was 2 hours or more, and then a couple more for the report write-up and recs.

 

[tr]

Transplant evals are a cornerstone of C/L psychiatry. Certainly often done by residents but under the supervision of the C/L attending. How do you have a transplant team that lacks access to a C/L service?

 

[PikminOC]

Transplant evals are a cornerstone of C/L psychiatry. Certainly often done by residents but under the supervision of the C/L attending. How do you have a transplant team that lacks access to a C/L service?

I did cl and never had to do this. Are your attendings teaching you how to do this?

 

[splik]

I having a hard time imagining what you are describing. I used to be responsible for transplant psychiatry at my institution. It is great opportunity for residents and other learners to be involved but only under direct supervision from an attending who is experienced and skilled in doing presurgical evaluations and knows the ins and outs of solid organ transplantation. There are a few different aspects of transplant psychiatry. One is the preoperative evaluation - at most institutions, a psychiatrist is not required for every patient. A SW or psychologist (or both) trained in doing these evaluations would do a psychosocial evaluation and if there are issues flagged, then a psychiatric evaluation may be requested. At most institutions including Stanford, something like the SIPAT would be done by SW not psychiatry. I actually did use the SIPAT for my evaluations but I was also being paid a lot of money and did this on a fee for service model (i.e. I got paid per evaluation). We only have residents do this work under direct supervision and all documentation is under the attending's name. If using something like the SIPAT, the scoring should be done with someone experienced otherwise it won't be accurate. You typically need 90 mins or so to do these evaluations.

The other aspects of transplant psych are focused on treatment optimization of patients pre- and post-transplant. This is more appropriate for residents to do, but you still need to have a decent knowledge base about the different medications and neuropsychiatry and psychological aspects of transplantation.

 

[frogly]

Transplant evals are a cornerstone of C/L psychiatry. Certainly often done by residents but under the supervision of the C/L attending. How do you have a transplant team that lacks access to a C/L service?

Hi, there is a CL service but no fellowship so it is not very big and not many attendings with CL background. I don’t know where the transplant service got this done prior to this suggestion

 

[frogly]

I did cl and never had to do this. Are your attendings teaching you how to do this?

I did cl and never had to do this. Are your attendings teaching you how to do this?

There will be a lecture we have been told. We have done capacity evals for rehab surgery etc generally on CL

 

[Celexa]

This is absurd. Transplant is a subspecialty and transplant evals can be done by residents, but should be properly supervised by attendings comfortable in the field. Transplant evaluations are also not a simple yes/no; the transplant psychiatrist also often has either a treating role OR at minimum identifies what mental health treatment may be needed to both optimize the patients symptoms prior to surgery and define what post surgical psychiatric care may be needed.

I question the quality and ethics of any transplant program who would accept random evaluations from general psych residents without supervision and predict severe moral injury on the part of the residents if you feel boxed into a gatekeeper role and unable to refer these patients to the level of care they need.

I just cannot emphasize enough that a transplant evaluation, while capacity questions can be at hand, is NOT a capacity evaluation per se.

Edit: forgot to mention 60 minutes is also completely inadequate for even a basic transplant eval. Much less one with significant disease and/or requiring collection of collateral. Social work should be doing a lot of that but the psychiatrist may also need to talk to the family at length.

 

[whopper]

There is no established criteria on how to do this. Someone mentioned the APA has "best practices" guidelines? Please show them here.

We have entered a phase where some patients are being told they cannot get a surgery without a psychiatrist clearing the person for surgery despite that there is no standard of care to "clear them"

There are readily available best practice guidelines for how this should be done by at least 2 medical societies and the American Psychological Association.

 

[Stagg737]

Question, genuinely have no idea. Is it a appropriate for a resident in an outpatient setting to perform transplant evaluations and clear patients for transplants? To be clear, this is the full SIPAT stuff I am talking about, not just capacity.
We do not have a transplant unit at our hospital, or transplant team. I believe the evals are for patients in another hospital, possible even one out of town that is owned by the organization. We are a little short on the details ourself, even though patients are already booked on our schedule. We have a SW who does plenty already in the clinic. No psychologists in the clinic, nor in the hospital either, we have to refer everyone out. No specific training, no chance to observe anyone doing it, and the clinic has already told us it is impossible to book any appointment slot longer than an hour, so we already have to conduct child patient h&p’s in 2 separate hour long appointments sometimes weeks apart. We can check out to an attending at the end but no direct supervision. No CL fellowships at this hospital either.
All the residents are very concerned with this, but I just wanted to get perspective

I agree that this sounds completely absurd. I'm at a program with a very robust C&L team where residents do both inpatient and outpatient evaluations of heart, liver, and kidney transplants as well as a few devices (LVADs mostly). Outpatient we get 90 minutes for an eval, but we have 2 hours blocked off in our schedule for these encounters. While we do the interviews ourselves (outpatient evals not done until 4th year, which by then we've all done numerous inpatient evals), they're always reviewed with one of the attendings and the attendings talk to the patients as well before anything is decided. We use a modified SIPAC for our ratings and we do rate their candidacy ourselves. However, the total pre-op evaluation process at our hospital is multi-disciplinary and occurs over 3 days with 6-10 hours worth of appointments each day. We are only a small part of the process and our primary purpose is more about finding any underlying psych issues that could be confounding for a transplant and getting them into our clinic if necessary.

I feel fairly confident about my ability to do transplant evals at this point, but I cannot imagine being thrown into an outpatient setting and being told to do a comprehensive eval in 60 minutes. What you describe seems like a major patient safety issue and you and your colleagues are right to be concerned. Frankly, I would encourage you to write the ACGME about this as this seems to be both unsafe and unethical if the complete extent of their evals are as you describe.

 

[Stagg737]

There is no established criteria on how to do this. Someone mentioned the APA has "best practices" guidelines? Please show them here.

We have entered a phase where some patients are being told they cannot get a surgery without a psychiatrist clearing the person for surgery despite that there is no standard of care to "clear them"

I agree that many of the requests for "psychiatric clearance" for surgeries are ridiculous and unnecessary. However, given the extent of the transplant process as well as the high demands on both the patient and their support system I do think thorough evaluations before transplant are warranted and these evals shouldn't be done by residents or anyone that doesn't have some level of experience working with transplant teams.

 

[erg923]

There is no established criteria on how to do this. Someone mentioned the APA has "best practices" guidelines? Please show them here.

We have entered a phase where some patients are being told they cannot get a surgery without a psychiatrist clearing the person for surgery despite that there is no standard of care to "clear them"

First. No. This is not SDN Journal Club or a peer reviewed article. So, no. I will not be digging into all that here.

I suppose we can debate what I called "Best Practice" but there are indeed a well agreed upon set of procedures set forth by multiple medical organizations for this purpose. I read 3 lengthy, multi-sourced documents before I did even one. This was standard and readily available training with the VA if one were to get into doing such evals as of 2015. Now....many ways to the top of the mountain of course, but none seemed like they did not agree upon what needs to be done, broadly. And certainly none suggested this could be done by undertrained/under-supervised psychiatry residents with no familiarity with the ethics, legality and clinical risks of the specific procedure in a single one-hour appointment.

I don't know what you mean by "phase?" There should be no "phases." At least not in the past decade or 15 years. In fact, some managed care orgs have had some degree of this procedure spelled out for many years now in order for them to agree to provide payment coverage for any organ transplant surgery. Liability, cost effectiveness, ROI and all that stuff, right? And yes, there is no psych "clearance' for ANY surgery. I don't know where that term came from and it is spurious to say the least.

 

[frogly]

Thank you all for your input. It does seem that us having some concerns is valid. The lack of transparency from management does not help.
Just to clarify, I think they would let us complete the eval over multiple sessions. Whether this would be 2 separate hour long appointments or an hour h&p and a 30 minute follow up is unclear.

 

[splik]

Thank you all for your input. It does seem that us having some concerns is valid. The lack of transparency from management does not help.
Just to clarify, I think they would let us complete the eval over multiple sessions. Whether this would be 2 separate hour long appointments or an hour h&p and a 30 minute follow up is unclear.

This is not acceptable either. It is not really fair for sick patients to have this evaluation process unnecessarily prolonged. You say "management" but this is your supervisors who are responsible for this.

 

[erg923]

Thank you all for your input. It does seem that us having some concerns is valid. The lack of transparency from management does not help.
Just to clarify, I think they would let us complete the eval over multiple sessions. Whether this would be 2 separate hour long appointments or an hour h&p and a 30 minute follow up is unclear.

I would NOT send a relative there, is all I am saying.

For me it would be about covering the needed bases for this kind of event....not just an extra hour with an MD psychiatrist who may have little experience with these patients and their risks/needs.

 

[24blue8]

We did a few in my clinic in residency. With supervision.

Don't worry, while we argue ourselves into needing more training to do anything, the SW, the psychologist and the NP they hire will be able clear up the backlog.

 

[frogly]

We did a few in my clinic in residency. With supervision.

Don't worry, while we argue ourselves into needing more training to do anything, the SW, the psychologist and the NP they hire will be able clear up the backlog.

They have no plans to hire anyone else. Very explicitly stated by them. Like I said, the one social worker we have will not be able to help per our supervisors (she does already have plenty)

 

[TexasPhysician]

We did them in residency in 90 min slots. Learning to do these evals in residency is very appropriate.

 

[Stagg737]

We did them in residency in 90 min slots. Learning to do these evals in residency is very appropriate.

I agree and think it's a valuable part of residency. However, learning to do them when you'll basically be on your own, with basically a single didactic session for training, only getting 60 minute slots, and not having other members of the transplant team/process easily accessible just sounds dumb.

Either the supervisors/managers at OP's program are doing a poor job of describing the process and the responsibility of residents, OP is missing some things or not fully understanding how this will work, or this is an incredibly irresponsible setup on the part of the hospital and a legitimate patient safety risk.

 

[comp1]

This seems to be confusion on the part of the residents and possibly the administration. Talk to your training director. If the OP is understanding the situation correctly...no, it's not standard. However, given the amount of confusion about expectations, I'm not sure the OP knows exactly what is supposed to be happening at these intakes.

 

[Candidate2017]

It is not ideal if you are not getting direct supervision.

However, this being residency, grab the bull by the horns. Be proactive. Work with fellow residents to gather and share resources and articles, discuss cases with each other, consult other attendings, advocate for electives at a transplant center, etc. It is your time to gain as much experience as you can and learn from reading, seeing, and doing. This is a special time in your career because you get to make mistakes and learn from them while having close to zero liability.

Would it be better for the patient if you had better training and supervision? Yes. Would it be better if you were learning at the feet of a transplant guru? Yes. I'm not saying you shouldn't advocate for better training, but the die is cast and you landed in a terrible system. It is what it is. Go forth with eyes open.

 

[aim-agm]

It is not ideal if you are not getting direct supervision.

However, this being residency, grab the bull by the horns. Be proactive. Work with fellow residents to gather and share resources and articles, discuss cases with each other, consult other attendings, advocate for electives at a transplant center, etc. It is your time to gain as much experience as you can and learn from reading, seeing, and doing. This is a special time in your career because you get to make mistakes and learn from them while having close to zero liability.

Would it be better for the patient if you had better training and supervision? Yes. Would it be better if you were learning at the feet of a transplant guru? Yes. I'm not saying you shouldn't advocate for better training, but the die is cast and you landed in a terrible system. It is what it is. Go forth with eyes open.

This is very ethically problematic.

First, do no harm.

 

[clozareal]

I've done several transplant evaluations in residency (and fellowship) on the C-L and outpatient services but this was always under supervision, we always talked about scoring of SIPAT afterwards, and I had a note template of suggested recommendations to the transplant team. It always took at least 90 minutes but only after several evaluations so doing it only one hour is really prohibitive and substandard for the standard of care.

I'm confused at why you are seeing outpatients without supervision from an attending during your residency other than "checking out" for something like this. I would bring it up with your program director. Residency really sucks in that you sometimes have very little control over what gets thrown at you.

If there really is no choice in the matter, then I agree with @Candidate2017. You'll have to reframe, accept that you'll have to do these appointments with minimal support, try to prepare as much as you can outside of these appointments if you want to provide better care such as doing extra reading or getting extra mentorship from those who are skilled in these evaluations (e.g., ACLP offers lots of mentorship but you can also look into ANPA, APA, etc.), and take advantage of the opportunity to have such a high volume of a subspecialized practice. It's annoying but you'll have to piecemeal your own education if the residency program refuses to provide this.

 

[Mass Effect]

First. No. This is not SDN Journal Club or a peer reviewed article. So, no. I will not be digging into all that here

I mean, we usually do provide resources to one another around here especially if there's disagreement about something. I'm not sure what the problem would be with you educating the rest of us who have looked and have not found what you're describing.

 

[whopper]

Erg-We both have been on SDN for years and I give you a lot of credibility. I mean this sincerely. I believe you. I'd still want to see the data not cause I don't believe you but just so I'm on top of the data.

I've brought this up in other threads. The emerging field of transplant psychiatry/psychology isn't part of the established psychiatry training curriculum. If a program teaches info on it that's great but what's going on is some patients are being denied treatment unless a psychiatrist clears them for transplantation despite that there's no standard of care as to what constitutes psych clearance.

Now all this said, there is emerging data that mental health evaluations before a transplant surgery are helpful especially so because most of the time immunomodulating treatments are given that can set off psych problems. I don't deny this, but that isn't the same as stating they are "psychiatrically clear" for transplant surgery (or device implant surgery). I do however have major problems when a patient who needs a surgery is being denied that surgery because I refuse to "clear" the person for surgery when there's no guidelines on how to do it. Further when I tell this to surgeons they're like "WTF?"

I tell the surgeon there are no guidelines, and then they ask me "why is the company requiring this?" and I tell them I don't know either. I've even tried to contact the manufacturer of the device stating why are they requiring this and do they have a set of guidelines for clearance and I either never get a response back or some idiot receptionist that doesn't know what I'm talking about.

 

[Sushirolls]

At the end of the day the place will probably hire an ARNP with FM certificates and extra psych certificate added to that, to do all the evals... and also round on the transplant patients when they present to the medical floors...

Problem solved....

 

[Merovinge]

At the end of the day the place will probably hire an ARNP with FM certificates and extra psych certificate added to that, to do all the evals... and also round on the transplant patients when they present to the medical floors...

Problem solved....

They have two certificates. Why would you want a lowly MD with only one board certification!?

 

[whopper]

On that note every time I had a patient requiring a "clearance" for surgery, go through the above frustrations, then say I can't write "clear" until I'm given a criteria, the patient is told by their surgeon to see someone else and is usually referred to a specific psychologist the surgeon used in the past.

I called one of them and asked the procedure for clearance. The psychologist agreed there's no standard but they just interviewed them and cleared them and then said something to the effect of "I get paid."

I wouldn't exactly call that appropriate, safe, or ethical care.

 

[singasongofjoy]

This is absurd. Transplant is a subspecialty and transplant evals can be done by residents, but should be properly supervised by attendings comfortable in the field. Transplant evaluations are also not a simple yes/no; the transplant psychiatrist also often has either a treating role OR at minimum identifies what mental health treatment may be needed to both optimize the patients symptoms prior to surgery and define what post surgical psychiatric care may be needed.

I question the quality and ethics of any transplant program who would accept random evaluations from general psych residents without supervision and predict severe moral injury on the part of the residents if you feel boxed into a gatekeeper role and unable to refer these patients to the level of care they need.

I just cannot emphasize enough that a transplant evaluation, while capacity questions can be at hand, is NOT a capacity evaluation per se.

Edit: forgot to mention 60 minutes is also completely inadequate for even a basic transplant eval. Much less one with significant disease and/or requiring collection of collateral. Social work should be doing a lot of that but the psychiatrist may also need to talk to the family at length.

Ditto re: questioning the ethics and what Celexa said above. I have only a bit of experience - grad school, internship rotation - on transplant teams, and those were mostly for lung/heart (some solid organ) but what OP is describing is mind-bogglingly different than my experiences. I suppose the in-depth-ness required might differ depending on the type of transplant (idk, like I imagine a cornea transplant is considerably different than a lung or heart transplant) but no. There are plenty of places around the country that do this and someone should maybe at least consult around their practices and reasoning behind their process- it's certainly much more a team approach that is informed by psychology, social work, psychiatry and the healthcare team and involves interviewing with pre- and post-caregiving team too. You can't do that in an hour. Then there were full team meetings about candidates. Maybe find AMCs that do those types of transplants and find out what their procedures are to at least think a bit more creatively / broadly about process?

 

[whopper]

A foundation in forensic psychiatry is don't go outside your box. There are plenty of cases in the books of psychiatrists going onto the witness stand and giving their "expert" opinions on something where there is no evidenced-base for their statements. The main cases taught by AAPL and forensic fellowships are the cases of James Grigson, MD, the guy who'd go on the witness stand, charge hundreds of dollars an hour (80's money too, probably over $1000 an hour these days) and say stuff with no evidence to back it up whatsoever.

So when any issue comes up, where there's a new and emerging new thing in our field we have to ask, what is the evidence based for this?

A few years ago, before there was any dating backing up SSRIs for hoarding, and it wasn't even yet recognized in the DSM (IV Was out at the time) there was a case in my locality where someone had severe and dangerous hoarding. There's legal precedents that you cannot commit someone against their will unless there's a treatment you can offer while involuntarily committed. While all the doctors in the case stated they'd try an SSRI, I asked all of them, "where is your evidence base to back this up, remember you're going to have to state this in court" and none of them could find one article backing up that it had strong evidence to treat hoarding. (Times have changed. Now there are some articles).

Point is, adding to what I said above, psychiatry's involvement in transplantation is not conventional. It's not part of a standard teaching curriculum. Of course we should embrace this area if there is something we can offer, but stay in your box. Only back up what the science backs up. Only do outside of this with transparency.

 

[splik]

Point is, adding to what I said above, psychiatry's involvement in transplantation is not conventional. It's not part of a standard teaching curriculum. Of course we should embrace this area if there is something we can offer, but stay in your box. Only back up what the science backs up. Only do outside of this with transparency.

It isn't part of the residency core curriculum but I would disagree that our involvement is not conventional as psychiatry/psychology is involved in transplant in every major transplant center in the country. Transplant psychiatry and psychology are established fields with research, assessment tools, guidelines, psychiatrists and psychologists are involved in selection committees, have academic appointments in surgical departments, and participate in committees nationally regarding candidacy for transplantation. Any decent C-L fellowship should teach their fellows to work with transplant patients and conduct evaluations. the ACLP (the C-L psychiatry organization) has an active transplant psychiatry group and there are presentations at the conference annually on transplant psychiatry.

 

[whopper]

Every psych residency is not attached to a transplant center. You're talking conventional for transplant, not conventional for psychiatry.

Every space center in the country has space medicine division. With all the fixings and trimmings like you mentioned for the transplant places.

Not all hospitals have a space medicine division.

I would tell a doctor asked to make expert opinions on space medicine to not do so unless that person had real expertise, knowledge and an evidence-based to back their statements.

Likewise I would tell psychiatrists not to make transplant psych opinions on the same grounds, and I have been in that situation, asked to write opinions such as "is this person clear for transplantation?"

Just as I would expect you to avoid answering questions on space psychiatry unless you had an evidence-based to answer upon.

If you have the expertise to do so, even-better, ad great if you were in a program that teaches this stuff, go for it. Just like if you have expertise to talk about space medicine go for it. Otherwise don't and just like with space-medicine don't be on the expectation that you're supposed to know this. It's not conventional, part of the curriculum, but maybe in the future.

 

[TankTuck]

I’m a resident and had a random outpatient consult a few weeks ago for renal transplant. Definitely was a first for me, on an outpatient basis. Essentially it comes down to what is best for the patient. Is he on a stable Med regimen,consistently adhering to them? If unable to do this, huge red flag that will lead to patient harm +\- rejection. Substance use, psychosis, or unstable mood? Apart from that you can look up contraindications for transplant. Do everything you normally would with adequate effort, and you will have your answer by the assessment. If not, schedule a follow up or discuss with colleagues.

 

[medhead1990]

Not saying anything new/profound but.

1. Transplant interview by psych is a HUGE deal you are there to help decide if this person is psychiatrically fit to use/care for the transplanted organ. As are all the decisions leading up to a transplant your decision in transplant candidacy has hundreds of thousands to millions (my understanding is a liver transplant makes about 1.5-2 million for a hospital system when all is said and done gross profit) of dollars hanging in the balance. I cant imagine a system that would take these interviews flippantly.
2. These are peculiar interviews/circumstances because of how big/deep the questions/consequences are. For example, An attending who had done a CL fellowship said during his fellowship he was interviewing a female to be a renal donor, and something felt off. Asked her to come back for a return visit (which i guess was not very common) and during the second interview was able to get out of her that she was being coerced to donate her kidney to her pimp.

 

[JohnnyWonderbread]

YMMV: at an university with a Center for Advanced Liver Diseases and Transplantation.

I think it's a little bizzare for an outpatient clinic setting. We do them on C/L psych, and often hepatology will consult for OLT (orthotopic liver transplantation). It's kinda funny, because i'm sure it's just part of a checklist for them (consult to C/L psych); often times, you get the consult, and the patient is comatose, and you end up getting collateral from family / friends (e.g., call some far-removed relative and ask them, "how do you think they would feel about blah, blah, blah"). Typically, it involves asking questions related to family support (e.g., do you have someone that can take you to your appointments at the drop of a hat?), attitudes towards being the recipient of an organ that is foreign to your body (e.g., would you be okay having someone else's organs?), attitudes towards being on immunosuppressants and of course, has the patient gone more than 1 year w/o any active substance use.

I've probably done 7-11 of them, but have carried patients on transplantation in the outpatient setting; it certainly can improve therapeutic alliance with a transplantation patient when you are more familiar with the process. It's not a consult that i am particularly fond of, but i can see its educational purpose.

 

[MedMan80]

I remember doing an LVAD evaluation while rotating through CL at my hospital. The patient was a veteran with a PTSD diagnosis, which flagged us for the consult. I remember it not being very different from a regular psych consult/see if the patient unstable etc..not the best way to do it i think