VA Emergency Department Psychiatry?

[prominence]

I am currently interested in pursuing an Emergency Department Psychiatrist position within the VA system. I understand that the Emergency Department at each VA is set up differently. I have heard that some smaller VA EDs are staffed by social workers alone and/or Mental Health Social Workers.

I would greatly appreciate hearing examples of how the setup is for ED psychiatrists are at different VA’s. Here are some specific questions that I am wondering:

1. How long is the tour of duty (i.e. 8 hours, 10 hours, 12 hours+)?

2. Is the assignment a pure ED Psychiatry position or is consultation-liaison psychiatry for the medical floors also involved?

3. Is it a day or night position for the ED Psychiatrist?

4. Are weekends and holidays required? If yes, is inpatient rounding and psychiatry consults on medical floors required on these specific days?

5. Are mental health social workers also on the ED team to manage cases that can be discharged as they do not need to be admitted to the inpatient psychiatric unit?

6. Do psychiatry residents see all the patients and then simply staff with the ED psychiatrist?

7. Since COVID, do any VAs utilize a remote ED Psychiatrist who sees the patient solely via video?

8. Does the ED Psychiatrist have to write a complete mental health history and assessment note or is there a more specific ER Psychiatry focused note?

9. Is the VA ED Psychiatrist purely a consultant (i.e. provides recommendations to ER physician on medication and/or disposition)? Or do they order lab tests and agitation medications to be completed within the ED?

Any insights would be greatly appreciated. Thank you in advance.

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[comp1]

Really good question. You're going to see HUGE varieties. There are many different levels of VA hospitals and they each have different requirements. I can tell you how mine is set up. M-F during business hours (8-4:30) excluding holidays, a team of providers (3 psychiatrists, 1 NP, 1 psychologist) who are dedicated to the inpatient psych unit primarily also see med floor and ED consults as they come in. There are typically 0-4 consults total coming in during an 8 hour business day split evenly between the med floor and ED. Med floor consults are rarely for psych unit admission consideration, ED consults almost always are. Now nights, weekends and holidays are TOTALLY different. Given the staff limits, there are multiple back-ups. First line overnight is a telehealth/remote NP who handles emergent issues on the inpatient unit, med floor consults and ED consults. Generally, they punt med floor consults to the morning if it's not emergent. They will see 0-3 mostly ED consults overnight. There's only one NP overnight, so if they're on vacation, there's a back-up system of contract social workers to cover the ED. In terms of the med floor and inpatient unit, there's an on call MD. They do NOT ever see patients overnight outside once a year truly bizarre circumstances, but they are available to put in orders remotely or provide curbsides if the overnight NP is on vacation or out sick. Weekend days and holidays are also handled by that on call MD. They will see med floor or psych inpatients who need to be seen on the weekend or holidays, but they don't stick around all day and only see those who need to be seen. The contract social worker sees ED consults on weekend and holiday days. They also have a resident assistant.

Now regarding your specific questions, again they will vary. All tours of duty are possible. Probably four 10's is most common, but 3.5 12's are also rarely done. I of course prefer 5 8's, but not everybody does. There will be pure ED consult positions, but the large majority of VA hospitals are not big enough to justify that. Night positions aren't the greatest use of a physician's time. I personally find that it is best to fill night shifts with NPs who can punt to the day if needed. There are VA positions that are 7 on, 7 off, but they are kind rare. In those cases, you would work holidays, but mostly those are done by a call pool. Some would require inpatient rounding, med floor consults too, some won't. It depends on the size of the facility. ED's do have social workers. They will work on discharge planning for cooperative patients. They're going to be moderately to highly resistant to working on placement for patients with chronic suicidality or moderate psychosis. They're generally going to want those discharged from the psych unit if one is attached to the hospital. MOST VAs have academic affiliations. Not all, but most. How residents are used will vary. Interns require near constant attending supervision by ACGME, so they are near useless. Some places do use resident moonlighters. Some places do have residents work alongside attendings on weekends and evenings. Yes, if you are working with residents you can "just staff" follow-ups. You have to directly see new admissions or new consults and addend with your own MSE. Some VA hospitals are so rural they ONLY have telepsych period. There are no psychiatrists around for hundreds of miles. So yes, the VA does telehealth. 100% telehealth jobs are extraordinarily competitive. You are competing with the entire country. ED consult notes are generally focused for all specialties. How much you actually order in an ED will vary and not just by VA. It'll vary by patient. Typically, you are a consultant and don't put in orders. But only you can order things like antipsychotics for outpatient, so you do have to put in those orders if they are needed. Please post here with additional questions. I don't really check DMs.

 

[Merovinge]

I trained at a VA that was a combined ED plus walk-in clinic model. Attending staffed it 8 hours 5 days a week (8:30-4:30 if memory serves). Had residents for most of the time but they certainly saw patient's on their own. Because they came in like clockwork, vets knew if they came in overnight and could wait to be seen what was going to happen (as this doc was a freaking rock star with boundaries). People would send down vets that voiced SI in any clinic throughout the hospital.

It was a great job because some days were very slow +resident support and you had a flat salary, but as always, there were days where things hit the fan and I'm sure they earned their keep over the years.

 

[sophia502]

I trained at a program that had a major VA presence in a major academic institution (and a city with a HUGE military and vet population), and spent a LOT of time in the ED. One thing I should mention that was an issue with our VA ED--the ED docs were locums and they, how do I say this ... did not give a **** about psych patients to a dangerous level. The other issue was, at least at the VA, the VA metrics of ED door to dispo time were really closely monitored and the ED docs felt a lot of pressure--this means we got some of the most ridiculous consults (demands to see the drunk and high vet RIGHT NOW AT 4 AM and get them admitted inpt now). They were also doing other very inappropriate **** to get their metrics to look pretty (pressuring psych residents to kick vets out in the middle of the night to the waiting room, or kick them out to the hospital in general to find the SW in the morning--this resulted in multiple vets self-harming after the inappropriate discharged). Honestly stuff that newspapers would love to see in light of all of the concern about vets and their mental health. But that's a whole other story!!


1. How long is the tour of duty (i.e. 8 hours, 10 hours, 12 hours+)?
- 8 hours for the attending

2. Is the assignment a pure ED Psychiatry position or is consultation-liaison psychiatry for the medical floors also involved?
- at our hospital, pure ED and C/L were two different teams. But this was a very large VA

3. Is it a day or night position for the ED Psychiatrist?
- day

4. Are weekends and holidays required? If yes, is inpatient rounding and psychiatry consults on medical floors required on these specific days?
- yes to weekends/holidays. A different set of attending were responsible for inpatient and consults

5. Are mental health social workers also on the ED team to manage cases that can be discharged as they do not need to be admitted to the inpatient psychiatric unit?
- yes, and they were very helpful

6. Do psychiatry residents see all the patients and then simply staff with the ED psychiatrist?
- mainly yes

7. Since COVID, do any VAs utilize a remote ED Psychiatrist who sees the patient solely via video?
- not at my hospital

8. Does the ED Psychiatrist have to write a complete mental health history and assessment note or is there a more specific ER Psychiatry focused note?
- looked pretty much like an intake

9. Is the VA ED Psychiatrist purely a consultant (i.e. provides recommendations to ER physician on medication and/or disposition)? Or do they order lab tests and agitation medications to be completed within the ED?
- this was a constant fight. In our ED, the ED docs felt that once psych was consulted we owned the patient. The psych leadership in our hospital was very weak and didn't push back (and didn't care since it was mainly the residents that ate ****). Also know that "code grays" are a thing in the VA--essentially code for agitated vets ANYWHERE in the hospital, and the psych ER resident and attending were responsible for going to these. They sucked--you are essentially walking into a complete ****show of a patient you don't know in the podiatry clinic and everyone is looking at you to take care of it. Vast majority of time it was just a vet being an dingus. One resident in my program was actually in a code gray in which the patient (on med/surg) pulled a gun.

So really--it is SO VA-dependent. I hear about these chill, functional VAs but mine wasn't that. So I'd definitely talk to as many other psychiatrists (and maybe residents) as you decide.