Why I hate the VA ED -- admission and handoff issues

[Doctor Bagel]

People at my program historically seem to dislike working through the VA ED for lots of reasons. Big ones include a total reluctance of the attendings to even look at the psych patients (there's not a separate psych ED btw), which leads to things like missing critical medical issues. I know ED folks don't like psych patients in general, but it seems especially horrible at our ED.

Anyway, we have this new policy due to duty hours changes where the VA ED folks decide whether or not to admit psych patients. In a way it's awesome for us because it cuts down our work load, and evaluating vets in the ED is a miserable experience -- lots of drunk people, lots of angry people, not a lot of true psychopathology. So, great, yeah. But, the ED docs still don't generally look at our patients. They're theoretically supposed to do vitals and eyeball them, but the eyeballing pretty much never happens. Vitals get missed, too. For example, we had a guy hit the floor yesterday in hypertensive urgency who did not have vitals taken downstairs. Labs almost never get drawn. Physical exams, yeah, no. For most psych patients, it's probably OK. Except these are vets with bad hearts and bad etoh problems so not ideal.

The big problem, though, is that when the decision is made in the ED to admit patients, we get the admission signout from the social worker and not the ED doc. Again, for a pure psych issue, probably OK. But, lots of our admissions are patients who have multiple medical problems and who initially were evaluated by physicians for medical stuff before they were evaluated by psych social workers. We get no sign out regarding any of their medical workup in the ED. Instead, we get to talk to our social worker, who has no clue what's happened on that end. Maybe because I hate the VA ED's attitude surrounding psych patients so much, I'm reading more into this and finding it more offensive than it is, but shouldn't we have the privilege of getting signout from another physician?

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[Chimed]

People at my program historically seem to dislike working through the VA ED for lots of reasons. Big ones include a total reluctance of the attendings to even look at the psych patients (there's not a separate psych ED btw), which leads to things like missing critical medical issues. I know ED folks don't like psych patients in general, but it seems especially horrible at our ED.

Anyway, we have this new policy due to duty hours changes where the VA ED folks decide whether or not to admit psych patients. In a way it's awesome for us because it cuts down our work load, and evaluating vets in the ED is a miserable experience -- lots of drunk people, lots of angry people, not a lot of true psychopathology. So, great, yeah. But, the ED docs still don't generally look at our patients. They're theoretically supposed to do vitals and eyeball them, but the eyeballing pretty much never happens. Vitals get missed, too. For example, we had a guy hit the floor yesterday in hypertensive urgency who did not have vitals taken downstairs. Labs almost never get drawn. Physical exams, yeah, no. For most psych patients, it's probably OK. Except these are vets with bad hearts and bad etoh problems so not ideal.

The big problem, though, is that when the decision is made in the ED to admit patients, we get the admission signout from the social worker and not the ED doc. Again, for a pure psych issue, probably OK. But, lots of our admissions are patients who have multiple medical problems and who initially were evaluated by physicians for medical stuff before they were evaluated by psych social workers. We get no sign out regarding any of their medical workup in the ED. Instead, we get to talk to our social worker, who has no clue what's happened on that end. Maybe because I hate the VA ED's attitude surrounding psych patients so much, I'm reading more into this and finding it more offensive than it is, but shouldn't we have the privilege of getting signout from another physician?

Wow. This is a bad outcome just waiting to happen. Have you been able to voice your concern with your PD or whoever is the director at the VA?

 

[Doctor Bagel]

Wow. This is a bad outcome just waiting to happen. Have you been able to voice your concern with your PD or whoever is the director at the VA?

It's been an ongoing conversation, but my impression is that the VA ED is unwilling to change how they do things. We are trying to document all these issues, so they can be addressed. For example, I emailed our VA person about the hypertensive guy. Maybe they'll do a better job of not missing vitals in the future. That's the one thing they do for our patients, so they better not at least miss out on that one.

I don't know, I think it's just indicative of the complete lack of respect they have for psych patients in their unit. The ED attendings are the official attendings for the psych patients -- why in the world do they think it's acceptable to not even look at the patients or verify their vitals?

 

[F0nzie]

Somehow when ED physicians hear "SI" it triggers a knee-jerk reflex to admit the patient to psych and it cloaks all of the patient's current medical issues. Seemed worse at the VA but happened frequently at other institutions.

Here are some of my experiences with working at the VA:

I was frequently getting overnight admissions to the psych ward by the VA ED physicians for "SI" with BAL > 300 without first letting patients sober up in the ED. I'd be doing psych H&Ps the next morning on vets that were like "where the f*ck am I?" Most of them not remembering making any SI statements in the ED or signing the voluntary admission form.

I also saw a lot of homeless vets without psychiatric issues being shuttled into the psych ward overnight because there was nowhere else for them to go and they were taking up vital space in the ED. I feel terrible for these vets, but having to do numerous unnecessary complete psychiatric assessments on patients with these issues seems like a misappropriate use of resources, excessive paperwork, and takes the place of other educational opportunities.

 

[Doctor Bagel]

Somehow when ED physicians hear "SI" it triggers a knee-jerk reflex to admit the patient to psych and it cloaks all of the patient's current medical issues. Seemed worse at the VA but happened frequently at other institutions.

Here are some of my experiences with working at the VA:

I was frequently getting overnight admissions to the psych ward by the VA ED physicians for "SI" with BAL > 300 without first letting patients sober up in the ED. I'd be doing psych H&Ps the next morning on vets that were like "where the f*ck am I?" Most of them not remembering making any SI statements in the ED or signing the voluntary admission form.

I also saw a lot of homeless vets without psychiatric issues being shuttled into the psych ward overnight because there was nowhere else for them to go and they were taking up vital space in the ED. I feel terrible for these vets, but having to do numerous unnecessary complete psychiatric assessments on patients with these issues seems like a misappropriate use of resources, excessive paperwork, and takes the place of other educational opportunities.

Both those things happen all the time here, too. At our university side, they have some dedicated psych rooms and are willing to let patients hang out there before making a decision about admission, which is especially useful for the drunk and high folks. At the VA, the attendings just want to get them out of their ED asap, which means sending 'em up to us.

 

[Doctor Bagel]

Probably because the facility covers any malpractice claims, and as long as they continue to work exclusively in a federal facility any adverse outcome won't really affect them.

Besides the physicians, this is also a potentially serious nursing issue. Their license is really specific about potential patient harm, and a nurse who is taking orders on a patient the physician has never laid eyes on is probably putting herself at risk. Failure to complete a basic nursing assessment, failure to take a set of vital signs, failure to ensure the physician is meeting basic standard of care. All those things are potentially actionable (and sue-able) on the RN side.

Instead of an email to someone who may or may not read it, consider making copies of the documentation and faxing it to the risk management office for the facility. Probably going to get you more of a response than contacting the (burned-out, ex-military, at the tail-end of their careers anyway) ER docs that work there.

Hmm, I never thought about it from a nursing perspective. Maybe at some point our department should pursue a risk management avenue. I'm not going to since I'm just a lowly PGY-2, though. One of my fellow residents got an official complaint from a VA ED attending accusing her of attempting to block a VA admission to the psych unit. 100% lame.

 

[nitemagi]

I did my chief year at a VA. There's a lot of politics going on behind the scenes. The only advice I could give is to organize all the residents and document every single miniscule medical error and issue that's dropped, including the ED attending involved. The only way to bypass the territoriality is to slap a stack of pages full of errors on their desk, along with your proposal as to how things should go.

We had it worse at our VA. Psych patients were all officially patients of the psych service, including heavily intoxicated ones, as soon as a triage nurse called them a psych patient. Many many near misses including DT's, hypertensive crises, and many other issues. The ED people dug in deep, not wanting to change their policies. A group of residents formed a committee, documented the hell out of what was happening, also surveyed other VA's to show this was an anomaly, and eventually took it to the administration, and won.

It took a lot of work by a lot of people, but it got changed.

Figure out who the attendings are that're liaisons to the ED, and coordinate a plan with them.

 

[WhoisJohnGalt]

People at my program historically seem to dislike working through the VA ED for lots of reasons. Big ones include a total reluctance of the attendings to even look at the psych patients (there's not a separate psych ED btw), which leads to things like missing critical medical issues. I know ED folks don't like psych patients in general, but it seems especially horrible at our ED.

Anyway, we have this new policy due to duty hours changes where the VA ED folks decide whether or not to admit psych patients. In a way it's awesome for us because it cuts down our work load, and evaluating vets in the ED is a miserable experience -- lots of drunk people, lots of angry people, not a lot of true psychopathology. So, great, yeah. But, the ED docs still don't generally look at our patients. They're theoretically supposed to do vitals and eyeball them, but the eyeballing pretty much never happens. Vitals get missed, too. For example, we had a guy hit the floor yesterday in hypertensive urgency who did not have vitals taken downstairs. Labs almost never get drawn. Physical exams, yeah, no. For most psych patients, it's probably OK. Except these are vets with bad hearts and bad etoh problems so not ideal.

The big problem, though, is that when the decision is made in the ED to admit patients, we get the admission signout from the social worker and not the ED doc. Again, for a pure psych issue, probably OK. But, lots of our admissions are patients who have multiple medical problems and who initially were evaluated by physicians for medical stuff before they were evaluated by psych social workers. We get no sign out regarding any of their medical workup in the ED. Instead, we get to talk to our social worker, who has no clue what's happened on that end. Maybe because I hate the VA ED's attitude surrounding psych patients so much, I'm reading more into this and finding it more offensive than it is, but shouldn't we have the privilege of getting signout from another physician?

All of this happens at our ER, with the exception of the signout issue. When an ED physician admits to psych, we get a call at whatever-hour-in-the-middle-of-the-night with like a 2 sentence sign-out from the physician because even though they're admitting, we have to "accept". We also have most of the problems discussed below, ESPECIALLY the problem with people being admitted with "SI" and crazy high BALs who aren't the least bit suicidal when they sober up. Issues with vitals, issues with not being evaluated for medical problems, we have all that too. Our PD just keeps telling us to document every little thing as well.

 

[WhoisJohnGalt]

How do the psych ward nurses take all this? Most places I've been through, if a patient sneezes, the psych nurse calls it "suspected pneumonia" and they're off to a medical ward. The VA psych nurses have to be flipping out over the cases you've had...

At my institution, it's really tough for our nurses who are used to responding that way. At the beginning of the year, they would just send patients down to the ER for everything they were remotely concerned about. Then the ER got tired of it and issued a memo that once a patient was admitted they couldn't go back to the ER. So now they have expanded the list of reasons to call a "rapid response" (just short of a code) which gets a bunch of trained nurses up there to evaluate. However, the rapid response team doesn't get the patient moved to a different floor unless it's a true emergency, which leaves the nurses with the patient they're uncomfortable with. It's a pretty terrible situation for everyone involved, but the chain of command at my program (who has spent many hours talking with the VA and laying out our well-documented concerns) pretty much agrees a patient will have to have a terrible outcome before it gets changed.

 

[Doctor Bagel]

Hmm, so the VA ED's suck every regarding psych patients. That's depressing. Our university ED does a much better job.

Speaking of ED stuff in general, I think it's weird that ED residents don't rotate in either neuro or psych.

 

[notdeadyet]

Hmm, so the VA ED's suck every regarding psych patients. That's depressing. Our university ED does a much better job.

Mmmm... I'd be careful about using "the VA" as if it's one organization. Counterintuitively, there's a big difference in protocol, procedures, and personality from one to the next. From medical school to residency, the two VA's I worked at were as different as the two academic hospitals.

Speaking of ED stuff in general, I think it's weird that ED residents don't rotate in either neuro or psych.

Agreed. Especially neuro. Medical school curriculum does not require a third year clerkship in neurology (mine didn't), so you could theoretically get all the way through an EM residency without doing any formal neuro training. Scary...

 

[Doctor Bagel]

Mmmm... I'd be careful about using "the VA" as if it's one organization. Counterintuitively, there's a big difference in protocol, procedures, and personality from one to the next. From medical school to residency, the two VA's I worked at were as different as the two academic hospitals.

Agreed. Especially neuro. Medical school curriculum does not require a third year clerkship in neurology (mine didn't), so you could theoretically get all the way through an EM residency without doing any formal neuro training. Scary...

Well, my generalized statement about the VA was based on all the posts here regarding other VAs that all seem to have inadequate systems in place to deal with mentally ill vets in the ED.

 

[Doctor Bagel]

At my institution, it's really tough for our nurses who are used to responding that way. At the beginning of the year, they would just send patients down to the ER for everything they were remotely concerned about. Then the ER got tired of it and issued a memo that once a patient was admitted they couldn't go back to the ER. So now they have expanded the list of reasons to call a "rapid response" (just short of a code) which gets a bunch of trained nurses up there to evaluate. However, the rapid response team doesn't get the patient moved to a different floor unless it's a true emergency, which leaves the nurses with the patient they're uncomfortable with. It's a pretty terrible situation for everyone involved, but the chain of command at my program (who has spent many hours talking with the VA and laying out our well-documented concerns) pretty much agrees a patient will have to have a terrible outcome before it gets changed.

When we changed our admission procedure with the VA, there was an initial thought of having the nurses be able to call the hospitalist service directly if they had medical concerns about patients. From my understanding, the hospitalist service reasonably vetoed that idea. I did get the hint from my call that the VA nurses are feeling a little overwhelmed. The guy showing up with the hypertensive urgency definitely freaked them out with good cause.

 

[whopper]

Wow. This is a bad outcome just waiting to happen. Have you been able to voice your concern with your PD or whoever is the director at the VA?

I've seen this problem happen in several places, even at institutions known to be of higher quality. A former teacher of mine worked in two Ivy League institutions and told me the same thing happened in their ERs. The situation in your VA may (or may not be) worse than most hospitals, but trust me, this is not unique to your VA.

It's the House of God phenomenon made real again. Doctors, as I've mentioned in other threads, often times are hard to replace, so hospitals are hesitant to get rid of bad ones. Even if they do, they have to be careful because doing so too much will lead to a reputation among doctors to stay away from such a place with arising rumors that the hospital doesn't treat doctors well.

Residents, on the other hand, are expected to do perfect work all the time, even when they are being taught and led by attendings that often times actually do a worse job than they do. This leads to a very frustrating predicament: the tail knows more than the head.

 

[nitemagi]

Mmmm... I'd be careful about using "the VA" as if it's one organization. Counterintuitively, there's a big difference in protocol, procedures, and personality from one to the next. From medical school to residency, the two VA's I worked at were as different as the two academic hospitals.

Agreed. Especially neuro. Medical school curriculum does not require a third year clerkship in neurology (mine didn't), so you could theoretically get all the way through an EM residency without doing any formal neuro training. Scary...

I would generally agree with this. There are national VA policies, as well as VISN policies, and individual hospital policies. The latter are obviously the easiest (though still difficult) ones to change.

I believe it's less of a house of god issue, though that can play into regular discounting of resident's opinions, and more often an issue of territoriality between ED and psychiatry. For example the emergency medicine literature says that BAL doesn't affect the ability to evaluate suicidality, whereas the psychiatric literature says it most definitely does. Both bodies are mostly expert opinion. So the ED believes they're right and they somehow convinced a hospital to have a policy that patients can be admitted to psych as long as their BAL is less than .250. Which is ridiculous, IMO. But it takes someone with authority within the administration to change such a policy. And that's tough to do. Even harder is getting the system to regularly follow new policies.

 

[Apollyon]

I've seen this problem happen in several places, even at institutions known to be of higher quality. A former teacher of mine worked in two Ivy League institutions and told me the same thing happened in their ERs.

The Ivies have good EM residencies, but not the strongest. The academic reputation doesn't spread around evenly.

 

[whopper]

Agree. Another problem is in institutions of higher respect, there can be even more narcissism, and the more of that, the worse this phenomenon mentioned above.

I mentioned this, but I know of a neurosurgery resident who is one of the highest respected programs in the country. He is emotionally abused regularly by some of his attendings, and based on what he's telling me, it's my opinion a lot of this neurosurgeon's inappropriate and unprofessional behavior is fueled by narcissism. He's trapped in that program and will have to suffer this guy for years. I wouldn't have touched that program, or any toxic program no matter the reputation with a ten foot pole if I could've gone elsewhere and know I could get good training without being someone's emotional punching bag.

The Ivies as I've mentioned in other threads is more of a name-brand. While many of them certainly deserve the level of respect they have, and as a whole they are better than many programs, the name-brand phenomenon often times extends further than what is deserved.

 

[sunlioness]

Do Emergency physicians do any required psychiatry rotations or get educated in psychiatric risk assessment? I ask because I am on phone back-up this week and this is the third time I've spoken to the resident and agreed that a patient could go home only to run into ornery ED attendings who "aren't comfortable" and "can't believe we would ever" send the patients home. It's the general run of the mill stuff. Parasuicidal gesture by a patient with borderline PD after a fight with boyfriend. Drunk guy who mouths off to cops about jumping off a bridge, but denies all once he's sober.

So I was wondering. I suppose this would be a good opportunity to reach out to the ED and offer to open a dialogue on risk assessment, but I'm a short timer now.

 

[atsai3]

Do Emergency physicians do any required psychiatry rotations or get educated in psychiatric risk assessment? I ask because I am on phone back-up this week and this is the third time I've spoken to the resident and agreed that a patient could go home only to run into ornery ED attendings who "aren't comfortable" and "can't believe we would ever" send the patients home. It's the general run of the mill stuff. Parasuicidal gesture by a patient with borderline PD after a fight with boyfriend. Drunk guy who mouths off to cops about jumping off a bridge, but denies all once he's sober.

So I was wondering. I suppose this would be a good opportunity to reach out to the ED and offer to open a dialogue on risk assessment, but I'm a short timer now.

If the ED attending isn't comfortable sending a patient home, he can keep her. But that doesn't mean psych needs to be involved, right? A sign off is a sign off.

 

[sunlioness]

This is totally true and that's happened. A few months ago, it happened with a patient who came to the ED c/o having ingested a small amount of percocet as a "suicide attempt" after an argument with family. A turkey sandwich later, the patient is denying all and okay with going home and family is okay with taking her. She had an appointment with her psychiatrist already scheduled within the next three days. The psych nurse saw her, ran her by me, and I elected not to admit. The ED attending complained, so a resident went down and concurred. The ED attending complained and so I went down and re-evaluated her personally. I still felt she was safe to go and the ED guy still "wasn't comfortable" and kept paging me to tell me so and ask me what I was going to do about it. I finally punted it to my boss who told the guy that it wasn't our problem. We had assessed the patient and decided not to admit her. His choice, at this point, was either to d/c her per our recommendation or keep her and sign her out to his replacement and let him/her do it.

So yeah, we don't have to admit anyone we don't want to, but the adversarial vibe of the whole thing is really off-putting and can't be ideal for care. I'd rather we could all be on the same page. Or at least if not precisely on the same page, we could respect our varying areas of expertise.

 

[nitemagi]

The territoriality is tough. EM isn't required per ACGME to do any psych rotations. In fact the only residency that is is neuro (1 month). Family medicine has to have training in "Human Behavior and Mental Health--
should acquire knowledge and skills in this area through a
program in which behavioral science and psychiatry are
integrated with all disciplines throughout the residents’ total
educational experience." That's quite loosely defined and I don't know of many quality and well thought out rotations for this. EM, as a generalist specialty, should have at least a month. Bygones.

 

[Sneezing]

Ohhhh, don't get me going on lack of psych training in our colleagues. EM, IM, and FP basically have none. If they do it will often be a mere 2 weeks with a psychologist or some other light rotation that doesn't convey what they really need to know. Mental health is prevalent in at least a 1/3 to half of the issues they all deal with on a daily basis. I believe they should all have at least 4 months of psych. 3 months inpatient, 1 month outpatient. IM could substitute 1 month IP for CL.

The disdain for psych I have seen and experienced by ED attendings is amazing. I've had one while a med student tell me psychiatric illness isn't real. I've had others just be plan mean. I do my best to assist as a consultant and team player but its frustrating.

The more psych rotations I do the more "ah ha" moments I have on reflection to earlier rotations as a med student or off service last year. The gaps and missing pieces of the patient behavioral puzzle are revealed. Fascinating stuff.

 

[whopper]

I've had one while a med student tell me psychiatric illness isn't real.

My response would be: If that's your opinion, then I'll expect to never receive any patients from you.

Fine by me. The nights this ER doctor is on duty should be very quiet nights.

Seriously, if any ER doctor did that, I'd consider reporting him to the administration. I'd actually expect even more patients from such an ER doctor because doctors like that often are a-holes and will dump to everyone else because they can't do a good job themselves. I wouldn't expect the administration to really do anything for the reasons I mentioned above. I would, however, try to do a kick ass job at the hospital, look elsewhere if this ER doctor was really ticking me off to the point where it got under my skin, and then let it be known to the hospital that I have other opportunities available, then see how'd they'd react.

So far, every place I've worked, doing that pretty much had the higher ups worried and giving me serious one on one time..."James we really don't want to see you go. Tell us what we can do to keep you here."

If you do a good job at an institution, make a good rep, and leave a hospital it does screw them. Such doctors are seen as morale leaders. Kinda like a sports team losing a key player. They entire team goes down a notch when such a person leaves. A colleague of mine attained that rep. When she left, almost everyone in the hospital saw it as a failure of leadership on the part of the hospital and almost everyone on her treatment team also left the hospital because they had little confidence in the doctor who took her place.

The hospital felt that sting. Further, several docs in the community knew she was a great doctor, so when she left, it just creates a bad taste in the mouths of other doctors who might consider working there.

A way to put this in your favor is the above. When you know your stock is high, don't complain too too much, but look at your opportunities elsewhere. See other things you like, make the right conversations....let the hospital know...voila. Now you got them eating out of your hand. You do a good job in a hospital, you're Donald Draper from Madmen. The rep will spread and you should do what you can to further it around (e.g. go to the right parties).

 

[nitemagi]

I agree that making yourself a commodity is always a good position to be in. It's a tough point as a resident though, dealing with undertrained attendings from other services though.

I think the med school educational process needs to figure out a better way to expose med students to the real upsides and diversity of psychiatry, including but not limited to diverse settings, populations, psychotherapy, etc. Otherwise med students get a mini-exposure and base most of their opinions on the opinions of outside attendings who also had a mini-exposure from their med school experience. Blind leading the blind.

 

[whopper]

It's a tough point as a resident though, dealing with undertrained attendings from other services though.

Agree. I remember having to go through several attendings as a resident where I could tell they didn't know what they were doing by the time I hit 2nd year. E.g. an attending giving out Ativan or Xanax to every single request.

I didn't think it was a matter of being undertrained so much as it were attendings were either didn't care or were lazy. When an attending has full range of being able to use CMEs, consult with colleagues and are in a university-setting, IMHO there's no excuse for this. E.g. there's UptoDate, and the attending doesn't even know how to use it and has no desire to do so. As a resident, when I felt I wasn't getting enough instruction, I'd look up the information on my own and end up knowing sometimes more than the attending....on my first read.

And as much as that may sound like a knock on my general residency program, from my experience, I've seen this problem happen everywhere.

I empathize with treatment teams where the attendings blow and everyone has to kowtow to the shmuck...because that's what's it's like to be a resident. I've never had a problem (at least I hope I didn't--of course I'm biased) whenever someone challenged my judgment using evidenced-based data in a collegial manner. I always tell residents and medstudents that if they heard something I didn't, they might be right and it's something they may know that I don't, and that we look into it together. The way medicine is, it's so large that it's not out of the ordinary for someone with less training to know a few facts here or there that even the top minds in the field don't know.

 

[Sneezing]

I agree that making yourself a commodity is always a good position to be in. It's a tough point as a resident though, dealing with undertrained attendings from other services though.

I think the med school educational process needs to figure out a better way to expose med students to the real upsides and diversity of psychiatry, including but not limited to diverse settings, populations, psychotherapy, etc. Otherwise med students get a mini-exposure and base most of their opinions on the opinions of outside attendings who also had a mini-exposure from their med school experience. Blind leading the blind.

Well, I'm just one, but when I get near them I tell them how much I love my job, my residency and the field and why its awesome. Maybe it'll sink for a few.

 

[nancysinatra]

Anyway, we have this new policy due to duty hours changes where the VA ED folks decide whether or not to admit psych patients.

Whoa, that just sounds bad. Because of duty hours, patient care is being downgraded? Seriously EM docs should never be in the position of admitting to psych. Although perversely all those unnecessary admissions would probably shorten length of stay and make the hospital look very efficient.

Likewise, just to play devil's advocate, after reading this thread, I think we in psych tend to complain a bit much about being handed medical problems that we should at least be able to start working up on our own. I work at a VA, and it's true, the EM docs barely even lay eyes on the psych patients. I'm not saying it's ok, but they are also busy with patients who are coding and patients who need intubation. If you were in their shoes, what would you do? I spent a lot of my first year complaining about the issues they miss, especially hypertension but sometimes worse things. And yeah, some of that neglect is no doubt due to stigma directed toward patients with psychiatric complaints. But after my off service rotations and just spending more time in the hospital, I could see that our psych unit was ALSO pathetic when it came to anything medical. In many psych units it seems like we want to cherry pick our patients and weed out anyone with any medical problem at all. What other inpatient medical specialty does that? Why can't we manage some of these common things ourselves?

I've also gotten some very silly medical questions from psych attendings. Totally unnecessary consult requests, for example. Or asking me to consult medicine about very mild hypertension without first trying a first line treatment.

If psych didn't turn away anything that is remotely medical, the situation might be a little better. We'd be forced to be trained better medically, and our field would get more respect within hospitals. Then maybe people would listen to us when we tell them that ED docs do not make good admission decisions!

 

[Doctor Bagel]

Whoa, that just sounds bad. Because of duty hours, patient care is being downgraded? Seriously EM docs should never be in the position of admitting to psych. Although perversely all those unnecessary admissions would probably shorten length of stay and make the hospital look very efficient.

Likewise, just to play devil's advocate, after reading this thread, I think we in psych tend to complain a bit much about being handed medical problems that we should at least be able to start working up on our own. I work at a VA, and it's true, the EM docs barely even lay eyes on the psych patients. I'm not saying it's ok, but they are also busy with patients who are coding and patients who need intubation. If you were in their shoes, what would you do? I spent a lot of my first year complaining about the issues they miss, especially hypertension but sometimes worse things. And yeah, some of that neglect is no doubt due to stigma directed toward patients with psychiatric complaints. But after my off service rotations and just spending more time in the hospital, I could see that our psych unit was ALSO pathetic when it came to anything medical. In many psych units it seems like we want to cherry pick our patients and weed out anyone with any medical problem at all. What other inpatient medical specialty does that? Why can't we manage some of these common things ourselves?

I've also gotten some very silly medical questions from psych attendings. Totally unnecessary consult requests, for example. Or asking me to consult medicine about very mild hypertension without first trying a first line treatment.

If psych didn't turn away anything that is remotely medical, the situation might be a little better. We'd be forced to be trained better medically, and our field would get more respect within hospitals. Then maybe people would listen to us when we tell them that ED docs do not make good admission decisions!

Honestly, changing our work load due to duty hours was necessary so the 2nd years (me!) wouldn't spend almost all the year on call. We traditionally had 1st and 2nd years do most the call, but the 1st years can't do much now due to the duty hours. We also don't have the money to hire faculty or NPs to cover services, so here we are. I'm honestly glad my program went that route instead of making me and my colleagues miserable (and arguably giving us a worse education because there's a point where call is counterproductive).

As for decisions about admissions, the ED has made the decisions on the university side for ages. Honestly, it seems to work pretty well over there. My understanding is that this is also not too atypical in the community. Our educational downside is that we no longer make admission decisions at either the VA or the university, but my program is going to find some way to replace that experience. I also got to make tons of those decisions on call last year at the VA, so I feel pretty OK on that one.

As for tolerance for medical issues, I agree that it's pretty low. As a resident, though, the downside is that you're covering the medical stuff by yourself because your attending isn't going to be able to help you. We also honestly admit lots of medically ill patients to our units, which I agree is good training. I'd still like some signout from a physician, though, when you send a medically complicated patient my way.