Your comments on this moonlighting gig

[Marasmus1]

Friday 5 pm to Monday 8 am Coverage of University Medical Center. No inpatient psychiatry unit so would provide coverage in CL and Emergency Department.

During the day 2 junior and 1 senior resident on call while NF team consists of 1 senior and 1 junior. I am required to be in the hospital from 9 am to 5 pm on Saturday and Sunday, the rest is phone call. As an attending on call I don`t do notes but should be available to residents for supervision if needed. Also required to co-sign their notes. Average census including both ED and CL 10-12.

Total compensation is 2.5k. Also included the malpractice insurance and lodging if traveling from outside city ( I am not).

What are your comments?

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[forchinet121]

Bad, being in the hospital 9-5 Saturday and Sunday is a huge dealbreaker for me because that kills your weekend for like barely any money

 

[Bartelby]

What PGY level are the senior and junior residents?

How many new consults per weekend on average?

How many overnight calls are typical?

Overall seems like a bad deal at first glance. $2500 per weekend / 16 hours in person = $156.25/hr. Add three nights of call onto that and it's quite bad.

 

[FlowRate]

If it was just 9-5 without the call it wouldn't be the worst thing ever although certainly not ideal. But with the call it's absolutely not worth it IMO.

But if you're a resident and have no other internal or external options other than this gig then it's really up to you if the money is worth it.

 

[G Sheb]

That sounds pretty bad.
First of all, how are you going to cosign notes for patients you don't see or evaluate, in a setting that is pretty risky? Especially if that includes discharges from the ER.
Compensation wise, that;s $156 for the 16 hours you are in the hospital. Not even counting the phone call. That's very low as well for a weekend moonlighting gig.

 

[surfguy84]

Friday 5 pm to Monday 8 am Coverage of University Medical Center. No inpatient psychiatry unit so would provide coverage in CL and Emergency Department.

During the day 2 junior and 1 senior resident on call while NF team consists of 1 senior and 1 junior. I am required to be in the hospital from 9 am to 5 pm on Saturday and Sunday, the rest is phone call. As an attending on call I don`t do notes but should be available to residents for supervision if needed. Also required to co-sign their notes. Average census including both ED and CL 10-12.

Total compensation is 2.5k. Also included the malpractice insurance and lodging if traveling from outside city ( I am not).

What are your comments?

Not good. I'm a resident moonlighter who gets a significantly higher hourly weekend rate with no phone call from home.

 

[TexasPhysician]

10 years ago as a resident, I earned $2k/weekend for rounding and I was done by 2-3pm. No call.

 

[VA Hopeful Dr]

10 years ago as a resident, I earned $2k/weekend for rounding and I was done by 2-3pm. No call.

10 years ago I did weekend coverage for our local psych hospital (no psychiatry residencies within 100 miles so they let us FPs cover some). Sat 8am-Sun 8am all in house was worth $1800.

OP gets to go home at night but also has to round on Sunday and be available by phone all 3 nights for an extra $700? Hard pass.

 

[Celexa]

That seems extremely underpaid, and also it sounds like these are not residents you know? There's a big difference between staffing senior residents you know and trust and staffing random residents you don't know as an outsider to the system.

 

[Marasmus1]

Ok I think I have excluded the most important information and sorry about that. I am an attending faculty in this university medical center so I know the system, residents and the departments well. Also I am doing my waiver job which means for extra additional income, this is my only moonlighting opportunity so this is pretty much my only option for extra cash. My base compenstion is not high which is 210 k. ( well for academia pretty average actually) . I thought if I did this weekend call once a month, I would increase it up to 240k annual compensation. I guess the question is it is worth it or not considering my situation?

 

[FlowRate]

this is my only moonlighting opportunity so this is pretty much my only option for extra cash. I guess the question is it is worth it or not considering my situation?

I already answered that. You're not asking us a normative/comparative question that we can answer e.g. is this moonlighting gig paying what other moonlighting gigs do/should pay? You're asking us to decide a question that only you can answer--is an extra $30k a year worth giving up one complete weekend every month?

 

[TexasPhysician]

Ok I think I have excluded the most important information and sorry about that. I am an attending faculty in this university medical center so I know the system, residents and the departments well. Also I am doing my waiver job which means for extra additional income, this is my only moonlighting opportunity so this is pretty much my only option for extra cash. My base compenstion is not high which is 210 k. ( well for academia pretty average actually) . I thought if I did this weekend call once a month, I would increase it up to 240k annual compensation. I guess the question is it is worth it or not considering my situation?

It doesn’t seem like you have options, so if it is worth it to you, go for it.

 

[Monocles]

Awful deal. There are night shifts out there that are basically glorified sleep study participant gigs that pay $2000 nightly.

 

[calvnandhobbs68]

Yeah OP agree with everyone else, it's not even worth having people comment on this if it's your ONLY moonlighting opportunity and you're on a waiver. It then basically comes down to how much you want that extra money, since it seems there's no other way for you to get it.

For other people looking on though, this is how academic contracts get you by the balls and end up semi-forcing people to do ridiculous weekend coverage like this that would easily be 2x more if you weren't locked into this system.

 

[Monocles]

Ok I think I have excluded the most important information and sorry about that. I am an attending faculty in this university medical center so I know the system, residents and the departments well. Also I am doing my waiver job which means for extra additional income, this is my only moonlighting opportunity so this is pretty much my only option for extra cash. My base compenstion is not high which is 210 k. ( well for academia pretty average actually) . I thought if I did this weekend call once a month, I would increase it up to 240k annual compensation. I guess the question is it is worth it or not considering my situation?

My bad I had missed this.

The economist inside me is offended on your behalf that they would even offer attendings this rate. But on the other hand if it's your ONLY option, you have to weigh your own opportunity costs (as in what you would rather do with your weekends, etc)

Good luck!

 

[Celexa]

Ok I think I have excluded the most important information and sorry about that. I am an attending faculty in this university medical center so I know the system, residents and the departments well. Also I am doing my waiver job which means for extra additional income, this is my only moonlighting opportunity so this is pretty much my only option for extra cash. My base compenstion is not high which is 210 k. ( well for academia pretty average actually) . I thought if I did this weekend call once a month, I would increase it up to 240k annual compensation. I guess the question is it is worth it or not considering my situation?

Lol well yeah if it's your only option for extra income it's your only option. It does make it at least a little better if you know the residents and system.

This is why I noped out of my old dept and the only academic opportunities I'm exploring are with depts that allow more flexibility.

 

[Marasmus1]

Yeah OP agree with everyone else, it's not even worth having people comment on this if it's your ONLY moonlighting opportunity and you're on a waiver. It then basically comes down to how much you want that extra money, since it seems there's no other way for you to get it.

For other people looking on though, this is how academic contracts get you by the balls and end up semi-forcing people to do ridiculous weekend coverage like this that would easily be 2x more if you weren't locked into this system.

Well I have to say, I have been having my fair share of doubts about academia since I started. I am interested in research, teaching and learning. However, I despise being abused and undercompensated. it seems I will have to be out of academia once my waiver is over. I wish there was a job where you could pursue academic interests while being fairly compensated for your work. I have not come across one yet

 

[comp1]

Eh, it's okay FOR academia. It's not okay outside of academia. It's not a horrible waste of your time, at least. Take it if it's your only option. Hopefully you can find something interesting to do while you're sitting around the hospital. Long term, push for the attending to be on home call if there's already 3 residents on site for 10 patients over 8 hours.

 

[G Sheb]

Eh, it's okay FOR academia. It's not okay outside of academia. It's not a horrible waste of your time, at least. Take it if it's your only option. Hopefully you can find something interesting to do while you're sitting around the hospital. Long term, push for the attending to be on home call if there's already 3 residents on site for 10 patients over 8 hours.

Not a good idea.
I would never discharge patients from the ER without seeing them.

 

[Stagg737]

If it's the only option, it's the only option. IF other options were available it's a bad deal. Imo getting $2.5k to be on home call for 48 hours and have residents check out to you wouldn't be bad, but if you physically have to go in for that amount of time you should be getting double that. I'm sure they'd argue that you've got residents working with you so it's not as much work, but it's still 9 hrs per day that you're physically on campus and unable to do other things.

For some context, I take weekend consult call (ER and floor) at our academic center where I'm physically present with another attending for ~5-6 hours and get paid $1k per day (would be $2k if only 1 attending is working, but also a few more hours). Additionally, any RVUs earned go towards our production bonus, so add ~50 RVUs per weekend. This is separate from any overnight call we take.

First of all, how are you going to cosign notes for patients you don't see or evaluate, in a setting that is pretty risky? Especially if that includes discharges from the ER.

This is pretty typical for attending positions in academia, as I looked at a few jobs with this set up. Residents check out to you by phone and you can do some chart review if you feel like it (which you should, but to each their own). Realistically, if you're working with good staff who can document safety plans well and know resources available for discharged patients then you're not really increasing your liability or providing further benefit be physically seeing the patients yourself. If you don't trust your staff to perform the basic necessities, then why work that job at all?

 

[calvnandhobbs68]

Not a good idea.
I would never discharge patients from the ER without seeing them.

This is literally what like every other consult service does with way more high risk stuff. You think the ophtho attending is coming to the hospital in the middle of the night even though they have resident coverage for a non-surgical ophtho issue they d/c home? No way. Put any other X specialty, especially surgical specialities, that needs to show up to the ER for consults (ENT, ortho, gen surg, etc), same thing.

I think it also helps if we don't delude ourselves that we can somehow mitigate risk well by having a "good" ER consult. Most of the risk eval is just CYA medicine. You can also have a list of info points you want to make sure the resident has gathered (ex. asking if they have access to firearms, collateral info, past suicide attempts, etc etc) and go over with them.

I mean in this area of telepsych, worst comes to worst and it's some story you're really on the fence with, you could also just have the resident connect to your doxy.me account or something and talk to the patient yourself for 10 minutes.

 

[comp1]

This is literally what like every other consult service does with way more high risk stuff. You think the ophtho attending is coming to the hospital in the middle of the night even though they have resident coverage for a non-surgical ophtho issue they d/c home? No way. Put any other X specialty, especially surgical specialities, that needs to show up to the ER for consults (ENT, ortho, gen surg, etc), same thing.

I think it also helps if we don't delude ourselves that we can somehow mitigate risk well by having a "good" ER consult. Most of the risk eval is just CYA medicine. You can also have a list of info points you want to make sure the resident has gathered (ex. asking if they have access to firearms, collateral info, past suicide attempts, etc etc) and go over with them.

I mean in this area of telepsych, worst comes to worst and it's some story you're really on the fence with, you could also just have the resident connect to your doxy.me account or something and talk to the patient yourself for 10 minutes.

Concur, we're darn near completely unable to predict who is going to going to hurt themselves (or others) and yet there's this belief that if we look the person in the eyes we can read their soul. Make sure the risk and protective factors are documented and anything that can be mitigated, is. Likely very little can be mitigated. That's as good as you're going to be able to get it from a liability perspective.

 

[FlowRate]

I wish there was a job where you could pursue academic interests while being fairly compensated for your work.

There are a couple of situations that fit that goal that I've seen. Obviously the waiver/visa situation complicates things for now.

You could work for a large but not-really "academic" institution (i.e. NOT a University system) that's affiliated with residency programs and medical schools. For example, Kaiser and some of the big hospital systems in various locales. Kaiser even has research positions/support to a certain degree.

You could work part time/affiliate with a residency program and then work another part time gig (often private practice--not super common outside of the northeast though AFAIK).

Not a good idea.
I would never discharge patients from the ER without seeing them.

Never, any patient, at all, ever? You're even more conservative than the very conservative attendings in one of the hospital systems in my training program. Even they OK'd discharges for pts that had absolutely no safety concerns come up. It was rare to get them to agree to discharge pts with any sort of safety concerns overnight but did happen occasionally.

In the other system where I worked, a robust safety plan and thorough, reassuring evaluation you could very frequently discharge pts overnight. You had to staff with the attending or 4th year but they didn't require eyes-on.

 

[forchinet121]

Not a good idea.
I would never discharge patients from the ER without seeing them.

This is standard practice, having a psychiatrist see a patient in the ED is absolutely not.

 

[G Sheb]

It is absolutely not standard practice in “academia” for patients to be discharged without being evaluated by attendings. Between my residency and two academic gigs I work at, all of them require attendings to see discharges (and two require attendings to see all patients evaluated).
I’m actually curious how are these notes being co-signed by attendings. They almost always say things like “I evaluated x and agree with so so assessments with exceptions noted below”. Are attendings actually writing this without seeing the patients?
You cannot attest a note in a supervisory role without evaluating the patient.

Residents miss things all the time (expected), especially PGY 1 and 2. Many also have interests to get people out so not to sign them out to an annoying attending..etc we’ve all been there. Even at the best places, there's usually this one resident who's struggling, and I don't think you want to risk your license for that. Even if you would trust them with 90% without seeing the patients, are you willing to take the liability for the 10% missed cases?
Not a good idea imo for an ER gig where the liability is the highest.

 

[Stagg737]

I’m actually curious how are these notes being co-signed by attendings. They almost always say things like “I evaluated x and agree with so so assessments with exceptions noted below”. Are attendings actually writing this without seeing the patients?
You cannot attest a note in a supervisory role without evaluating the patient.

You can absolutely attest a note in a supervisory role without directly seeing the patient as this is the entire basis of "indirect supervision" through ACGME and "general supervision" through CMS. The attestation would read something like:

"I did not personally see the patient but have discussed the case with this resident (sometimes says 'including E/M, history, physical, etc) and agree with documentation unless otherwise stated below."

As far as I know, CMS does not reimburse for general supervision in any setting, but many insurance companies do reimburse for indirect/general supervision in outpatient clinics as this was how the outpatient clinic where I did my residency operated. Attendings only directly laid eyes on patients who were Medicare/caid or complex cases. The ER is a bit unique as it's technically an outpatient setting, so I suppose a hospital could try and bill insurance for indirectly supervised encounters. Where I'm currently at if a resident sees a patient in the ER overnight and discharges them we just sign as the above and the encounter just doesn't get billed, though overnight discharges from the ER are pretty rare.

Source for supervisory definitions through ACGME and CMS: You are being redirected...

 

[FlowRate]

It is absolutely not standard practice in “academia” for patients to be discharged without being evaluated by attendings. Between my residency and two academic gigs I work at, all of them require attendings to see discharges (and two require attendings to see all patients evaluated).
I’m actually curious how are these notes being co-signed by attendings. They almost always say things like “I evaluated x and agree with so so assessments with exceptions noted below”. Are attendings actually writing this without seeing the patients?
You cannot attest a note in a supervisory role without evaluating the patient.

Residents miss things all the time (expected), especially PGY 1 and 2. Many also have interests to get people out so not to sign them out to an annoying attending..etc we’ve all been there. Even if you would trust them with 90% without seeing the patients, are you willing to take the liability for the 10% missed cases? It's your license that is on the line.
Not a good idea for an ER gig where the liability is the highest.

Patient came in for feeling anxious at 6PM on Friday. ED asked psychiatry to see the patient for funsies. Patient says their anxiety is better now that they have 25mg of hydroxyzine on board. They have never, at all, at any point in their life, had any suicidal thoughts or whims. Patient has a psych intake appointment on Monday.

Your program is going to make the patient wait until 9AM Saturday to discharge?

Nobody cares about psych billing. The ED needs to move patients up or out. "I have discussed the case with Dr. X who approved discharge." No need for the attending to attest the note at all. It's so incredibly expensive to take up ED beds with mildly anxious patients waiting for 14 hours for an attending.

Also, two require attendings to see all evals? As in they can't be admitted to inpatient psych / transferred to outside inpatient unit without being seen by an attending?

 

[G Sheb]

Patient came in for feeling anxious at 6PM on Friday. ED asked psychiatry to see the patient for funsies. Patient says their anxiety is better now that they have 25mg of hydroxyzine on board. They have never, at all, at any point in their life, had any suicidal thoughts or whims. Patient has a psych intake appointment on Monday.

Your program is going to make the patient wait until 9AM Saturday to discharge?

Nobody cares about psych billing. The ED needs to move patients up or out. "I have discussed the case with Dr. X who approved discharge." No need for the attending to attest the note at all. It's so incredibly expensive to take up ED beds with mildly anxious patients waiting for 14 hours for an attending.

Also, two require attendings to see all evals? As in they can't be admitted to inpatient psych / transferred to outside inpatient unit without being seen by an attending?

Whoah, easy there with the projections.
No they don't wait. They just hire a psychiatrist who supervises residents, covers the overnight shift and sees the patients.

 

[Stagg737]

Patient came in for feeling anxious at 6PM on Friday. ED asked psychiatry to see the patient for funsies. Patient says their anxiety is better now that they have 25mg of hydroxyzine on board. They have never, at all, at any point in their life, had any suicidal thoughts or whims. Patient has a psych intake appointment on Monday.

Your program is going to make the patient wait until 9AM Saturday to discharge?

Nobody cares about psych billing. The ED needs to move patients up or out. "I have discussed the case with Dr. X who approved discharge." No need for the attending to attest the note at all. It's so incredibly expensive to take up ED beds with mildly anxious patients waiting for 14 hours for an attending.

Also, two require attendings to see all evals? As in they can't be admitted to inpatient psych / transferred to outside inpatient unit without being seen by an attending?

Whoah, easy there with the projections.
No they don't wait. They just hire a psychiatrist who supervises residents, covers the overnight shift and sees the patients.

A psychiatrist seeing the above case is a complete waste of time and resources. Basic anxiety without SI/HI/AVH doesn't even need to be seen by SW (which would be much more appropriate) let alone a psych resident or attending. If an ER can't handle basic psych stuff (depression/anxiety without SI, mild to moderate agitation, drunkicidal with current intoxication, etc) then that's not an ER I'd ever want to work in...

The bolded is also crazy to me. Patient comes in after being found trying to hang themselves with no physical injury, reports depression for past 2 months, and is agreeable to psych admission without further complications doesn't need to be seen by psych either. The inpatient team can do a full evaluation when the patient arrives there.

 

[G Sheb]

You can absolutely attest a note in a supervisory role without directly seeing the patient as this is the entire basis of "indirect supervision" through ACGME and "general supervision" through CMS. The attestation would read something like:

"I did not personally see the patient but have discussed the case with this resident (sometimes says 'including E/M, history, physical, etc) and agree with documentation unless otherwise stated below."

As far as I know, CMS does not reimburse for general supervision in any setting, but many insurance companies do reimburse for indirect/general supervision in outpatient clinics as this was how the outpatient clinic where I did my residency operated. Attendings only directly laid eyes on patients who were Medicare/caid or complex cases. The ER is a bit unique as it's technically an outpatient setting, so I suppose a hospital could try and bill insurance for indirectly supervised encounters. Where I'm currently at if a resident sees a patient in the ER overnight and discharges them we just sign as the above and the encounter just doesn't get billed, though overnight discharges from the ER are pretty rare.

Source for supervisory definitions through ACGME and CMS: You are being redirected...

That attestation is sort of useless then.
First, because, as you said, most likely you can't bill.
Second and most importantly, how is this going to help you in case there is a lawsuit and you're saying you have NOT seen the patient? LOL. It looks like something a lawyer would run away with. You're better off not attesting.
And if you're saying in your program "overnight discharges are pretty rare", aren't you basically saying the same thing? It seems like your program for the most part frowns on residents discharging patients without being seen by attendings.

And of course if you pick the most obvious example of someone who needs to be discharged, then there's no point to hire a psychiatrist. Like at all. But clearly these aren't the only patients coming overnight. SMH.

 

[Stagg737]

That attestation is sort of useless then.
First, because, as you said, most likely you can't bill.
Second and most importantly, how is this going to help you in case there is a lawsuit and you're saying you have NOT seen the patient? LOL. It looks like something a lawyer would run away with. You're better off not attesting.
And if you're saying in your program "overnight discharges are pretty rare", aren't you basically saying the same thing? It seems like your program for the most part frowns on residents discharging patients without being seen by attendings.

And of course if you pick the most obvious example of someone who needs to be discharged, then there's no point to hire a psychiatrist. Like at all. But clearly these aren't the only patients coming overnight. SMH.

To the bolded, not at all. We just rarely get situations overnight where:
A. There isn't an obvious dispo plan
B. Patients can't or shouldn't be seen in the morning
C. A patient is clinically complex enough that it requires an actual attending psychiatrist to evaluate them

The only situation I can think of which really requires the clinical acumen of an experienced psychiatrist at that moment is a patient reporting SI/HI who is completely calm and cooperative with apparent capacity who is demanding to leave RIGHT NOW with a questionable safety plan. Frankly, the only reason this would require an attending to see them in person over a good resident is legal CYA. Realistically, there is no such thing as a "psychiatric emergency" that doesn't require direct medical or legal intervention.

You can argue that it's an increased legal liability, but if the documentation from the resident is appropriate then what are you adding to their treatment course by seeing the in person other than saying "I physically saw them"? A competent resident after their intern year should be able to do a thorough safety eval, suicide assessment, safety plan, and dispo plan and document it appropriately so as to hold up in court. Additionally, this is a great example of ACGME's goals for resident progression. A quote from their CLER (Clinical Learning Environment Review) team reviews and policies:

"The ultimate goal of GME is to provide resident and fellow physicians with the clinical experiences necessary to acquire the knowledge, skills, and abilities that they need to deliver the safest and highest quality patient care. In order to achieve this, residents and fellows need appropriate supervision throughout their training. Providing close direct supervision provides the necessary comfort and assurance to minimize issues of patient safety for patients receiving care from residents and fellows in training. However, it is essential that residents and fellows are given the opportunity to provide care under indirect supervision to ensure that they develop into physicians who can practice independent of the training environment, and have the skills to ensure they deliver safe patient care over the 30 or more years of their clinical careers.

Patient care billing requirements, payment policies, and regulatory and accreditation rules may be influencing CLEs and residency programs to place restrictions on the amount of patient care that residents and fellows can perform without direct supervision. When this occurs, it impedes the ability of residents to progress from direct supervision through indirect supervision to successful independent practice at the completion of training."

We can argue about whether residents seeing patients overnight in the ER without direct supervision is appropriate, but it's directly stated in several ACGME documents that they eventually should.

 

[hallowmann]

Not a good idea.
I would never discharge patients from the ER without seeing them.

At first, I was wondering if this is serious, then...

It is absolutely not standard practice in “academia” for patients to be discharged without being evaluated by attendings. Between my residency and two academic gigs I work at, all of them require attendings to see discharges (and two require attendings to see all patients evaluated).
I’m actually curious how are these notes being co-signed by attendings. They almost always say things like “I evaluated x and agree with so so assessments with exceptions noted below”. Are attendings actually writing this without seeing the patients?
You cannot attest a note in a supervisory role without evaluating the patient.

Residents miss things all the time (expected), especially PGY 1 and 2. Many also have interests to get people out so not to sign them out to an annoying attending..etc we’ve all been there. Even at the best places, there's usually this one resident who's struggling, and I don't think you want to risk your license for that. Even if you would trust them with 90% without seeing the patients, are you willing to take the liability for the 10% missed cases?
Not a good idea imo for an ER gig where the liability is the highest.

We were DCing ED consults at night at my large academic institution by PGY2. We were the only ones in-house covering all of the psych beds (almost 100) , consults, and the ED by ourselves. We documented safety plans and risk assessments on everyone anyway (100% CYA and realistically does nothing to predict or prevent suicide as noted above), but if we were DCing someone with SI from the ED we had to call our on-call seniors, and they didn't even need to come in for it. As for the attendings, I believe in my entire time I called the adult attendings twice overnights (we had to call and staff child staff with any ED consults going home). Absolutely no attending was called in from home call and even senior residents rarely had to be called in. This was (and still is as far as I know) the norm.

As for billing and staff liability, etc, our consult notes were cosigned by ED staff who had liability in the case regardless. If they thought it was a clear admit they made the call and we encouraged not even consulting us (meaning boarding in the ED for 1-10 days).

I'm honestly shocked you're at an academic institution that has Psychiatry attendings come in over night. Our place had to pay psych staff $400/hr just to get enough to agree to stay late from 5-8PM covering the crisis unit (at most 3 admits and the rest get turfed to the overnight resident). No way would they have had enough coverage for overnight call with likelihood of being called in. At best they'd hire midlevels, and I don't think they'd even do that.

 

[G Sheb]

At first, I was wondering if this is serious, then...

We were DCing ED consults at night at my large academic institution by PGY2. We were the only ones in-house covering all of the psych beds (almost 100) , consults, and the ED by ourselves. We documented safety plans and risk assessments on everyone anyway (100% CYA and realistically does nothing to predict or prevent suicide as noted above), but if we were DCing someone with SI from the ED we had to call our on-call seniors, and they didn't even need to come in for it. As for the attendings, I believe in my entire time I called the adult attendings twice overnights (we had to call and staff child staff with any ED consults going home). Absolutely no attending was called in from home call and even senior residents rarely had to be called in. This was (and still is as far as I know) the norm.

As for billing and staff liability, etc, our consult notes were cosigned by ED staff who had liability in the case regardless. If they thought it was a clear admit they made the call and we encouraged not even consulting us (meaning boarding in the ED for 1-10 days).

I'm honestly shocked you're at an academic institution that has Psychiatry attendings come in over night. Our place had to pay psych staff $400/hr just to get enough to agree to stay late from 5-8PM covering the crisis unit (at most 3 admits and the rest get turfed to the overnight resident). No way would they have had enough coverage for overnight call with likelihood of being called in. At best they'd hire midlevels, and I don't think they'd even do that.

Yeah that's why.
Not enough staff to cover.
I'm equally shocked that ED attendings would take full liability for psychiatric decisions when most of the time they can't tell schizophrenia from bipolar from delirium from psychosis from personality disorder..etc.
I think the key is that I'm in a large metro area and perhaps they don't have the same shortage of psychiatric staff as in other places. And there's also a much higher load of psych patients so that many ERs have dedicated ER spaces with their own nursing/MHW staff. The ED attendings, who are also exceptionally busy, will not want to deal with all the psych issues, so it's a win win for the hospital.
Heck, many places have dedicated medical NPs and PAs to help the psychiatrist with medical issues, even overnight, lol.

Of course in your case the psych attendings aren't taking any liability, but regardless, clinically, there's no higher risk environment than an ER. I question the wisdom of taking the liability of discharging a patient without seeing them. We're up in arms when we're supervising NPs outpatient (for good reason), so I wonder why are people willing to give the ED a pass, when it's much higher risk.
Clinically as well, it's not only about 'documenting a safety plan'. Yeah some patient will cooperate with a safety plan and kill themselves afterwards. Clinical acumen is absolutely important. It comes after seeing many, many patients; and I see it all the time, residents reach different levels at different speeds. There are always misses. That patient who's coming with anxiety may very well be psychotic if the inexperienced resident didn't manage to elicit the psychosis. Your exposure to inpatient and outpatient is also important in making these decisions, so you actually know who is a better treated in which environment.
I guess I am luck and happy to be working in an environment where these things can be afforded and appreciated.

 

[Celexa]

At first, I was wondering if this is serious, then...

We were DCing ED consults at night at my large academic institution by PGY2. We were the only ones in-house covering all of the psych beds (almost 100) , consults, and the ED by ourselves. We documented safety plans and risk assessments on everyone anyway (100% CYA and realistically does nothing to predict or prevent suicide as noted above), but if we were DCing someone with SI from the ED we had to call our on-call seniors, and they didn't even need to come in for it. As for the attendings, I believe in my entire time I called the adult attendings twice overnights (we had to call and staff child staff with any ED consults going home). Absolutely no attending was called in from home call and even senior residents rarely had to be called in. This was (and still is as far as I know) the norm.

As for billing and staff liability, etc, our consult notes were cosigned by ED staff who had liability in the case regardless. If they thought it was a clear admit they made the call and we encouraged not even consulting us (meaning boarding in the ED for 1-10 days).

I'm honestly shocked you're at an academic institution that has Psychiatry attendings come in over night. Our place had to pay psych staff $400/hr just to get enough to agree to stay late from 5-8PM covering the crisis unit (at most 3 admits and the rest get turfed to the overnight resident). No way would they have had enough coverage for overnight call with likelihood of being called in. At best they'd hire midlevels, and I don't think they'd even do that.

What I find most entertaining about this discussion so far is that there are at least four separate questions talking past each other, namely--

1. Is it common for residents to see and discharge patients overnight without an attending evaluation the patient?

2. Is it standard of care?

3. Is it a good idea for the resident's training?

4. Is it a bad situation for the attending?

To my eye the answers are:

1. Absolutely yes, I trained this way as well.

2. Again yes, both because the answer to 1) is yes and because the standard of care in mental health care is so pitifully low if residents are held to the basics of safety plans and risk assessment they're already above average

3. Sometimes, context dependent, a function of volume, setting, ancillary staff support, and supervision (including the ability to debrief difficult cases)

4. Sometimes, again context dependent, a function of the same factors as 3) plus $$$$$$$

Also there is absolutely no chance my prior department could find the money OR the people to staff an in person attending 24/7, and they have no incentive to when they can just make the residents do the work.

 

[calvnandhobbs68]

Of course in your case the psych attendings aren't taking any liability, but regardless, clinically, there's no higher risk environment than an ER. I question the wisdom of taking the liability of discharging a patient without seeing them. We're up in arms when we're supervising NPs outpatient (for good reason), so I wonder why are people willing to give the ED a pass, when it's much higher risk.

So this isn't really true. As far as I know, any time a resident is providing patient care using their training license, it's technically under the supervision of an attending. So even for these overnight "never called the attending" evals, there was some attending on call who is available.

I think the key is that I'm in a large metro area and perhaps they don't have the same shortage of psychiatric staff as in other places.

This may not have anything to do with it. As with most things in medicine, it's likely regional culture. I've been exposed to 3 major academic hospital systems setups and all the setups had some period of time where a social worker covered psych consults in the ER. One of the systems actually has an entire structured team that is basically only social workers doing ER consults with a psych resident moonlighting.

 

[splik]

So this isn't really true. As far as I know, any time a resident is providing patient care using their training license, it's technically under the supervision of an attending. So even for these overnight "never called the attending" evals, there was some attending on call who is available.

If the resident never called the attending then in the event of a bad outcome it is the resident who would be on the hook for failure to consult with the attending. At least where I am, we refuse to cosign the notes if the residents don't call us to discuss the case (which they are required to do unless they're just admitting them or keeping them overnight).

 

[SmallBird]

Yeah that's why.
Not enough staff to cover.
I'm equally shocked that ED attendings would take full liability for psychiatric decisions when most of the time they can't tell schizophrenia from bipolar from delirium from psychosis from personality disorder..etc.
I think the key is that I'm in a large metro area and perhaps they don't have the same shortage of psychiatric staff as in other places. And there's also a much higher load of psych patients so that many ERs have dedicated ER spaces with their own nursing/MHW staff. The ED attendings, who are also exceptionally busy, will not want to deal with all the psych issues, so it's a win win for the hospital.
Heck, many places have dedicated medical NPs and PAs to help the psychiatrist with medical issues, even overnight, lol.

Of course in your case the psych attendings aren't taking any liability, but regardless, clinically, there's no higher risk environment than an ER. I question the wisdom of taking the liability of discharging a patient without seeing them. We're up in arms when we're supervising NPs outpatient (for good reason), so I wonder why are people willing to give the ED a pass, when it's much higher risk.
Clinically as well, it's not only about 'documenting a safety plan'. Yeah some patient will cooperate with a safety plan and kill themselves afterwards. Clinical acumen is absolutely important. It comes after seeing many, many patients; and I see it all the time, residents reach different levels at different speeds. There are always misses. That patient who's coming with anxiety may very well be psychotic if the inexperienced resident didn't manage to elicit the psychosis. Your exposure to inpatient and outpatient is also important in making these decisions, so you actually know who is a better treated in which environment.
I guess I am luck and happy to be working in an environment where these things can be afforded and appreciated.

Your perspective on how after hours emergency psychiatry functions is even more fringe then your perspective on tax deferred retirement accounts.

 

[FlowRate]

Whoah, easy there with the projections.
No they don't wait. They just hire a psychiatrist who supervises residents, covers the overnight shift and sees the patients.

Projections? More like assuming we were talking about the same thing (overnight resident-only coverage.) It's insane to me that you worked in programs that actually had attendings in-house overnight.

As for your "go tell top 20" post, overnight RESIDENT coverage is the norm, not in-house attendings.

Meanwhile, in the community, it's mostly social workers seeing after hours psych cases in the ED.

A psychiatrist seeing the above case is a complete waste of time and resources. Basic anxiety without SI/HI/AVH doesn't even need to be seen by SW (which would be much more appropriate) let alone a psych resident or attending. If an ER can't handle basic psych stuff (depression/anxiety without SI, mild to moderate agitation, drunkicidal with current intoxication, etc) then that's not an ER I'd ever want to work in...

Right, I was intentionally painting something egregious to see if G was really serious about EVERY patient having to be seen by an attending before they can be let out of the ED.

 

[G Sheb]

Projections? More like assuming we were talking about the same thing (overnight resident-only coverage.) It's insane to me that you worked in programs that actually had attendings in-house overnight.

Right, I was intentionally painting something egregious to see if G was really serious about EVERY patient having to be seen by an attending before it can be let out of the ED.

I find it equally shocking that you're shocked that there are in-house attendings overnight.
I'm literally talking about here about several top 20 academic institutions. Some have the resources to deal with the increased liability, and some do what they can.
And let's leave it at that. LOL.

 

[Bartelby]

I was a resident at a large academic program and have been an attending at another. In both, residents could discharge a patient from the ER without having an attending see the patient. The standard of care looks at what at least a respectable minority of reasonably prudent practitioners would do under similar circumstances, so as the experience of many (most?) posters on this board attest discharging patients from the ER when only the resident has seen them falls well within the standard of care.

I also find that it is not all that stressful to do most of the time. I am able to access the patient's chart and review it. I discuss the case in detail with the resident, and can direct them to go back and gather more data if needed. I walk through their assessment and reasoning with them, and I review their (highly detailed) note in full. I then write an addendum if needed outlining anything else that was considered. I am okay with this in a way that I would not be okay with many of the "supervision" setups for practicing NPs. In those situations, the psychiatrist is typically not talking in depth about every case and carefully going through the NP's findings and reasoning.

In addition, if you're not sure based on what the resident has told you then you can act conservatively and admit cases that likely could have really gone out of the ER.

All that said, it can feel uncomfortable to put trust in the work of other less experienced people, especially if you don't know them. There is always the risk the resident will do something stupid and highly damaging that you would have caught had you been there in person. I have not yet seen it happen, and I don't know anyone who has been sued under those circumstances, but I'd bet it occurs. When you consider a role like this you have to weigh that risk in however heavily it registers for you.

 

[G Sheb]

I was a resident at a large academic program and have been an attending at another. In both, residents could discharge a patient from the ER without having an attending see the patient. The standard of care looks at what at least a respectable minority of reasonably prudent practitioners would do under similar circumstances, so as the experience of many (most?) posters on this board attest discharging patients from the ER when only the resident has seen them falls well within the standard of care.

I also find that it is not all that stressful to do most of the time. I am able to access the patient's chart and review it. I discuss the case in detail with the resident, and can direct them to go back and gather more data if needed. I walk through their assessment and reasoning with them, and I review their (highly detailed) note in full. I then write an addendum if needed outlining anything else that was considered. I am okay with this in a way that I would not be okay with many of the "supervision" setups for practicing NPs. In those situations, the psychiatrist is typically not talking in depth about every case and carefully going through the NP's findings and reasoning.

In addition, if you're not sure based on what the resident has told you then you can act conservatively and admit cases that likely could have really gone out of the ER.

All that said, it can feel uncomfortable to put trust in the work of other less experienced people, especially if you don't know them. There is always the risk the resident will do something stupid and highly damaging that you would have caught had you been there in person. I have not yet seen it happen, and I don't know anyone who has been sued under those circumstances, but I'd bet it occurs. When you consider a role like this you have to weigh that risk in however heavily it registers for you.

It's actually a regulation in my state that a staff psychiatrist has to be present, all the time, in state-designated psychiatric ERs.
That much pretty much means every psychiatric ER that is worth its salt has an in-house psychiatrist, all the time.
This also happens in places that are not state designated, as they would certainly like to lower their liability, if they can afford it.
I understand your perspective, but as the high risk environment that the ER is, I veer on the conservative side. There is always the rare really obvious case, but it's not a risk I would like to take when other options are better (and pay more as well).

 

[SmallBird]

It's actually a regulation in my state that a staff psychiatrist has to be present, all the time, in state-designated psychiatric ERs.
That much pretty much means every psychiatric ER that is worth its salt has an in-house psychiatrist, all the time.
This also happens in places that are not state designated, as they would certainly like to lower their liability, if they can afford it.
I understand your perspective, but as the high risk environment that the ER is, I veer on the conservative side. There is always the rare really obvious case, but it's not a risk I would like to take when other options are better (and pay more as well).

Interesting, what state?

 

[comp1]

I see a couple of people worried about liability....but not a lot of demonstration of increased liability. Don't you think programs (some very prestigious) would not be doing resident discharges overnight if they were being sued all the time?

 

[Stagg737]

I think the key is that I'm in a large metro area and perhaps they don't have the same shortage of psychiatric staff as in other places. And there's also a much higher load of psych patients so that many ERs have dedicated ER spaces with their own nursing/MHW staff. The ED attendings, who are also exceptionally busy, will not want to deal with all the psych issues, so it's a win win for the hospital.

For context, I'm at a large academic center (~1,000 beds) in a mid-sized metro that has a (small) dedicated psych space with a separate MH team (RN and SW) who see the "easy" cases before psychiatry is consulted. Other hospitals in this metro have similar setups. We do always have a dearth of psych patients requiring care but even so no one wants to physically be seeing ER psych patients overnight. The minimal salary for such positions is something hospitals just aren't willing to pay.

We're up in arms when we're supervising NPs outpatient (for good reason), so I wonder why are people willing to give the ED a pass, when it's much higher risk.

There's a very significant difference between supervising an NP who spent 2-3 months to get a "PMHNP" certificate sometimes with no actual clinical psych experience and supervising a psychiatry resident, typically PGY-2+ in an ER.

Clinical acumen is absolutely important. It comes after seeing many, many patients; and I see it all the time, residents reach different levels at different speeds. There are always misses. That patient who's coming with anxiety may very well be psychotic if the inexperienced resident didn't manage to elicit the psychosis. Your exposure to inpatient and outpatient is also important in making these decisions, so you actually know who is a better treated in which environment.

I don't disagree and have certainly seen cases where having more experience/acumen made a difference in the treatment plan. I still don't understand why cases that are more complex cannot wait 6-10 hours to be seen by the primary psych team the following morning, especially given many of those cases will require further observation before making an appropriate dispo plan anyway.

It's actually a regulation in my state that a staff psychiatrist has to be present, all the time, in state-designated psychiatric ERs.
That much pretty much means every psychiatric ER that is worth its salt has an in-house psychiatrist, all the time.

That makes a huge difference in this discussion, state laws/mandates supersede meeting minimum requirements for the standard of care. If we're talking about stand-alone psych ERs, then I also probably agree with your second statement. However, for "psych ERs" embedded in a true medical ER Idk that I would agree. In an ideal world every ER would have a psychiatrist on staff 24/7, but it's honestly not necessary in many places as a 2am dispo is often unnecessary and more for the convenience of the patient and sometimes hospital admins trying to maximize profits than actual patient care.

I'll still emphasize that there really isn't anything that qualifies as a true "psychiatric emergency" where a psychiatrist alone is needed and a medical physician or legal team (police/EMS, behavioral teams, etc) isn't necessary. And in both those situations, the psychiatrist probably isn't going to be seeing that patient until the following day anyway if the "emergency" occurs overnight.

 

[ObsequiousAplomb]

This has been an interesting discussion. Some of the more recent points have actually left me a little bit confused. It seems G was talking about standalone psychiatric emergency rooms and most of the other commenters were talking about medical ERs with psych patients or psych ERs embedded within a medical ER.

Scenario 1:
I have definitely never seen a medical ER that has ER physicians and psych SW require an attending psychiatrist be present in the facility at all times. I've also never seen one that required the attending psychiatrist to come into the ER while on home call. The SW (if there is one) may do some psych screening and call the attending. A resident would do that, too, if this were a facility with in-house residents. Someone is there to do the initial screening, whether that is an ER attending or a SW or nurse or other psychiatric provider. Subtle psychosis doesn't meet emergency treatment criteria, so idk why anyone would refuse to discharge someone with an OP problem.

Scenario 2:
I have not seen a standalone psychiatric ER that didn't have a psychiatrist on-site 24/7. I've never seen one that has ER or other physicians, so the psychiatrist would be the only person present. Frequently the on-site physician is a moonlighting PGY-3+, operating under their own license. I didn't know that there were programs that allowed the only physician on site for an ER to be someone with a training license. Where I live, training licenses aren't sufficient for filing or accepting an involuntary hold except in a very narrow set of circumstances.

Were people saying that scenario 2 frequently is manned by a PGY-2 without their own license and no other on-site physicians of any specialty? I know in my own program sometimes I was the only physician on-site in PGY-3 outpatient. But not before that, and my peers at different sites within our program were never the only physician on-site. I'm not saying that I wouldn't feel comfortable manning the fort alone (aside from one SW, one tech, and one RN), just that I was never given that opportunity. Scenario 1 happened all the time during PGY-2. Residents from another program in our city that were sharing a site (a VA) in their PGY-1 weren't allowed to work some of the call shifts we did, since we were the PGY-2s on that rotation. I thought there was some kind of ACGME rule for on-site supervision in PGY-1 but remote was okay after. I wasn't clear on how that worked out if there were no other physicians of any specialty present.

 

[G Sheb]

For context, I'm at a large academic center (~1,000 beds) in a mid-sized metro that has a (small) dedicated psych space with a separate MH team (RN and SW) who see the "easy" cases before psychiatry is consulted. Other hospitals in this metro have similar setups. We do always have a dearth of psych patients requiring care but even so no one wants to physically be seeing ER psych patients overnight. The minimal salary for such positions is something hospitals just aren't willing to pay.


There's a very significant difference between supervising an NP who spent 2-3 months to get a "PMHNP" certificate sometimes with no actual clinical psych experience and supervising a psychiatry resident, typically PGY-2+ in an ER.


I don't disagree and have certainly seen cases where having more experience/acumen made a difference in the treatment plan. I still don't understand why cases that are more complex cannot wait 6-10 hours to be seen by the primary psych team the following morning, especially given many of those cases will require further observation before making an appropriate dispo plan anyway.



That makes a huge difference in this discussion, state laws/mandates supersede meeting minimum requirements for the standard of care. If we're talking about stand-alone psych ERs, then I also probably agree with your second statement. However, for "psych ERs" embedded in a true medical ER Idk that I would agree. In an ideal world every ER would have a psychiatrist on staff 24/7, but it's honestly not necessary in many places as a 2am dispo is often unnecessary and more for the convenience of the patient and sometimes hospital admins trying to maximize profits than actual patient care.

I'll still emphasize that there really isn't anything that qualifies as a true "psychiatric emergency" where a psychiatrist alone is needed and a medical physician or legal team (police/EMS, behavioral teams, etc) isn't necessary. And in both those situations, the psychiatrist probably isn't going to be seeing that patient until the following day anyway if the "emergency" occurs overnight.

Long wait times is a big problem for hospital costs. it is also not great care to let someone wait for 10 hours before they are evaluated. What if someone was brought against their will? OK to let them languish for 10 hours? It is an "emergency" in the sense these patients are assumed not safe outside the ER. A trigger happy EM physician is also not the ideal person to calm an agitated patient..etc. There's a lot of push in these places to dispo patients quickly as they are taking an ED bed.
All of these issues led to dedicated psych ER and there have been studies showing that the model has been very successful in reducing unnecessary admissions, reducing wait times and coordinating better care.

And for reference, I am talking about both standalone psych ERs and ERs with dedicated psych spaces. State regulations apply to both if the facility is a state-designated psych ER. From my experience, even non-state designated psych ERs will employ overnight psychiatrists to oversee dispositions and supervise residents. That includes top programs in the country.

I disagree regarding resident supervision. Starting PGY2s miss things all the time, which is again fine and expected. I don't think it's wise to run the risk of your license on that. Remember that whole discussion was started when @comp1 suggested ALL discharges over the weekend could be handled over phone call. That's when I made my comment. Not even overnight. I would personally not do this. I think the liability is very high and I do not think this is better education.

And yes, obviously this is not the standard of care everywhere, but we all know what this means. There are simply not enough resources to provide better care.

 

[Stagg737]

This has been an interesting discussion. Some of the more recent points have actually left me a little bit confused. It seems G was talking about standalone psychiatric emergency rooms and most of the other commenters were talking about medical ERs with psych patients or psych ERs embedded within a medical ER.

Scenario 1:
I have definitely never seen a medical ER that has ER physicians and psych SW require an attending psychiatrist be present in the facility at all times. I've also never seen one that required the attending psychiatrist to come into the ER while on home call. The SW (if there is one) may do some psych screening and call the attending. A resident would do that, too, if this were a facility with in-house residents. Someone is there to do the initial screening, whether that is an ER attending or a SW or nurse or other psychiatric provider. Subtle psychosis doesn't meet emergency treatment criteria, so idk why anyone would refuse to discharge someone with an OP problem.

Scenario 2:
I have not seen a standalone psychiatric ER that didn't have a psychiatrist on-site 24/7. I've never seen one that has ER or other physicians, so the psychiatrist would be the only person present. Frequently the on-site physician is a moonlighting PGY-3+, operating under their own license. I didn't know that there were programs that allowed the only physician on site for an ER to be someone with a training license. Where I live, training licenses aren't sufficient for filing or accepting an involuntary hold except in a very narrow set of circumstances.

Were people saying that scenario 2 frequently is manned by a PGY-2 without their own license and no other on-site physicians of any specialty? I know in my own program sometimes I was the only physician on-site in PGY-3 outpatient. But not before that, and my peers at different sites within our program were never the only physician on-site. I'm not saying that I wouldn't feel comfortable manning the fort alone (aside from one SW, one tech, and one RN), just that I was never given that opportunity. Scenario 1 happened all the time during PGY-2. Residents from another program in our city that were sharing a site (a VA) in their PGY-1 weren't allowed to work some of the call shifts we did, since we were the PGY-2s on that rotation. I thought there was some kind of ACGME rule for on-site supervision in PGY-1 but remote was okay after. I wasn't clear on how that worked out if there were no other physicians of any specialty present.

I have generally been talking about scenario 1, as there are many places where standalone psych ERs just don't exist. I agree that it would be weird for a standalone psych ER (or any stand alone ER) to not have a psychiatrist available 24/7. Though in states with FPA NPs would be included as clinical staff.

Where I did residency, psych residents on overnight call took it from home and only saw ER patients overnight if it was a stat consult. Non-stat consults were seen first thing in the morning by the consult team. I would get a stat ER consult every 3-4 overnight call shifts, but I knew residents who never had to go in overnight at all. The state where I trained also allowed residents to file involuntary holds and testify in court with a training license (no separate full license).

Long wait times is a big problem for hospital costs. it is also not great care to let someone wait for 10 hours before they are evaluated. What if someone was brought against their will? OK to let them languish for 10 hours? It is an "emergency" in the sense these patients are not safe outside the ER. A trigger happy EM physician is also not the ideal person to calm an agitated patient..etc. There's a lot of push in these places to dispo patients quickly as they are taking an ED bed.
All of these issues led to dedicated psych ER and there have been studies showing that the model has been very successful in reducing unnecessary admissions, reducing wait times and coordinating better care.

I'd argue the most valuable thing this does is provide more efficiency to the system to move patients through faster. I'd be interested in seeing studies that this model leads to better care outcomes over systems where the patient is just seen the following morning.

Letting patients sit depends on why the patient was brought against their will. If they're intoxicated then doing an eval ASAP isn't appropriate. If they're obviously manic or psychotic, an immediate eval is almost never necessary and I'd argue getting them a solid night's sleep is more important than transferring care overnight. Imo SI (and some psychotic patients) are the only situations where an immediate full eval may be required, and again many of those cases are cut and dry enough that an attending laying eyes on the patient is unnecessary. Again, I'd be interested in specific situations (short of residents doing crappy evals or the situation I previously laid out) where a patient is really going to benefit significantly more from having an attending on-site and evaluating them. Either way, most larger places (and even many smaller ones) will have SW or some form of telehealth coverage available for an initial eval so patients don't have to sit unaddressed for hours.

Also, if "emergency" means that they're not safe outside the ER then an eval isn't even necessary as you've already determined they're not safe. So patient requires monitoring, which again does not require a psychiatrist. Actual psych "emergencies" are when a patient has developed some medical complication d/t their diagnosis or treatment (which requires medical intervention) or where they're an immediate physical threat to themselves or others which will require police intervention or intervention from other behavioral response professionals. You can argue a psychiatrist is needed to prescribe meds for agitation, but frankly any physician should be able to treat agitation and does not specifically require psychiatric expertise. ER docs treating agitation will vary just like psychiatrists treating agitation varies, however ER physicians are taught how to handle agitation in their training and should be fully capable of doing so without psych recommendations.

 

[ObsequiousAplomb]

Agreed that ER physicians are trained to de-escalate and most frequently much better trained in use of parenteral medications for calming people down. They have good protocols and the staff also have the training necessary to monitor airways in the event of overshooting. I know I would rather have an EM doctor and an EM nurse in an ER monitoring me after Versed or Ativan than a psychiatrist or a psych nurse in AP psych ER or IP unit.

And also agreed that there is a vary wide variety in the clinical acumen of psychiatrists and ER doctors. I've never seen an ER doctor default to Haldol 10 instead of 5 IM or give Zyprexa 20, 30, or 40 IM in a single administration. I've seen plenty of psychiatrists in Psych ERs and IP units do that. In fact, when we do overshoot the first thing we do is send the patient to a medical ER....

I've heard often what G is saying about evidence indicating that there are fewer frivolous admits when psych ERs are compared to medical ones. I believe there are some obvious confounds - holding someone overnight in the psych ER for observation or after giving medication doesn't count as an admission but putting someone an IP unit for
Freestanding psych ERs also preferentially receive the 911 calls for "I ran out of my meds and it's Saturday at 1 AM" that also aren't legit emergencies. Same thing with people who are under arrest but tell the officer "I need my Seroquel before I get booked", etc. I'm sure there is also plenty of good data supporting them.

 

[hamstergang]

Scenario 2:
I have not seen a standalone psychiatric ER that didn't have a psychiatrist on-site 24/7. I've never seen one that has ER or other physicians, so the psychiatrist would be the only person present. Frequently the on-site physician is a moonlighting PGY-3+, operating under their own license. I didn't know that there were programs that allowed the only physician on site for an ER to be someone with a training license. Where I live, training licenses aren't sufficient for filing or accepting an involuntary hold except in a very narrow set of circumstances.

Were people saying that scenario 2 frequently is manned by a PGY-2 without their own license and no other on-site physicians of any specialty? I know in my own program sometimes I was the only physician on-site in PGY-3 outpatient. But not before that, and my peers at different sites within our program were never the only physician on-site. I'm not saying that I wouldn't feel comfortable manning the fort alone (aside from one SW, one tech, and one RN), just that I was never given that opportunity. Scenario 1 happened all the time during PGY-2. Residents from another program in our city that were sharing a site (a VA) in their PGY-1 weren't allowed to work some of the call shifts we did, since we were the PGY-2s on that rotation. I thought there was some kind of ACGME rule for on-site supervision in PGY-1 but remote was okay after. I wasn't clear on how that worked out if there were no other physicians of any specialty present.

If I'm not misremembering (and I definitely might have some details wrong), where I did residency (starting back in 2011), PGY-1s and 2s, with a PGY-3 for training for some period of time, took overnight call at a free-standing psych hospital with a psych ER section. The residents called the attending to review disposition. The attending would have to come in to do involuntary commitment papers.

 

[hallowmann]

So this isn't really true. As far as I know, any time a resident is providing patient care using their training license, it's technically under the supervision of an attending. So even for these overnight "never called the attending" evals, there was some attending on call who is available.

If the resident never called the attending then in the event of a bad outcome it is the resident who would be on the hook for failure to consult with the attending. At least where I am, we refuse to cosign the notes if the residents don't call us to discuss the case (which they are required to do unless they're just admitting them or keeping them overnight).

The case I was referring to was where the ED staff for the patient cosigned the psych resident's notes. I assume the liability there would fall on the ED staff (and obviously still the resident), who are liable in the case regardless.

Honestly, we often offered admission if there was anything more than passive SI or chronic fleeting SI without intent or plan. The only situation where we discharged patients at moderate risk were when they refused admission and had social supports that could monitor them and supported the idea of discharge. This changed a bit with the development of our obs crisis unit which had a much lower threshold for admission.

With admissions or if we placed a hold/filed on them, they're coming in anyway and we didn't have to staff.

I know it's all state law dependent, but I'm kind of surprised residents aren't filing or committing patients in other states. Literally within the first week of my first psych rotation during intern year I had to file an involuntary hold for one patient and testify at a commitment hearing for another. I'm starting to get why there's so much variability in psych training. We were basically thrown into the deep end seeing tons of patients and having to figure out things on our own. For good or bad it made covering nights in PGY2 easier.