EM/Psych Combined Training

[americanturkey]

I am a student interested in emergency psychiatry. I believe I will need training in both specialties to accomplish my career goals.

There do no appear to be any combined programs but I do not understand why as there is a clear need and existing career path. Many hospitals have even built entire psych units in the ED to fill the need. A dual trained person could act as a sort of one physician emergency psych service. At this point I am considering actually doing both residencies (either a 3 year of each or with some credit towards the intern year of the second).

Why does this not exist? How could a student approach petitioning the powers that be to pursue this training in a 5-6 year period?



(if there is a better location for this thread please let me know)

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[Mass Effect]

I am a student interested in emergency psychiatry. I believe I will need training in both specialties to accomplish my career goals.

There do no appear to be any combined programs but I do not understand why as there is a clear need and existing career path. Many hospitals have even built entire psych units in the ED to fill the need. A dual trained person could act as a sort of one physician emergency psych service. At this point I am considering actually doing both residencies (either a 3 year of each or with some credit towards the intern year of the second).

Why does this not exist? How could a student approach petitioning the powers that be to pursue this training in a 5-6 year period?

(if there is a better location for this thread please let me know)

I don't understand what you're wanting to do? The people who run psych EDs don't do a dual residency. They do a psych residency, where they get training in emergency psychiatry. Community hospitals usually will take anyone with psych training to run the psych ED and if there isn't one, they just do psych consults in the ED. Academic hospitals usually want someone with fellowship training (after psych residency) in consultation-liasion/emergency psychiatry. There's no need to do a primary ED residency or a combined residency, which as you said, isn't a thing.

 

[americanturkey]

I don't understand what you're wanting to do? The people who run psych EDs don't do a dual residency. They do a psych residency, where they get training in emergency psychiatry. Community hospitals usually will take anyone with psych training to run the psych ED and if there isn't one, they just do psych consults in the ED. Academic hospitals usually want someone with fellowship training (after psych residency) in consultation-liasion/emergency psychiatry. There's no need to do a primary ED residency or a combined residency, which as you said, isn't a thing.

You are correct. I would like to do both. I am suggesting that dual training could create a new practice model in an existing field in which a dual trained emergency physician could act as the psych consultant.

It has the potential to reduce overhead. Instead of staffing an emergency psych service of any sort a hospital could hire this one person who, being in the department, could rapidly do psych consults while also moving the meat.

 

[Mass Effect]

You are correct. I would like to do both. I am suggesting that dual training could create a new practice model in an existing field in which a dual trained emergency physician could act as the psych consultant.

It has the potential to reduce overhead. Instead of staffing an emergency psych service of any sort a hospital could hire this one person who, being in the department, could rapidly do psych consults while also moving the meat.

What level of training are you at? I ask because what you propose would actually be kind of ridiculous in practice. No EM doc needs a psych residency to notice psych illness and do a basic eval and no ED wants an EM physician doing lengthy psych consults. It would be like suggesting hiring an EM doc to also rush patients to the OR for appendectomies. It just wouldn't be a thing.

 

[americanturkey]

What level of training are you at? I ask because what you propose would actually be kind of ridiculous in practice. No EM doc needs a psych residency to notice psych illness and do a basic eval and no ED wants an EM physician doing lengthy psych consults. It would be like suggesting hiring an EM doc to also rush patients to the OR for appendectomies. It just wouldn't be a thing.

I'm am 4th year med student. I have seen patients frequently tie up a bed over night and occasionally board for multiple days in the ed either waiting for patch evaluation or placement into inpatient for treatment. That is an costly and inefficient use of resources. So while you are correct that the model I am suggesting would be a costly use of one ED docs time, I believe in the whole it could be a more efficient use of resources across an entire hospital system.

So it's not really like hiring an ED doc to also act as a tech. It's more like hiring them to act as consulting psychiatrists. Yes they would personally turn out somewhat fewer RVUs but they would increase the efficiency across the department more.

Also I understand this model doesn't currently exist. I think it is at least as viable as building an EPS or contracting with a telepsych company and would like to make it exist and be an option.

 

[Mass Effect]

I'm am 4th year med student. I have seen patients frequently tie up a bed over night and occasionally board for multiple days in the ed either waiting for patch evaluation or placement into inpatient for treatment. That is an costly and inefficient use of resources. So while you are correct that the model I am suggesting would be a costly use of one ED docs time, I believe in the whole it could be a more efficient use of resources across an entire hospital system.

So it's not really like hiring an ED doc to also act as a tech. It's more like hiring them to act as consulting psychiatrists. Yes they would personally turn out somewhat fewer RVUs but they would increase the efficiency across the department more.

Also I understand this model doesn't currently exist. I think it is at least as viable as building an EPS or contracting with a telepsych company and would like to make it exist and be an option.

But what you're not understanding is that consultant psychiatrists is already a thing. It already exists. If you've seen a patient board in the ED for days awaiting a psych EVAL, then you're rotating at a pretty crappy place. Psych evals are done within hours in the ED at every place I've worked. Yes, they board awaiting placement because there's a shortage of psych beds, but that isn't going to change if the ED doc does the psych eval. What you're suggesting would never happen because it's redundant. ED docs are ED docs and psych docs are psych docs. There is no need for an ED-trained doc to do psych evals because at most EDs, that's all they'd be doing.

 

[americanturkey]

But what you're not understanding is that consultant psychiatrists is already a thing. It already exists. If you've seen a patient board in the ED for days awaiting a psych EVAL, then you're rotating at a pretty crappy place. Psych evals are done within hours in the ED at every place I've worked. Yes, they board awaiting placement because there's a shortage of psych beds, but that isn't going to change if the ED doc does the psych eval. What you're suggesting would never happen because it's redundant. ED docs are ED docs and psych docs are psych docs. There is no need for an ED-trained doc to do psych evals because at most EDs, that's all they'd be doing.

I get the feeling you have largely worked in large city hospitals as these are the places that get psych evals done within hours. Your experience of quick psych consults is certainly not the norm. Consider the many hospitals that use mobile crisis teams to do these evals. They are definitely not getting all there evals done within hours.

I think saying it is redundant to existing models is true because it is a new model for delivering the same service (at, I believe, a potential better value). In fact ABEM criteria specifically states that creating combined training should address existing career routes.

I imagine the first people using POCUS were told it was redundant when a tech down the hall could do the same thing and that had spawned a huge development in our ED practice.

 

[Mass Effect]

I get the feeling you have largely worked in large city hospitals as these are the places that get psych evals done within hours

Actually, that's not true.

Your experience of quick psych consults is certainly not the norm

What's your source for this?

Consider the many hospitals that use mobile crisis teams to do these evals. They are definitely not getting all there evals done within hours.

Those are usually rural hospitals without an on-site psych service. And I am still not familiar with any place where it takes "days." Mobile crisis teams generally do evals within 24 hours.

Aside from the fact that I think it's a waste in terms of efficiency, I also believe it's a waste of training. If you want to be a psychiatrist, be a psychiatrist. If you want to be an ED doc, be an ED doc. No matter the route you choose, you will treat patients in both realms. Integrated residency is not necessary.

 

[americanturkey]

Actually, that's not true.



What's your source for this?



Those are usually rural hospitals without an on-site psych service. And I am still not familiar with any place where it takes "days." Mobile crisis teams generally do evals within 24 hours.

Aside from the fact that I think it's a waste in terms of efficiency, I also believe it's a waste of training. If you want to be a psychiatrist, be a psychiatrist. If you want to be an ED doc, be an ED doc. No matter the route you choose, you will treat patients in both realms. Integrated residency is not necessary.

Thank you for your sharing your experience. However, I do not see it the same way as you do. I am going to pursue both specialties and my post is less about whether or not I should and instead aimed at understanding how I can do so with as little waste of training years as possible.

 

[DeadCactus]

There are no combined residencies and trying to create one in time to train in one is not realistic. Pick the specialty you like best, pursue residency training in that, and then apply for the second residency if you still want it. Emergency medicine to psychiatry would probably have the best odds of getting some credit for the first residency as EM residencies tend to be stricter in what counts but anyone interested in this is likely more interested in psychiatry if they had to pick.

There are combined programs like FM/Psych, IM/Psych, and EM/Peds where the extra training opens up a new practice model (i.e. an outpatient clinic that covers both physical and mental health, a geriatric psychiatry ward, working in a pediatric ED). Many of the other combined residencies simply offer a chance to practice half-time in two specialties. The real value of the latter type is as a liaison between two services rather than as filling a clinical niche. Pursuing both residencies to then split your time between inpatient psychiatric care and the emergency department while working as a liaison to improve care is a reasonable career goal, especially in academics. Pursuing both residencies because you think an ED is going to higher you to disappear into a room for 60 minutes to do a psychiatric evaluation is likely to end in disappointment. An ED with enough volume ot need an inhouse psychiatrist isn't going to spare you the time to do a good evaluation and an ED slow enough isn't going to have the volume to warrant wasting a residency trained psychiatrist there.

Your example of POCUS is a great analogy. There are plenty of academic POCUS folks developing and validating cool scans, but then you look out into the real world and FAST, procedures, and bedside echo are the only studies really done because it doesn't make sense to tie up the EM physicians to do a DVT scan or biliary scan when it's not an imminent emergency and a tech can do it while the attending sees 2 other patients. Sure, ultrasound is more useful in rural setting but you're still not going to see someone do an EM residency and a Radiology residency so they can go work in Ft Tumbleweed and do a few scans a month.

 

[Mad Jack]

You are correct. I would like to do both. I am suggesting that dual training could create a new practice model in an existing field in which a dual trained emergency physician could act as the psych consultant.

It has the potential to reduce overhead. Instead of staffing an emergency psych service of any sort a hospital could hire this one person who, being in the department, could rapidly do psych consults while also moving the meat.

No one in their right mind would want to do this. It would actually reduce billing overall, as you can't bill for both emergency care and a psych consult on the same patient as one provider. So you'd be working harder to generate less revenue, unless you only were brought in to consult on patients that weren't your own, which would entirely negate the point of your idea since it still requires two providers

Wow this is an old post, didn't realize when replying

 

[redpanda]

If you're interested in working in psychiatry and spending a bunch of time doing emergency evaluation, consider a psychiatry residency that has you rotate through a decently sized, busy psych ER that also has the inpatient psych beds to admit to. For example, the UPMC program has a busy psych ED in Western Psychiatric Hospital. I have a colleague that now works mostly in the psych ED there.

 

[Lexdiamondz]

It has the potential to reduce overhead. Instead of staffing an emergency psych service of any sort a hospital could hire this one person who, being in the department, could rapidly do psych consults while also moving the meat.

This is impossible. EM is a field where your patient encounters are generally limited to 15 mins and you're expected to see at bare minimum 2 patients per hour. There's almost no feasible way to field psych consults quickly while also tending to medical and trauma codes, performing procedures and moving the meat. Even on a semi-busy shift a single 30 minute convo would absolutely destroy your workflow - never mind seeing multiples of these.

 

[Sushirolls]

I have worked in a Psych ED, and also other hospital settings where consulted in the typical ED as a psychiatrist, I can say if OP actually does this s/he will be gravely disappointed in years to come. Time will have been wasted, but some times you need to learn from mistakes.