ER Psychiatrist

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damusiel

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Hello,

I really wanna become a psychiatrist in the ER setting. I want to help the mentally ill and give consults to emergency physicians.

How do you become a ER Psychiatrist and what are the pros and cons??
How much do you get paid?
What do I have to do?

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Emergency Psychiatrists tend to work in a self-contained PER/PES/CPEP/CSU (depending on where you are based) and mostly (but not always) are based in county hospitals providing care to an indigent or under-insured population. While the work may involve providing consultation to the ED, this more often falls in the province of consultation liaison psychiatry though will depend on the hospital. Emergency care for psychiatric patients is really moving away from a medical model and demphasizing medical aspects of care with more attention to meeting the needs of these patients (which is often that they are homeless, just got out of prison/jail, lack access to care/basic medical needs,do not have or do not use regular mental health services, have untreated substance use disorders, unstable social situations). It takes a certain type of personality to enjoy the work. Many people you have no hope in ever helping. Many of them do not belong there. This is why there is a move (positive imho) to get rid of/rebrand psychiatric emergency rooms into less medicalized settings for people in crisis (though with psychiatrists present). As these environments can potentially be traumatic for patients (they may be attacked or raped by other patients, they may be forcibly drugged, secluded, restrained) there is again a move to make these spaces safer and more therapeutic with less coercion. Unfortunately, this move comes at a time when the acuity of psychiatric patients is increasing, beds are decreasing. In some counties they put psychiatric patients in jail to be evaluated as they are too lazy to put funding into care for these patients.

Most of the patients will likely have a substance use problem or be intoxicated or withdrawing from drugs/alcohol. You will have to work with angry, assaultive, belligerence, aggressive patients. This is the setting you are most likely to be attacked as a psychiatrist. Not just the patients, also family member/friends etc. There will be lots of personality pathology. You may also see patients from as young as 2 right up to 100+ with a wide range of psychopathology as well as a large range of people who do not have. Your job is to keep people out of hospital, figure out who actually needs to be admitted, see as many patients as you can, as quickly as you can.

Pay will depend as always on whether it is an academic or non-academic setting and geographic locale. That is to say pay can be anywhere from 140-320k for 40hr weeks. You will get paid more if you work nights, and if you work more than 40hrs a week. Depending on the part of the country you are in (some states will only have a single hospital with a psychiatric emergency services) it is usually easy to find this kind of work as most psychiatrists dont want to.

It is not really possible to do this as clinical work full time for long without burning out or having a mental breakdown. Many people will do this for a few years, or take a few shifts for extra cash or have this as a part of their work mixed in with say private practice (outpatient) or consultation-liasion psychiatry.
 
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It is not really possible to do this as clinical work full time for long without burning out or having a mental breakdown. Many people will do this for a few years, or take a few shifts for extra cash or have this as a part of their work mixed in with say private practice (outpatient) or consultation-liasion psychiatry.

I know an attending who has done this work full time for over a decade and loves it (he's fairly old too). I've been doing this work as a moonlighter for 6 months and do really like it. The substance use rates and character pathology rates are high but that just adds to the skill needed to do the job well, remain empathic, and keep everyone safe. Get to see some new-onset cases of a variety of illness which is the bee's knees to me. It is a small niche of psychiatry, but not a terribly popular one, so definitely something one could find if they really wanted to do it.
 
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After 3 years of private practice, ER psych is sounding really good right now.


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To become an ER psychiatrist you need to become a psychiatrist! In short:

BA or BS with appropriate premedical coursework completed (typically 4 years)
MD or DO (4 years)
Psychiatry residency (4 years)

While in residency you can get plenty of exposure to the ER. The aforementioned salary range sounds about right (it's pretty broad depending on the specifics of any given situation). At this point (if you are still in college), the decision should be about:

1 - Do you want to become a physician?
2- If so, do you want to become a psychiatrist (you will not really know until you have done some rotations)?

I recommend checking out the pre-med forum for advice about the general path to becoming a psychiatrist. From there, working in an ER or other acute setting should be no problem.
 
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Members of aaep can tell you what it is like and how they got there.
 
It is not really possible to do this as clinical work full time for long without burning out or having a mental breakdown.

This is not true and contradicted by the evidence I've seen. This "burnout" thing is the same nugget you hear from folks discussing EM without having a lot of experience in EM.

In any emergency care setting you will have burn out. But for all of splik's valid criticisms above, folks love it. Yes, there's can be a futility to it (true of anyone dealing with SMI) but you do the work for the saves you do get to participate in making. Yes, the patients are sad, desperate, and vulnerable (btw, the violence they may face in a decent PES is far, far less than what they face on the street when they leave its doors), but these are the patients many of us went into medicine to treat. Yes, you get a lot of substance intoxication, BPD flare-ups, and psychosis, but PES's bread and butter is just a different grain than those of outpatient longitundinal care psychicatry (depression, anxiety, and BPD flare-ups).

PES is not particularly popular work. You tend to have moonlighters and hobbiests and folks using it as a first job to get in with an academic setting or hospital. But some of us make a career out of it. The acuity, the diversity, the pace, and the helping of patients who need it most is incredibly rewarding. It fits in well with academic interests, as it makes for a great teaching ground for sick/not sick and diagnosis with limited evidence (I notice the residents who turn their nose up at PES are often the ones who have premature diagnosis issues and sometimes make important misses).

For interested parties, I'd recommend looking at AAEP as mentioned above and try to moonlight in a variety of PES's. If you end up doing the job full time for a year or so, you'll see if it's the right job for you.
 
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No continuity. Just dispo'ing.... like a dispatcher. PRNs if severely agitated.
This is the yardstick of being a horrible PES doc. Doing it well is much harder. The equivalent would be the description of an outpatient psychiatrist:

"All continuity... Just listen to people talk and ask questions... Throw one of 20 meds at it one at a time, titrating slowly...."

(Btw, if you don't think PES has continuity, you either work in a very flush county, or haven't spent much time in one. PES is the continuity clinic for the SMI with heavy drug or psychosocial issues. We do decanoates and clozapine and the like. Continuity is the problem.)
 
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PES is not particularly popular work. You tend to have moonlighters and hobbiests and folks using it as a first job to get in with an academic setting or hospital.

In my experience the pay isn't the best. I suspect because at the places I work they commonly utilize residents and NPs the latter who are often willing to do double duty in a social worker role performing disposition arrangements, insurance auths etc. :wacky:
 
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In my experience the pay isn't the best. I suspect because at the places I work they commonly utilize residents and NPs the latter who are often willing to do double duty in a social worker role performing disposition arrangements, insurance auths etc. :wacky:

Nooooooo!!! They're taking our jobs!


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Nooooooo!!! They're taking our jobs!


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79bd7f1be9ceaa0567ebaee0a51aae9f_about-than-just-our-jobs-dey-took-our-jerbs-meme_600-337.jpeg
 
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Any decent psychiatry residency will give you PLENTY of ED exposure. If it doesn't then that program has serious issues. Also, the APA emergency psychiatry manual is absolute garbage- I was writing a couple of chapters for my hospital's upcoming manual of emergency medicine (organized by the EM department) and flipped through it for reference, quickly tossing it aside and forgetting that I checked it out of the library
 
Any decent psychiatry residency will give you PLENTY of ED exposure. If it doesn't then that program has serious issues. Also, the APA emergency psychiatry manual is absolute garbage- I was writing a couple of chapters for my hospital's upcoming manual of emergency medicine (organized by the EM department) and flipped through it for reference, quickly tossing it aside and forgetting that I checked it out of the library

I encourage you to burn anything from the APA.
 
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I encourage you to burn anything from the APA.
What about the DSM-V?
Although I do love to criticize our diagnostic reification of symptoms and labelling for insurance purposes system, but do we really have anything better?
The only thing I hate about doing psych ED work is when I am seeing someone at 3:00 am who just needs to talk someone. I was almost tempted to put in the note that the patient was suicidal because they were obviously trying to get me to kill them! That was last night, I set up the follow-up outpatient with my colleague cause I'm evil. :p
 
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What about the DSM-V?
Although I do love to criticize our diagnostic reification of symptoms and labelling for insurance purposes system, but do we really have anything better?
The only thing I hate about doing psych ED work is when I am seeing someone at 3:00 am who just needs to talk someone. I was almost tempted to put in the note that the patient was suicidal because they were obviously trying to get me to kill them! That was last night, I set up the follow-up outpatient with my colleague cause I'm evil. :p

This is why I don't do call. I do need to sleep.
I don't know a whole lot about the systems which construct DSM and how they battle it out in "committee" for the criteria, but I do take issue with the behind the scenes politicking that does go on in creating/modifying labels.
 
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What about the DSM-V?
Although I do love to criticize our diagnostic reification of symptoms and labelling for insurance purposes system, but do we really have anything better?
The only thing I hate about doing psych ED work is when I am seeing someone at 3:00 am who just needs to talk someone. I was almost tempted to put in the note that the patient was suicidal because they were obviously trying to get me to kill them! That was last night, I set up the follow-up outpatient with my colleague cause I'm evil. :p

As for the DSM I really like the concept and I use it however I may never recover from the latest version's exclusion of PDD and Asperger's, in fact this has disturbed me to such a degree that I may need to self-present to your ED with SI just to talk at 3:00 am sometime, lol.
 
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As for the DSM I really like the concept and I use it however I may never recover from the latest version's exclusion of PDD and Asperger's, in fact this has disturbed me to such a degree that I may need to self-present to your ED with SI just to talk at 3:00 am sometime, lol.

I'd speak with ASD experts before getting that upset. They in no way excluded the diagnosis, but the artifical lines we drew between autism, asperger's and PDD were not nearly as borne out in the literature as one would like. It was for the same reason types of schizophrenia got the axe. Does it help us file away things neatly in our head? Absolutely! Does the research bear out these subtypes with genetic/neuroimaging/functional studies in ways that are not tautologically true? Unfortunately not.
 
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Any emergency psychiatrists here that can help me with some first job advice?
 
A lot of academic centers in the northeast seem to have a psych ED. Not just intoxication either. Do residency at one of these places and make it clear that's what you want to do after graduation.
 
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