Frustration with C/L

[DrZoidberg17]

Long-time lurker here. Just wanted to vent some frustrations with being on a consult service. In my hospital we operate strictly as consultants and do not directly make medication changes. It is very frustrating when the medical team does not follow recommendations given. Honestly, I doubt they even read our notes. They feel psychiatry is just a place to dump unwanted patients from their service. How do you all deal with this? What can I say in the documentation that is passive-aggressive enough to get the point across while still being professional? Any suggestions?

For some background, I am a PGY-4. My attending has confided similar frustrations and will back me up with whatever route I decide. Thanks in advance!

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[Bartelby]

1- for habitual offenders, talk to the team directly after the consult. Do your best to educate them. If they keep ignoring recommendations or placing inappropriate consults....

2- talk to someone higher up. A service chief can take this up with the other service. Systems issues sometimes respond best to systems-based responses. If higher-ups will not hold a meeting to discuss with these services or if behaviors don't change, then...

3- be glad you're a PGY-4 who can leave this environment in a matter of months! Institutional culture and norms can be the difference in a great job and an endlessly frustrating one. It takes a long time and a lot of work to build a good hospital culture, and if one is not present you really need the backing of leadership to help shape it. Keep that in mind when you start looking for jobs.

 

[Monocles]

Long-time lurker here. Just wanted to vent some frustrations with being on a consult service. In my hospital we operate strictly as consultants and do not directly make medication changes. It is very frustrating when the medical team does not follow recommendations given. Honestly, I doubt they even read our notes. They feel psychiatry is just a place to dump unwanted patients from their service. How do you all deal with this? What can I say in the documentation that is passive-aggressive enough to get the point across while still being professional? Any suggestions?

For some background, I am a PGY-4. My attending has confided similar frustrations and will back me up with whatever route I decide. Thanks in advance!

In some ways this is a curse and a blessing at the same time. Sounds like the consulting team is still primary and thus ultimately responsible for the outcome. The best and sometimes ONLY thing you can do is your due diligence and make the best recommendations you can for your patient. If the primary team ignores it then there's not much to do.

I've been on CL services with the exact same issue. You can always say a peaceful mantra to yourself "not my circus, not my monkeys" as you've already given your best effort and can't MAKE primary do anything.

EDIT: Another potential solution is share your plan and recommendations with the patient (if appropriate) and provide psychoeducation at the end of your consult interview. That way patient is informed on what the standard of care SHOULD be, and might also be able to advocate for themselves if the primary team decides to ignore your recs.

 

[dl2dp2]

This is very common and why I hate C/L. LMAO

Frankly, I doubt complaining to superiors matters. Hospitalists and teaching services that deal a lot with behavioral health issues care more, but if it's a very technical subspecialty service (heart failure, BMT, etc.) they generally don't follow that closely with consultants. Nobody cares either since the drivers of the revenue aren't your service. They call you as a courtesy and the PAs who staff the day-to-day don't really give a crap. There's nothing you can really do and I wouldn't bother doing anything in the notes.

 

[comp1]

C/L is not for me. It's a bit like child psych. You have the identified patient and then you have the actual patient, the consulting team. I would concur with above that a resident complaining to superiors isn't likely to help and might make enemies. Hospital teams turn over way too much in an academic environment for that to result in much. Also...I've seen the kind of dynamic the OP describes at literally every C/L place I've worked. The mantra that has helped me is remembering that however bad it is for you...it's worse for the internists and they keep doing this forever.

 

[Merovinge]

I went into psychiatry after being absolutely amazed as a M3 about CL service, the variety of patient's seen, the raw pathology (I saw NMS, 5-HT syndrome, cannabinoid hyperemesis, catatonia, someone who's kidneys were starting to decline out after the best 35 years of their life on lithium, all in 1 month as a med student), and the difference it can make to have psychiatry on board. Most attendings were very appreciative and professional, even the specialty surgeons.

Ho boy does CL work in community hospitals look like a completely different world. It was easily the worst job I have done. It can be very thankless, very passive-aggressive environment, and frankly a bit soul sucking. Thankfully CL makes up a tiny fraction of total psychiatry, so as a PGY4 I would just recognize that unless you want to bang your head into this wall, it will be very easy to not do as an attending. Also, just like you are not your patient's pathology, you are also not your institution's pathology, I definitely would do my best to not let it get to you. You will have plenty of opportunity to make a huge difference in countless lives in this field moving forward.

 

[hamstergang]

In my hospital we operate strictly as consultants and do not directly make medication changes. It is very frustrating when the medical team does not follow recommendations given.

I only work outpatient, but I love when people don't follow through with my recommendations -- it makes my job much easier for the next visit as I don't have to do any new thinking to come up with a plan.

(I do love more when they do follow through with my recommendations and improve, however.)

 

[splik]

Long-time lurker here. Just wanted to vent some frustrations with being on a consult service. In my hospital we operate strictly as consultants and do not directly make medication changes. It is very frustrating when the medical team does not follow recommendations given. Honestly, I doubt they even read our notes. They feel psychiatry is just a place to dump unwanted patients from their service. How do you all deal with this? What can I say in the documentation that is passive-aggressive enough to get the point across while still being professional? Any suggestions?

For some background, I am a PGY-4. My attending has confided similar frustrations and will back me up with whatever route I decide. Thanks in advance!

Being passive-aggressive and being professional are (or should be) mutually exclusive. It is never appropriate to vent frustrations in the medical records. I spent several years working full time on a consult service and now do so part time. It's not for everyone but I personally love not being responsible for the patients. The first rule of consults is "honor thy turf." If the team does not want to take on board your recommendations, sign off. Whenever my residents complain about the primary teams not taking on board our suggestions, I tell them to call the team, tell them it seems like they feel comfortable managing this situation since they have not taken on board our recommendations, and that we will sign off. If they want us to see the patient again, we politely decline until they have enacted the recommendations. Either they will make the changes, or they will not. If they don't see value in the consult service, that may be an indictment of the service and the relationships the leadership of the service/your department has with other services. People often forget the liaison part of C-L. We have regular leadership meetings with hospital medicine, emergency medicine, OB, and neuro to make sure we are providing a high quality service and that expectations are managed. Sometimes people will call psych as a CYA or to turf patients etc, but the quality of consults goes up when there is consistent communication and liaison to other services. This is not really something you should be responsible as a resident (unless you are C-L chief).

 

[Monocles]

The mantra that has helped me is remembering that however bad it is for you...it's worse for the internists and they keep doing this forever.

I only work outpatient, but I love when people don't follow through with my recommendations -- it makes my job much easier for the next visit as I don't have to do any new thinking to come up with a plan.

You guys are hilarious and I love this community.

 

[deleted1100659]

yep thats what my CL experience was in residency.

"Patient's dog died while she was in the hospital and were scared shell decompensate if we tell her the news, can you tell it to her and explain death?"

 

[whopper]

I've seen a repeating dysfunctional dynamic in 5 out of 5 hospitals with C&L.

1-The non-psych providers don't know when it is appropriate to order a C&L consult so they often times order it when not needed. Then the C&L needs to waste about 30 minutes per case figuring out what was going on and often it wasn't needed in the first place.

2-the non-psych provider has no desire to fix this because it's not their time wasted. The C&L psych attending doesn't give a $hit cause it's the residents and medstudents having their time wasted doing the detective work.
Residents and medstudents are seen as fodder and no one in the administration gives a $hit that their time is being wasted so everyone looks the other way while medstudent/resident gets mad. Nurses say "oh look, crybaby resident, oh woe is me" while they laugh at the resident. (I do not advocate any of this, but merely stating what is really going on).

As an attending I tried to fix the above and no one gave a $hit even that I as an attending was trying to address this.

3-Problem repeats.

My recommendations. Have clear guidelines as to what constitutes a valid request for C&L. The provider requesting the C&L should have the following answered. 1-why order the consult? At least a paragraph of info should be given. Not just a "she looked like she needed one" bull$hit response.
2-If a capacity eval is ordered the provider MUST document that they discussed the options with the patient and why the capacity issue is in question. 3-Have the provider who ordered the consult's contact info ready. If they are not available by the time the consultant sees the consult the nurse on duty has to be able to answer the questions the C&L provider has or the C&L provider might not be able to answer.

Several times I did a consult, the nurse on duty didn't know why it was ordered other than it was ordered, and when I attempted to contact the $chmuck who ordered the consult they are not on duty and the patient has no psych complaint. Then the residents waste an hour trying to figure out what happened.

If you are asked to do C&L get paid per case. That way for each bull$hit case they throw at you, you won't feel bad that your time is being wasted cause it's not with the cash flowing into your pocket. 5 bull$hit cases? Great!

 

[whopper]

"Patient's dog died while she was in the hospital and were scared shell decompensate if we tell her the news, can you tell it to her and explain death?"

My response:
There is no data showing that psych providers are better at explaining this phenomenon vs other medical providers and this is within the primary providers responsibility. Recommendation: Primary provider explain this to patient.

HAVE A NICE DAY.

 

[Stagg737]

Wow, we have 2 C&L services (one at our academic hospital, one at VA) and neither were that bad. Our academic service was a fantastic experience IMO and did not have a lot of the problems spoken above. We also have a messaging system that all clinical staff are required to have on during duty hours, so if there's a legit bad consult we can just message for clarification and not waste time running around. The consult orders in the system are also pretty solid, so we know if we can put in orders, what the CC is, and usually a sentence or two of comments.

At the VA we don't place orders and occasionally get garbage consults. Since it's a VA though, if it's a bad consult our attendings may actually discontinue the consult and place a comment to please place a new consult with the question they would like answered or further details. Typically that's for the consults that come in and just say "capacity" or "med recs".

That being said, I also (briefly) got to see the type of CL work described in OP. I'd never take that as a salaried position but actually seemed like a decent set-up for a per consult or per encounter payment model. The limited patient responsibility and liability if the primary team doesn't like your recs is also a plus.

 

[nexus73]

My response:
There is no data showing that psych providers are better at explaining this phenomenon vs other medical providers and this is within the primary providers responsibility. Recommendation: Primary provider explain this to patient.

HAVE A NICE DAY.

I’d do it if, like you suggested, the hospital is paying me RVUs for this nonsense.

 

[whopper]

IS the RVUs paying you good enough money? Then fine.

I really hate saying that, but as someone who really tried, seriously hundreds of hours, to fix these problems for real and getting ignored, well then, money in my pocket? Fine.

(Waiting for someone who never spent 1 second trying to fix this problem go on a triggered hate rant against me).

 

[AD04]

@dl2dp2

Can you change your name back?

 

[mistafab]

If you give recommendations, they are ignored, and If the bad outcome happens - the primary team will have a hard time telling the court why they ignored the advice of the expert. Especially when they made the patient pay for the advice.

 

[comp1]

If you give recommendations, they are ignored, and If the bad outcome happens - the primary team will have a hard time telling the court why they ignored the advice of the expert. Especially when they made the patient pay for the advice.

Honestly, outside of very egregious things that pharmacy is going to catch first and legal holds that can't be ignored, no one's likely to get sued if they follow or don't follow psych's recs...

 

[Mass Effect]

Being passive-aggressive and being professional are (or should be) mutually exclusive. It is never appropriate to vent frustrations in the medical records. I spent several years working full time on a consult service and now do so part time. It's not for everyone but I personally love not being responsible for the patients. The first rule of consults is "honor thy turf." If the team does not want to take on board your recommendations, sign off. Whenever my residents complain about the primary teams not taking on board our suggestions, I tell them to call the team, tell them it seems like they feel comfortable managing this situation since they have not taken on board our recommendations, and that we will sign off. If they want us to see the patient again, we politely decline until they have enacted the recommendations. Either they will make the changes, or they will not. If they don't see value in the consult service, that may be an indictment of the service and the relationships the leadership of the service/your department has with other services. People often forget the liaison part of C-L. We have regular leadership meetings with hospital medicine, emergency medicine, OB, and neuro to make sure we are providing a high quality service and that expectations are managed. Sometimes people will call psych as a CYA or to turf patients etc, but the quality of consults goes up when there is consistent communication and liaison to other services. This is not really something you should be responsible as a resident (unless you are C-L chief).

I'm at a hospital right now where some services are very appreciative and some aren't. I get paid per consult so I don't care if the patient isn't being harmed. But how would one go about setting up leadership meetings with some of these other services who put in consults and ignore the reccs? And what do you go over in the meetings, just appropriate use of the CL service?

 

[Mass Effect]

Honestly, outside of very egregious things that pharmacy is going to catch first and legal holds that can't be ignored, no one's likely to get sued if they follow or don't follow psych's recs...

That's what I used to think until a team that continued to give a patient all his regular meds and hospital meds with no changes despite psych dx and reccs that the patient had serotonin syndrome. Didn't end well for the team.

 

[robellis]

I'm at a hospital right now where some services are very appreciative and some aren't. I get paid per consult so I don't care if the patient isn't being harmed. But how would one go about setting up leadership meetings with some of these other services who put in consults and ignore the reccs? And what do you go over in the meetings, just appropriate use of the CL service?

You get paid per patient or wrvu? If per patient that’s very interesting how much per patient are they giving?

 

[Merovinge]

That's what I used to think until a team that continued to give a patient all his regular meds and hospital meds with no changes despite psych dx and reccs that the patient had serotonin syndrome. Didn't end well for the team.

Yup saw a VA patient admitted to medical floor who was prescribed clozapine, non-adherent, no discussion with psychiatry, resumed at full dosage, multiple severe seizures intubated on the ICU, didn't hear what happened after that.

 

[clozareal]

One of the highest yield things I found on C-L is to clarify exactly what the consult question is and flesh it out in more specific details. For me, if the team isn't following my recommendations, I will chat with them to figure out why that was the case, if I truly answered their consult question or if they were looking for something else, or if my recommendations were specific or realistic enough. I often see C-L notes be super vague about what they want or they might be way too long for a busy primary team to read fully. If they see enough of these useless notes, there's a certain sense of "why bother" by the primary team. Either that or they aren't sure how to enact the specific recommendations given. I try to give them a chance to explain why they didn't follow the recommendations and found that over the phone or messaging is not enough—I will physically go to their location and talk with them and their team. If it is truly a disagreement on what is best for the patient, then I will sign off until the recommendations are followed. But there are many other reasons why a team doesn't follow recommendations.

I agree with everyone else above that part of C-L is learning when to appropriately sign off. If you remain on a case without signing off despite making repeated, well-explained, and clearly communicated recommendations, then it's important to ask "whose needs are being served here?" It's not the patient's. I guess you can say that you're helping psychotherapeutically, but the continued presence of a C-L psychiatrist on such a case can allow the primary team to have a false belief that the problem is actually being addressed and an undue sense of security that help is immediately available if things get out of control (which you are trying to prevent). Compromise is often necessary, but acquiescence to, or passive observation of, inappropriate treatment of psychopathology is unacceptable.

 

[Mass Effect]

You get paid per patient or wrvu? If per patient that’s very interesting how much per patient are they giving?

$185 is the standard, but was able to negotiate to $200 after a few months. This is a 1099.

 

[cleareyedguy]

Long-time lurker here. Just wanted to vent some frustrations with being on a consult service. In my hospital we operate strictly as consultants and do not directly make medication changes. It is very frustrating when the medical team does not follow recommendations given. Honestly, I doubt they even read our notes. They feel psychiatry is just a place to dump unwanted patients from their service. How do you all deal with this? What can I say in the documentation that is passive-aggressive enough to get the point across while still being professional? Any suggestions?

For some background, I am a PGY-4. My attending has confided similar frustrations and will back me up with whatever route I decide. Thanks in advance!

There are plenty of reasons the primary team doesn't follow your rec's. Maybe you or the general c-l team haven't historically answered their questions in specific, helpful terms. Maybe they pick up on the fact that a trainee from a different department is overtly critical. Maybe they considered your suggestion and simply decided to go in a different direction. It's important to remember that you are the consultant providing a service for the primary team--and lots of consultant suggestions get shrugged off for a variety of reasons. If you have something specific, you might need to call and tactfully suggest it; over the long haul, they'll develop respect.

 

[aim-agm]

Maybe they considered your suggestion and simply decided to go in a different direction.

That's fine, so long as they document that and why.

 

[Bartelby]

Consulting a specialist on a case and then disregarding the recommendations is unlikely to look good for the primary team unless they can make a very compelling case for why their chosen course of treatment was better. I'm sure a plaintiff's attorney would love to see documented recommendations by a specialist with the highest qualifications to answer the relevant question ignored, it leaves the primary team with a lot of explaining to do (specifically why a reasonably prudent practitioner under similar circumstances would have disregarded that consultation). Imagine if cardiology made recommendations that you ignored and within days the person died of the issue they had warned you about. It doesn't look good.

With that said, I think the reason lawsuits are pretty unlikely is that for most psychiatric issues the issue is not immediately life and death. The person will also be returning to their outpatient team who, one hopes, will catch and correct any hospital mistakes. The main place liability is likely to come up would be situations like those listed above where the primary teams poor management decisions led directly and obviously to the bad outcome. Unfortunately in cases where you were consulting but your recommendations were not followed I suspect you would be named in the lawsuit, but I suspect you could get yourself dropped early on.

 

[Dharma]

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.852.7362&rep=rep1&type=pdf

Great and necessary read with some tips coming from CL Giant, Dr. George B. Murray (author of Limbic Music, another must-read).

Principle 3: Don't be afraid to sign-off when necessary.

Love the bolded below... a Dr. Murray gem.

On the surface, it may seem that the consultee is not being served either. In a subtle way, though, this is not so. The consultee believes that the patient has a psychiatric problem. The consultant’s opinions may be rejected, but misperceptions of the problem will persist. The continued presence of a psychiatrist on such a case allows the consultee a false belief that the problem is being addressed, and an undue sense of security that help is immediately available if things get out of control. In fact, it has been advocated (G. B. Murray, personal communication, 1999) that when signing off in these situations, one ought quietly, but intentionally, to foster anxiety in the mind of the consultee with a note ending with the statement, “call back when something happens.”

 

[deleted452516]

some general principles I follow when it seems we are not being heard:

1. face to face communication > phone > text > just leaving your note
2. make sure you have worked with the primary team to develop a clear consult question to which you can provide a discrete answer. if the question is vague your assessment/recs will be also.
3. order your recs from most to least important, for surgical teams do not exceed 3 recs.
4. while hopefully already concise and focused, shorten assessment/recs each day, until you are only addressing the single most important point.
5. in an academic setting don't be afraid to suggest the intern discuss with their senior, or even request to speak to their senior.
6. as highlighted beautifully by Dharma, don't be afraid to sign off when needed.
7. no note wars
8. when feeling frustrated and ignored listen to prince

 

[FlowRate]

Several posters mentioned most of what I would have said. In short, communicate recs face to face or by phone, write concise A+P's, sign off if recs ignored despite following-up by phone or in person, require at least one member of the primary team to join in the discussion with the patient when doing capacity assessments.

It is interesting to see the role of hospital culture on CL services. In residency we rotated on CL in two different hospital systems. In system 1, the CL service was (by resident opinion) overly-involved and took over too many aspects of patient care for the primary teams, even leading to issues like EM residents neglecting to see patients who were prematurely labeled as "psych" but who actually had active medical issues. System 1 had built this overly-involved culture over many, many years and it came from the vice chair on down. In system 2, the CL service set reasonable expectations and boundaries for each service and fostered a relationship with EM where we were consulted on a lot less fluff than in system 1. We were still very involved but not hand-holding or taking over care like in system 2. Again a top-down culture built over many years.

So you'd have to get service directors on board with changing how psychiatry interfaces with other services AND they'd have to do the slow work of building those relationships with other service directors. It's not something a PGY-4 is going to change before graduation.

 

[Salpingo]

1- for habitual offenders, talk to the team directly after the consult. Do your best to educate them. If they keep ignoring recommendations or placing inappropriate consults....

2- talk to someone higher up. A service chief can take this up with the other service. Systems issues sometimes respond best to systems-based responses. If higher-ups will not hold a meeting to discuss with these services or if behaviors don't change, then...

3- be glad you're a PGY-4 who can leave this environment in a matter of months! Institutional culture and norms can be the difference in a great job and an endlessly frustrating one. It takes a long time and a lot of work to build a good hospital culture, and if one is not present you really need the backing of leadership to help shape it. Keep that in mind when you start looking for jobs.

This is great advice, and I can't agree more with #1. When you actually show up to talk to someone in person, and avoid the passive aggressive chart war, you (1) show you really care and stand behind your recommendations, (2) model good communication skills. If you feel dismissed or diminished by the primary team, there's a good chance the patient feels similarly. This isn't necessarily because the team is composed of a bunch of jerks (although that might be in the differential), but maybe they're burnt out or overloaded and out of capacity, which has gotten worse with COVID and visitor restrictions. Sometimes it just takes an enthusiastic PGY-4 to reinvest in the case.

The potentially gratifying aspect of C/L is that you're not only taking care of patients, but also your colleagues, who are (hopefully) higher functioning and receptive to change, since they presumably were motivated to help others. That said, there will be some terminal cases where you'll have to move on to #2 or #3, depending on patient safety. If its really egregious, there should be some recourse with patient safety/"near miss" reporting or QI/QA.

 

[Salpingo]

This is very common and why I hate C/L. LMAO

Frankly, I doubt complaining to superiors matters. Hospitalists and teaching services that deal a lot with behavioral health issues care more, but if it's a very technical subspecialty service (heart failure, BMT, etc.) they generally don't follow that closely with consultants. Nobody cares either since the drivers of the revenue aren't your service. They call you as a courtesy and the PAs who staff the day-to-day don't really give a crap. There's nothing you can really do and I wouldn't bother doing anything in the notes.

Its interesting that you brought up those two services - I'm not sure how it is at other hospitals, but where I've been BMT and HF take complete ownership of their patients, almost to the point that its infantilizing. They then struggle in areas where they don't have absolute control (e.g. the patient refuses to eat, get out of bed, etc). So many of their consults come with some expectation that we can impose behavioral changes the same way they can change CVP or immunosuppression. When you show up and then give advice for managing their profound hypoactive delirium, its like a Furry person showing up to an S&M convention - it just doesn't address their needs, and both parties leave confused and a little scared. Those cases are best served with some sort of embedded model, but its tough to get institutional and financial investment.

Midlevel providers are another story. My sense is that their training really emphasizes an assembly line approach where the patient is moved down a conveyor line of consults, which is reinforced by their schedule (see the patient for a few days then pass them along). That said, these services can also have true veterans who have been at the institution for decades, and can be great allies. Similarly, it can be helpful to engage with the nurses, who may have been around the longest, take the brunt of the face-to-face care, and can help remind the team about your advice (if they like you).