This is interesting.
I've got to say that as someone who has done ER psych for the past year and a half that doing 1.5 consults/hr is A LOT if you're doing full, good assessments. I averaged about 3-4 per shift (6-8 hours) and that started burning me out. If you're just going to be the overly conservative "everyone with SI gets admitted and if they don't like it then invol" and those people are all auto-accepted then I guess it would be fine. But if you're doing legit risk assessments, recommending necessary resources (not providing them, that's SW's job), and documenting appropriately then 40 minutes per eval would be awful. That pay is only decent if the vast majority of these consults are super straightforward, which I'm sure they are not otherwise they shouldn't bother having a psychiatrist seeing these patients. I wouldn't touch this position, but after doing this for a while I also would never accept an ER telepsych job in the first place.
ER is the highest liability setting for psychiatry. D/c someone who was suicidal or dangerous and they try something and you better have strong documentation if that goes to court. Every patient is high acuity, so assessments need to be solid. That takes time and can be emotionally exhausting. Depending on the ER, if you say they need inpatient admission but no one will accept them then the ER docs are going to be hounding you about what to do. Do you piss off ER docs and admin and say they have to sit in the ER until placed (maybe for days) or find a way to justify letting patients reporting dangerousness and high acuity complaints discharge? Things could vary significantly based on the system, but there can be a lot more to these positions than just doing a basic assessment and giving a 1x recommendation...
Just because they're doing the med assessments and SW is supporting doesn't mean a lawyer won't come after you if something goes wrong. We're still physicians, if we miss something medical the ER doc isn't the only one on the hook. Good documentation can mitigate a lot of risk, but thinking that because other people are involved that a lawyer wouldn't go after you too if there's a lawsuit is a dangerous way to view things.
The VA has a decent suicide assessment form if you google "VA risk assessment tool, CSRE". It used to be over 60 pages long but I see they've cut it down to around 10 pages. A thorough suicide assessment is going to include the obvious demographics, but also go in depth with past attempts and SI, means, intent, planning, etc as well as looking at positive/protective factors and include thorough exploration of current social situation and background, previous ER visits or encounters with reports of SI if you have that available, and availability of outpatient follow-up and ongoing care. This takes time to perform and often more time to document.
The 7a-7p is low, however may not be a bad side gig if it’s not too strenuous and you have time to leisure around the house.
I mean kinda sorta. That’s a 48 hr work week rather than most psych doing less than forty for 306 median in salaried with benefits jobs.
So I talked to a current physician today, because I had similar questions.
This is my thought. On days I do the ed gig I would schedule some outpatient roles throughout the day, so I'd essentially be double dipping on days of ed coverage. So about 4 hours of outpatient spread throughout the day. For the 24hr that would be about 5k a day earned.
To me I'm seeing this as ~400/consult. From that angle, does it still seem bad to you?
Target gift card is tempting..
Hmm yea. My attendings admit everyone coming directly from any kind of tx center or clinic.
Run. These are the cases where liability is going to be the highest and you're not getting paid more to do a good evaluation and documentation that will actually cover you if something goes wrong. I am quite thorough with my evals and documentation (thanks OCPD traits) and still encounter times when things could still go wrong. Our state screeners for involuntary admission to state facilities are all telehealth and there are times when I have to fight to get invols upheld or represented.
If you're missing something, then that doesn't mitigate any liability. It just gives lawyers twice as many docs to go after as you said. If 2 docs don't miss anything, agree on a plan, and then there is a bad outcome then there may be some liability mitigation. But as the psychiatrist who is the "expert" being consulted that liability is getting shifted from the ER docs to you. It does not help the psychiatrist in any way, just everyone else as multiple people here have said.
Thanks for your thoughts, they are helpful.
Those cases are very high risk. In my state this gets reported as acute med neglect and is handled legally. If you discharge a pediatric patient endorsing active SI without a documented case number for acute neglect and something happens to the child, regardless of what a parent would say in the moment, you have lost the lawsuit before it even starts. Usually protective custody/legal involvement changes a parent's tune, but not always.
I'll give you an irl example from last month:
Depends on the situation and how much we have documented from previous visits. Sometimes we have patients who have been admitted so many times to so many different facilities that no hospitals within a 3 hour radius will accept them which can get messy. I certainly have patients that sit in our ER for 2-3 days trying to figure out how we can safely d/c them or get them accepted and I will see them as follow-ups after initial eval. We also have frequent flyers where I can get the eval and note done in 20 minutes because it's the same presentation 3x or more per month, but most of the time our nurses and ER docs take care of those without me being consulted.
Highly variable and dependent on how disorganized they are, but usually these are quite a bit shorter. If really disorganized and unable to participate could be a couple minutes, but then will have to be seen again later as state won't accept an invol on these people unless they're still psychotic 24 hours after last reported use. If they sober up and are linear/organized but still hallucinating they can leave unless they're demanding inpatient. Either way those are quicker as the liability/risk is typically lower and usually less assessment is necessary.
Agree to agree to agree
In a lot of ways you’re right.
Oh come on, this nonsense that being hospitalized for 5 days is the cause of a child (or parent's) psychopathology is just utter rubbish. We are required by law to hospitalize patient's who have acute SI as a result of mental illness, it's literally the job. That's not being anxious, it's upholding the ethical, legal, and professional requirements of work. I just saw a patient yesterday who was 100% convinced that the school flagging her google search on how to OD saved her life by getting her into the ED.
Just because anything can happen does not mean we should move through the world expecting all unlikely things to be equally likely to happen. Yes you can get lung cancer having never been exposed to smoke/carcinogens (I lost a mentor this way), but that does not mean that you might as well smoke anyway. Doing the right thing clearly lowers the risk of both being sued, but more importantly in losing the lawsuit or being forced to settle/placed on the registry. It's a probabilistic world, we're all just living in it.
