Uncharted territory. Surgery asks you to clear a psychiatric patient for surgery.

[whopper]

It's all in the title.

I've gotten requests to say a patient with no history of violence, or anything that would make them worth putting under the microscope excluded from a surgery.

Then a surgeon says I have to write a letter saying the patient is cleared for surgery.

So I ask the surgeon why. The surgeon tells me he's implanting a device and the company that makes the device won't allow for it to be done unless a psychiatrist clears the patient and I am provided NO CRITERIA of what constitutes psychiatric clearance for surgery.

So I tell the surgeon, what exactly is the criteria and he tells me he doesn't know. I tell him that there is nothing in the standard of care, at least that I'm aware of, or in the academic curriculum of psychiatry where one is "cleared for surgery," by psychiatry and that I cannot write a letter where I "clear" someone where I don't even know what the criteria for this is. He tells me he doesn't know what to tell me other than plenty of other psychiatrists from his experience have done this letter and that he can't do the surgery without it.

And now the patient who needs the surgery won't get the surgery.

So that's where it is, except that I asked him to contact the company that makes the device and have them provide me with this so-called "criteria."

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[Sushirolls]

Just like IM/FM doesn't clear anyone for ECT, they offer risk reduction options to mitigate risk of the procedure.

Don't be the person who clears. Someone else can fall on that sword.

Try to get the criteria or exactly what this company is looking for.

Do consult and use the usual phrases, clinically stable at this time, possible risks of depression relapse, or SUDs relapse, etc but can be mitigated by sleep hygiene, recovery work, whatever/etc. At this time there are no psychiatric contraindications for surgery is about as 'clear' as you are going to get.

 

[NITRAS]

I may not be able to offer anything useful, but I’ve seen psychiatric “clearance” for bariatric surgery pretty frequently.

The single most crazy, manipulative patient I’ve ever taken care of. I was covering an LTAC and a lady who originally had a roux en y for weight loss and had a cascade of complications that resulted in years of hospitalization, recurrent fungemias/abscesses. Despite having lost hundreds of pounds and a spit fistula (due to recurrent infections) she insisted on triple Meals. She had demands of narcotics (first patient I’ve seen on IV methadone) while she had jugs of masticated food at bedside. She would work the nursing staff and administration.

I remember reading her psych “clearance” note in her records from years earlier and thinking. . .” Well. They missed that one. “

 

[PsyDr]

It's not psychiatric clearance. The guidelines require a psychological assessment and define test selection. This is basic part and parcel of psychological assessment in spinal surgery, in both manufacturers guidelines and ODG. Bariatric surgery association guidelines used to have something similar, then they moved to a clinical impression approach.

 

[nrmp]

It's all in the title.

I've gotten requests to say a patient with no history of violence, or anything that would make them worth putting under the microscope excluded from a surgery.

Then a surgeon says I have to write a letter saying the patient is cleared for surgery.

So I ask the surgeon why. The surgeon tells me he's implanting a device and the company that makes the device won't allow for it to be done unless a psychiatrist clears the patient and I am provided NO CRITERIA of what constitutes psychiatric clearance for surgery.

So I tell the surgeon, what exactly is the criteria and he tells me he doesn't know. I tell him that there is nothing in the standard of care, at least that I'm aware of, or in the academic curriculum of psychiatry where one is "cleared for surgery," by psychiatry and that I cannot write a letter where I "clear" someone where I don't even know what the criteria for this is. He tells me he doesn't know what to tell me other than plenty of other psychiatrists from his experience have done this letter and that he can't do the surgery without it.

And now the patient who needs the surgery won't get the surgery.

So that's where it is, except that I asked him to contact the company that makes the device and have them provide me with this so-called "criteria."

I believe what he is asking you is that patient had capacity to make a decision for implanting a device which I believe is likely could be for pain management. So basically like a bariatric clearance that we do, I believe the same concept applies. So the criteria would be- patient explains full procedure, is he/she able to understand risk/benefits, aftercare and future life adjustments. I believe that just because you are a psychiatrist for that particular patient doesn't mean you have to do this clearance and patient can go to a psychiatrist who does bariatric/pain procedure clearances.

 

[clausewitz2]

It's all in the title.

I've gotten requests to say a patient with no history of violence, or anything that would make them worth putting under the microscope excluded from a surgery.

Then a surgeon says I have to write a letter saying the patient is cleared for surgery.

So I ask the surgeon why. The surgeon tells me he's implanting a device and the company that makes the device won't allow for it to be done unless a psychiatrist clears the patient and I am provided NO CRITERIA of what constitutes psychiatric clearance for surgery.

So I tell the surgeon, what exactly is the criteria and he tells me he doesn't know. I tell him that there is nothing in the standard of care, at least that I'm aware of, or in the academic curriculum of psychiatry where one is "cleared for surgery," by psychiatry and that I cannot write a letter where I "clear" someone where I don't even know what the criteria for this is. He tells me he doesn't know what to tell me other than plenty of other psychiatrists from his experience have done this letter and that he can't do the surgery without it.

And now the patient who needs the surgery won't get the surgery.

So that's where it is, except that I asked him to contact the company that makes the device and have them provide me with this so-called "criteria."

If he knows so many other psychiatrists who are willing to write these letters and know just what to do, it does lead one to wonder why on earth he would insist on asking you to do it. Can't he just call up one of these other psychiatrists?

 

[whopper]

I believe what he is asking you is that patient had capacity to make a decision for implanting a device which I believe is likely could be for pain management.

I did ask him, "doctor, are you asking me for a capacity evaluation?" He specifically said he doesn't know. He repeated himself and said, "like I said this company that makes this device wants a psychiatrist to clear the patient for surgery and never mentioned anything about capacity."

If he knows so many other psychiatrists who are willing to write these letters and know just what to do, it does lead one to wonder why on earth he would insist on asking you to do it. Can't he just call up one of these other psychiatrists?

Cause they aren't treating my specific patient. She'd have to be seen by one of them and I'm admittedly making an assumption here but I get the impression these psychiatrists aren't worth their title if they're willing to sign something where they have no idea nor this surgeon what "psychiatric clearance" exactly means.

I may not be able to offer anything useful, but I’ve seen psychiatric “clearance” for bariatric surgery pretty frequently.

As have I and guess what? I've seen no criteria that exactly makes one "cleared" for bariatric surgery. If someone knows what this alleged criteria is please do inform all of us, and inform us as to why there's no published criteria I know of and why this isn't taught in a psychiatry curriculum.

I have actually read a few reports where the mental health professional cleared someone for bariatric surgery and no where in the report did this evaluator state the specific criteria. In short it was the equivalent of an initial interview and the doctor just wrote cleared at the end.

In any forensic psychiatric report I'd put the question, something to the effect of, "As established in X v Y the criteria for Z is defined as...." And then answer, "based on the legal criteria, it is my opinion within reasonable medical certainty that Joe Blow meets the criteria for Z based on the following...." and then show the evidence I gathered during my evaluation.

Where as the bariatric reports I've seen it's basically. "Joe Blow meets criteria." and there's only an initial evaluation written with no legal or professional criteria that was clearly explained nor evidence that justifies the criteria. In short is suggests to me it's just a clinician who either doesn't understand they are answering something they clearly don't know is outside their league, and/or they were more interested in writing a half-assed report for the money.

If someone wants me to write a report with specific criteria for me to answer, yeah sure I'd answer those specific criteria, but saying this person is "cleared for surgery" when there's no criteria given to me as to what makes one cleared? No way.

 

[PsyDr]

I did ask him, "doctor, are you asking me for a capacity evaluation?" He specifically said he doesn't know. He repeated himself and said, "like I said this company that makes this device wants a psychiatrist to clear the patient for surgery and never mentioned anything about capacity."

100% this is not a capacity evaluation. The standards of care are created to identify individuals who are at risk for poor surgical outcomes of implantable devices as defined by the professional literature because psychological factors are predictive of surgical outcome in this area.

 

[erg923]

I did ask him, "doctor, are you asking me for a capacity evaluation?" He specifically said he doesn't know. He repeated himself and said, "like I said this company that makes this device wants a psychiatrist to clear the patient for surgery and never mentioned anything about capacity."



Cause they aren't treating my specific patient. She'd have to be seen by one of them and I'm admittedly making an assumption here but I get the impression these psychiatrists aren't worth their title if they're willing to sign something where they have no idea nor this surgeon what "psychiatric clearance" exactly means.



As have I and guess what? I've seen no criteria that exactly makes one "cleared" for bariatric surgery. If someone knows what this alleged criteria is please do inform all of us, and inform us as to why there's no published criteria I know of and why this isn't taught in a psychiatry curriculum.

I have actually read a few reports where the mental health professional cleared someone for bariatric surgery and no where in the report did this evaluator state the specific criteria. In short it was the equivalent of an initial interview and the doctor just wrote cleared at the end.

In any forensic psychiatric report I'd put the question, something to the effect of, "As established in X v Y the criteria for Z is defined as...." And then answer, "based on the legal criteria, it is my opinion within reasonable medical certainty that Joe Blow meets the criteria for Z based on the following...." and then show the evidence I gathered during my evaluation.

Where as the bariatric reports I've seen it's basically. "Joe Blow meets criteria." and there's only an initial evaluation written with no legal or professional criteria that was clearly explained nor evidence that justifies the criteria. In short is suggests to me it's just a clinician who either doesn't understand they are answering something they clearly don't know is outside their league, and/or they were more interested in writing a half-assed report for the money.

If someone wants me to write a report with specific criteria for me to answer, yeah sure I'd answer those specific criteria, but saying this person is "cleared for surgery" when there's no criteria given to me as to what makes one cleared? No way.

With respect, I think you are making this overly complex.

The surgeon is saying "clearance," but that's not really what he means and that's not your role. "Clearance" is ultimately the surgeons decision, of course. He wants you to meet with the patient to figure out if they have mental health issues that would affect their ability to have and benefit from the surgery (including any post op lifestyle restrictions/behavior changes, follow-up adherence, unrealistic expectations, etc). This would require that you have a good understanding of what the surgery entails, what is helps with and what it doesn't help with, and pain psychology in general. Obviously, levels of pain catastrophization, somatization, substance use, coping skills, social supports are all important aspects to assess in addition to general mental health functioning. It is an opinion on risk. How much risk is acceptable is actually up the the surgeon. Not you. Noone should ever be writing "cleared" in evaluations such as these.

If you dont have any experience in this area, then just don't do it. The surgeon can call on all the psychiatrists who do this for him all the time. Why is he asking you now anyway?

 

[Sushirolls]

I may not be able to offer anything useful, but I’ve seen psychiatric “clearance” for bariatric surgery pretty frequently.

The single most crazy, manipulative patient I’ve ever taken care of. I was covering an LTAC and a lady who originally had a roux en y for weight loss and had a cascade of complications that resulted in years of hospitalization, recurrent fungemias/abscesses. Despite having lost hundreds of pounds and a spit fistula (due to recurrent infections) she insisted on triple Meals. She had demands of narcotics (first patient I’ve seen on IV methadone) while she had jugs of masticated food at bedside. She would work the nursing staff and administration.

I remember reading her psych “clearance” note in her records from years earlier and thinking. . .” Well. They missed that one. “

These types of patients can also pop up, not just post bariatric surgery, but from any surgery. A hip, a knee, a back, a hysterectomy, etc.

 

[PsyDr]

With respect, I think you are making this overly complex.

The surgeon is saying "clearance," but that's not really what he means and that's not your role. "Clearance" is ultimately the surgeons decision, of course. He wants you to meet with the patient to figure out if they have mental health issues that would affect their ability to have and benefit from the surgery (including any post op lifestyle restrictions/behavior changes, follow-up adherence, unrealistic expectations, etc). This would require that you have a good understanding of what the surgery entails, what is helps with and what it doesn't help with, and pain psychology in general. Obviously, levels of pain catastrophization, somatization, substance use, coping skills, social supports are all important aspects to assess in addition to general mental health functioning. It is an opinion on risk. How much risk is acceptable is actually up the the surgeon. Not you. Noone should ever be writing "cleared" in evaluations such as these.

With all due respect, your opinion is in direct conflict with the relevant body of literature and guidelines.

 

[whopper]

The surgeon is saying "clearance," but that's not really what he means and that's not your role. "Clearance" is ultimately the surgeons decision, of course.

That's what I told him. I told him that anesthesia and surgery "clear" the patient. He again reiterated that the company that makes the device says a psychiatrist has to clear the patient and he has no idea what the criteria is for clearance but that other psychiatrists have done so.

So am I making this more complicated? Again the surgeon himself said he doesn't know what "clearance by a psychiatrist" means.

He wants you to meet with the patient to figure out if they have mental health issues that would affect their ability to have and benefit from the surgery (including any post op lifestyle restrictions/behavior changes, follow-up adherence, unrealistic expectations, etc).

No. I told him because I don't want to repeatedly call him up and get everything out of way that aside from capacity did he want me to answer issues of violence, compliance, severe mood or other psych disorders.
Again he said he doesn't know what "psychiatric clearance" is.
Also you can hypothesize this is what he wants. You don't know what he wants.

Why is he asking you now anyway?

Good question. My patient told me she's not getting the surgery until I clear her. So I asked her what she meant by that and she said "I don't know, but my surgeon said you have to clear me and cause you're a doctor and he's a doctor I thought you'd know what this meant." So I told her to provide me with his contact information, sign a release, and I told her I'd call him. So he took the initiative an got my contact information before I got his, called him up and the above events happened.

And guess what? Maybe I'm dumb, gullible and optimistic but I figure if a doctor asks me to do something he actually knows what he's asking me for. This guy doesn't know what he's even asking me for, said it from is mouth and said, the company wants it, and he doesn't even understand what it is.

Even the surgeon doesn't know what "psychiatric clearance" is regarding this device, but like I said other doctors were willing to sign on and say their patient was cleared.

 

[wolfvgang22]

With all due respect, your opinion is in direct conflict with the relevant body of literature and guidelines.

What guidelines and what literature? I really am interested.

 

[Old&InTheWay]

Why is a device manufacturer so involved in medical decision making?

Also (sorry if I missed it) but what is the surgery/device? I think the specifics are important in terms of understanding what is being sought.

 

[Psychresy]

I have absolutely nothing to add. Would just like to say I so very much appreciate this forum and that we have an outlet for this kind of discourse amongst colleagues. Things like this are what worry me when residency is finished - so nice to know there are still people to turn to no matter where I am practicing.

 

[whopper]

As I wrote above, the surgeon told me he's going to contact a representative from the company and provide me with their information. If I get an actual set of the criteria (or lack thereof), I'll write it here.

Until then, I'm clueless and will not write the patient meets a set of criteria not knowing what that criteria is.

 

[PsyDr]

@Old&InTheWay For the same reason the humanitarian device exemption process exists in the FDA. Outcome stuff affects recalls and approvals.

Someone asked: medtronic guidelines, ODG, CO WC guidelines, ACP/APS guidelines, the old AHCPR guidelines, the USPTF Recommendations, etc.

 

[Fan_of_Meehl]

It's all in the title.

I've gotten requests to say a patient with no history of violence, or anything that would make them worth putting under the microscope excluded from a surgery.

Then a surgeon says I have to write a letter saying the patient is cleared for surgery.

So I ask the surgeon why. The surgeon tells me he's implanting a device and the company that makes the device won't allow for it to be done unless a psychiatrist clears the patient and I am provided NO CRITERIA of what constitutes psychiatric clearance for surgery.

So I tell the surgeon, what exactly is the criteria and he tells me he doesn't know. I tell him that there is nothing in the standard of care, at least that I'm aware of, or in the academic curriculum of psychiatry where one is "cleared for surgery," by psychiatry and that I cannot write a letter where I "clear" someone where I don't even know what the criteria for this is. He tells me he doesn't know what to tell me other than plenty of other psychiatrists from his experience have done this letter and that he can't do the surgery without it.

And now the patient who needs the surgery won't get the surgery.

So that's where it is, except that I asked him to contact the company that makes the device and have them provide me with this so-called "criteria."

It's impossible to answer a consultation question that hasn't even been stated (at all, let alone clearly). A lot of these types of situations involve wanting to try to play 'tag, you're it' with respect to a) liability and/or b) telling a psychiatric patient 'no.'

 

[clausewitz2]

It's impossible to answer a consultation question that hasn't even been stated (at all, let alone clearly). A lot of these types of situations involve wanting to try to play 'tag, you're it' with respect to a) liability and/or b) telling a psychiatric patient 'no.'

Best consult question I ever got working on psych consult and liaison service:

'patient transferred to LTAC'. Just that single page and a line in previous day's note 'consult psychiatry' with no explanation.

Hell of it was that it ended up being a really fascinating, case-reportable sort of situation but good lord is that an unpromising start

 

[VA Hopeful Dr]

Have you tried Googling whatever the device is and "psychiatric clearance" to see what pops up?

 

[Old&InTheWay]

Have you tried Googling whatever the device is and "psychiatric clearance" to see what pops up?

Is it an orgasmatron?

The Orgasmatron: Strange tale of a pleasure implant

Pleasure-inducing implants can induce orgasms at the push of a button, but as Frank Swain discovers, there’s a curious history behind this technology

www.bbc.com

 

[splik]

It's pretty common for patients to require a psychological evaluation prior to certain procedures including solid organ transplantation, live organ donation, bariatric surgery, spinal cord stimulator implantation, gender affirming surgeries, epilepsy surgery, and DBS for Parkinson's disease and BSO for PMDD. In general these should be done by a specialist experienced in this area, consulting to the surgeon. I have experience doing some of these evaluations, but not others. Even so, I refuse to do these evaluations for my own patients since there is a conflict of interest. Also, I bill the surgeons for this kind of evaluation not the patient.

There is no such a thing as "clearance" for surgery from a psychiatric or medical perspective. Our job is optimize patients from a psychosocial and psychiatric perspective and identify patients who are obviously poor candidates. Surgeons are often looking for a check box, or else absolution from liability in the even of a bad outcome. Appropriately trained psychiatrists and psychologists do have value to add in conducting these evaluations.

 

[whopper]

Splik, agree, which is why I specifically asked the surgeon for criteria cause if there were specific criteria I could answer I would've done it. The surgeon and I both told each other we weren't trying to be difficult and that if there was a way to move this process forward we would've.

The surgeon, who was quite polite to me, told me that he didn't know the criteria but thought I would cause "it's psychiatry and none of the other psychiatrists ever called me up and asked questions like you did."

Again we have psychiatrists doing things not knowing what they're really doing. E.g. I witnessed a psychiatrist in the last few months clear someone to fly a plane and the psychiatrist doesn't know how to fly a plane or evaluate someone for this but literally wrote the patient is clear to fly a plane.

Have you tried Googling whatever the device is and "psychiatric clearance" to see what pops up?

The thought crossed my mind but I don't know which specific device it is. I didn't feel like spinning a wheel that likely would get me nowhere until I was told of the specific device. The surgeon didn't yet tell me, but by the time that device-specific train of thought crossed my mind it was after hours. I'm calling his office again this coming Monday.

 

[PikminOC]

Splik, agree, which is why I specifically asked the surgeon for criteria cause if there were specific criteria I could answer I would've done it. The surgeon and I both told each other we weren't trying to be difficult and that if there was a way to move this process forward we would've.

The surgeon, who was quite polite to me, told me that he didn't know the criteria but thought I would cause "it's psychiatry and none of the other psychiatrists ever called me up and asked questions like you did."

Again we have psychiatrists doing things not knowing what they're really doing. E.g. I witnessed a psychiatrist in the last few months clear someone to fly a plane and the psychiatrist doesn't know how to fly a plane or evaluate someone for this but literally wrote the patient is clear to fly a plane.



The thought crossed my mind but I don't know which specific device it is. I didn't feel like spinning a wheel that likely would get me nowhere until I was told of the specific device. The surgeon didn't yet tell me, but by the time that device-specific train of thought crossed my mind it was after hours. I'm calling his office again this coming Monday.

There are complex faa guidelines that need to be met in terms of flying a plane. There are criteria for that.

 

[Crayola227]

For the record, there are two types of clearances for flying, one requires an Air Medical Examiner (AME) certified by the FAA, and the AMEs know who they are and what they are supposed to do. The other is called "Basic Med" and it's very straightforward. You are basically just certifying that the patient does NOT have about a half-dozen specified conditions that are immediately disqualifying for flying (bipolar disorder of any type is immediately and completely disqualifying for one, so having a psychiatrist say you are fit to fly might make more sense than you would think. Mental health and centrally acting meds are some top issues for grounding). It does NOT require any special knowledge about aviation on the part of the doc from the FAA's perspective, and I believe the only requirement is to have a valid medical license.

In general, if the pilot has a valid driver's license, ever had an FAA medical certificate from an AME that was in not revoked, and does not have those conditions, they can fly under basic med, which has certain restrictions on type of plane, its size, passengers, for hire, and where one can fly.

My bf owns a plane so I've learns some basic ins and outs of this, and talked with some knowledgeable docs about it (AME and docs that fly).

Quite a few psychiatrists and neuropsychologists are involved in evaluating pilots and working with HIMS AMEs (Human Intervention Motivational Study AMEs) which is basically the aviation world's version of PHP oversight for mental health and substance use issues in pilots.

You don't need to really know anything about flying per se when it comes to signing off o Basic Med as a standard doc, or even as an AME, however this is in part because FAA rules are extremely detailed and laid out and technical. In fact, I would almost consider becoming a HIMS AME or other consultant to the FAA specially as a psychiatrist, there's high demand, low supply (sometimes only one HIMS AME per several states, people will fly to see you), and you can charge a LOT of money depending on the issues, and not have to deal with insurance. The patient population (pilots) tend to be high-functioning, highly motivated, and have income.

As far as altruism goes, pilots are in need of this sort of care. As much as our industry goes on about the doctor shortage, there is a huge looming pilot shortage. Helping airmen get in the air and stay there (and others in the aviation industry like air traffic controllers, etc) is a big need for society. And AMEs are not only in short supply but the average age is in the 60s and retiring.

Also, only 10% of AMEs are women.

A bit off topic, but possibly the amount of aero-med useful for any MD to be aware of.

 

[NickNaylor]

Sounds goofy, and if the surgeon isn't able to give you any actual useful information, then I would just provide a letter that documents your working diagnoses for the patient and the current status of their illness (e.g., if they have MDD, are their depressive symptoms controlled?). If that constitutes "clearance" for the surgeon, great. If not, maybe it'll serve as a starting point for what the surgeon is actually wanting you to comment on. I agree that providing blanket "clearance" is a pointless question. All you can really comment on is whether or not there are psychiatric issues with might complicate the medical management of the patient and the degree to which those issues are active.

 

[Stagg737]

Sounds goofy, and if the surgeon isn't able to give you any actual useful information, then I would just provide a letter that documents your working diagnoses for the patient and the current status of their illness (e.g., if they have MDD, are their depressive symptoms controlled?). If that constitutes "clearance" for the surgeon, great. If not, maybe it'll serve as a starting point for what the surgeon is actually wanting you to comment on. I agree that providing blanket "clearance" is a pointless question. All you can really comment on is whether or not there are psychiatric issues with might complicate the medical management of the patient and the degree to which those issues are active.

This is how I feel about consults that just say “capacity” without any obvious indication of why they’re asking this. Doubly so when I can’t get a response from the consulting team.

 

[hallowmann]

I agree with everyone else here that clearance is not a thing. Surgeons use that term, but the field "clearing" the patient doesn't, because it doesn't have meaning. Estimation of risk is all that anyone can do. Estimation of whether that risk will improve with X-treatment, and that waiting for X-treatment is or is not in the patient's best interest.

I'd be curious to know what the company says. You would think the surgeon would have some idea what the evaluation required, because they've supposedly gotten them before, but maybe that's expecting too much from that surgeon to read one psychiatry consult note that they requested.

 

[whopper]

My bf owns a plane so I've learns some basic ins and outs of this, and talked with some knowledgeable docs about it (AME and docs that fly).

I'm aware of this. In the case I mentioned above the psychiatrist I mentioned cleared the patient and NOT THE BASIC CLEARANCE. Again a doctor thinking he can wave his wand and say things he has no expertise in saying.

Just a few days ago I was asked by a patient's employer to say that he could do several things at his job that involved operating heavy machinery. I Refused. To help him out I wrote that I could say he's doing well, doesn't even suffer a mental health disorder as far as I could tell, and that the employer shouldn't be asking the treating doctor for a fitness-for-duty evaluation which is what the employer was asking because that would be an extensive evaluation that was going overboard.

While I was a resident time and time again doctors would write bogus consults. E.g. "competency evaluation" but they wouldn't state for what, we had to spend 30 minutes finding out what was asked for in the first place, and constantly tell the nursing staff in the future the attending or nurse should write "capacity evaluation" the reason for it, and that the resident would not do that themselves as we were told to do by prior attendings. If the evaluation for capacity for treatment that they need to write in the chart that they already explained to the patient the risks and benefits. Out of 3 years of residency NOT ONCE did I see the doctor write in the chart that the risks and benefits were mentioned and the majority of patients, when I asked them, told me the doctor wanted to do an invasive procedure and when the patient simply asked what was going on the doctor then immediately told the nurse to write for a "competency evaluation."

None of the psych attendings did anything to stem the above problem. Each time this happened they just told a resident to look into it and never did they actually try fix the situation. We had a few of these types of requests a day wasting hours a day.

My 4th year, as a chief resident I started doing what the attendings should've done. If there was an order for a "competency evaluation," we simply wrote back that we don't do competency evaluations and walked away. I told the residents 1) No-they don't have to call the other attending, wait for him to call back and then correct the order, just tell the nurse and walk away saying we don't do "competency evaluations." 2) If the nurse still wanted the evaluation he/she had to call the doctor and correct the order as a "capacity evaluation." 3) Then when we started the "capacity evaluation" if the doctor didn't record that he/she discussed the risks and benefits with the patient we simply wrote into the chart that we do not do that and will wait for the doctor to do it himself and then if they still wanted the evaluation then we'd do it.

Each time a doctor or nurse got pissed at the resident and started giving the resident flack the resident was instructed to tell the person to contact me if they had a problem. I then did what the attending should've done my first 3 years. "No we don't do competency evaluations we do capacity evaluations. Do you want one? Then write capacity evaluation, and you have to say for what purpose." "Did you write the purpose of the evaluation? IF not we wait for you to put it in before we start." "I can't have my resident doing all of this work that you should've done before you gave us this order." "Did you discuss the risks and benefits? IF not we do not do that for you since you are the treating doctor."

The head of my department even agreed with me as did the hospital lawyers. The prior attendings would just tell the resident to do all the work the treating doctor was supposed to have done such as discuss the risks and benefits themselves.

The first 3 months this happened I was getting called multiple times a day by nurses where I repeatedly told them the above and something to the effect of, "don't make the psych residents do something you were supposed to have done." A few times one of them would try to browbeat me or the resident, and then I'd call the hospital lawyer to tell the nurse or doctor "no, the chief resident is correct the psych resident is not supposed to tell the patient the risks and benefits of the treatment, the treating doctor is supposed to do it."

 

[Crayola227]

I'm aware of this. In the case I mentioned above the psychiatrist I mentioned cleared the patient and NOT THE BASIC CLEARANCE. Again a doctor thinking he can wave his wand and say things he has no expertise in saying.

Just a few days ago I was asked by a patient's employer to say that he could do several things at his job that involved operating heavy machinery. I Refused. To help him out I wrote that I could say he's doing well, doesn't even suffer a mental health disorder as far as I could tell, and that the employer shouldn't be asking the treating doctor for a fitness-for-duty evaluation which is what the employer was asking because that would be an extensive evaluation that was going overboard.

While I was a resident time and time again doctors would write bogus consults. E.g. "competency evaluation" but they wouldn't state for what, we had to spend 30 minutes finding out what was asked for in the first place, and constantly tell the nursing staff in the future the attending or nurse should write "capacity evaluation" the reason for it, and that the resident would not do that themselves as we were told to do by prior attendings. If the evaluation for capacity for treatment that they need to write in the chart that they already explained to the patient the risks and benefits. Out of 3 years of residency NOT ONCE did I see the doctor write in the chart that the risks and benefits were mentioned and the majority of patients, when I asked them, told me the doctor wanted to do an invasive procedure and when the patient simply asked what was going on the doctor then immediately told the nurse to write for a "competency evaluation."

None of the psych attendings did anything to stem the above problem. Each time this happened they just told a resident to look into it and never did they actually try fix the situation. We had a few of these types of requests a day wasting hours a day.

My 4th year, as a chief resident I started doing what the attendings should've done. If there was an order for a "competency evaluation," we simply wrote back that we don't do competency evaluations and walked away. I told the residents 1) No-they don't have to call the other attending, wait for him to call back and then correct the order, just tell the nurse and walk away saying we don't do "competency evaluations." 2) If the nurse still wanted the evaluation he/she had to call the doctor and correct the order as a "capacity evaluation." 3) Then when we started the "capacity evaluation" if the doctor didn't record that he/she discussed the risks and benefits with the patient we simply wrote into the chart that we do not do that and will wait for the doctor to do it himself and then if they still wanted the evaluation then we'd do it.

Each time a doctor or nurse got pissed at the resident and started giving the resident flack the resident was instructed to tell the person to contact me if they had a problem. I then did what the attending should've done my first 3 years. "No we don't do competency evaluations we do capacity evaluations. Do you want one? Then write capacity evaluation, and you have to say for what purpose." "Did you write the purpose of the evaluation? IF not we wait for you to put it in before we start." "I can't have my resident doing all of this work that you should've done before you gave us this order." "Did you discuss the risks and benefits? IF not we do not do that for you since you are the treating doctor."

The head of my department even agreed with me as did the hospital lawyers. The prior attendings would just tell the resident to do all the work the treating doctor was supposed to have done such as discuss the risks and benefits themselves.

The first 3 months this happened I was getting called multiple times a day by nurses where I repeatedly told them the above and something to the effect of, "don't make the psych residents do something you were supposed to have done." A few times one of them would try to browbeat me or the resident, and then I'd call the hospital lawyer to tell the nurse or doctor "no, the chief resident is correct the psych resident is not supposed to tell the patient the risks and benefits of the treatment, the treating doctor is supposed to do it."

Well the joke would be on that psychiatrist if he's not an AME. Any sort of fraud on those FAA forms is a felony with some hefty penalties and possible jail time. The forms are pretty clear, I guess he can't read or he wasn't worried about it. I would report that to the FAA.

 

[whopper]

I contacted the FAA, not about the above doctor but because I heard forensic evaluators with the right certifications with the FAA can charge a lot of money. After several attempts, calls, e-mails, written letters and no response I gave up. I don't have the FAA certifications but a pilot's license was something I considered getting anyway.

 

[cara susanna]

There actually are standards for bariatric evaluation psychological clearance that psychologists use, but I'm not sure if that's the same thing as what they'd be asking a psychiatrist.

 

[Stagg737]

I'm aware of this. In the case I mentioned above the psychiatrist I mentioned cleared the patient and NOT THE BASIC CLEARANCE. Again a doctor thinking he can wave his wand and say things he has no expertise in saying.

Just a few days ago I was asked by a patient's employer to say that he could do several things at his job that involved operating heavy machinery. I Refused. To help him out I wrote that I could say he's doing well, doesn't even suffer a mental health disorder as far as I could tell, and that the employer shouldn't be asking the treating doctor for a fitness-for-duty evaluation which is what the employer was asking because that would be an extensive evaluation that was going overboard.

While I was a resident time and time again doctors would write bogus consults. E.g. "competency evaluation" but they wouldn't state for what, we had to spend 30 minutes finding out what was asked for in the first place, and constantly tell the nursing staff in the future the attending or nurse should write "capacity evaluation" the reason for it, and that the resident would not do that themselves as we were told to do by prior attendings. If the evaluation for capacity for treatment that they need to write in the chart that they already explained to the patient the risks and benefits. Out of 3 years of residency NOT ONCE did I see the doctor write in the chart that the risks and benefits were mentioned and the majority of patients, when I asked them, told me the doctor wanted to do an invasive procedure and when the patient simply asked what was going on the doctor then immediately told the nurse to write for a "competency evaluation."

None of the psych attendings did anything to stem the above problem. Each time this happened they just told a resident to look into it and never did they actually try fix the situation. We had a few of these types of requests a day wasting hours a day.

My 4th year, as a chief resident I started doing what the attendings should've done. If there was an order for a "competency evaluation," we simply wrote back that we don't do competency evaluations and walked away. I told the residents 1) No-they don't have to call the other attending, wait for him to call back and then correct the order, just tell the nurse and walk away saying we don't do "competency evaluations." 2) If the nurse still wanted the evaluation he/she had to call the doctor and correct the order as a "capacity evaluation." 3) Then when we started the "capacity evaluation" if the doctor didn't record that he/she discussed the risks and benefits with the patient we simply wrote into the chart that we do not do that and will wait for the doctor to do it himself and then if they still wanted the evaluation then we'd do it.

Each time a doctor or nurse got pissed at the resident and started giving the resident flack the resident was instructed to tell the person to contact me if they had a problem. I then did what the attending should've done my first 3 years. "No we don't do competency evaluations we do capacity evaluations. Do you want one? Then write capacity evaluation, and you have to say for what purpose." "Did you write the purpose of the evaluation? IF not we wait for you to put it in before we start." "I can't have my resident doing all of this work that you should've done before you gave us this order." "Did you discuss the risks and benefits? IF not we do not do that for you since you are the treating doctor."

The head of my department even agreed with me as did the hospital lawyers. The prior attendings would just tell the resident to do all the work the treating doctor was supposed to have done such as discuss the risks and benefits themselves.

The first 3 months this happened I was getting called multiple times a day by nurses where I repeatedly told them the above and something to the effect of, "don't make the psych residents do something you were supposed to have done." A few times one of them would try to browbeat me or the resident, and then I'd call the hospital lawyer to tell the nurse or doctor "no, the chief resident is correct the psych resident is not supposed to tell the patient the risks and benefits of the treatment, the treating doctor is supposed to do it."

This is beautiful. I feel fortunate to be at a place where we do capacity evals but only when proper steps have been taken and that attendings have no problems stepping in for residents taking crap.

To the original point, we do a fair amount of transplant and device evals on our consult service, but we never “clear” the patient for a procedure. We do a fairly extensive social eval, psych history, and basic capacity stuff and then provide an opinion on how good of a candidate a patient is based on how well we think they can comply with the necessary recovery/maintenance as well as pacyhological risk factors (substance HC, SI/attempts, social support, etc). After that, the primary doc/surgeon decides if they’ll do the procedure where I’m at.

 

[whopper]

We do a fairly extensive social eval, psych history, and basic capacity stuff and then provide an opinion on how good of a candidate a patient is based on how well we think they can comply with the necessary recovery/maintenance as well as pacyhological risk factors (substance HC, SI/attempts, social support, etc). After that, the primary doc/surgeon decides if they’ll do the procedure where I’m at.

And had I simply been asked to do a psych/SES evaluation that would've been fine with me. The problem was I was asked to write the patient was "psychiatrically clear" with the asking doctor admitting he didn't know what that meant.

A little more of the consultation problem I had above in residency, this was at my general psych resident. This same problem wasn't happening at U of Cincinnati. The problem with my general psych residency was we had a few attendings who were lazy and subpar. The attending doing the consult service instead of fixing the problems, simply made the resident do extra work to cover up for the problems that he should've fixed himself. HE simply looked at the resident, told the resident to call the IM attending who wrote the consult and stay by the phone until he called back, sometimes over an hour later (per attending sometimes we had over 5 doing the same problem a day). I even brought up with him that we should fix the consult service and he would only stare dismissively and not respond. Some of the attendings even admitted to wanting to be in academia simply just wanting residents to do the grunt-work. Aside that I had no respect for this, these doctors were poor by academic standards-poor instruction, poor clinical skills, and no publications. They struck out, 3 strikes and no hits.

When I did my fellowship at U of Cincinnati (and this was years ago, places change although most of the attendings there then are still there now) the attendings were on top of the consult service and they would've gotten rid of inept attendings. Where I did general residency the head of the department told me she couldn't get rid of inept attendings cause she couldn't easily replace them.

While I was at SLU the consult problem was similar to general psych residency. The problem at SLU was about a year before I joined the department collapsed with every attending minus 4 leaving the department. So the doctor covering consult service alternated every few days with no consistency. By the time I got there things were somewhat better with the department positions being mostly filled but now most of the attendings were newbies not knowing how the institution worked and some of them weren't experienced, many of them fresh graduates who never put their foot down to an attending before. The consultation service was still being regularly rotated with no consistency with various attendings handling things differently.

So whenever I did consult service, daily I encountered problems, but if I tried to fix them, the next attending would've erased the gains I created. Low pay, a poor retirement benefit system, the department was still recovering from the implosion it suffered the year prior, I got sick of it and left after I attempted to fix a lot of issues that were ignored. These all occurred over 5 years ago so I hope the department now is in a much better state. I can say that they do have 3 highly incredible attendings there that are some of the best in the country so I do recommend applicants consider SLU, but don't how the department is doing now.

 

[Merovinge]

I can say that they do have 3 highly incredible attendings there that are some of the best in the country so I do recommend applicants consider SLU, but don't how the department is doing now.

I'm sure you know more about this than me but I can imagine SLU being in a really tough place given that Wash U is so nearby and St Louis isn't exactly a trendy place to live with psychiatrists clamoring to move there. It would seem to be all the top talent would get sucked up by Wash U leaving SLU with people wanting to be in an academic institute but not making the cut at Wash U.

 

[PikminOC]

For the record, there are two types of clearances for flying, one requires an Air Medical Examiner (AME) certified by the FAA, and the AMEs know who they are and what they are supposed to do. The other is called "Basic Med" and it's very straightforward. You are basically just certifying that the patient does NOT have about a half-dozen specified conditions that are immediately disqualifying for flying (bipolar disorder of any type is immediately and completely disqualifying for one, so having a psychiatrist say you are fit to fly might make more sense than you would think. Mental health and centrally acting meds are some top issues for grounding). It does NOT require any special knowledge about aviation on the part of the doc from the FAA's perspective, and I believe the only requirement is to have a valid medical license.

In general, if the pilot has a valid driver's license, ever had an FAA medical certificate from an AME that was in not revoked, and does not have those conditions, they can fly under basic med, which has certain restrictions on type of plane, its size, passengers, for hire, and where one can fly.

My bf owns a plane so I've learns some basic ins and outs of this, and talked with some knowledgeable docs about it (AME and docs that fly).

Quite a few psychiatrists and neuropsychologists are involved in evaluating pilots and working with HIMS AMEs (Human Intervention Motivational Study AMEs) which is basically the aviation world's version of PHP oversight for mental health and substance use issues in pilots.

You don't need to really know anything about flying per se when it comes to signing off o Basic Med as a standard doc, or even as an AME, however this is in part because FAA rules are extremely detailed and laid out and technical. In fact, I would almost consider becoming a HIMS AME or other consultant to the FAA specially as a psychiatrist, there's high demand, low supply (sometimes only one HIMS AME per several states, people will fly to see you), and you can charge a LOT of money depending on the issues, and not have to deal with insurance. The patient population (pilots) tend to be high-functioning, highly motivated, and have income.

As far as altruism goes, pilots are in need of this sort of care. As much as our industry goes on about the doctor shortage, there is a huge looming pilot shortage. Helping airmen get in the air and stay there (and others in the aviation industry like air traffic controllers, etc) is a big need for society. And AMEs are not only in short supply but the average age is in the 60s and retiring.

Also, only 10% of AMEs are women.

A bit off topic, but possibly the amount of aero-med useful for any MD to be aware of.

In my experience, the excluded categories are showing up in my office.

 

[FlowRate]

I contacted the FAA, not about the above doctor but because I heard forensic evaluators with the right certifications with the FAA can charge a lot of money. After several attempts, calls, e-mails, written letters and no response I gave up. I don't have the FAA certifications but a pilot's license was something I considered getting anyway.

The job is Aviation Medical Examiner. If you're into substance abuse treatment you could become a HIMS AME which is more specifically focused on substance use as well as other mental health issues.

Getting an medical certificate even on a simple SSRI is a bunch of hoops to jump through and additional monitoring. Still probably better focused on FP who do this work since it's not like you're managing MH conditions and any sort of complicated regimen is an automatic DQ.

 

[Mass Effect]

And had I simply been asked to do a psych/SES evaluation that would've been fine with me. The problem was I was asked to write the patient was "psychiatrically clear" with the asking doctor admitting he didn't know what that meant.

Late to the party, but agree there's no "psychiatric clearance". I agree with @splik and a few others though that these are standard for some types of surgery and rather than clearance, you're basically saying there's no psychiatric reason the patient can't have the surgery. I had one of these in residency in a cardiac patient with bipolar disorder and the surgeon called asking for "prognosis". I was surprised to say the least, but my attending trained at Yale where they apparently had cardiac psychiatry (?) and he told me what they were really looking for. He said he did these all the time in residency. We met with the patient and basically made sure he wasn't manic and that he understood the risks as well as the follow-up/care plan then hammered out a short note stating the patient understands the risks as well as the follow-up/care plan and added that he wasn't acutely manic on our exam, didn't require acute psychiatric care, and therefore there's no psychiatric contraindication to having the procedure. It was a ridiculous waste of time. Interestingly, there are psychiatrists out there doing this work full time.

 

[whopper]

I'm sure you know more about this than me but I can imagine SLU being in a really tough place given that Wash U is so nearby and St Louis isn't exactly a trendy place to live with psychiatrists clamoring to move there. It would seem to be all the top talent would get sucked up by Wash U leaving SLU with people wanting to be in an academic institute but not making the cut at Wash U.

I wasn't aware of this clash until I moved to St. Louis. This dynamic is happening. How much? Some doctors offered a job at SLU are offered over a50K more than their starting salary at Wash U and the doc still chooses Wash U. Also I met a psychiatric NP who was a Wash U graduate, was looking for work, and I told her to join SLU and she refused, and someone (not the NP) told me that Wash U people avoid SLU.

I joined SLU over Washington U because SLU has Alan Felthous, one of the top forensic psychiatrists in the country and I had the opportunity to work directly with him but also Henry Nasrallah used to work at U of Cincinnati had just joined SLU and I was so impressed with working with him. That's not sarcasm. He's a gentleman, cares about the field, is a passionate teacher, and is very approachable. He's the type of guy that will try to help you out if you need it, and he was at SLU as their then new chair.

But like I said, when I joined SLU and it wasn't the fault of the doctors I mentioned above, it was recovering from an internal implosion. Further there were significant infrastructure problems with SLU (that were university and hospital-wide, not just a department thing) at least at that time, that were infuriating. E.g. a printer and one out of 3 computers for the doctors in the inpatient unit was broken, and it was never fixed despite dozens of work order requests. Each time you called IT they simply responded to put in another work order. A 2nd year resident told me they were broken long before she was there, and guess what? My last day at SLU they were still broken.

The above was just one issue out of dozens of other problems. I thought to myself stay here, where these computers don't work out of dozens of other problems...
Either that or go to private practice, make 2-3x as much money, work about 70% the amount of hours, and actually restart liking going to work.

I chose the latter.

Shortly afterwards Washington U did offer me an invitation to join but I was just forming my private practice and I knew a few former Washington U doctors who told me I'd encounter similar problems there too. I just stayed in private practice and I've been much happier and wealthier since, but I do miss teaching.

I can't say those same problems are happening at SLU now, and I hope they are fixed. I also know that on my way out another doctor came in who is excellent who was given more control to fix the type of problems that were happening, and that SLU does have some truly exceptional physicians including top people such as George Grossberg who is not only a top geriatric psychiatrist but also a very nice guy and cares about people. But the original point, yes that dynamic is happening, that of people having an idea that Washington U is above SLU in rep and willing to even accept significantly less pay to be part of an institution because of that reputation.

For me the lure of potentially joining Washington U at this point would be mostly because if my kids wanted to go to college there they'd have free tuition and it they applied it may help them to get in. Per year it's over $55K! Aside from myself my wife is in academia and was offered a job there a few months ago but didn't take up the offer.

 

[robellis]

I think you’re taking this thing too seriously and being pedantic. See the guy, write a note that says you did a full psych eval and don’t see any reason why he can’t have surgery from your perspective, and move on...or if you are afraid of the liability simply refer him to someone else that does these evals, very simple

 

[Mad Jack]

I did ask him, "doctor, are you asking me for a capacity evaluation?" He specifically said he doesn't know. He repeated himself and said, "like I said this company that makes this device wants a psychiatrist to clear the patient for surgery and never mentioned anything about capacity."



Cause they aren't treating my specific patient. She'd have to be seen by one of them and I'm admittedly making an assumption here but I get the impression these psychiatrists aren't worth their title if they're willing to sign something where they have no idea nor this surgeon what "psychiatric clearance" exactly means.



As have I and guess what? I've seen no criteria that exactly makes one "cleared" for bariatric surgery. If someone knows what this alleged criteria is please do inform all of us, and inform us as to why there's no published criteria I know of and why this isn't taught in a psychiatry curriculum.

I have actually read a few reports where the mental health professional cleared someone for bariatric surgery and no where in the report did this evaluator state the specific criteria. In short it was the equivalent of an initial interview and the doctor just wrote cleared at the end.

In any forensic psychiatric report I'd put the question, something to the effect of, "As established in X v Y the criteria for Z is defined as...." And then answer, "based on the legal criteria, it is my opinion within reasonable medical certainty that Joe Blow meets the criteria for Z based on the following...." and then show the evidence I gathered during my evaluation.

Where as the bariatric reports I've seen it's basically. "Joe Blow meets criteria." and there's only an initial evaluation written with no legal or professional criteria that was clearly explained nor evidence that justifies the criteria. In short is suggests to me it's just a clinician who either doesn't understand they are answering something they clearly don't know is outside their league, and/or they were more interested in writing a half-assed report for the money.

If someone wants me to write a report with specific criteria for me to answer, yeah sure I'd answer those specific criteria, but saying this person is "cleared for surgery" when there's no criteria given to me as to what makes one cleared? No way.

I mean, in all fairness, I've asked several surgeons to clarify what they were asking for capacity for, exactly, in more normal in-hospital situations and they often can't answer. It's so far outside their area they literally have no idea what they're doing a great deal of the time and kind of rely on us to determine what is reasonable. This is obviously different than that, but it seems they just expect us to be able to divine the appropriate solutions to their requests by nature of our training or something

 

[Sushirolls]

I mean, in all fairness, I've asked several surgeons to clarify what they were asking for capacity for, exactly, in more normal in-hospital situations and they often can't answer. It's so far outside their area they literally have no idea what they're doing a great deal of the time and kind of rely on us to determine what is reasonable. This is obviously different than that, but it seems they just expect us to be able to divine the appropriate solutions to their requests by nature of our training or something

That's because when they did their training, no one put them on the spot to say this is how it is and they need to step up and know what capacity is, or competency, or even how to manage post op delirium. The cycle continues.

So glad I'm not working in a hospital doing C/L work.

 

[Mass Effect]

I mean, in all fairness, I've asked several surgeons to clarify what they were asking for capacity for, exactly, in more normal in-hospital situations and they often can't answer. It's so far outside their area they literally have no idea what they're doing a great deal of the time and kind of rely on us to determine what is reasonable. This is obviously different than that, but it seems they just expect us to be able to divine the appropriate solutions to their requests by nature of our training or something

This is where psychiatry gets the short end of the stick. They would never consult cardiology or neurology or GI and say "I don't know what my question is, but please see the patient and do your thing". It just wouldn't happen. Any other consultant would say call back when you know and hang up the phone.

 

[clausewitz2]

This is where psychiatry gets the short end of the stick. They would never consult cardiology or neurology or GI and say "I don't know what my question is, but please see the patient and do your thing". It just wouldn't happen. Any other consultant would say call back when you know and hang up the phone.

Neurology may be the exception to that. At least when i rotated with the neuro consult service at our institution they got a lot of consults that amounted to 'weird patient, has neurons'

 

[FlowRate]

This is obviously different than that, but it seems they just expect us to be able to divine the appropriate solutions to their requests by nature of our training or something

As I was taught, the first step of any psychiatry consult is clarifying what the actual question is. But that's not in the concrete, playing the "gotcha" game with the consulting doc, way you see out of really burnt out residents. I found it helpful to just treat every unclear consult as "Patient acting funny, don't know what to do." Or often it's "patient and the healthcare team aren't getting along for some reason, please help."

That said, the level of involvement and number of low-effort calls you get is really dependent on institutional culture. There was one hospital where I really didn't mind being on consults because they were usually reasonable situations with reasonable expectations from both the teams and our own leadership. The other hospital was completely different due to the lack of boundary setting by the psychiatry leadership.

I really like dropping this article because it resonated with the latter experience. "The Liaison Psychiatrist as Busybody" (Sorry, can't find free full text.)

 

[hallowmann]

I mean, in all fairness, I've asked several surgeons to clarify what they were asking for capacity for, exactly, in more normal in-hospital situations and they often can't answer. It's so far outside their area they literally have no idea what they're doing a great deal of the time and kind of rely on us to determine what is reasonable. This is obviously different than that, but it seems they just expect us to be able to divine the appropriate solutions to their requests by nature of our training or something

We sometimes have consults that literally just say "help", but its rare enough that when it does happen the order gets printed and posted on the board in the consults workroom.

Like @FlowRate said, the first thing I was taught in C/L was to clarify the question. I don't blame them for not knowing how to manage something they were never taught, but if they come away from the consult thinking they need to contact psych for every patient with a psych diagnosis that needs a procedure, then I didn't do my job well. They are the only ones that can discuss risks and benefits with patients, and they should be used to it. Having a well controlled psychiatric condition doesn't somehow change that. The other thing is that half the time we get consults its for managing the frustration felt by the primary team or nursing staff. Validating their concerns and frustration is half or more than half the battle. Usually they're very appreciate and it works out.

We do have burnt out residents that approach it with that "gotcha" attitude or who try really hard to get out of consults, but I view this like I view getting an admit from the ED. They probably don't know everything they should, but they often know "this patient needs admission" or "this patient needs evaluation". Its probably in the interest of the patient for me to clarify why in the interest of actually helping.

I have a bit less patience for delirium consults, because our director of C/L hammers that stuff down and has had numerous interdisciplinary lectures, meetings, QIs, made smart phrases and protocols, etc. to address this issue. If you are FM/IM and you didn't learn how to identify, evaluate and manage acute delirium, then your training did a disservice. If you are listening to the nurse that says your patient has dementia or schizophrenia because they are hearing voices at night while they're septic and encephalopathic, you need to put your doctor brain back on. You don't need to page Neuro and Psych simultaneously.

Also, since we got on the topic of annoying consults, I will also add the weird case I saw on the chemical dependency service of a hospitalist trying to prescribe a patient with alcohol use disorder in withdrawal IV ethanol for some unclear reason. The floor pharmacists pushed back and so he called us insisting we recommend it. The thing is, the guy was already on symptom-triggered management and had only needed 7 mg of Ativan in the 24 hrs. He also had no history of withdrawal seizures. None of us could understand it. We recommended either continuing symptom-triggered, transitioning to a taper, and/or adding on a gabapentin taper for symptom management. It was weird.

 

[clausewitz2]

We sometimes have consults that literally just say "help", but its rare enough that when it does happen the order gets printed and posted on the board in the consults workroom.

Like @FlowRate said, the first thing I was taught in C/L was to clarify the question. I don't blame them for not knowing how to manage something they were never taught, but if they come away from the consult thinking they need to contact psych for every patient with a psych diagnosis that needs a procedure, then I didn't do my job well. They are the only ones that can discuss risks and benefits with patients, and they should be used to it. Having a well controlled psychiatric condition doesn't somehow change that. The other thing is that half the time we get consults its for managing the frustration felt by the primary team or nursing staff. Validating their concerns and frustration is half or more than half the battle. Usually they're very appreciate and it works out.

We do have burnt out residents that approach it with that "gotcha" attitude or who try really hard to get out of consults, but I view this like I view getting an admit from the ED. They probably don't know everything they should, but they often know "this patient needs admission" or "this patient needs evaluation". Its probably in the interest of the patient for me to clarify why in the interest of actually helping.

I have a bit less patience for delirium consults, because our director of C/L hammers that stuff down and has had numerous interdisciplinary lectures, meetings, QIs, made smart phrases and protocols, etc. to address this issue. If you are FM/IM and you didn't learn how to identify, evaluate and manage acute delirium, then your training did a disservice. If you are listening to the nurse that says your patient has dementia or schizophrenia because they are hearing voices at night while they're septic and encephalopathic, you need to put your doctor brain back on. You don't need to page Neuro and Psych simultaneously.

Also, since we got on the topic of annoying consults, I will also add the weird case I saw on the chemical dependency service of a hospitalist trying to prescribe a patient with alcohol use disorder in withdrawal IV ethanol for some unclear reason. The floor pharmacists pushed back and so he called us insisting we recommend it. The thing is, the guy was already on symptom-triggered management and had only needed 7 mg of Ativan in the 24 hrs. He also had no history of withdrawal seizures. None of us could understand it. We recommended either continuing symptom-triggered, transitioning to a taper, and/or adding on a gabapentin taper for symptom management. It was weird.

There's this weird idea I see advocated for among inpatient medicine/gen surg folks sometimes that we should be prescribing ethanol or even just PRN beer for patients who drink heavily while hospitalized. I've never heard a reasonable explanation for this. Frankly have more patience for the toxicology approach of 'slam them with enough Valium to self-taper, we can always intubate'

 

[Taddy Mason]

There's this weird idea I see advocated for among inpatient medicine/gen surg folks sometimes that we should be prescribing ethanol or even just PRN beer for patients who drink heavily while hospitalized. I've never heard a reasonable explanation for this. Frankly have more patience for the toxicology approach of 'slam them with enough Valium to self-taper, we can always intubate'

I saw this when I worked as a CNA in undergrad, but it was always older attendings who trained in the 60s and 70s and also basically in the the middle of nowhere in a part of the country near the top in terms of alcohol consumption/capita. One of hospitals where I worked kept Stroh’s in the pharmacy specifically for one of the surgeons who was very adamant about this.

 

[FlowRate]

There's this weird idea I see advocated for among inpatient medicine/gen surg folks sometimes that we should be prescribing ethanol or even just PRN beer for patients who drink heavily while hospitalized. I've never heard a reasonable explanation for this. Frankly have more patience for the toxicology approach of 'slam them with enough Valium to self-taper, we can always intubate'

The most justified version of the argument is that the person is going to go back to drinking and you'd rather them not be mixing alcohol and autotapering benzos. I don't find it very compelling, but there is a logic to it.

 

[Crayola227]

Sometimes I feel like a doc wants to do something because "it's a little outside the box and it'll be 'neat'", like anything off the beaten track of seemingly taboo, like "can you believe I just Rx'd this dude beer!!" Or "I wrote an order for ketamine for headache!" Not saying you shouldn't do the latter in some cases, not my point.