Psychiatry Consultation and The John Henry Effect

One of my administrators dropped by my office, notifying me that the psychiatry consultation service is down on Relative Value Units (RVUs) in the last few months and asked what I was doing in August.

I was off service.

Now that doesn’t mean that the service shut down for the month, because I’m one of three doctors who take turns running it. So I told him I was doing what I honestly could regarding Charge Capture on my documentation in our Electronic Health Record, which is Epic. I mean it’s made by Epic, not that I think it’s an epic EHR, in popular slang.

I’m beginning to feel like I understand what the John Henry effect is. More on that later.

Interactions with administration like that sometimes gets me to thinking about my future, especially now that our academic medical center is placing more emphasis on physician billing, hence the focus on RVUs. In all fairness, my administrators work hard on behalf of faculty and I didn’t get the impression I was being put under the microscope.

I’ve also been working on a brief orientation for faculty members who might cover the consultation service but not have much or no experience. Not that my colleagues are busting down the door to cross cover but they have other obligations and may need to trade clinical service coverage for a number of days or weeks.

Dips in the RVU stats could make the consultation service less attractive.

Anyway, putting together a quick and dirty summary of how I run the service got me musing about not only my future, but the future generally of one man hit-and-run psychiatry consultation operations in general hospitals.

So this is what I’ve come up with so far:

Sit down rounds  8-8:30 AM in staff consult office across the hall from my office. The resident prints a list of patients we’ve seen the previous day along with new consults. The resident also checks the voice mail messages from the overnight on-call resident.

After sit-down rounds, we see new consults, usually patients who’ve attempted suicide in the intensive care units (ICUs) which are best to decompress first because of the premium on limited critical care beds. Generally the main customers are those with delirium and suicide aftermath. Volume seems to be growing and while the absolute number per day doesn’t sound like a lot, it’s the level of complexity that counts.

I like the tag team method most of the time unless it gets really busy. That means we’re a movable feast seeing patients as a group, which allows me to watch residents and medical students try their interviewing skills in real time enabling me to provide useful feedback based on direct supervision (I don’t worry about the Hawthorne effect). It sacrifices trainee independence development for efficiency, but if we always used the scout method with the trainee seeing patients first and reporting back to staff, then going back for me to interview the patient, even if my interview is brief we’d be in the hospital until after 7 PM every day. On the other hand, the scout method works best when we’re flooded with a lot of patients in a day or several all at once. I like to divide and conquer then, so that’s when trainees see patients independently and present cases to me. I will see patients on my own as well to share the load.

When I interview patients with residents, I usually do the talking and the resident does the writing and, while I know that sounds like I use them as scribes, they’re also participating in the interview.

Moving patients from the medical units to psychiatry inpatient wards is a cumbersome affair littered with inefficiency because there are many steps, so a lot of places to drop the ball. Generally, for transfers from MICU/general med to the medical-psychiatry unit (MPU), we tell the primary team to call the admission-transfer center (ATC) to get the patient’s name on the wait list and we expect them to call the medical hand-off to the senior medicine resident on the MPU. We handle the legal, getting the voluntary or filing for hold orders and call the psychiatric hand-off to the senior medicine resident–if we know a bed is available which we often don’t. We usually don’t know when a bed opens on the MPU because the ATC doesn’t notify us; often the patients are transferred after 5 PM. Transfers to general psychiatry go through the psychiatry triage pager. They hunt down a bed and call the resident who calls the inpatient psychiatry admission person for one of three adult units and they’re all on separate pagers (which the residents know about).

The consult service goes to Code Greens (management of violent patients) in the ER (despite the presence of ER psychiatry staff) and anywhere in the general hospital, the Centers for Development Disabilities, even outpatient clinics—everywhere but downtown it seems. But we don’t need to go to Code Greens on any of the psychiatry units including the MPU. The frequency with which Code Greens are called varies tremendously but even one or two can put a serious dent in the day if we’re already overrun with consult requests.

We sometimes have to go the outpatient med/family or med/surg clinics to see patients who have mentioned that they’re thinking about suicide. Like Code Greens, this can cramp us but sometimes clinic staff are understandably too nervous to have suicidal patients escorted by security to the ER where they can be seen by the ER psychiatry staff. The other reason for doing this is that, because we’re a large academic medical center, we have this hyperspecialized interdependency which includes many physicians who have had virtually no experience talking to patients with psychiatric illness.

We’re expected to manage outside crisis calls from suicidal patients. These come through the hospital operator and the faculty can end up taking them if the rotating Family Medicine resident is carrying the resident consult pager because that’s the one the UIHC operator calls. I don’t expect Family Medicine residents to handle suicide crisis calls so I take them.

Consult faculty (with or without a resident) end up seeing the ER boarding patients waiting for a psychiatric bed to open up somewhere in the state when our units are full (which is common) on weekends and holidays as of the fall of 2014 and if you’re not on duty, you don’t have to worry about this.

Think of us as a fire brigade, called to put out fires all over the hospital.

Nigella fire trucks and Dr. Jim Amos

 

So as I pointed out above, I don’t worry about the Hawthorne effect. As you can see, the consultation service faculty works pretty hard, not that everyone else doesn’t, but it can be pretty hectic because it’s not really governed by a schedule. You go where and when the fire alarm blows.

I don’t really have time to worry about RVUs either. On the other hand, there is also such a thing as the John Henry effect. In fact, the traditional model, which is what our psychiatry consultation service is based on, is considered behind the times. in other words I’m swinging a hammer. The Academy of Psychosomatic Medicine nowadays favors the integrated model (along with recommendations for how managed care should cover it) rather than the traditional model–and it’s definitely more of a steam drill than one man with a hammer.

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Just as an aside, it’s not true that there’s no educational component on my traditional consult service. Just type “CPCP” in the search box on this blog site and see for yourselves. I do what I can about the other listed problems with a non-integrated service. So the John Henry effect may fit in my case because I’m aware of the integrated model and I work very hard to compete with it in my traditional model. There’s an important difference. You can hear my hammer sucking wind not so much because I believe I’m better than the steam drill–but because all I have is a hammer.

 

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