In the last couple of days while I’ve been trying to update the broken links on my blog, I’ve been thinking about what my “typical day in the life” is like as a consultation-liaison (C-L) psychiatrist. I’m taking a break from the broken links to outline my typical day on the job. I can reflect on it more because I’m in phased retirement and actually spend less time working. Times are approximate and won’t account for every minute.
I have a light breakfast and check the consultation list from home using remote access. This gives me a sense of where to prioritize my time, usually the critical care units. The number of consultation requests and what my consultees may be expecting from me is important to know ahead of time. I have access to the electronic health record (EHR) folder listing the new consultation requests. It sometimes makes me look clairvoyant to the trainees.
I check to see if there are any open beds on our general psychiatric units and the medical-psychiatry unit. Most of the time there are none. I note the yellow warning messages about the emergency department (ED) and general hospital beds being full and the need to safely expedite discharges. I resist the development of alarm fatigue.
I look over EKG results to see who already has a prolonged QTc interval, which will influence a decision to use antipsychotics for agitation. I check the lab values to see who might need transfer to the medical-psychiatry unit. I look over any consultation notes left by the residents who were on call overnight and which I will need to edit, make comments, and co-sign after I’ve interviewed the patients.
I look at the Medication Administration Record to see what medications the patients are actually getting, and compare it to the Pharmacy Medication History note, which lists what the patients are prescribed.
I check the demographics information about any family contacts (Legal Next of Kin) of the patients. I also check our scanned media file for records documenting guardianship or Durable Power of Attorney for Health Care Decisions. That’s where I can find other legal paperwork including mental health commitment papers which alert me to involuntary treatment status.
I check PubMed for any pertinent articles which would guide my recommendations about complicated medical and psychiatric issues. I make a mental note of anything that might be a good topic for a Clinical Problems in Consultation Psychiatry (CPCP) practice-based learning opportunity. It’s getting harder to find time for them as the service has gotten steadily busier over the years. I’m ambivalent about using a PubMed app for my smartphone. The abstracts are hard to read on such a small screen. On the other hand, I think it’s important to ask focused questions when consulting the evidence based medical literature.
I look for Social Work notes which are often the most helpful source of background information about the patients I’ll be seeing during the day.
I look over my consultee’s History and Physical and Progress Notes. I take a quick look at the Physical and Occupational Therapy Notes. I look for Neuropsychology testing results.
I round with the trainees, often a couple of residents and a couple of medical students. We discuss the patients we need to see in enough detail to work out who we need to see right away and anticipate who might need to be transferred to a secure psychiatric unit.
I go over some of what I usually do to assess delirium, suicide risk assessment, and decisional capacity assessments–but this often gets interrupted by calls for new consultations or Code Greens. A Code Green in the general hospital or med-surg clinic, or the ED is a crisis involving a patient who is potentially or actively violent and needs immediate attention from a dedicated pit crew of nurses, the C-L Psychiatrist, and others in order to manage the issue as safely as possible.
I can usually manage to give quick instructions about the Mini-Cog for evaluation of delirium, the suicide safety plan, and the bare bones of the 4 Abilities Model of decisional capacity assessment before we get called to put out a fire somewhere in the hospital. I also mention how frequently I find patients who are demoralized from their medical problems. They are the ones who nod vigorously in agreement when I ask they if they are “sick and tired of being sick and tired.” I have a few handouts some of which can be used as assessment tools.
We decide whether the number of consult requests for the morning allow us to visit the patients as a group (which I prefer) or if we need to divide and conquer. It isn’t the raw number of consultations that dictates the approach–it’s the level of difficulty.
The pager goes off, sometimes incessantly as we rush around the hospital, usually without using the elevator. That’s just an idiosyncrasy of mine and I don’t insist everyone take the stairs just because I do. It’s the only exercise I get anymore and that’s my justification.
I bring my chair with me and the patients get a big kick out of this. It was a gift to me from Dr. Tim Thomsen, who spent a lot of his own money on buying a few for his Palliative Care service. I will always be grateful for his generosity.
We get about 15-20 minutes with each patient but there’s wide variability in how much time we spend with them. Our interviews are often interrupted with pages to go hither and yon. That’s what it’s like to be a smoke jumper on a one man hit-and-run C-L Psychiatry service.
Time to grab a working lunch and I usually take the resident’s pager at least 3 days of the week so they can attend lectures and Grand Rounds. I confess I usually don’t have time to go to Grand Rounds and I tell the residents who ask me if I’m going, “Somebody’s gotta mind the shop.” I would just get paged out anyway on most days. During this time or shortly before, I complete any legal paperwork and run errands to the business office for processing them. This has to be done before the day gets too far gone because the county courthouse closes early most days anymore.
12 Noon-5:00 PM
This can be the busiest time and we can be paged right up until just before 5 PM. Usually, there’s a late page around 4 PM or a little later. This not uncommonly is a urgent call and may entail getting an Emergency Hold order which we can’t get until after 5:00 PM because the courthouse closes by 3:00 PM.
There is no schedule per se. The pages are unpredictable. It’s almost impossible to plan for any other activity, which is why I appreciate the supplementary C-L Psychiatry lectures made by the Academy of C-L Psychiatry (ACLP). I’m not sure how often the residents view these outstanding powerpoint presentations, mostly because I’m always on the move. I check my pedometer, which usually looks like the one below.
At the end of each day, I practice mindfulness meditation, something I’ve been doing since the summer of 2014. That’s a quick and dirty example of a day in the life of a C-L Psychiatrist, at least for me. It doesn’t include everything I do, but it’s a pretty fair idea.