A problem with employed jobs

[nexus73]

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[AD04]

I don't know why you deleted it. But the main question is do you have any leverage? Is the psychiatric department profitable? Will the hospital be harmed if the psychiatric department was closed? I don't think your request is out of line. Frankly, if my pay is capped, my work is also capped. I don't do free work.

P.S. Why do you even stay?

 

[randomdoc1]

We're valuable in the community and deserve to be paid our worth. Simple as that. Didn't even get to see what you posted lol.

 

[MedMan80]

Our hospital values us, partly because we're an essential service and employed docs are hard to come by. I'm sure they are paying locums atleast double of what we get, better to keep us happy rather than have to rely more on locum coverage.

 

[deleted1100659]

my job started to suck so I jumped ship. It looks like a better job, of course I cant predict the future, but at least worst case scenario ill be in a significantly nicer city. With crappy jobs, if you stay its unlikely to get less crappy, so its worth it just to try a different one that you may end up liking a lot more.

 

[randomdoc1]

my job started to suck so I jumped ship. It looks like a better job, of course I cant predict the future, but at least worst case scenario ill be in a significantly nicer city. With crappy jobs, if you stay its unlikely to get less crappy, so its worth it just to try a different one that you may end up liking a lot more.

kind of reminds me of dating...

 

[deleted1100659]

kind of reminds me of dating...

story of my divorce, lol

 

[Merovinge]

Human's are so bad cutting ties with bad situations, it's far from a problem unique to medicine, although it seems people in the corporate world feel increasingly enabled to shift jobs for higher pay/better positions. Steve Levitt (Economist from University of Chicago) has done some nice work in this domain for anyone interested in further reading on our inability to fully process sunk costs and a different perspective than psychology has had on it.

 

[nexus73]

I was basically just saying that when employed there's little incentive to go above and beyond, unless this is some internal motivator for you. You get paid to provide care for patients, you do good work, you're collegial etc. But doing extra work for free doesn't make rational sense. When the hospital is having a rough time, and is short on funds due to travel nurse costs and elective procedures not ramping up, and the hospital is over capacity, and they want psych to be available earlier or later than is reasonable to see consults to get them out or go to the ED at 7am, or stay until 7pm in case someone comes in, all while trying to get transfers in from other hospitals to keep the psych unit census up, and we won't pay you extra for the extra work...it just baffles me why administrators are shocked when docs push back against this.

 

[randomdoc1]

I was basically just saying that when employed there's little incentive to go above and beyond, unless this is some internal motivator for you. You get paid to provide care for patients, you do good work, you're collegial etc. But doing extra work for free doesn't make rational sense. When the hospital is having a rough time, and is short on funds due to travel nurse costs and elective procedures not ramping up, and the hospital is over capacity, and they want psych to be available earlier or later than is reasonable to see consults to get them out or go to the ED at 7am, or stay until 7pm in case someone comes in, all while trying to get transfers in from other hospitals to keep the psych unit census up, and we won't pay you extra for the extra work...it just baffles me why administrators are shocked when docs push back against this.

As an employer I'm puzzled at this too. Employee retention IS the employer's job and a trajectory like that won't exactly win people over. I understand there's limitations of what employers can do also, but it looks like many could be putting in more effort. Not to mention, the people who do stay and tolerate these terrible conditions, you're selecting for lower tier providers. The really good ones you gotta work for a little but it has great potential to be a symbiotic relationship for all parties.

 

[FlowRate]

I was basically just saying that when employed there's little incentive to go above and beyond, unless this is some internal motivator for you. You get paid to provide care for patients, you do good work, you're collegial etc. But doing extra work for free doesn't make rational sense. When the hospital is having a rough time, and is short on funds due to travel nurse costs and elective procedures not ramping up, and the hospital is over capacity, and they want psych to be available earlier or later than is reasonable to see consults to get them out or go to the ED at 7am, or stay until 7pm in case someone comes in, all while trying to get transfers in from other hospitals to keep the psych unit census up, and we won't pay you extra for the extra work...it just baffles me why administrators are shocked when docs push back against this.

It's just "bad" management. Maybe "good" if focused solely on short-term superficial fixes. But bad for retention. If they're asking you to do extra work then it's fair to ask for incentive pay in return.

 

[Stagg737]

It's just "bad" management. Maybe "good" if focused solely on short-term superficial fixes. But bad for retention. If they're asking you to do extra work then it's fair to ask for incentive pay in return.

Agree with this 100%. When COVID first hit a lot of people took pay cuts or had to pick up slack elsewhere, but for most this was a temporary situation which I don't think is unreasonable given that situation. Short of short-term emergencies, I wouldn't want to be somewhere that this was the norm. It's completely appropriate to ask for extra compensation or incentive pay for increased workload. I personally wouldn't consider a FTE position that is flat pay without any form of incentive unless duties outline were very specific.

 

[Candidate2017]

I was basically just saying that when employed there's little incentive to go above and beyond, unless this is some internal motivator for you. You get paid to provide care for patients, you do good work, you're collegial etc. But doing extra work for free doesn't make rational sense.

Existentially, I'm beginning to feel that knowing I did an excellent job doesn't psychically or financially sustain me any better than meeting the community standard of care. I wonder if it makes sense to practice "good" psychiatry while others who adhere to the de facto community standard of care (seeing 30-40 inpatients a day, having a majority of outpatiens on benzos and/or stims) are doing more than fine. This is especially true when I've seen good, expert psychiatrists get sued for random reasons while lesser psychiatrists continue on their blissful journey.

 

[Merovinge]

Existentially, I'm beginning to feel that knowing I did an excellent job doesn't psychically or financially sustain me any better than meeting the community standard of care. I wonder if it makes sense to practice "good" psychiatry while others who adhere to the de facto community standard of care (seeing 30-40 inpatients a day, having a majority of outpatiens on benzos and/or stims) are doing more than fine. This is especially true when I've seen good, expert psychiatrists get sued for random reasons while lesser psychiatrists continue on their blissful journey.

One cannot fall into outcome based thinking in these scenarios. The question that should help you sleep at night is did you do the best you could for your patient given the system/environment you practice in. Yes, bad doctors can keep practicing and stay at nicer resorts and yes, great doctors get sued for trivial reasons (although I imagine they win the overwhelming majority of these lawsuits, it still is a horrendous experience to be sure). You ideally got into medicine agreeing to take care of patients to the best of your ability, there was a lot of other forks in the path if you just wanted to print money at the expense of human lives.

The only thing we can control in this world is our own actions, not the results of them. I live a much happier life doing the best I can for others even when it means making a few less dollars along the way (and I am very fiscally oriented individual since my childhood years).

 

[randomdoc1]

Existentially, I'm beginning to feel that knowing I did an excellent job doesn't psychically or financially sustain me any better than meeting the community standard of care. I wonder if it makes sense to practice "good" psychiatry while others who adhere to the de facto community standard of care (seeing 30-40 inpatients a day, having a majority of outpatiens on benzos and/or stims) are doing more than fine. This is especially true when I've seen good, expert psychiatrists get sued for random reasons while lesser psychiatrists continue on their blissful journey.

Along these lines as well, there is a silent large following for evidence based care. We bear more healthy influence than we give ourselves credit for. Yes, initially in practice, before your name/brand gets established, it sounds like people expect you to be their legalized drug dealer and that's what the community bases your worth on. But in my experience, as you continue to practice evidenced based care which results in good outcomes (how earth shattering right?), your patient population matures/develops and that becomes your brand. I discovered many patients and prospectives are impressed by a clinic's evidence based and controlled substance "minimalist" approach. It has this odd ring similar to going organic, vegetarian, etc. And we attract a good chunk of the earthy types too lol. Anyways, it can stick out in sort of a healthy way amidst all the standard pill mills which many patients have shared is a turn off and rightfully so. Some who are on a ton of scheduled meds have even begged for a consultation and it was quite an experience to see a patient with severe borderline personality disorder on both a benzo and a stim, arriving with her mother for a consult as they listen eagerly to you describe your working diagnoses and full heartedly agree that they did not find the benzo helpful and if anything harmful due to the dependence while cycling in and out of withdrawal. Then they follow through on their taper and enroll in a DBT program. These patients are out there <3.

The ones who want to dole out money to the pill mills, well, it's their life and we're the ones ready to work with those who truly want to get better. Often times, a portion of the former eventually realizes they are getting nowhere fast and convert too. All in the stages of change, nothing we can do if someone isn't interested in even considering change.

 

[smalltownpsych]

Inpatient hospital stays and psychiatrists are expensive. Insurance companies don’t want to pay for it and the administrators pass the pressure on to us. Exceptional administrators help us by being a buffer or advocate, the typical administrators throw us under the bus continually and then eventually close down the unit.

 

[Sushirolls]

Big Box shops should have a high priority for the human capital. To work towards retention and quality recruitment.

However this isn't the case, admin turns over and jobs hops as is the nature of their careers to ever climb to the higher fruits.

And lastly, the production mill of midlevels has changed the calculous. Quality, experience, training, etc doesn't matter. Do you have a functioning license? And knowing the market is ever increasing (my local area saturated and saturated with ARNPs), they have less incentive to value the human capital because there is another pliable "yes (wo)man" to step up and replace you or the other ARNP.

Big Box shop policies become more protectionist, in their favor 100% and designed to send you down river when things go bad. Because after you get chewed up, there is another ARNP to fill the empty spot.

This is the future. Hence, greater odds of valuing yourself, you have to value yourself, and you have to open your private practice - or be willing to walk from any Big Box shop job the second they scat on you.

 

[randomdoc1]

Big Box shops should have a high priority for the human capital. To work towards retention and quality recruitment.

However this isn't the case, admin turns over and jobs hops as is the nature of their careers to ever climb to the higher fruits.

And lastly, the production mill of midlevels has changed the calculous. Quality, experience, training, etc doesn't matter. Do you have a functioning license? And knowing the market is ever increasing (my local area saturated and saturated with ARNPs), they have less incentive to value the human capital because there is another pliable "yes (wo)man" to step up and replace you or the other ARNP.

Big Box shop policies become more protectionist, in their favor 100% and designed to send you down river when things go bad. Because after you get chewed up, there is another ARNP to fill the empty spot.

This is the future. Hence, greater odds of valuing yourself, you have to value yourself, and you have to open your private practice - or be willing to walk from any Big Box shop job the second they scat on you.

Yes, independent physicians team up! I've been networking with a group of independently practicing physicians in primary care and I think it would be cool for that network to grow and we foster this niche in medicine. We deserve our autonomy back (and the pay we deserve) and it's good to be away from the politics, noise, fights over money, etc. In PP it is totally feasible to make even more than big box and without all the crap that comes with it. Why? Because we control the overhead and big entities have way too many middle men who don't do sh_t other than be parasites on our earnings. Sorry, kind of a raw reaction, but...imho it's truth.

 

[SmallBird]

Big Box shops should have a high priority for the human capital. To work towards retention and quality recruitment.

However this isn't the case, admin turns over and jobs hops as is the nature of their careers to ever climb to the higher fruits.

And lastly, the production mill of midlevels has changed the calculous. Quality, experience, training, etc doesn't matter. Do you have a functioning license? And knowing the market is ever increasing (my local area saturated and saturated with ARNPs), they have less incentive to value the human capital because there is another pliable "yes (wo)man" to step up and replace you or the other ARNP.

Big Box shop policies become more protectionist, in their favor 100% and designed to send you down river when things go bad. Because after you get chewed up, there is another ARNP to fill the empty spot.

This is the future. Hence, greater odds of valuing yourself, you have to value yourself, and you have to open your private practice - or be willing to walk from any Big Box shop job the second they scat on you.

I just don't think that's how it is. I have been an administrator. I have been at those meetings where we decide how to staff units, how to set expectations, how we will ensure quality. 90% of the energy is directed at figuring out how to work with providers who are digging-in-there heels on not wanting to make slight changes towards being more evidence based, or being open to even the most meager participation in QI, or write discharge summaries within the time requirements. People come in at 8am, leave by 2pm, and make over $350k a year. I think everyone needs to chill TF out about how horrible everything is. And then a ton of energy was spent trying to find ways to offer raises and ensure vacation requests could be covered. This is an N = 1 but it is at a very boxy big box shop and I can't believe we are the only ones where the leaders aren't at least somewhat focused on quality of care.

 

[Sushirolls]

I've been in Admin. I've sat on QI committees too.
I've seen multiple Big Box shops and flavors of them.
Can quality still exist perhaps as you described? Yes. But I'd venture to say, your experience is the exception and those pockets are declining every day as the slow steady march towards their final maturation stage progresses.


Today's anecdotes:
I recently had the experience to socialize with various docs at former Big Box shop I worked at after long time. Things are worse. An IM and FM, more recently jumped shipped. Another specialist who started there knows they are bad, doesn't care, plays the wRVU game, and basically states if schedule isn't full I'm not working that day. They tolerate this behavior because they show their true colors - they only care about the wRVUs. This doc produces, but on this doc's terms, so they grumpy go along with it. Another specialist at another hospital Big Box shop in town was over worked, forced to supervise ARNP, and not paid accordingly. Plus, the rapid societal decline of blue state crime waves directly impacted this person - more than once - so is now moving after being on the receiving end of blue state policy induced crime.

Personal anecdote:
I've been a "never again" person for returning to an employed job but I may actually be considering it. Still in process of locking in a large tract of land in deep red state to pursue transition out of medicine into ranching/farming. The job will be a clock in clock out mentality as means to fund my exit.

 

[nexus73]

I just don't think that's how it is. I have been an administrator. I have been at those meetings where we decide how to staff units, how to set expectations, how we will ensure quality. 90% of the energy is directed at figuring out how to work with providers who are digging-in-there heels on not wanting to make slight changes towards being more evidence based, or being open to even the most meager participation in QI, or write discharge summaries within the time requirements. People come in at 8am, leave by 2pm, and make over $350k a year. I think everyone needs to chill TF out about how horrible everything is. And then a ton of energy was spent trying to find ways to offer raises and ensure vacation requests could be covered. This is an N = 1 but it is at a very boxy big box shop and I can't believe we are the only ones where the leaders aren't at least somewhat focused on quality of care.

I agree this is the inpatient setup that works just fine. Admin at our hospital is not ok with things working fine.

Why don't you come in earlier? Why don't you stay later. The hospitalist wanted a consult because this guy was bummed out waiting for SNF why didn't you take 30-40 minutes to do a consult...(after all the hospitalists help psych out when someone has a rash, they'll come for 3 minutes and prescribe something). These ED patients are backing up, why don't you admit them you have 4 open beds on the unit, nevermind they're low acuity beds and the 4 ED patients are psychotic and attacking nurses, why don't you let them attack your nurses plus attack the depressed guy who will be their roommate. We don't understand you're world. No, we can't come to your treatment team and see how you handle the psych patient flow, we just know you're not doing a good job. The ICU admits people to medical beds, they move in ventilators and IV pumps, and we get low RN ratios, why can't psych admit psychotic or actively suicidal people to a medical bed? No we don't have 1:1 sitters it's not in the budget. Someone is boarding in the ED and it's 6:45 PM, why isn't someone from psych in house? Who is on call? No the ED doctors aren't comfortable restarting the patient's home dose of Prozac 20 mg. The ICU doctors round on 20 patients a day (and are done at noon), why can't psych see 20 patients per day? I don't understand why talking to patients takes so long, ICU is way more complex than psych and they see way more patients, what you're telling me is not what I want to hear so next month at this same meeting I'm going to bring up the same exact issue yet again.

This is the garbage I'm dealing with weekly/monthly. For an extra $84K as medical director.

 

[Merovinge]

I agree this is the inpatient setup that works just fine. Admin at our hospital is not ok with things working fine.

Why don't you come in earlier? Why don't you stay later. The hospitalist wanted a consult because this guy was bummed out waiting for SNF why didn't you take 30-40 minutes to do a consult...(after all the hospitalists help psych out when someone has a rash, they'll come for 3 minutes and prescribe something). These ED patients are backing up, why don't you admit them you have 4 open beds on the unit, nevermind they're low acuity beds and the 4 ED patients are psychotic and attacking nurses, why don't you let them attack your nurses plus attack the depressed guy who will be their roommate. We don't understand you're world. No, we can't come to your treatment team and see how you handle the psych patient flow, we just know you're not doing a good job. The ICU admits people to medical beds, they move in ventilators and IV pumps, and we get low RN ratios, why can't psych admit psychotic or actively suicidal people to a medical bed? No we don't have 1:1 sitters it's not in the budget. Someone is boarding in the ED and it's 6:45 PM, why isn't someone from psych in house? Who is on call? No the ED doctors aren't comfortable restarting the patient's home dose of Prozac 20 mg. The ICU doctors round on 20 patients a day (and are done at noon), why can't psych see 20 patients per day? I don't understand why talking to patients takes so long, ICU is way more complex than psych and they see way more patients, what you're telling me is not what I want to hear so next month at this same meeting I'm going to bring up the same exact issue yet again.

This is the garbage I'm dealing with weekly/monthly. For an extra $84K as medical director.

Hahaha, so many similar experiences working for a hospital system. Hilarious listening to bureaucrats and clueless to pernicious doctors of other specialties make terrible comparisons with no understanding of the actual treatment of psychiatric patients. There is no amount of money you could pay me to do that type of work again.

 

[SmallBird]

I guess I agree that lots of things are sh#t at lots of places, and that some things are sh#t at all places. But I don't buy into the idea that there is some type of irresistible structural force that is going to inevitably drive everything to the bottom. There are systems with administrators who have an interest in the value we add and want to structure services in high quality ways. There are systems with administrators who are uninformed but willing to listen. And then, there are, no doubt, places where things suck, but frequently everyone aside from the medical director may experience only small annoyances and continue to make a lot of money for a reasonable amount of work. The last category of places that are badly run and also pay badly for lots of work is, in my view, not the the majority.

You point out another problem which we have to own which is that there are also a lot of doctors who do nothing to add value, are resistant to any type of engagement or work that doesn't add to their billing, and are likely a major factor in driving hospitals to want to exert more role over our functions.

I did not enjoy being a medical director all the time and I agree it was stressful. But when I applied my knowledge to improving things that represented an alignment between best practice, quality metrics, and fiscal responsibility I got zero push back from administration and did not get told to see more patients or stay later or be more responsive to the hospital. But when I got asked those questions I made sure to respond in good faith and robustly.

 

[Candidate2017]

You point out another problem which we have to own which is that there are also a lot of doctors who do nothing to add value, are resistant to any type of engagement or work that doesn't add to their billing, and are likely a major factor in driving hospitals to want to exert more role over our functions.

First, we add plenty of value. So much value that hospitals often take a cut of our billings. Like our pimp. I tried to flip the script once and asked for a percentage of their facility fees.

Second, yes we are resistant to work that doesn't add to our billing/income. We are committed to keeping slavery abolished.

People come in at 8am, leave by 2pm, and make over $350k a year. I think everyone needs to chill TF out about how hrrible everything is.

Leaving at 2 pm doesn't mean we aren't working. There are notes to finish, pages to answer, paperwork, naps to make up for 3 am pages from last night and tonight...

 

[Trismegistus4]

Leaving at 2 pm doesn't mean we aren't working. There are notes to finish, pages to answer, paperwork, naps to make up for 3 am pages from last night and tonight...

Ordinarily I'd agree with you, but where I work now, some of my "colleagues" are getting away with murder. There's one guy who rounds on his 10-12 patients in about 1 hour, then drops a 35-minute time statement plus a psychotherapy add-on statement into each note and bills a 99233 + 90833 on everyone, copies-forward every note and doesn't change anything except to hit refresh so the med list updates (so the subjective section contains the same "I assumed care of the patient today, I discussed such-and-such with the patient" statement it did 5 days ago,) then high-tails it out of there by noon. And if someone asks him to do something that would keep him there later, he gets an attitude, like he's too important for that. Others, I rarely see around, and I don't really know when they see their patients.

I don't want to be forced to stay until 5, let alone 7, but there's a balance somewhere. One of the reasons I'm wary of leaving my current job is that I fear any other job will involve either seeing more patients (and having to stay longer) for the same amount of money, or seeing the same number of patients (and having the same flexibility with my time) but making less money. How do you tease this out when looking at jobs? I have a feeling hospitals wouldn't want to answer honestly when asked about a typical schedule, or it would reflect badly on me for asking, since as @nexus73 recently said in another thread, our admins sometimes bring up this idea that technically they're paying us for 12-hour days.

 

[nexus73]

Ordinarily I'd agree with you, but where I work now, some of my "colleagues" are getting away with murder. There's one guy who rounds on his 10-12 patients in about 1 hour, then drops a 35-minute time statement plus a psychotherapy add-on statement into each note and bills a 99233 + 90833 on everyone, copies-forward every note and doesn't change anything except to hit refresh so the med list updates (so the subjective section contains the same "I assumed care of the patient today, I discussed such-and-such with the patient" statement it did 5 days ago, then high-tails it out of there by noon. And if someone asks him to do something that would keep him there later, he gets an attitude, like he's too important for that. Others, I rarely see around, and I don't really know when they see their patients.

I don't want to be forced to stay until 5, let alone 7, but there's a balance somewhere. One of the reasons I'm wary of leaving my current job is that I fear any other job will involve either seeing more patients (and having to stay longer) for the same amount of money, or seeing the same number of patients (and having the same flexibility with my time) but making less money. How do you tease this out when looking at jobs? I have a feeling hospitals wouldn't want to answer honestly when asked about a typical schedule, or it would reflect badly on me for asking, since as @nexus73 recently said in another thread, our admins sometimes bring up this idea that technically they're paying us for 12-hour days.

Billing fraud sounds, bad, like it's not just an oopsie. They don't just make you take a coding remediation class after months/years of this.

If you want to know the real hours per day and real salary, ask the doctors when you do the preliminary phone calls. My general sense is they're more than happy to tell you the truth. If the are hesitant and say you have to discuss with HR it usually means the hours per day and pay is average at best.

 

[painballer27]

Ordinarily I'd agree with you, but where I work now, some of my "colleagues" are getting away with murder. There's one guy who rounds on his 10-12 patients in about 1 hour, then drops a 35-minute time statement plus a psychotherapy add-on statement into each note and bills a 99233 + 90833 on everyone, copies-forward every note and doesn't change anything except to hit refresh so the med list updates (so the subjective section contains the same "I assumed care of the patient today, I discussed such-and-such with the patient" statement it did 5 days ago, then high-tails it out of there by noon. And if someone asks him to do something that would keep him there later, he gets an attitude, like he's too important for that. Others, I rarely see around, and I don't really know when they see their patients.

I don't want to be forced to stay until 5, let alone 7, but there's a balance somewhere. One of the reasons I'm wary of leaving my current job is that I fear any other job will involve either seeing more patients (and having to stay longer) for the same amount of money, or seeing the same number of patients (and having the same flexibility with my time) but making less money. How do you tease this out when looking at jobs? I have a feeling hospitals wouldn't want to answer honestly when asked about a typical schedule, or it would reflect badly on me for asking, since as @nexus73 recently said in another thread, our admins sometimes bring up this idea that technically they're paying us for 12-hour days.

Where is this? How much is your colleague making per annum?

 

[smalltownpsych]

A system that sees their job to make sure docs do a good job will tend to attract docs that won’t do a good job thus reinforcing that the system does need to crack down on those damn docs doing crummy work leading to good docs leaving because they hate being micromanaged and treated with that type of negative expectation. Kind of a vicious cycle. What is even worse is that the political system and insurance companies are all doing this too.

Also, there is no requirement for additional documentation that will ever ensure that I am actually helping my patients. Mainly because if I wasn‘t any good at my job, then I would have to put my energy into good documentation so that people wouldn’t find it out.

 

[Trismegistus4]

Where is this? How much is your colleague making per annum?

I don't want to reveal too much lest I be identified. But the crazy thing is, we are on straight salary. There is no RVU bonus or any other productivity-based measure, so he doesn't even personally benefit from doing this.

 

[painballer27]

I don't want to reveal too much lest I be identified. But the crazy thing is, we are on straight salary. There is no RVU bonus or any other productivity-based measure, so he doesn't even personally benefit from doing this.

I see. I guess he's benefitting in the form of extra time to go and run an afternoon clinic/work another job if they wanted. I don't understand the 90833 add on though if that's the case unless someone is telling him to do it

 

[randomdoc1]

I see. I guess he's benefitting in the form of extra time to go and run an afternoon clinic/work another job if they wanted. I don't understand the 90833 add on though if that's the case unless someone is telling him to do it

The VA tells you to do it. They do keep tabs on your RVUs and try to emphasize to bill 99214 as well if you can. I had a colleague who had a high no show rate and they just put in him the Dom to up his productivity. Which I can see both sides, if you're seeing few patients and making full salary, it's hard for a place to financially sustain that.

 

[Candidate2017]

I don't want to be forced to stay until 5, let alone 7, but there's a balance somewhere. One of the reasons I'm wary of leaving my current job is that I fear any other job will involve either seeing more patients (and having to stay longer) for the same amount of money, or seeing the same number of patients (and having the same flexibility with my time) but making less money. How do you tease this out when looking at jobs? I have a feeling hospitals wouldn't want to answer honestly when asked about a typical schedule, or it would reflect badly on me for asking,

As psychiatrists, our job is to ask pointed and personal questions of strangers (Do you have thoughts of killing yourself? Were you sexually abused as a child? Tell me about your father?). But yet, most psychiatrists seem to have problems posing straightforward questions to employers.

I treat employer interviews like a one hour new consult. I have a 50 point checklist of questions, some of which include income, hours. Most of my questions focus on patient safety, adequate staffing, patient population, administrative procedures. It's easy to come up with your own template to interview employers. Think about your past experience and problematic issues that pop up during your daily work. Perhaps it's terrible EMR, lack of security, lack of social workers, pressure to admit everyone or treat teens, heavy call schedule, etc.

If an employer cannot tolerate a thoughtful discussion, then we need not go further. Unfortunately, my A&P usually ends up as: this position sucks, doesn't pay enough, will keep looking, should start a practice.

 

[deleted456421]

As psychiatrists, our job is to ask pointed and personal questions of strangers (Do you have thoughts of killing yourself? Were you sexually abused as a child? Tell me about your father?). But yet, most psychiatrists seem to have problems posing straightforward questions to employers.

I treat employer interviews like a one hour new consult. I have a 50 point checklist of questions, some of which include income, hours. Most of my questions focus on patient safety, adequate staffing, patient population, administrative procedures. It's easy to come up with your own template to interview employers. Think about your past experience and problematic issues that pop up during your daily work. Perhaps it's terrible EMR, lack of security, lack of social workers, pressure to admit everyone or treat teens, heavy call schedule, etc.

If an employer cannot tolerate a thoughtful discussion, then we need not go further. Unfortunately, my A&P usually ends up as: this position sucks, doesn't pay enough, will keep looking, should start a practice.

Would love to see your checklist. Mine goes like this:
1. Is the position salaried or production-based?
2. What is the average census (if inpatient, number of beds and daily admissions, if outpatient, total panel size and maximum frequency of appointment availability)?
3. If outpatient, what is your no-show rate?
4. If inpatient, what is your restraint rate?
5. What EMR do you use? Been burned by several crappy ones. Epic and CPRS are decent.
6. How much midlevel supervision do you require?
7. What teaching opportunities for medical students are available? Do you allow me to decline teaching midlevels?
8. What is your salary or RVU rate?
9. What control do I have over new referrals (outpatient) or admissions (inpatient)?
10. What is staffing like (if inpatient, how many nurses and mental health techs, if outpatient, do I need to do vitals, call pharmacies, or make VNA referrals)?
11. If outpatient, will I be expected to manage IOP patients? If so, have you dedicated weekly appointments? Been burned by this when I took on IOP clients who clearly needed weekly follow-up but I only had monthly availability.
12. If outpatient, who completes disability and conservatorship paperwork? If myself, do you give me dedicated time? Some SWs will prep these documents.
13. Am I expected to present or attend conferences about patients at a state-level? I literally hate having to justify my plan to a committee of people with no insight about the patients I treat. Even worse, having to characterize patients I've never met or only met briefly.
14. If outpatient, how much time do I get for new patient slots and follow-ups?
15. How much time do I get for administrative tasks? This varies in importance based on EMR quality.
16. What do you expect regarding cross-coverage? What does your cross-coverage system look like? Am I on call or, per my last job, is everyone expected to pitch in to triage patients and provide refills for vacationing "providers?"
17. What benefits do you offer? 401k, loan repayment, health/dental/vision insurance, paid time off (if salaried), maternity/paternity benefits, gym memberships, financial advisors, etc.?
18. Is there a non-compete? If so, how restrictive is it? This should be closer to the top.
19. Can I moonlight or have a private practice? Surprisingly, many (edit: at least one) state allows companies to prevent such arrangements.
20. What are the consequences for leaving? Is employment at-will or "at-will?" Some states allow you to leave without any notice for any reason whatsoever while others are "at-will" but allow punishment for breaking contracts.

I'm sure I'll think of others and will edit accordingly.

 

[hallowmann]

I was basically just saying that when employed there's little incentive to go above and beyond, unless this is some internal motivator for you. You get paid to provide care for patients, you do good work, you're collegial etc. But doing extra work for free doesn't make rational sense. When the hospital is having a rough time, and is short on funds due to travel nurse costs and elective procedures not ramping up, and the hospital is over capacity, and they want psych to be available earlier or later than is reasonable to see consults to get them out or go to the ED at 7am, or stay until 7pm in case someone comes in, all while trying to get transfers in from other hospitals to keep the psych unit census up, and we won't pay you extra for the extra work...it just baffles me why administrators are shocked when docs push back against this.

The problem is that these people don't care about true success even for the system. They don't care about good outcomes. Their goal as administrators is to pad the resume enough over the next few years to move on to somewhere better. The ones I see that do this are there 4-5 yrs and then peace out. They make short term profit for the system by "trimming the fat" and overextending the people that actually produce. It doesn't matter if the place suffers from losing people left and right, they're gone by the time everyone leaves and is burnt out. Physicians always stay longer on the sinking ship. We are risk averse, and it shows. We care about abandoning patients, and it shows. We actually care about the outcomes. This is the issue. They don't want to know what we do, because it doesn't feed into their goals.

As an employer I'm puzzled at this too. Employee retention IS the employer's job and a trajectory like that won't exactly win people over. I understand there's limitations of what employers can do also, but it looks like many could be putting in more effort. Not to mention, the people who do stay and tolerate these terrible conditions, you're selecting for lower tier providers. The really good ones you gotta work for a little but it has great potential to be a symbiotic relationship for all parties.

This puzzles you because you are actually invested in the long-term success of your business and actually care about your work. The same can't be said about those administrators.

Yes, independent physicians team up! I've been networking with a group of independently practicing physicians in primary care and I think it would be cool for that network to grow and we foster this niche in medicine. We deserve our autonomy back (and the pay we deserve) and it's good to be away from the politics, noise, fights over money, etc. In PP it is totally feasible to make even more than big box and without all the crap that comes with it. Why? Because we control the overhead and big entities have way too many middle men who don't do sh_t other than be parasites on our earnings. Sorry, kind of a raw reaction, but...imho it's truth.
I don't want to reveal too much lest I be identified. But the crazy thing is, we are on straight salary. There is no RVU bonus or any other productivity-based measure, so he doesn't even personally benefit from doing this.

Can you actually tell me a bit more about this? Are you saying you are contracting with DPCs or similar smaller PC practices to provide psych support/integrative care?

 

[splik]

19. Can I moonlight or have a private practice? Surprisingly, many states allow companies to prevent such arrangements.


I'm sure I'll think of others and will edit accordingly.

are you aware of any states that prohibit this? As non-competes (restrictive covenants) only apply after you leave a job, even states with strong prohibitions against non-competes do not prevent organizations stopping you from working elsewhere. In addition, physicians are exempt from many labor laws unless unionized.

 

[randomdoc1]

Can you actually tell me a bit more about this? Are you saying you are contracting with DPCs or similar smaller PC practices to provide psych support/integrative care?

We're just networking. I'll be meeting with the owner (an internist) of an independent primary care practice. They started 2 years before I opened. More so to become peers, colleagues. We'd have great cross referral potential but that's far from the primary reason for meeting. My primary goal is for us to be resources to each other to thrive, grow, and sustain our independent model. They've already brought on 1-2 specialists such as pulmonary. Over the years, not to brag, but I do think I've built up some good skills for working through the complexities of insurance, rate negotiation, marketing, etc. I know some things that keep physicians from joining the independent route include:
-risk aversion
-learning how to work with insurance
-the accounting back end
-HR can be a whole book series, it's a challenge as a psychiatrist navigating the nuances of the different personalities and knowing when and how to draw boundaries so I can only imagine what it's like for someone who's not as trained in behavioral health
-work flow optimization (EHRs, syncing all your information into one platform saves a sh_tload of time, patient scheduling and what to do with lateness and no shows, patient messages, etc.-->this time all adds up, especially if you don't have the ancillary staff of a healthcare system)

But I want to provide whatever help is able to be provided. This is all feasible, hard concrete skills that are teachable (although HR can be a bit of a fine art), and gives us the resources to really carry out our visions. The more people on board (especially the wrong ones), the more conflicting agendas. It's just better when there's a united front.

 

[Trismegistus4]

Billing fraud sounds, bad, like it's not just an oopsie. They don't just make you take a coding remediation class after months/years of this.

I agree, to take it to that extent is particularly egregious, but isn't it kind of the norm for a little bit of rule-bending (as opposed to rule-breaking) to go on? People on this forum are talking as though it's the norm when doing inpatient to leave by 2pm. If we assume we're billing a 99232 on most follow-ups, and that in general that means we're spending 25 minutes with each one, and that we're spending an hour with new patients, then if on a given day we have 2 new admits and 9 follow-ups, that's 5 hours and 45 minutes of rounding... are most inpatient psychiatrists starting rounds at 8am and rounding straight through until 1:45pm, on a total of 11 patients? Thus these people who are talking about leaving by 2pm 1) have not taken a lunch or any other break, and 2) have not even started notes?

 

[deleted456421]

are you aware of any states that prohibit this? As non-competes (restrictive covenants) only apply after you leave a job, even states with strong prohibitions against non-competes do not prevent organizations stopping you from working elsewhere. In addition, physicians are exempt from many labor laws unless unionized.

Minnesota allows this. They could fire me with cause if any external revenue wasn’t provided directly to the hospital. Had a contract lawyer review the offer and said it was legal.

 

[calvnandhobbs68]

I agree, to take it to that extent is particularly egregious, but isn't it kind of the norm for a little bit of rule-bending (as opposed to rule-breaking) to go on? People on this forum are talking as though it's the norm when doing inpatient to leave by 2pm. If we assume we're billing a 99232 on most follow-ups, and that in general that means we're spending 25 minutes with each one, and that we're spending an hour with new patients, then if on a given day we have 2 new admits and 9 follow-ups, that's 5 hours and 45 minutes of rounding... are most inpatient psychiatrists starting rounds at 8am and rounding straight through until 1:45pm, on a total of 11 patients? Thus these people who are talking about leaving by 2pm 1) have not taken a lunch or any other break, and 2) have not even started notes?

Yeah this is pretty typical for other specialities too TBH. Take a look at all the ICU notes where they all state they spent "X" number of minutes of critical care time per day on each patient. These are things that are very hard to verify unless someone literally follows you around on a unit all day.

 

[SmallBird]

I agree, to take it to that extent is particularly egregious, but isn't it kind of the norm for a little bit of rule-bending (as opposed to rule-breaking) to go on? People on this forum are talking as though it's the norm when doing inpatient to leave by 2pm. If we assume we're billing a 99232 on most follow-ups, and that in general that means we're spending 25 minutes with each one, and that we're spending an hour with new patients, then if on a given day we have 2 new admits and 9 follow-ups, that's 5 hours and 45 minutes of rounding... are most inpatient psychiatrists starting rounds at 8am and rounding straight through until 1:45pm, on a total of 11 patients? Thus these people who are talking about leaving by 2pm 1) have not taken a lunch or any other break, and 2) have not even started notes?

Why would you spend 25 minutes on a follow up? I never bill based on time on inpatient. You also shouldn't need an hour for a new patient when you have a food crisis eval to start from.

 

[nexus73]

I've never seen other specialties bill based on time. I have seen nephrologists consulted by medicine to manage hypercalcemia put a note in every day during a patient's 40 day hospitalization. And every note was basically the same thing, calcium has normalized, continue whatever med it was, and refer for outpatient workup for hyperparathyroidism. For 40 days. The lady was delirious, no meaningful conversation, so I assume nephro was "seeing" the patient for less than 30 seconds, and probably another 30 seconds to copy the previous day's note. Sure it's just a 99231, but I guess that's how you see 30 patients a day without breaking a sweat.

 

[Trismegistus4]

Why would you spend 25 minutes on a follow up? I never bill based on time on inpatient. You also shouldn't need an hour for a new patient when you have a food crisis eval to start from.

I’m guilty of rounding like this (albeit breaking for lunch). That said, your example assumes the 99232 is based on time. One can also bill based on complexity. This gets more complex than the outpatient codes but taking a medically necessary

1. expanded problem focused history: 1+ HPI and 1+ ROS gets this. Ie “so and so reports symptoms of depression improved overnight. Denies SI today”

2. Expanded and problem focused exam: our MSE gets this

3. meeting 2 out of 3 of

I. three problem points

II. three data points and/or

III. moderate risk

is easy enough. Prescription management gets you moderate risk. Problem points gets you 1 point for the current issue(s) if stable or improving and up to 2 points for self limited issues. Ie MDD, GAD, and insomnia.

True, but the person I'm referring to is too stupid to understand billing by complexity and thinks you're just supposed to drop a time statement into every note.

 

[Candidate2017]

True, but the person I'm referring to is too stupid to understand billing by complexity and thinks you're just supposed to drop a time statement into every note.

What does it matter if another psychiatrist is too stupid to understand how to bill by complexity vs. time? Their patients are still likely 99232s. Even an NP reading random buzzwords from First Aid for Psychiatry could dictate a 99232-worthy note.

To be fair, if other specialists (especially highly paid specialists) read our notes, they'd conclude we are all intellectually disabled, severe, when it comes to documentation and billing. This is a 99232 example from a cardiology website:

Brief note example that fulfills the criteria for a 99232​

I’m not a fan of minimalist notes, I think it can breed complacency and doesn’t help with the thought process. The following shows however that when sticking to the criteria for a 99232 we can still achieve what we need to with a minimal note.

Interval history
Chest pain has improved, still some intermittent chest pain.
No shortness of breath or dizziness.

2 interval HPI points, 2 ROS points. (Only need 1-3 HPI points and 1 ROS point)

Objective points
BP 100/70, HR 90, temp 98.0, 98% 02sat on 2 liters, Alert and oriented, Laying in bed , JVP normal at 8cm at 45degrees, carotid upstroke normal, Cardiac exam, regular rhythm, no murmurs noted , 2+ radial pulses bilateral, Lungs clear bilaterally, respiratory effort normal, Abdomen soft and non tender

Theoretically we could stop here, we have 2 of the 3 main sections with all criteria fulfilled, interval HPI has the necessary points and the physical exam has 8 bullets, remember only 6 needed. This highlights how knowledge of what’s required can allow focus on main issues if that is the aim. In reality the note will continue thought.

Assessement
Chest pain – stable, markers negative, EKG reviewed and no changes noted.
Hypertension, chronic, controlled
Diabetes Mellitus, controlled
Smoker – nicotine patch

​

 

[Trismegistus4]

What does it matter if another psychiatrist is too stupid to understand how to bill by complexity vs. time? Their patients are still likely 99232s. Even an NP reading random buzzwords from First Aid for Psychiatry could dictate a 99232-worthy note.

You missed the part where I said this character bills a 99233 + 90833 on everybody. But your point that you don't need to spend 25 minutes to bill a 99232 is valid.