For those times when you just need to vent a bit

[sunlioness]

A masters level therapist gave a patient a screening tool and then sent her to me to be treated for her social anxiety.

Patient is already taking an SSRI and has taken others in the past. They kinda help, as one might expect. But apparently it's on me to find a med to make it all go away.

Some therapists need a punch in the face. I mean what do they think they're doing? Do they devalue their own role that much?

(Forgive me. I had 32 patients scheduled yesterday and I'm just done. Just done. Why can't I be done?)


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[Shikima]

A masters level therapist gave a patient a screening tool and then sent her to me to be treated for her social anxiety.

Patient is already taking an SSRI and has taken others in the past. They kinda help, as one might expect. But apparently it's on me to find a med to make it all go away.

Some therapists need a punch in the face. I mean what do they think they're doing? Do they devalue their own role that much?

(Forgive me. I had 32 patients scheduled yesterday and I'm just done. Just done. Why can't I be done?)


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I had a guy show up who was rip roaring pissed off that he had a panic attack on the plane which got him an ambulance ride to the ER, of course with a bill, and emotes all over the place how it's my fault and how dare I not call him. I talk to his therapist that this isn't a medication issue as he has had a long course of anxiety - her response; "Why can't he just have a higher dosage of Xanax?"

 

[sunlioness]

Oh, Shikima . . . Why won't you prescribe them xandy bars?


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[smalltownpsych]

More and more of the masters therapists really don't know what they're doing. I work with new grads all the time that are pretty clear about that. On the other hand, the pressure to fix it with a pill is throughout society. I'm a little different in my approach because my goal is to keep or get the majority of my patients off of medications. The work is more difficult in some ways, but trust me there is much more success and reward in that direction.

 

[Doctor Bagel]

Don't you guys know that the ultimate target goal should be complete elimination of anxiety? You need Xanax until you reach that point.

 

[sunlioness]

More and more of the masters therapists really don't know what they're doing. I work with new grads all the time that are pretty clear about that. On the other hand, the pressure to fix it with a pill is throughout society. I'm a little different in my approach because my goal is to keep or get the majority of my patients off of medications. The work is more difficult in some ways, but trust me there is much more success and reward in that direction.

What exactly are they learning in those two years of fancy expensive schooling and clinical practica?

And DocBagel, you are absolutely right. And my own personal Xanax level is obviously subtherapeutic. Will you call me in some?

 

[Psyxh1]

Don't you guys know that the ultimate target goal should be complete elimination of anxiety? You need Xanax until you reach that point.

I'm trying to understand the issue here in Shikima's example. Do they expect too much of Psychiatrists? If a patient had unstable hypertension after previously being managed on hypertension meds, you would expect them to go to the doctor to have their medications changed or tweaked. In a parallel situation, if this patient was being seen to have his panic attacks under control(through meds + therapy) and had an episode on the plane, the therapist must have sent him to have his medications reevaluated so as to better manage his episodes.

 

[sunlioness]

I'm having a really bad couple of days.

I just need to hold it together for two more months.

A large male patient burst into my office while I was talking to another patient. It turns out he just wanted to know where another doc's office was.

But I just about crapped my pants. And I may have just gone on a loud obscenity laden telephone rant to a friend about how much this place sucks that could possibly have been overheard

And now I feel awful.

So that's me. How are you?


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[OldPsychDoc]

Don't you guys know that the ultimate target goal should be complete elimination of anxiety? You need Xanax until you reach that point.

Propofol works better for that target.

 

[nexus73]

I like yoga. Or simple mindfulness/meditation. The "headspace" app has 10 free guided sessions. Might help to re-center.

 

[Attending1985]

32 patients in a day. That sounds absolutely terrible. Is that typical for you?

 

[sunlioness]

32 patients in a day. That sounds absolutely terrible. Is that typical for you?

It sadly is not at all unusual. The mid to upper 20s in eight hours is probably more typical. It feels impossible to provide good care. Especially since while you're trying to provide good care, you're getting bothered by people who need stuff signed, or a prior authorization, or paperwork . . . It's just constant. Patients showing up early who want to be seen right then. Patients showing up late wanting to be seen right then. A dangerous neighborhood in an open access building . . . I could go on.

I meditate 10-20 minutes every day. It really is great. Probably why I've made it this far. But you can't out meditate a toxic environment.

 

[Attending1985]

Forgive me but why dd you take this job?

 

[sunlioness]

Well, I didn't know it was going to be like this. I should've asked better questions. I wouldn't say the position was deliberately misrepresented, just that there was a lack of the complete picture and I didn't have the experience to know what questions to ask. And I genuinely think the people who work here think all of this is normal. I can't figure that out. But I think they do. A lot of them are part time and either do this to supplement income from their own practices or are semi retired or are part time stay at home parents. That probably mitigates things to a large degree.

One of the boss-type docs told me, "The first year you work here is really awful. It really is. Everything seems to get messed up. But after that you get used to it and it really does get better. You'll see." She's a nice lady and a good doc. I like her. But it wasn't a terribly convincing argument.

And it's near where I grew up. That was the initial impetus. But I can make $50K more per year seeing half as many patients with better support in a safer setting elsewhere and fly here for the weekend whenever I want.

So that's what I'm going to do.



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[F0nzie]

Propofol works better for that target.

Looking forward to my screening colonoscopy


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[daru1]

I'm trying to understand the issue here in Shikima's example. Do they expect too much of Psychiatrists? If a patient had unstable hypertension after previously being managed on hypertension meds, you would expect them to go to the doctor to have their medications changed or tweaked. In a parallel situation, if this patient was being seen to have his panic attacks under control(through meds + therapy) and had an episode on the plane, the therapist must have sent him to have his medications reevaluated so as to better manage his episodes.

If you're equating the treatment of hypertension to the treatment of Anxiety/Panic, we're going to need you to come back when you finish your intern year. There is a false equivalency that you aren't getting, and probably won't get until you have some more clinical experience. I'm not knocking you in an ad hominem sort of way, just that you need to have a few more patients under your belt before you try to make this sort of comment.

 

[F0nzie]

Well, obviously, I didn't know it was going to be like this. People paint a picture, right? I should've asked better questions. I wouldn't say the position was deliberately misrepresented, just that there was a lack of the complete picture and I didn't have the experience to know what questions to ask.

And it's near where I grew up.



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The reality of many jobs out there is they offer X but they want XYZ so they can double or triple production. It is easy for employers to capitalize on this because this is the same paradigm we went through in residency. It is familiar to us such that we do not see anything wrong with it. But as time passes by, under the surface we become angry and resentful and we agree to do what we never wanted to do. Better questions during the interview may help, but better questions with responses in the form of a written contract with specifics and limitations may be more effective. Now may be a good time to take some PTO... Hope you feel better soon!




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[sunlioness]

The reality of many jobs out there is they offer X but they want XYZ so they can double or triple production. It is easy for employers to capitalize on this because this is the same paradigm we went through in residency. It is familiar to us such that we do not see anything wrong with it. But as time passes by, under the surface we become angry and resentful and we agree to do what we never wanted to do. Better questions during the interview may help, but better questions with responses in the form of a written contract with specifics and limitations may be more effective. Now may be a good time to take some PTO... Hope you feel better soon!




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Yeah. When I talked to the boss type doc, she told me I could ask for a salary increase if my productivity could justify it. I needed to be exceeding my targets. I asked for my numbers, which she provided.

And I laughed out loud. I wasn't even reaching my target. They want 75% utilization and I'm hovering around 69%. So no raise here. I was right around the other docs in the department though, so I don't think I'm doing anything wrong. I think things are just set up that way.

I should've read the contract better. It's 40 hours/week, but those must be clinical hours. No admin time for charting, phone calls, whatever. Sure you can take time for that, but then you're working more than forty hours/week.

I'm the most exhausted hardworking slacker I know.

I'm taking a long weekend for my birthday at the end of the month and going to the mountains with some old college friends. That'll help.

 

[cookymonster]

I'm assuming these are mostly 15 minute follow ups. How late are they allowed to show up and still be seen? When I last saw outpatients two years ago it took about 3 minutes per patient just to walk them in and out.

 

[sunlioness]

Yes, 15 minute checks. And honestly? As late as they want.

I did just put my foot down at 90 minutes a little bit ago.


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[wolfvgang22]

I'm trying to understand the issue here in Shikima's example. Do they expect too much of Psychiatrists? If a patient had unstable hypertension after previously being managed on hypertension meds, you would expect them to go to the doctor to have their medications changed or tweaked. In a parallel situation, if this patient was being seen to have his panic attacks under control(through meds + therapy) and had an episode on the plane, the therapist must have sent him to have his medications reevaluated so as to better manage his episodes.

Short answer, yes.

Conditions like anxiety disorders tend to be chronic.
Medicines are just one tool, and will never be "The One Answer" to psychiatric illness. Most patients with serious illness need to do the hard work of psychotherapy. Also, one panic or anxiety attack ( these are different things) doesn't mean medications aren't working or need to be changed. A stressful situation such as being on a crowded airplane might trigger an attack, but that is the situation, not necessarily a need to prescribe more dope.

Our society wants a quick fix, an instant iPhone answer to all problems. Most patients today want Xanax, an instant acting, feel good cover-up drug for problems, but with downsides much like other addictive street drugs and alcohol. Xanax "bars" are a common street drug, by the way for a reason. Lay people (including some poorly trained LCSWs) often expect medication to solve problems without much work by the patient.

Very little in medicine works well with that kind of expectation. Most people with hypertension need to eat right, lose weight, stop smoking, stop drinking, and get some exercise. Most people don't want to do any of that in a serious way, and so have sub optimal results. Every doctor needs to be able to say eventually "Look, you aren't going to get much better until you do your part" to the patient. But we increasingly aren't allowed to say that by our employers.

Psychiatry has been down this road we are on with benzodiazepines before with barbiturates (a more dangerous group of medication), but back then patient satisfaction scores and threats of litigation didn't drive clinical policies and influence patient care as much as they do now.

 

[Psyxh1]

If you're equating the treatment of hypertension to the treatment of Anxiety/Panic, we're going to need you to come back when you finish your intern year. There is a false equivalency that you aren't getting, and probably won't get until you have some more clinical experience. I'm not knocking you in an ad hominem sort of way, just that you need to have a few more patients under your belt before you try to make this sort of comment.

Thanks for your response. Would you mind elaborating somewhat? Are you saying that everyone expects Psychiatry to completely cure everything with medications when the issue many times is better addressed through other means? Is it especially rich because even a therapist was expecting this of Shikima for a patient who had longstanding anxiety? I may have misinterpreted his post as the therapist having sent the patient to him after the panic attack on the plane to have his medications readjusted instead of Shikima meeting with the therapist to let her know that the patient's issues were better addressed through non-pharmacological avenues and then getting the retort about the Xanax. In the first case(where I assumed that she first sent the patient to Shikima) a therapist does not have as much familiarity with medications so after a patient has a major episode perhaps she was contemplating that a Psychiatry consult was in order to see if his medications could be readjusted to better control his attacks before delving into talk therapy for his root issues. I know it's important to be judicious with benzos but if certain situations cause panic attacks in this patient, can't they be intercepted by prophylaxis with a benzo just before the patient is put into a stimulating environment(plane ride)? If it fails, would increasing the dosage for the next time the patient is in a panic inducing scenario be more likely to prevent his episode? Of course if his panic attacks are unpredictable and unanticipated then this wouldn't really be viable. Again, I apologize if I'm displaying my sheer ignorance but I would like to be edified.

 

[st2205]

Thanks for your response. Would you mind elaborating somewhat? Are you saying that everyone expects Psychiatry to completely cure everything with medications when the issue many times is better addressed through other means? Is it especially rich because even a therapist was expecting this of Shikima for a patient who had longstanding anxiety? I may have misinterpreted his post as the therapist having sent the patient to him after the panic attack on the plane to have his medications readjusted instead of Shikima meeting with the therapist to let her know that the patient's issues were better addressed through non-pharmacological avenues and then getting the retort about the Xanax. In the first case(where I assumed that she first sent the patient to Shikima) a therapist does not have as much familiarity with medications so after a patient has a major episode perhaps she was contemplating that a Psychiatry consult was in order to see if his medications could be readjusted to better control his attacks before delving into talk therapy for his root issues. I know it's important to be judicious with benzos but if certain situations cause panic attacks in this patient, can't they be intercepted by prophylaxis with a benzo just before the patient is put into a stimulating environment(plane ride)? If it fails, would increasing the dosage for the next time the patient is in a panic inducing scenario be more likely to prevent his episode? Of course if his panic attacks are unpredictable and unanticipated then this wouldn't really be viable. Again, I apologize if I'm displaying my sheer ignorance but I would like to be edified.

Vistaril, is that you?

 

[Guyton]

Are you saying that everyone expects Psychiatry to completely cure everything with medications when the issue many times is better addressed through other means?

Anxiety disorder treatment usually requires a combination of pharmacotherapy and psychotherapy. I believe the frustration with the therapist voiced by the OP is in relation to the therapist's screening the patient for a disorder and then failing to provide the treatment that the therapist is ostensibly qualified to render- i.e. therapy. Judging from the volume of patient's the OP is seeing in a day, it is unrealistic for her to provide psychotherapy in addition to the pharmacotherapy . When the therapist sends the patient to a psychiatrist who practices psychoparmacology largely to the exclusion of therapy, there is often an implied message received by the patient that some medication adjustment is warranted. This then creates tension when the psychiatrist feels maximal medical improvement has been achieved. So, not everyone expects psychiatry to completely cure everything with medications. However, this bias is engendered when a patient is sent away from the therapist to a "prescriber."

 

[dl2dp2]

And I laughed out loud. I wasn't even reaching my target. They want 75% utilization and I'm hovering around 69%. So no raise here. I was right around the other docs in the department though, so I don't think I'm doing anything wrong. I think things are just set up that way.

I should've read the contract better. It's 40 hours/week, but those must be clinical hours. No admin time for charting, phone calls, whatever. Sure you can take time for that, but then you're working more than forty hours/week.

The way you describe this job is fairly typical of similar CMHC type jobs. Your colleagues probably see most patients for 3-5 min and bill 99213. I worked in a facility like this and can sympathize. As expected, the turnover is very high, and the clinic hasn't had a doc who worked there for longer than 1 year for a long time. Often they recruit new graduates and they don't last more than a few months. Unfortunately the patients are too poor to be able to effectively get out of this type of clinic. This is very similar to the kind of care you get with Medicaid-type programs regardless of where you are or what specialty you are practicing.

Because of the dramatically divergent level of resources indigent patients have compared to privately insured patients, it's not realistic to render the same standard of practice across the board, necessitating "tiering" of care quality. There are people who are doing research on how to effectively improve tiering, funded by agencies like PCORI (i.e. medical home model, "group psychopharm" - the Mayo clinic model, etc.) If you are at all academically oriented, this experience can be informative, and significantly contributive to improving mental health care for the indigent. If you are more clinically oriented, rest assured you can find a lot of really good jobs around and this is why nobody stays.

The only CMHC job that's worth taking for the long run is one associated with the state government or some federal agency, like the VA. In those cases, your salary is essentially decoupled from your performance, and you can never get fired, and your higher ups don't care how many patients you see, so your patient load ends up being very low, and it becomes a very relaxing job.

 

[sunlioness]

One time I was treating a guy for bipolar depression. I had just started him on lamotrigine with some minor improvement.

He went to see his therapist who told him he was depressed (correct) and that he needed to be on an antidepressant. He had been on SSRIs before without benefit and with sexual side effects. Sex was really his only enjoyment at that point and he was reluctant to risk it. His therapist told him, "Celexa never causes sexual side effects". She got the PCP whose office she worked out of to d/c the lamictal and start Celexa.

I didn't know about this until a month later when the patient comes to his follow up with me. His mood had deteriorated markedly and he was impotent. He wanted back on lamictal, but was even more frustrated to learn he'd have to go through the titration process again. He was angry. I was too.

I reached out to the therapist to try to discuss it with her. No response.

That was a long time ago, but it's stuck with me.

I should also add that I've worked with some really amazing masters level therapists and PCPs.


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[mgdsh]

I had a patient fire me because I wouldn't write her a letter to get out of her parking ticket.

 

[dl2dp2]

I reached out to the therapist to try to discuss it with her. No response.

This is an interesting vignette. This type of thing happens ALL THE TIME also at my old clinic. The reason for this is that the midlevels tend to stick around longer, and therefore can often dictate care. They are also usually the managers and run the clinic, even though you would get paid more as a consultant. There is a lot of power play, and at times midlevels can be potentially dangerous, and your name is still the attending of record. However, the management will always be on their side because it's not an MD. Make sure you document clearly what transpired, and have a legit answer in case of bad outcome/lawsuit.

Occasionally an MD runs a for profit CMHC. In my very limited experience, in this kind of scenario often the ethics of the MD is compromised at least to some extent.

 

[Bartelby]

Thanks for your response. Would you mind elaborating somewhat? Are you saying that everyone expects Psychiatry to completely cure everything with medications when the issue many times is better addressed through other means? Is it especially rich because even a therapist was expecting this of Shikima for a patient who had longstanding anxiety? I may have misinterpreted his post as the therapist having sent the patient to him after the panic attack on the plane to have his medications readjusted instead of Shikima meeting with the therapist to let her know that the patient's issues were better addressed through non-pharmacological avenues and then getting the retort about the Xanax. In the first case(where I assumed that she first sent the patient to Shikima) a therapist does not have as much familiarity with medications so after a patient has a major episode perhaps she was contemplating that a Psychiatry consult was in order to see if his medications could be readjusted to better control his attacks before delving into talk therapy for his root issues. I know it's important to be judicious with benzos but if certain situations cause panic attacks in this patient, can't they be intercepted by prophylaxis with a benzo just before the patient is put into a stimulating environment(plane ride)? If it fails, would increasing the dosage for the next time the patient is in a panic inducing scenario be more likely to prevent his episode? Of course if his panic attacks are unpredictable and unanticipated then this wouldn't really be viable. Again, I apologize if I'm displaying my sheer ignorance but I would like to be edified.

I think your questions are good ones! You will see with experience where the frustration comes from.

The patient who was described has a problem with regulation of anxiety. Various psychotherapeutic modalities would approach this from various angles, but a key assumption across therapies is that modification of beliefs and behaviors will lead to an improved ability to cope with the symptom (in this case anxiety/panic). For instance, an ACT-based therapist might emphasize that anxiety is a normal part of the human experience and conceptualize the problem not as a problem of anxiety per se but as a problem of the individual's fusion with and dread of anxiety. A traditional cognitive behavioral therapist might frame panic attacks as a phobic response to the bodily sensations of anxiety (tachycardia, diaphoresis, heightened perception from epinephrine and tingling in the extremities with lightheadedness from hyperventilation with blowing off of CO2 for instance) and utilize exposure exercise to desensitize the patient. A psychodynamic therapist might hypothesize that the panic attacks are a manifestation of a conflict that is not fully within conscious awareness and seek to help the patient better understand the origins and scope of the underlying anxiogenic issues.

What's common across these approaches is the emphasis on teaching the patient a new way to understand and relate to the symptoms. By the therapist's emphasizing the medications an alternate view is reinforced: these symptoms are outside of your control and you need to seek an external force to control them (which in the case described above did not appear to be a realistic description). In a way it is an abdication of the psychotherapeutic task, and it can also come across as the therapist pairing with the ill part of the patient ("why can't you just put him on the right meds, doc?") rather than allying with the well part of the patient.

At this point you might be wondering why we would use medications at all. The answer there (in treatment of many anxiety disorders, from my perspective) is that it does lead to an improvement in quality of life and/or can help the patient engage in the psychotherapy. It is also appropriate for the therapist to discuss when they feel the medication regimen is not optimal with the psychiatrist; however, it's important for the therapist and psychiatrist to remain allied and avoid splitting off into a blame game.

One other issue when it comes to xanax / BDZ specifically: continued escalation with the goal of eliminating anxiety is a dangerous game, because anxiety is a part of the human condition and succumbing to pressure to increase the dose whenever there is a bad week will likely mean dependence and other problems in the long run. When the therapist in split treatment advocates for doing so you have a problem.

 

[downwithDTB]

This is an interesting vignette. This type of thing happens ALL THE TIME also at my old clinic. The reason for this is that the midlevels tend to stick around longer, and therefore can often dictate care. They are also usually the managers and run the clinic, even though you would get paid more as a consultant. There is a lot of power play, and at times midlevels can be potentially dangerous, and your name is still the attending of record. However, the management will always be on their side because it's not an MD. Make sure you document clearly what transpired, and have a legit answer in case of bad outcome/lawsuit.

Occasionally an MD runs a for profit CMHC. In my very limited experience, in this kind of scenario often the ethics of the MD is compromised at least to some extent.

MD's ethics are compromised because she owns the clinic, but if it's owned by midlevels or non-medical personnel who have poor grasp of how decisions affect patient outcome, or by an insurance company whose only goal is cost minimizing, leading to situations described above... that's not ethically dubious?

 

[sunlioness]

So a patient comes in and says his lorazepam isn't lasting long enough. He's on 0.5mg BID prn. I tell him we can temporarily go to TID prn while waiting for the SSRI to kick in and for him to get off the waiting list for therapy. He is agreeable.

I wrote for 0.5mg TID PRN. He looks at it and tells me he's taking 1mg BID. No . . . . Last time you were here, I wrote for 0.5

"That's true. But since then I saw my other psychiatrist and he upped it."

Huh?

But yeah. The guy is seeing two psychiatrists and he didn't tell me that initially. I told him, he can't be doing that. It's confusing and counter productive. He needs to pick one and be consistent. He asks if I will give him more Ativan. I say no. He says he'll have to go with the other guy. I say, no hard feelings. He says I should feel bad about it because I'm covered and the other guy isn't.

I am declining to feel bad about it.


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[thoffen]

Thanks for your response. Would you mind elaborating somewhat? Are you saying that everyone expects Psychiatry to completely cure everything with medications when the issue many times is better addressed through other means? Is it especially rich because even a therapist was expecting this of Shikima for a patient who had longstanding anxiety? I may have misinterpreted his post as the therapist having sent the patient to him after the panic attack on the plane to have his medications readjusted instead of Shikima meeting with the therapist to let her know that the patient's issues were better addressed through non-pharmacological avenues and then getting the retort about the Xanax. In the first case(where I assumed that she first sent the patient to Shikima) a therapist does not have as much familiarity with medications so after a patient has a major episode perhaps she was contemplating that a Psychiatry consult was in order to see if his medications could be readjusted to better control his attacks before delving into talk therapy for his root issues. I know it's important to be judicious with benzos but if certain situations cause panic attacks in this patient, can't they be intercepted by prophylaxis with a benzo just before the patient is put into a stimulating environment(plane ride)? If it fails, would increasing the dosage for the next time the patient is in a panic inducing scenario be more likely to prevent his episode? Of course if his panic attacks are unpredictable and unanticipated then this wouldn't really be viable. Again, I apologize if I'm displaying my sheer ignorance but I would like to be edified.

There are many things at play in this scenario and in this response. Although your thinking is going to raise hair on many necks, it is not necessarily wholly unreasonable. Nonetheless, it requires cautious thought and exploration of treatment goals with patient before being settled upon.

• Firstly, it should be stressed, that this kind of split treatment should be handled differently. Never should a therapist tell a patient what meds they need or need adjusted, and never should a med provider tell the patient what they should be doing in therapy. It is not wrong, however, to explore the patient's concerns about the efficacy of their treatment on either end, and to encourage communication of these concerns. It is most prudent, however, if you have a feeling about how another provider is managing your patient, to communicate with them directly and to have discussed the boundaries of split treatment with written consent to do so, ideally up front before treating a patient. "I'm here because my therapist tells me I need more Xanax" is deplorable, as is "I'm here because my psychiatrist says you should be doing DBT instead" (provided these statements are to established patients, although they are still problematic in different ways for new patients).
• It is absolutely the responsibility of a non-medical provider of anxiety treatment to know a lot about medication treatments for anxiety, especially how they may interact with their treatment
• To the above, there are quite many expert CBT therapists that consider benzodiazepines absolutely contraindicated in their treatment of anxiety disorders. Treatments for anxiety typically involve an exposure methodology, wherein the patient is gradually exposed imaginally, in vivo, or in combination to stimulus that makes them anxious yet is actually not dangerous. The intent is to do so without providing any means of artificially reducing the anxiety. In fact, in the end, you want them to feel as though their worst fear is coming true. The goal here is to get them to the point where their anxiety has naturally peaked and is starting to resolve on its own without intervention. In this fashion, you eliminate means which reinforce through avoidance or medications that their anxiety is valid and that they cannot handle it on your own. The amount of anxiety experienced with subsequent trials goes down and down.
• Pharmacologically, benzodiazepines develop ready physiologic tolerance, and have little evidence to support benefit over chronic use. They do, however, create significant dependence (psychological > physiological), and do carry abuse potential, and may still have impairments in cognitive function in states of tolerance; Xanax, with its short half-life, carries the most abuse potential of BZDs
• In long-standing anxiety disorders, pharmacologic treatment is very unlikely to achieve remission of symptoms
• Additionally, oral benzodiazepines may take time to reach therapeutic efficacy; coupled with tolerance, you may often find situations in which someone takes a benzodiazepine and feels relief of anxiety merely because their anxiety had achieved its natural peak before the BZD kicked in (if it even would). In this case, it's not helpful for the patient to attribute efficacy to Xanax, and potentially promoting the illness due to reinforcing the idea of lack of control. Yet, if the patient had experienced remission of symptoms spontaneously, it would be very therapeutic to orient them to their ability to manage without.
• To use your hypertension example, say you were a counselor specializing in lifestyle modification (diet, exercise). Would you send your patient to PCP for HTN med adjustment if your pt. was non-adherent to diet and not exercising? The answer here may be yes because of the dangers of HTN and the likelihood of actually managing it by taking more meds. But it would be pretty fishy if that patient shows up to the PCP doorstep and said that their lifestyle counselor said you needed to fix me by increasing my amlodipine, and no of course I'm not exercising or cutting salt. There needs to be a collective understanding of the problem & treatment goals & responsibilities. Nonetheless, the PCP might actually be able to fix that # whereas the psychiatrist is, at best, limited, and at worst, able to provide a short-term solution with low efficacy and high dependence.
• All that said, there may be a patient that would benefit from a higher dose of PRN Xanax prior to encountering a necessary and not regularly recurrent high-intensity stressor, but it would be a carefully selected patient for me

 

[OldPsychDoc]

Vistaril, is that you?

Again, I apologize if I'm displaying my sheer ignorance but I would like to be edified.

I think not... This is a rather un-Vistaril-like statement of fallibility and humility.

 

[MacDonaldTriad]

Careful, if we say his name 3 times.....

 

[Ceke2002]

@sunlioness If it helps I'm currently sitting here mentally punching your patients in the face for you.

Seriously though, that is ridiculously entitled and disrespectful behaviour to turn up outside of an allotted appointment time and then demand to be seen (bonafide emergency situations aside of course). And shame on the place you work for if they're encouraging this sort of behaviour by making you actually see these patients instead of, oh I don't know, trying to educate them to take some personal responsibility for themselves and their treatment. And unless you're at the 'completely out of touch with reality' stage of mental illness, having a diagnosis of a psychiatric illness does not preclude you from showing some damn manners!

 

[erg923]

What exactly are they learning in those two years of fancy expensive schooling and clinical practica?

And DocBagel, you are absolutely right. And my own personal Xanax level is obviously subtherapeutic. Will you call me in some?

How much time off do you take? Use it. The patients flow never stops, and its really been getting to me the past couple months.

I took off the whole week. Killed all the weeds and laid sod. Organized the basement storage area. Date day and date night with the wife. Left for the Masters Tourney yesterday!

 

[dl2dp2]

MD's ethics are compromised because she owns the clinic, but if it's owned by midlevels or non-medical personnel who have poor grasp of how decisions affect patient outcome, or by an insurance company whose only goal is cost minimizing, leading to situations described above... that's not ethically dubious?

Well... the midlevels running the clinic can claim that they don't know what is and isn't viable from a medical perspective, but yes, the *system* isn't very ethical. The balance of poor clinical care has to be hedged against the outcome of no care at all. This was what happened to a lot of patients in my clinic. The common scenario is: I think the patient is too sick to stay in an outpatient setting, but not quite sick enough for involuntary. The patient doesn't want IOP or inpatient, and/or can't pay for it. I want to discharge the patient due to liability/lack of adequate care, the clinic director says: we don't turn down patients--he has nowhere to go, and two other Medicaid clinics in town just closed. What am I gonna say to that? So I wait until the patient becomes grossly suicidal and psychotic, and I send the patient to the ER, and the ER discharges him back to us. But at least now the liability rests partially with the ER, and if things escalate, I just keep sending people to the ER until they get admitted somewhere. The cycle continues...from a cost perspective, this is extremely inefficient...

Furthermore, the management is under pressure from hospital administration, especially because usually these clinics LOSE money, and the hospital kicks in a significant subsidy because some other player like the city or state government mandates the clinic stay open to satisfy some other requirement (i.e. getting training grants, being a "center of excellence" certified, etc.). And because the non-MDs run the show, they often don't know how to effectively bargain with Medicaid/state agencies that provide block grants that make these clinics viable. So you end up with a system where nobody takes any ownership with the way things are, and the system stays indefinitely.

My only redeeming thought is that if the patient decides to suicide or overdose, and I'm on the witness stand, I'll explain to the jury exactly what was and wasn't done and why. My conscience is clear, even if my malpractice takes a hit.

 

[deleted736562]

Well... the midlevels running the clinic can claim that they don't know what is and isn't viable from a medical perspective, but yes, the *system* isn't very ethical. The balance of poor clinical care has to be hedged against the outcome of no care at all. This was what happened to a lot of patients in my clinic. The common scenario is: I think the patient is too sick to stay in an outpatient setting, but not quite sick enough for involuntary. The patient doesn't want IOP or inpatient, and/or can't pay for it. I want to discharge the patient due to liability/lack of adequate care, the clinic director says: we don't turn down patients--he has nowhere to go, and two other Medicaid clinics in town just closed. What am I gonna say to that? So the cycle continues.

Furthermore, the management is under pressure from hospital administration, especially because usually these clinics LOSE money, and the hospital kicks in a significant subsidy because some other player like the city or state government mandates the clinic stays open to satisfy some other requirement (i.e. getting training grants, etc.). And because the non-MDs run the show, they often don't know how to effectively bargain with Medicaid/state agencies that provide block grants that make these clinics viable. So you end up with a system where nobody takes any ownership with the way things are, and the system stays indefinitely.

My only redeeming thought is that if the patient decides to suicide or overdose, and I'm on the witness stand, I'll explain to the jury exactly what was and wasn't done and why. My conscience is clear, even if my malpractice takes a hit.

Sounds like a total nightmare...

 

[dl2dp2]

Sounds like a total nightmare...

Well I think the research in this area is actually very interesting. One thing you could do is develop some kind of technology driven solution. For example, you can have an app or device that automates care coordination for very sick patients. There are multiple venture based companies working on this type of thing. The ACA actually also has worked on getting this better by starting specific quality improvement initiatives with state Medicaid admin... some of those in large states run in the billions. So progress will, if slowly, come.

 

[Shikima]

Youngly, please read up on physiological dependency and psychological dependency. Then read about Xanax both biochemically and onset of action.

Next, please consider this next point carefully; Benzo's are an unsustainable resource for controlling anxiety.

 

[st2205]

I think not... This is a rather un-Vistaril-like statement of fallibility and humility.

Yeah, the comments don't add up but those unique grammar errors permeate all posts just like Vistaril and all of his multiple accounts.

 

[sunlioness]

I'm giving thought to being sick tomorrow, sleeping in, and eating cookies. See how I feel when the alarm goes off.

All I know is I kinda cried on the way home this evening because I knew I was out of cheese. I shoulda just stopped and got some cheese.


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[finalpsychyear]

Well, I didn't know it was going to be like this. I should've asked better questions. I wouldn't say the position was deliberately misrepresented, just that there was a lack of the complete picture and I didn't have the experience to know what questions to ask. And I genuinely think the people who work here think all of this is normal. I can't figure that out. But I think they do. A lot of them are part time and either do this to supplement income from their own practices or are semi retired or are part time stay at home parents. That probably mitigates things to a large degree.

One of the boss-type docs told me, "The first year you work here is really awful. It really is. Everything seems to get messed up. But after that you get used to it and it really does get better. You'll see." She's a nice lady and a good doc. I like her. But it wasn't a terribly convincing argument.

And it's near where I grew up. That was the initial impetus. But I can make $50K more per year seeing half as many patients with better support in a safer setting elsewhere and fly here for the weekend whenever I want.

So that's what I'm going to do.



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Sorry to hear your time there recently has been so hectic. I keep hearing stories like yours and it seems like everyone really loves to really try and squeeze as much as they can out of doctors working for certain employers these days. What kind of notice do you have to give to drop a job like this? 2 weeks, 1 month.. i can't imagine they can enforce anythng longer than that. Hope you get your 50k more seeing half the load sooner than later.

 

[sunlioness]

Four months. 120 days. I talked them down to 90. I have two more months. I had a lawyer read my contract way too late .... Looking for a way to get out. Breaching would be bad. Very, very bad.

I'm documenting to try to protect myself, "Pt heretofore unknown to me presents forty minutes late for his 15 minute appointment after having been lost to follow up for five months ...." Things of this nature.


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[keifernny2]

Four months. 120 days. I talked them down to 90. I have two more months. I had a lawyer read my contract way too late .... Looking for a way to get out. Breaching would be bad. Very, very bad.

I'm documenting to try to protect myself, "Pt heretofore unknown to me presents forty minutes late for his 15 minute appointment after having been lost to follow up for five months ...." Things of this nature.


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Hopefully you get back to a clinic that you don't have that kind of trouble setting boundaries in, as it sounds like you are not allowed to manage your own practice at all.

On the plus side, the thing I miss about living in a city is getting groceries (and even cheese!) delivered any time you want.

 

[sunlioness]

Yeah. I really can't. I have no control over any of it.

That will change this summer. I'm going back where I was before and I kinda can't wait.

My mother laughed at me because I mail ordered toilet paper. I thought it was brilliant.


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[OldPsychDoc]

I'm giving thought to being sick tomorrow, sleeping in, and eating cookies. See how I feel when the alarm goes off.

All I know is I kinda cried on the way home this evening because I knew I was out of cheese. I shoulda just stopped and got some cheese.


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I would have brought you cheese...and wine to go with it.

 

[finalpsychyear]

I'm giving thought to being sick tomorrow, sleeping in, and eating cookies. See how I feel when the alarm goes off.

All I know is I kinda cried on the way home this evening because I knew I was out of cheese. I shoulda just stopped and got some cheese.


Sent from my iPad using Tapatalk

Maybe maxing out your sick days/vaca will force their hand to let you go? Maybe I've been watching too much saul.

 

[sunlioness]

I would have brought you cheese...and wine to go with it.

You are very sweet. Everyone needs cheese to go with their whine. A violin might also be nice . . . and all I have is a guitar.

I remember when I interviewed the Big Boss said that the top quality he looked for in an potential new hire was someone who "wouldn't call off with the sniffles." In retrospect, I'm wondering if this was some sort of red flag. Of course you shouldn't call off with the sniffles. I have never in my life called off with the sniffles. As an intern I was on call in the ICU with bilateral viral conjunctivitis and covered it like a boss. (I told my chiefs ahead of time, "Hey, I might be contagious. Is that a problem?" "No," they said.)

But what in his mind are "the sniffles" exactly? Because I'm thinking that I may have just called off with the sniffles. But really I called off with a raging case of the "can't evens". Is that different?

People call off a lot. I think it's a survival strategy. I've been seeing a lot of people whose doc just left. "Are you going to be my new psychiatrist?" they ask. "No." I say. Some sigh resignedly. Some look like they're about to cry. Some get mad.

I should be working on credentialing stuff, but I'm staring out the window and thinking about a bath and a nap.

 

[Shikima]

You are very sweet. Everyone needs cheese to go with their whine. A violin might also be nice . . . and all I have is a guitar.

I remember when I interviewed the Big Boss said that the top quality he looked for in an potential new hire was someone who "wouldn't call off with the sniffles." In retrospect, I'm wondering if this was some sort of red flag. Of course you shouldn't call off with the sniffles. I have never in my life called off with the sniffles. As an intern I was on call in the ICU with bilateral viral conjunctivitis and covered it like a boss. (I told my chiefs ahead of time, "Hey, I might be contagious. Is that a problem?" "No," they said.)

But what in his mind are "the sniffles" exactly? Because I'm thinking that I may have just called off with the sniffles. But really I called off with a raging case of the "can't evens". Is that different?

People call off a lot. I think it's a survival strategy. I've been seeing a lot of people whose doc just left. "Are you going to be my new psychiatrist?" they ask. "No." I say. Some sigh resignedly. Some look like they're about to cry. Some get mad.

I should be working on credentialing stuff, but I'm staring out the window and thinking about a bath and a nap.

How long before your current contract ends?