How was your experience at a CMHC?

[Symmetry11]

Were the patients challenging? Did you feel like you impacted their health? Was is stressful? Did you feel fairly compensated? Do you think there is a better way to help under served populations? Can you do PP with this job?

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[sunlioness]

Yep.

Not much.

Yes.

No.

There has to be.

Probably.


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[Symmetry11]

Yep.

Not much.

Yes.

No.

There has to be.

Probably.


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Could you please elaborate on why you felt you didn't impact their health much and why CMHC's are not as effective in treating patients? Also, were these the factors that made it so stressful? I imagine going through as many patients as you would at a CMHC has to be stressful but also rewarding if you get the job done.

 

[smalltownpsych]

At the community mental health centers that I have seen and worked at there was too much emphasis on medications and compliance. The psychiatrists are marginalized into a med management role and overwhelmed by the sheer number of patients they see. Poorly trained therapists who feel their job is to tell the patients how to live their lives and that see every problem as "refer for med change" or "are you taking your meds". There are typically no psychologists involved in these settings and if so they are often marginalized as well. There is also a lack of structured day treatment/activity programs that have been demonstrated to be effective. There is also the agency mentality that saps the life out of many govt agencies. Also there is lack of coordination and cooperation and the politics amongst the various agencies in the community that deal with the patients and sometimes outright hostility. If you are going into that area, just be prepared. I kind of like it myself because I like to fight the system. I had to leave though because they just don't pay.

 

[Symmetry11]

At the community mental health centers that I have seen and worked at there was too much emphasis on medications and compliance. The psychiatrists are marginalized into a med management role and overwhelmed by the sheer number of patients they see. Poorly trained therapists who feel their job is to tell the patients how to live their lives and that see every problem as "refer for med change" or "are you taking your meds". There are typically no psychologists involved in these settings and if so they are often marginalized as well. There is also a lack of structured day treatment/activity programs that have been demonstrated to be effective. There is also the agency mentality that saps the life out of many govt agencies. Also there is lack of coordination and cooperation and the politics amongst the various agencies in the community that deal with the patients and sometimes outright hostility. If you are going into that area, just be prepared. I kind of like it myself because I like to fight the system. I had to leave though because they just don't pay.

So what other options are there to help the under served? Could a psychiatrist do pro bono work a day or two a week to not deal with the hassles of a CMHC or is it better to deal with that stuff and still get compensated?

 

[sunlioness]

Open your own practice and take Medicaid. Or work some hours in a free or sliding scale clinic.

Or better yet, get some sort of policy experience and advocate for a system better than CMH.

You can't impact anyone's health when you don't know them, they have a thick chart written in bad handwriting and all you get is fifteen minutes to figure it out. And you're repeating that experience about thirty back to back times a day while your phone is constantly ringing and people are constantly in your office needing paper work filled out.

Add to that, a salary in the mid 100s and no chance of raise because despite how many patients you see every day, you're not meeting your "utilization targets" and no.

It just flat out sucks. And both docs and patients deserve better.

Also smalltownpsych is right. Get used to hearing, "My therapist scheduled this appointment because my meds aren't helping my anger."

Or maybe the people who are there for court ordered treatment, but they won't tell you why and their PO hasn't sent the records. Or they're there for court ordered treatment and you know why and they have substance issues, but you can't prescribe naltrexone because some judge in your county decided that drugs designed to help with addiction are as bad as the addictive substance itself.


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[Shikima]

It goes for the VA too. Especially with the marginalized therapists.

Now that I think about it.... Government does a bad job in health care.

 

[AcronymAllergy]

It goes for the VA too. Especially with the marginalized therapists.

Now that I think about it.... Government does a bad job in health care.

This actually hasn't been the experience at he VAs where I've worked, but as the saying goes, "if you know one VA, you know one VA." The universal theme at VAs with which I'm familiar has been understaffing--folks leave or rotate out of positions more quickly than they can be filled, backfilling approval for these positions is often woefully delayed, and space to have the necessary number of providers (even if funding for all those providers were magically available) is in short supply.

VA psychiatrists do often seem to be asked to fill a primarily medication management role, and there's always pressure to see more patients (although perhaps not to the extent of the typical CMHC), but because they're so sought after, if a psychiatrist made it known that they'd only come on board if they could provide therapy, it might be possible to work something out. Folks here who've interviewed for VA positions would know more about that than me, as I only have a psychologist's perspective (which is basically, "we value psychologists but don't have any trouble finding them, so you won't be getting anything special"). VA psychiatrists also seem to be able to spend more time with patients than at a typical CMHC, and as antiquated as CPRS is, having centralized EMR that's been around for a couple decades beats having to track down paper charts in understaffed medical records rooms.

Same goes for therapists. In the VAs where I've worked, they're generally well-regarded and have as much institutional support as any other service. There's a much bigger push (at least in my experience) for EBPs than at the typical CMHC, although because of some of the understaffing issues, therapists aren't necessarily able to see patients weekly as would be ideal.

Unlike CMHCs, there's the whole snafu situation that is C&P/service connection, which adds various layers of frustration for providers.

 

[notdeadyet]

Folks have very different impressions of VAs, CMHCs, corrections, etc. and portray their experiences very differently. At first I thought it was a regional thing, but I think that it is really an issue of staffing. Which troubles me.

CMHCs experiences with the endless sea of warm bodies you see every q3 months is a reflection of short staffing. Many VAs can be similar affairs with few resources to send your veterans too because you lack the people to offer the programming. Corrections work can be constant triage when you have a handful of psychiatrists caring for thousands of inmates. PES's can be just IMing psychotic folks, putting suicidal folks in a corner without sharp objects, and refilling meds without spending more than 5 minutes with a patient. Academic gigs can see you with more and more patients piled on because they're not going to go anywhere, and hey, we all have to pitch in.

But a lot of folks have the opposite experiences at all these places and a lot of the time it seems to boil down to staffing. When you have more staff delivering the services and you can deliver them more appropriately, folks seem to be much more satisfied with working in public psychiatry. What troubles me about this is that I think it furthers the issue of underserved by consolidating psychiatrists. Psychiatrists will naturally flock to areas where their work life is more satisfying and leave other areas worse up for psychiatrists, which short-staffs and makes those jobs even less desirable.

 

[hamstergang]

So what other options are there to help the under served? Could a psychiatrist do pro bono work a day or two a week to not deal with the hassles of a CMHC or is it better to deal with that stuff and still get compensated?

I think this forum could be a little more helpful to you if we understood your motivation for asking all these questions. Do you have some sort of practice in mind, and if you get the sense it's not possible then you won't pursue medical school and then psychiatry? Or are you set on your path and are just trying to get a sense of what's possible for you more than 8 years down the line? Or, what?

 

[F0nzie]

I think I may have developed PTSD working at my CMHC. There is a case manager that likes to suddenly storm in my office to observe my startle response. Pretty hilarious!


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[sunlioness]

I think I may have developed PTSD working at my CMHC. There is a case manager that likes to suddenly storm in my office to observe my startle response. Pretty hilarious!


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Yeah. That's me when my phone rings

 

[Doctor Bagel]

Were the patients challenging? Did you feel like you impacted their health? Was is stressful? Did you feel fairly compensated? Do you think there is a better way to help under served populations? Can you do PP with this job?

I briefly did community MH part-time with the thought that I'd start a private practice. I wound up combining it with an inpatient job and then bailed for full-time inpatient. Here's what I have for the community job in my neck of the woods.

1. yes. Patients were pretty seriously ill. However, with the agency I worked for, the type of patients you had varied based on which clinic you were in. My patients were mainly SPMI (severe/persistent mentally ill) who lived in group homes with refractory illness. I filled in some in a clinic on the other side of town, and there I saw a lot of borderline personality disorder. Mine were easier overall because access to therapy was pretty limited. In my clinic, there were lots of patients with lots of med trials, and minor but not major success stories. It felt a bit like providing palliative care.

2. See above about palliative care. I honestly didn't feel too impactful, but I think being there maybe gave a little more than I thought. Patients certainly seemed grateful because my agency had such a shortage of providers. Lots of things limited my ability to help, though, including significant psychosocial factors for my patients, and big problems in the agency with therapists who were overworked and quitting all the time. 60+ patients on a panel, $40k/year, first job out of school = only sticking around for six months or so.

3. Compensation was OK. More than academic/VA jobs although with fewer benefits. Benefits weren't so great. Not compensation on the level you see in the money thread going on right now, but you'd make above $200k working full-time. Pretty close to $200k but above $200k.

4. Don't know. Maybe not.

5. Yeah, totally. That's the upside. Lots of folks do part-time community + private practice. Community agencies are usually pretty flexible with work arrangements because they are so freaking short- staffed and happy to get what they can. Things to watch out for, though, are how much your agency might expect you to do when you're not there. Mine was actually pretty good in that there was no expectation for me to answer my phone or emails on days I wasn't there. Not so true with other places in my town from what I've heard.

 

[splik]

3. Compensation was OK. More than academic/VA jobs although with fewer benefits. Benefits weren't so great. Not compensation on the level you see in the money thread going on right now, but you'd make above $200k working full-time. Pretty close to $200k but above $200k.

there are huge regional variations in psychiatrist compensation, OR has (one of) the best medicaid reimbursement rates for mental health in the country too. where I am, one of the largest community mental health centers pays about 145k, and there are some parts of the country where you can expect to make quite a bit over 200k.

 

[smalltownpsych]

So what other options are there to help the under served? Could a psychiatrist do pro bono work a day or two a week to not deal with the hassles of a CMHC or is it better to deal with that stuff and still get compensated?

I really think that the best way to help the underserved is for doctoral level clinicians with managerial skills to be in administrative roles. Although the director jobs seem to be filled by social workers who make 60-80k a year so I wouldn't do it as a psychologist and no way a psychiatrist would do it.

 

[milesed]

I think I may have developed PTSD working at my CMHC. There is a case manager that likes to suddenly storm in my office to observe my startle response. Pretty hilarious!


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aka "the Cramer entry".
I had a nurse who did this. I'd laugh and tell her to go back out, knock and wait.

 

[Doctor Bagel]

there are huge regional variations in psychiatrist compensation, OR has (one of) the best medicaid reimbursement rates for mental health in the country too. where I am, one of the largest community mental health centers pays about 145k, and there are some parts of the country where you can expect to make quite a bit over 200k.

$145k for full-time work as a physician in a really expensive city. Why are people doing that? I guess if you have no debt, a trust fund and/or a spouse with a good income, it could be feasible. I couldn't pay the interest on my loans, save and pay rent on that salary where you live. I'm guessing that work is being entirely taken over by nurse practitioners and probably nurse practitioners just out of school to reduce their salaries too.

 

[sunlioness]

Here it's $165.

I can't do it.


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