Meaning and money

[Horners]

Have been wrestling quite a bit with these thoughts in my mind and wanted to get perspectives from folks with experience on this.

I tend to over complicate my thoughts about the future and how I plan to practice (currently in residency).

My impression thus far is that insurance based private practice is a game where you find some symptoms correlating to some axis I (aka billable) diagnosis, you push meds which may or may not be effective and to some degree you help the patient.

I often see patients coming in with the alphabet soup diagnoses “patient has a history of MDD GAD ADHD DMDD PTSD” when I see that, I immediately think, this is a traumatized patient with a personality disorder and some psychiatrist out there calls it MDD and gives the patient Zoloft with no real effect because the primary issue with the patient is personality, but the issue with treating personality is that it takes time, effort and addressing genuine catastrophic thought processes which are indeed super valuable but do not make economical sense to do as insurance doesn’t reimburse well for therapy.

^ that is my impression of practicing in the insurance world. I want to be wrong about this so please educate me.

In the private pay fee for service world, I imagine myself as this “see through the BS” psychiatrist who doesn’t jump to medications that treat symptoms and actually addresses the real root causes of dysfunction for the patient without being pulled by the insurance machine to make a diagnosis and push medications which may or may not be helpful.

Of course the downside to this fee for service kind of practice is that I cannot really scale it, I don’t have real equity in it because these patients are only tied to me personally.

My question(s) boils down to:
1. Can I practice psychiatry meaningfully and build a great business? Or will the two forever be at odds?

2. How exactly wrong am I in my impressions of the private pay vs insurance world? Please be brutal.

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[deleted1100659]

1. Yes. Just because other people may be **** doctors does not mean you have to be one. Every past diagnosis I hear that a patient has is a "patient reported diagnosis" until I confirm the diagnosis or have ample evidence to confirm to the diagnosis. I treat accordingly with the goal of improving patient quality of life and ensuring its done in a safe manner as possible.

2. You can go into academics, community mental health, hospital based practices, etc. Each sector prioritizes different things. Usually the private practices are production based, "turn and burn" conveyor belt psychiatry (from my experience so far). Community mental health they get funding through other sources (im in this setting) and we have access to things like ACT team, substance abuse groups, supported employment, etc. I had a patient today, when i first saw him, was on 16 psych meds. I have him down to 3. Hes doing amazing. He had severe TD from all the antipsychotics they through on him, just from peeling away his meds and adding austedo his QOL has drastically improved. Some of the hospital systems seem to prioritize quality as well, each setting has its own pros and cons. Community setting will be your higher/possibly highest acuity setting in outpatient, as I definitely see the sickest of the sick

 

[Sushirolls]

I take insurance.
I don't do much therapy at all.
But I do spend time to get more of a reflective diagnosis and undue the alphabet soup diagnoses (mostly from ARNPs previously treating them).
I use pharmacotherapy but always give real expectations of what it can offer - especially in context of axis II - and openly discuss.
People get informed and pointed in the right direction even when I'm not doing intervention XYZ.

You are still in training and full of hope and vigor. Good for you. Keep shaping your dream.

At my current stage its less about the quality I offer but coming to terms with the lower levels of engagement that patients bring with them. I.e. the conflict of 'fix me, fix me great, and do it fast' or the 'I'm going the motions of being in your office but I'm going to ignore or disagree with most of your recommendations.'

You paint a concerned picture of insurance based pharmacotherapy heavy practices. A neurostimulation practice could equally turn their noses up at therapy practices for a myriad of reasons.

In summary pick a delivery model of cash or insurance, probably doesn't matter, but be ready to navigate offering what you can (accept what you can't) and accept the limited progress of patients that you know could have achieved so much more. You can't do it all, and you can't "fix" 'em all.

 

[clozareal]

You can definitely build a great business for yourself in private practice and be profitable for your services. I don't see how providing a service and getting paid for it would be at odds if the patient is aware of what they are paying for.

Scaling it is a different question. If you want to scale, you can still do a fee for service model and take a cut of the services being provided by your team for doing the admin work (marketing, managing referrals and intakes, handling the billing/finances, etc.). The more common way is to contract with insurances which if you have a group, the leverage in negotiation is higher and I've seen it be higher than common rates for private pay in the area.

I know many solo private practice psychiatrists in my area who accept 1-3 insurances that approximate their private pay rates. You get a different set of patients than you would if you take insurance.

I think you're suffering from a selection bias from seeing complex patients in resident clinics that stay there and don't get discharged because they can't go anywhere else that will take them. In the community, private and group practice patients are much less complex, the threshold to discharge patients who aren't following your recommendations is much lower, and the barrier to get in the front door and be in your care is much higher. If you don't want to work with patients personality disorders, then you can screen this out and refer to those who are better equipped to treat these types of patients.

 

[rjs2131]

You can definitely have a PP that is insurance-based and do meaningful work (including therapy). Insurance guidelines do make it difficult to bill higher rates (99214+) via insurance if you aren't prescribing medication, but that's something to think about down the road in terms of the split you want. The nice thing about PP is that you can choose that split and figure out what amount you're willing to sacrifice to be able to have a handful of therapy patients (or not).

It helps me to think about insurance coding/billing/diagnoses as a separate entity. I tend to use the "anxiety unspecified" or "depression unspecified" diagnoses a lot when I'm initially working with patients so that I don't feel pressured to put them into a box that doesn't quite fit. Over time, they usually fit into something more clearly but even if they don't, I'm okay with just classifying them as "unspecified" as long as we're doing good work and they're making progress. I'm sure people have differing opinions on this but personally, as long as I have a reasonable understanding of the patient and they are improving/moving in a positive direction with our interventions, I don't care so much about having the "exact" diagnosis.

 

[R. Matey]

I think having a strong referral network of therapists you trust can go a long way too in PP. You may not be able to help every patient yourself, but at the very least, you can have some faith in where they're going.

 

[whopper]

IMHO this is an ethnical business model.

You profit as much as you can off of everything you can that's still following the ethical rules, so your bottom line won't be hurt by working on the cases that don't make so much money and doing the balancing act.

Fortunately several things that turn up a better profit are good practice such as good documentation, not wasting time, using efficient EHR and communication methods.

 

[Candidate2017]

My impression thus far is that insurance based private practice is a game where you find some symptoms correlating to some axis I (aka billable) diagnosis, you push meds which may or may not be effective and to some degree you help the patient.

I often see patients coming in with the alphabet soup diagnoses “patient has a history of MDD GAD ADHD DMDD PTSD” when I see that, I immediately think, this is a traumatized patient with a personality disorder and some psychiatrist out there calls it MDD and gives the patient Zoloft with no real effect because the primary issue with the patient is personality, but the issue with treating personality is that it takes time, effort

^ that is my impression of practicing in the insurance world. I want to be wrong about this so please educate me.

In the private pay fee for service world, I imagine myself as this “see through the BS” psychiatrist who doesn’t jump to medications that treat symptoms and actually addresses the real root causes of dysfunction for the patient

Yes, 3rd party payor practice is a game. Not the one you visualize. But more like an adventure quest where you dodge controlled substance seekers, admin nonsense, trainwreck regimens from patients' prior NPs, lawsuits, etc. Occasionally, as part of your quest, you may even run across patients that are willing to do the work to get better or stay well, in addition to collecting bonuses.

You are correct that treating personality takes time and effort. However, that time and effort must come from the patient not the psychiatrist. You are incorrect to assume the treating psychiatrist is just throwing meds at a patient for billing purposes, has not tried non-pharmacological approaches, and has not already "seen through the BS" of the patient.

It's quite common in the academic world to believe psychiatry is a procedural specialty and lay blame on a psychiatrist/resident if a patient does not get better. Don't fall into that trap. Would you blame a PCP for throwing HTN, DM, and nicotine meds at an obese patient who has no interest in diet, exercise, and smoking cessation? And for whom meds are barely working? Psychiatrists merely point the way and can only engage with patients who want to meaningfully engage. To think otherwise is to be narcissistic faculty. Or a social worker.

Anyway, the problem isn't "seeing through the BS". It's about accepting it and shoveling through mounds of it in the middle of a hurricane.

 

[Horners]

Great discussion I very much appreciate all of your collective insights on this, too many good posts to reply to you all individually.

I guess there’s another root to this issue, which is really a systemic issue.

Why are axis II not reimbursed? The quality of mental health care and actually efficiency at our jobs would greatly increase if we had sensible diagnoses such as “current major depressive episode secondary to underlying cluster B personality disorder/traits”

So that the patient and all providers reading can work on the patient’s actual problem which would be DBT focused interventions.

Admittedly, I am very cynical nowadays with my diagnostic approach and I am quick to believe really the majority of what I see is behavioral/personality issues that medications don’t fully address.

I definitely don’t know what I don’t know and maybe that’s what I’m struggling with. Maybe it’s an ego thing for me to actually want to “help” the patient.

 

[clozareal]

Usually you would have another diagnosis along with a personality disorder diagnosis to get reimbursement. That's not the issue. The issue is with psychiatrists/psychotherapists with enough training to feel like they can treat these patients.

DBT isn't the only treatment that works for borderline personality disorder.

You can definitely help patients with personality disorders, but you'll need to learn the tools outside of your training in order to do so if you're not getting it from your training program.

 

[Horners]

Usually you would have another diagnosis along with a personality disorder diagnosis to get reimbursement. That's not the issue. The issue is with psychiatrists/psychotherapists with enough training to feel like they can treat these patients.

DBT isn't the only treatment that works for borderline personality disorder.

You can definitely help patients with personality disorders, but you'll need to learn the tools outside of your training in order to do so if you're not getting it from your training program.

And if axis II was reimbursed there would be investment into incorporating these tools into psychiatric education and eventually treatment which actually will reduce re admits and suicide.

Have psychiatrists ever lobbied to actually fight this? Insurance companies aren’t going to start doing it out of the goodness of their hearts

 

[splik]

Why are axis II not reimbursed? The quality of mental health care and actually efficiency at our jobs would greatly increase if we had sensible diagnoses such as “current major depressive episode secondary to underlying cluster B personality disorder/traits”

This is a semi-myth, and is partly geographic. All the major commercial insurance companies and medicare do reimburse care for patients with personality disorders. However, often community mental health services will only cover care for patients with certain diagnoses (e.g. MDD, bipolar, schizophrenia, schizoaffective, PTSD). Also inpatient admissions typically require more than a personality disorder diagnosis, though suicidal ideations or suicide attempt could potentially count though some will want an F code as a primary diagnosis.

However, the mental health parity act and the ACA only require mental health coverage for what are called "parity diagnoses". States also have their own laws and definitions of what diagnoses count. Personality disorder diagnoses typically are not included. Sometimes BPD is included, but not other diagnoses.

In the states I trained and worked in, there was no problem with reimbursement for care for pts with personality disorders unless they were reliant on medicaid (and then half the problem is the lack of services available to that patient population not the reimbursement).

I think you are conflating different issues. The reason that so much care is bad out there is because of laziness, greed, incompetency, and self-preservation. The laziness as you describe is the fact it is easier to prescribe a pill than it is to formulate patients more thoughtfully and provide more comprehensive care. The greed is that volume pays. It is not that therapy doesn't pay, but that the more patients you see the more money you will make. The incompetency is that so many psychiatrists and others are poorly trained in phenomenological interviewing and psychological formulation. The self-preservation is that really getting in the trenches with patients and sitting with painful emotions and exploring traumatic experiences is exhausting and can lead to vicarious traumatization. Much simpler to dissociate by using telemedicine, shorter visits, focusing on symptoms, and prescribing drugs.

Once you finish training you have significant latitude in where and how you practice, the colleagues you surround yourself with, the patients you treat, and the modalities that you use.

I am very fortunate that I have complete flexibility in when I see patients (never before 10, usually later), how long I spend with them (i have 2.5 hours for new pt evals and usually an hour for follow ups), see patients for weekly or twice weekly therapy where indicated, and do not prescribe very often (though also have pts who require complex psychopharm management). And I am employed and see mostly pts with insurance, including medicare and medi-cal [though most medi-cal plans will not reimburse for therapy by MDs] I will add that my work set up in highly unusual and likely only works for academic quaternary care programs.

 

[Horners]

This is a semi-myth, and is partly geographic. All the major commercial insurance companies and medicare do reimburse care for patients with personality disorders. However, often community mental health services will only cover care for patients with certain diagnoses (e.g. MDD, bipolar, schizophrenia, schizoaffective, PTSD). Also inpatient admissions typically require more than a personality disorder diagnosis, though suicidal ideations or suicide attempt could potentially count though some will want an F code as a primary diagnosis.

However, the mental health parity act and the ACA only require mental health coverage for what are called "parity diagnoses". States also have their own laws and definitions of what diagnoses count. Personality disorder diagnoses typically are not included. Sometimes BPD is included, but not other diagnoses.

In the states I trained and worked in, there was no problem with reimbursement for care for pts with personality disorders unless they were reliant on medicaid (and then half the problem is the lack of services available to that patient population not the reimbursement).

I think you are conflating different issues. The reason that so much care is bad out there is because of laziness, greed, incompetency, and self-preservation. The laziness as you describe is the fact it is easier to prescribe a pill than it is to formulate patients more thoughtfully and provide more comprehensive care. The greed is that volume pays. It is not that therapy doesn't pay, but that the more patients you see the more money you will make. The incompetency is that so many psychiatrists and others are poorly trained in phenomenological interviewing and psychological formulation. The self-preservation is that really getting in the trenches with patients and sitting with painful emotions and exploring traumatic experiences is exhausting and can lead to vicarious traumatization. Much simpler to dissociate by using telemedicine, shorter visits, focusing on symptoms, and prescribing drugs.

Once you finish training you have significant latitude in where and how you practice, the colleagues you surround yourself with, the patients you treat, and the modalities that you use.

I am very fortunate that I have complete flexibility in when I see patients (never before 10, usually later), how long I spend with them (i have 2.5 hours for new pt evals and usually an hour for follow ups), see patients for weekly or twice weekly therapy where indicated, and do not prescribe very often (though also have pts who require complex psychopharm management). And I am employed and see mostly pts with insurance, including medicare and medi-cal [though most medi-cal plans will not reimburse for therapy by MDs] I will add that my work set up in highly unusual and likely only works for academic quaternary care programs.

This was great. Thank you for spending the time to write that out. I genuinely just want to have a fulfilling career and also create a business that I’m proud of.

Maybe at this stage in the game, I really see a ton of BPD and I get so frustrated because I am still mainly in the inpatient/ED/CL portions of my training and I feel so useless because I’ll spend time really talking to these patients and all of their destructive thought processes unravel in front of me and I see so much space to really work (and I do it when I can) but their follow up care is typically therapists who are hugely useless (I’m sure there are good ones out there, and the ones with good ones don’t make it to where I see them) and/or lazy/incompetent prescribers.


Anyone in this group who worked in a partial or IOP or who has done DBT groups/clinic care to chime in? Would love to hear about that aspect of care.

 

[clausewitz2]

1. Yes. Just because other people may be **** doctors does not mean you have to be one. Every past diagnosis I hear that a patient has is a "patient reported diagnosis" until I confirm the diagnosis or have ample evidence to confirm to the diagnosis. I treat accordingly with the goal of improving patient quality of life and ensuring its done in a safe manner as possible.

So much this. All of my intake assessments start with "Patient is a something-something yo m/f/person with historical dx of ....". Short of truly compelling documentation I am not going to assume anything about what they are dealing with apart from the information I collect myself.

EDIT: as to #2 of your post, private practice insurance-based psychiatry can be a production line if maximizing income is really the only goal but depending on your payors and where you are, you really don't have to take much of a financial hit to pump the brakes and slow down for cases that deserve it. I am mostly in private insurance-based practice and I don't have appointments that run shorter than 30 minutes. Sure, sometimes this is probably unnecessary for my high-functioning adult ADHD folks some of the time, but you'd be surprised how often stretching things out and having the time to probe even a little bit dredges up concerns about whether or not they have a handle on their drinking or insomnia or intense worry about their job performance or a horrific personal relationship. I tell people I don't want to invent problems where they don't exist but also want to make sure they get their money's worth, and after a few repetitions even the folks who initially just want to have their stimulants refilled, thanks, often get into other things troubling them.

And if not, great. If you don't have much to say to your psychiatrist, you are probably winning at life. That usually gets a laugh.

 

[clausewitz2]

I think having a strong referral network of therapists you trust can go a long way too in PP. You may not be able to help every patient yourself, but at the very least, you can have some faith in where they're going.

I have learned this the hard way. When I was just starting out and had a lot of empty slots it was easy to (for appropriate cases) say "sure, I'll see you for therapy as well on a weekly basis." Now that I struggle to get an established patient an urgent 30 minute slot less than 3 weeks out, this is no longer nearly as feasible. I have had to learn to relinquish my desire to apply the intervention that I strongly suspect will be helpful myself and instead provide encouragement and reinforce motivation to seek that intervention from someone else. A good referral network helps a lot.

I work with a practice of therapists who are pretty specialized so for some issues they are absolutely top-notch (although with a long waiting list), but if someone presents with classic BPD they are not necessarily the greatest fit.

 

[clausewitz2]

It's quite common in the academic world to believe psychiatry is a procedural specialty and lay blame on a psychiatrist/resident if a patient does not get better. Don't fall into that trap.

I hate this attitude. Even surgeons understand that there is only so much they can do and a fair amount of their outcome is out of their hands. The vascular surgeons don't blame themselves when their repeat customers come in for another partial amputation because they won't take their insulin and stop smoking.

 

[ObsequiousAplomb]

This was great. Thank you for spending the time to write that out. I genuinely just want to have a fulfilling career and also create a business that I’m proud of.

Maybe at this stage in the game, I really see a ton of BPD and I get so frustrated because I am still mainly in the inpatient/ED/CL portions of my training and I feel so useless because I’ll spend time really talking to these patients and all of their destructive thought processes unravel in front of me and I see so much space to really work (and I do it when I can) but their follow up care is typically therapists who are hugely useless (I’m sure there are good ones out there, and the ones with good ones don’t make it to where I see them) and/or lazy/incompetent prescribers.


Anyone in this group who worked in a partial or IOP or who has done DBT groups/clinic care to chime in? Would love to hear about that aspect of care.

I mean this in a nice way, though it may sound harsh.

Have you considered that your impression is a little arrogant and a self-centered view of the situation? You say you're working in ED/CL/IP. I imagine by IP you are referring to short-term, acute care, < 7 day average LOS. So by spending time to sit with the patient you mean what, exactly? 5, 10, or 15 more minutes than the average ED/CL/IP provider?

I find it hard to believe you talk to the person for more than two total hours during their stay. An average OP psychiatrist spends 40-60 minutes the first time, then 10-30 minutes each follow-up. Their therapist is probably spending 40-55 minutes each time they meet with the patient. Assuming all of this time is spent being incompetent, never seeing the thought process, never seeing the patterns of emotional expression?

The OP providers, even the ones that really churn through their caseload, are spending more time with the patient than you ever will in those roles. They see the patient on multiple days across multiple weeks, months, and years. They probably sit with the patient for just as long as if not longer than you are, every encounter for 20+ encounters.

Comparing doctors who have 5 minute OP follow-ups with the rare IP doctors with 30 minutes to talk to each patient is an apples and oranges comparison. I'm sure you have seen IP docs spend < 5 minutes with a patient. The goal of these short-term, acute-care IP facilities isn't to address the root cause of the patient's suffering. It's to stabilize them just enough that they can go out and get the outpatient treatment.

IME, the OP docs that do < 10 minute follow-ups are usually treating patients who have never and probably will never be hospitalized. Or they're working in a for-profit community program where they can access the SW, therapist, group home staff, etc, and they're just continuing Haldol Dec shots. Neither of those are people catering to patients with a personality disorder.

 

[clausewitz2]

Maybe at this stage in the game, I really see a ton of BPD and I get so frustrated because I am still mainly in the inpatient/ED/CL portions of my training and I feel so useless because I’ll spend time really talking to these patients and all of their destructive thought processes unravel in front of me and I see so much space to really work (and I do it when I can) but their follow up care is typically therapists who are hugely useless (I’m sure there are good ones out there, and the ones with good ones don’t make it to where I see them) and/or lazy/incompetent prescribers.

Careful here. I don't doubt that this is probably true in many circumstances, but it is always worth stepping back for a moment and examining whether you are getting drawn into the split. Folks with BPD are prone to generating rescuer/savior fantasies in clinicians who accept uncritically the idea that they'll finally be the ones to fix them, unlike all those other idiots they've seen in the past who were just too greedy or stupid to do their jobs right. Being on the good side of the split is intoxicating and sometimes you can leverage it for positive ends but it will not last forever.

 

[Horners]

I mean this in a nice way, though it may sound harsh.

Have you considered that your impression is a little arrogant and a self-centered view of the situation? You say you're working in ED/CL/IP. I imagine by IP you are referring to short-term, acute care, &lt; 7 day average LOS. So by spending time to sit with the patient you mean what, exactly? 5, 10, or 15 more minutes than the average ED/CL/IP provider?

I find it hard to believe you talk to the person for more than two total hours during their stay. An average OP psychiatrist spends 40-60 minutes the first time, then 10-30 minutes each follow-up. Their therapist is probably spending 40-55 minutes each time they meet with the patient. Assuming all of this time is spent being incompetent, never seeing the thought process, never seeing the patterns of emotional expression?

The OP providers, even the ones that really churn through their caseload, are spending more time with the patient than you ever will in those roles. They see the patient on multiple days across multiple weeks, months, and years. They probably sit with the patient for just as long as if not longer than you are, every encounter for 20+ encounters.

Comparing doctors who have 5 minute OP follow-ups with the rare IP doctors with 30 minutes to talk to each patient is an apples and oranges comparison. I'm sure you have seen IP docs spend &lt; 5 minutes with a patient. The goal of these short-term, acute-care IP facilities isn't to address the root cause of the patient's suffering. It's to stabilize them just enough that they can go out and get the outpatient treatment.

IME, the OP docs that do &lt; 10 minute follow-ups are usually treating patients who have never and probably will never be hospitalized. Or they're working in a for-profit community program where they can access the SW, therapist, group home staff, etc, and they're just continuing Haldol Dec shots. Neither of those are people catering to patients with a personality disorder.

You may very well be correct to assume that I could be arrogant with little insight, seriously.

And quite honestly, I think my diagnostic attitude towards patients might not be seasoned enough to truly make razor sharp assessments. I don’t think I’m completely clueless, I think I probably am missing things that I am not aware of.

In regards to time. The overwhelming majority of my patients I spent 10 minutes in IP except for the few I feel like truly would benefit from the time spent with them.

ED assessments, I tend to take my time (typically 45-60 minutes) if the question to admit or d/c isn’t painfully obvious.

 

[Horners]

Careful here. I don't doubt that this is probably true in many circumstances, but it is always worth stepping back for a moment and examining whether you are getting drawn into the split. Folks with BPD are prone to generating rescuer/savior fantasies in clinicians who accept uncritically the idea that they'll finally be the ones to fix them, unlike all those other idiots they've seen in the past who were just too greedy or stupid to do their jobs right. Being on the good side of the split is intoxicating and sometimes you can leverage it for positive ends but it will not last forever.

I came here for insights and I want to know where I’m going wrong or where I can go wrong, so I definitely appreciate that.

I think it’s important to reality check my self. I’ll be sure to reflect on this.

I do want to say though, i don’t think these alphabet soup diagnoses people are “idiots” I think they know as well or better than I do. But they need to slap an Axis I dx on there to get paid.

 

[dl2dp2]

My question(s) boils down to:
1. Can I practice psychiatry meaningfully and build a great business? Or will the two forever be at odds?

2. How exactly wrong am I in my impressions of the private pay vs insurance world? Please be brutal.

You are not thinking about this the right way. Private pay *is* the great business with meaningful delivery of care that you are looking for. Just because something doesn't scale does not mean that it's not a great business. Big error. Many great businesses, especially in professional services, do not scale BY DESIGN. Think about top boutique professional services firms, their profit per partner wildly exceeds the average executive comp of a fortune 500 company that "scales".

The reason you are thinking wrong is this: the problem with private pay psychiatry is not that it's bad business because it doesn't scale, it's that it's a great service but it's not ACCESSIBLE for those who don't have the money. Furthermore, to be brutally honest, the value-add for people who can't afford private pay is very often not as high as for those who can. The typical Medicaid recipient just cannot generate much monetary benefit from becoming intensive therapy that shore up people's identity so they can pursue a lucrative professional career (which is inaccessible because of OTHER issues unrelated to their mental health). Do you understand how this works now?

You need more conceptual clarity. Do you CARE about access (in that way)? I would argue that if you do care about access, the issue cannot be solved by altering patterns of your individual practice. You'd have to work in a different capacity (i.e. administration, research, policy, etc). The govt decided that everyone deserves SOME mental health care, but there is a HUGE variance in terms of "quality" (however you define it) and intensity. It's simply not feasible to cover everyone for the kind of "high-quality"/ "meaningful" care that private psychiatrists are delivering in practice. In fact, it's very hard to PROVE scientifically that the alphabet soup style practice you are decrying is WORSE than whatever kitchen sink intensive therapy you want to throw at this patient. Hence the proliferation of NPs, etc. etc. And in fact it may NOT be worse in some metric.

If you think about it, is a $20 bag from Walmart "worse" than a $2000 bag from Gucci? Not in the sense that they can fulfill the same function on a practical basis--that's a question of access. But do *you* prefer to make a bag for Gucci or Walmart, that's a personal professional chocie. Don't confuse the two questions.

 

[Horners]

You are not thinking about this the right way. Private pay *is* the great business with meaningful delivery of care that you are looking for. Just because something doesn't scale does not mean that it's not a great business. Big error. Many great businesses, especially in professional services, do not scale BY DESIGN. Think about top boutique professional services firms, their profit per partner wildly exceeds the average executive comp of a fortune 500 company that "scales".

The reason you are thinking wrong is this: the problem with private pay psychiatry is not that it's bad business because it doesn't scale, it's that it's a great service but it's not ACCESSIBLE for those who don't have the money. Furthermore, to be brutally honest, the value-add for people who can't afford private pay is very often not as high as for those who can. The typical Medicaid recipient just cannot generate much monetary benefit from becoming intensive therapy that shore up people's identity so they can pursue a lucrative professional career (which is inaccessible because of OTHER issues unrelated to their mental health). Do you understand how this works now?

You need more conceptual clarity. Do you CARE about access (in that way)? I would argue that if you do care about access, the issue cannot be solved by altering patterns of your individual practice. You'd have to work in a different capacity (i.e. administration, research, policy, etc). The govt decided that everyone deserves SOME mental health care, but there is a HUGE variance in terms of "quality" (however you define it) and intensity. It's simply not feasible to cover everyone for the kind of "high-quality"/ "meaningful" care that private psychiatrists are delivering in practice. In fact, it's very hard to PROVE scientifically that the alphabet soup style practice you are decrying is WORSE than whatever kitchen sink intensive therapy you want to throw at this patient. Hence the proliferation of NPs, etc. etc. And in fact it may NOT be worse in some metric.

If you think about it, is a $20 bag from Walmart "worse" than a $2000 bag from Gucci? Not in the sense that they can fulfill the same function on a practical basis--that's a question of access. But do *you* prefer to make a bag for Gucci or Walmart, that's a personal professional chocie. Don't confuse the two questions.

In regards to accessibility, if I were to do a cash PP, I would implement some sort of sliding scale or payment plan to increase access. Obviously not a perfect system, but I think it would help.

Not sure I agree your conception that a good business is not a scalable business. I’m not sure why you think that, please elaborate if you can. Boutique doesn’t equal more revenue or more profit.

From what I understand, the proliferation of NPs isn’t because alphabet soup providers are equivalent to cash PP psychiatric care, the proliferation of NPs is done exactly to scale and stretch one MD into 5 MDs. They simply function as forever residents with varying degrees in quality.

I would be very, very hard pressed to accept the idea that they have similar outcomes unless I see some demographic controlled studies on the two and I’m open to reading it.

If we’re talking about bags, I kind of don’t want to be Walmart or gucci, I want to be Kate Spade… lol I hope that metaphor translates

EDIT: I realize Kate Spade died by suicide and I’m actually not referring to that. I’m literally talking about quality of bag. Their bags are like $100-$500+ so not $20, not $2000. Just want to be clear about that.

 

[Candidate2017]

The reason that so much care is bad out there is because of laziness, greed, incompetency, and self-preservation. The laziness as you describe is the fact it is easier to prescribe a pill than it is to formulate patients more thoughtfully and provide more comprehensive care.

I am very fortunate that I have complete flexibility in when I see patients (never before 10, usually later), how long I spend with them

I will add that my work set up in highly unusual and likely only works for academic quaternary care programs.

Again, this is the BS attitude perpetuated by the academic world that patients are mere objects to be acted upon by psychiatrists, and if patients don't get better it's because their "psychiatrists are incompetent, lazy, and greedy (except for me, of course)."

It doesn’t matter how much time you spend or how thoughtful your case formulation, or if you're Becker or Linehan or Freud, the patient must be willing to undergo painful change on some level.

I hate this attitude. Even surgeons understand that there is only so much they can do and a fair amount of their outcome is out of their hands. The vascular surgeons don't blame themselves when their repeat customers come in for another partial amputation because they won't take their insulin and stop smoking.

What the academic BS people don't understand is that proceduralists and surgeons screen for patients who are appropriate candidates for their intervention.

While psychiatry is not a procedural specialty, psychotherapy itself is a procedure. But not every patient who passes through clinic is appropriate for, or can tolerate, the surgeon's scalpel or the psychiatrist's gold standard intervention of actual psychotherapy.

 

[Candidate2017]

I really see a ton of BPD and I get so frustrated because I am still mainly in the inpatient/ED/CL portions of my training and I feel so useless because I’ll spend time really talking to these patients and all of their destructive thought processes unravel in front of me and I see so much space to really work (and I do it when I can) but their follow up care is typically therapists who are hugely useless (I’m sure there are good ones out there, and the ones with good ones don’t make it to where I see them) and/or lazy/incompetent prescribers.

So... you feel frustrated, useless, helpless, and view therapists and psychiatrists as largely useless, lazy and incompetent. Does this sound familiar? Like a certain patient population with a certain diagnosis?

Borderline patients are masters of projective identification, and OP it seems you have introjected a lot. Have you recognized this? Has your supervisor pointed this out?

 

[Horners]

So... you feel frustrated, useless, helpless, and view therapists and psychiatrists as largely useless, lazy and incompetent. Does this sound familiar? Like a certain patient population with a certain diagnosis?

Borderline patients are masters of projective identification, and OP it seems you have introjected a lot. Have you recognized this? Has your supervisor pointed this out?

Interestingly I’ve actually clarified I don’t view other mental health care professionals as any of those things. My main gripe isn’t with other clinicians, it’s with the insurance industry and how it forces us to give a patient an axis I diagnosis in order to get reimbursed, which actually I’ve been educated on from Splik.

I’m frankly not sure why SDN threads tend to devolve into name calling or these unfair assumptions. I also have never gone to therapy or seen a psychiatrist, might not be a bad idea to see one. I really just wanted to learn, not only about the business side of things, but your general thoughts about treating patients in a meaningful way. Maybe that came off as narcissistic or self-centered and I probably still have learning to do, which is why I started this thread…

But to assume I am personality disordered off of assumptions and an internet discussion, I find hard to swallow, and I’m sorry you feel that way.

 

[calvnandhobbs68]

I came here for insights and I want to know where I’m going wrong or where I can go wrong, so I definitely appreciate that.

I think it’s important to reality check my self. I’ll be sure to reflect on this.

I do want to say though, i don’t think these alphabet soup diagnoses people are “idiots” I think they know as well or better than I do. But they need to slap an Axis I dx on there to get paid.

Or to prescribe meds. As you alluded to, some of this is playing an insurance game whether you actually take insurance or not.

I'll never get Rexulti approved by insurance for someone for instance if I they don't have a MDD diagnosis. I'll never get Latuda approved for someone unless I give them a bipolar disorder diagnosis. We can go on and on but the point is that when you get to some of these complicated patients especially where you've exhausted other treatment options and you're having to go to branded meds, they have to have a diagnosis that fits into the FDA approved box for the med.

 

[calvnandhobbs68]

In the private pay fee for service world, I imagine myself as this “see through the BS” psychiatrist who doesn’t jump to medications that treat symptoms and actually addresses the real root causes of dysfunction for the patient without being pulled by the insurance machine to make a diagnosis and push medications which may or may not be helpful.

You're talking about incredibly different patient populations here. A lot of those "alphabet soup" diagnosed patients you're seeing in your resident clinic are in a resident clinic for a reason. They are not functional enough or do not have a high enough paying job to pay $300/hr for private pay psychiatry. Cash psychiatry is a limited slice of the overall market which essentially self screens out patient who would be unable to afford it. Most of your resident clinic population (or FQHC population) has "****ty life syndrome"....where you're correct, many of the problems are socioeconomic, trauma, drug use, personality traits, etc etc. But you aren't going to be capturing this patient population in a private pay clinic, as noted above.

I mean you're running into one of the realities of psychiatry here and butting up against what we can realistically do for people, unless you want to start volunteering your time essentially. When I was in a FHQC for 2 years as a resident, I ran into this all the time too. I bet you're depressed, you work at Wendy's 50 hours a week, can barely pay your bills and have a ton of trauma....but if I was an attending what are you going to do about that? Do weekly psychotherapy for basically free?

 

[ObsequiousAplomb]

Interestingly I’ve actually clarified I don’t view other mental health care professionals as any of those things. My main gripe isn’t with other clinicians, it’s with the insurance industry and how it forces us to give a patient an axis I diagnosis in order to get reimbursed, which actually I’ve been educated on from Splik.

I’m frankly not sure why SDN threads tend to devolve into name calling or these unfair assumptions. I also have never gone to therapy or seen a psychiatrist, might not be a bad idea to see one. I really just wanted to learn, not only about the business side of things, but your general thoughts about treating patients in a meaningful way. Maybe that came off as narcissistic or self-centered and I probably still have learning to do, which is why I started this thread…

But to assume I am personality disordered off of assumptions and an internet discussion, I find hard to swallow, and I’m sorry you feel that way.

Horners, they weren't saying you have a personality disorder. I also wasn't saying that. Nobody here was name calling.

Candidate2017 was saying you introjected a component of the projective identification. The presence of splitting and any features of a cluster B personality disorder does not imply that you have a personality disorder. It's just that part of the challenge of talking to and providing care to patients who employ these defenses is that one can identify or introject. Rescue fantasies, collusion with the notion that all their problems are external, etc, are all things that occur in psychiatrically "normal" people who interact extensively with people who engender these feelings in us.

Blaming the insurance companies is another form of externalization of the problem. The presence of what was formerly an Axis II disorder does not preclude the presence of what was formerly an Axis I disorder. The presence of a not-as-lucrative icd-10 diagnosis does not mean that there isn't one that would be better for billing, prior authorization, or other purposes that can apply. Usually more inpatient days are covered if you code schizophrenia (F20.9), psychotic mania (F30.2), secondary mania, or substance-induced psychosis (F19.959) as unspecified psychotic disorder not due to a known substance or general medical condition (F29). Which one are your encounters typically coded as?

If you're addressing a problem, put it in the problem list, assessment, and plan. There will be plenty to bill insurance appropriately in an insurance-taking clinic. In one that takes private pay, it doesn't matter what diagnoses you put on the note unless you're planning to use it for insurance prior authorization for a prescription.

 

[FlowRate]

In the private pay fee for service world, I imagine myself as this “see through the BS” psychiatrist who doesn’t jump to medications that treat symptoms and actually addresses the real root causes of dysfunction for the patient without being pulled by the insurance machine to make a diagnosis and push medications which may or may not be helpful.

Of course the downside to this fee for service kind of practice is that I cannot really scale it, I don’t have real equity in it because these patients are only tied to me personally.

My question(s) boils down to:
1. Can I practice psychiatry meaningfully and build a great business? Or will the two forever be at odds?

2. How exactly wrong am I in my impressions of the private pay vs insurance world? Please be brutal.

A somewhat different take... our expertise is in phenomenological diagnosis and medication management. I'm very pro therapy and that's the main thing missing from my current practice situation. I agree with others that often the right thing is to help direct the patient to a therapist or therapeutic modality that you think will be most helpful. I think it would be really hard to feel like a true expert in multiple therapies if you're trying to provide the full spectrum. Many therapists spend years developing a specific niche/expertise in just one therapy modality.

Why are axis II not reimbursed? The quality of mental health care and actually efficiency at our jobs would greatly increase if we had sensible diagnoses such as “current major depressive episode secondary to underlying cluster B personality disorder/traits”

You can absolutely write the latter part in your assessment/formulation while including MDD, BPD as dx codes.

Maybe at this stage in the game, I really see a ton of BPD and I get so frustrated because I am still mainly in the inpatient/ED/CL portions of my training and I feel so useless because I’ll spend time really talking to these patients and all of their destructive thought processes unravel in front of me and I see so much space to really work (and I do it when I can) but their follow up care is typically therapists who are hugely useless (I’m sure there are good ones out there, and the ones with good ones don’t make it to where I see them) and/or lazy/incompetent prescribers.

Anyone in this group who worked in a partial or IOP or who has done DBT groups/clinic care to chime in? Would love to hear about that aspect of care.

Yes, I did 6 mo with primary role (4 patients) as "med backup" and secondary role (2 pts) as primary therapist in DBT PHP in residency. There's lots of evidence for BPD resolving with time and treatment but it's not usually quick. I think sometimes an interested third party on the inpatient unit can help patients step out of some rigid cognitions but I wouldn't make the assumption that their outpatient therapists haven't been doing the same. Just wait for your outpatient months when you get to experience the constant pull for new medications/dose changes from your constantly-in-crisis BPD patients. Half the time you'll be the beloved savior who's actually showing they care but "doing something" for the patient and the other half of the time they'll hate you for trying to do your best to consolidate medications or simply drawing the appropriate boundary that a med change/dose change isn't the right thing at that time.

In regards to accessibility, if I were to do a cash PP, I would implement some sort of sliding scale or payment plan to increase access. Obviously not a perfect system, but I think it would help.

Much easier said than done. Truly needy patients say (reality of financial concerns for some people often includes priority issues) they can barely afford $10 copays. It would be really hard to not feel resentful when your most difficult patients are also paying you 1/10 of what your other patients are.

I’m frankly not sure why SDN threads tend to devolve into name calling or these unfair assumptions.

You're over-reading their comment. Not sure if you've had the didactics on projective identification yet since you identified likely being in first or second year of residency. The idea is that if you're seeing a lot of borderline patients and going along with the projective identification then you may end up feeling similarly to those patients. They're not necessarily saying that you have BPD. And it's essentially normal at your developmental stage as a psychiatrist (junior resident) to not always be aware of having internalized the projective identification. Heck, it's normal at times for anyone, whether non-psychiatrist or an experienced one, to not be aware of having done the same.

 

[dl2dp2]

In regards to accessibility, if I were to do a cash PP, I would implement some sort of sliding scale or payment plan to increase access. Obviously not a perfect system, but I think it would help.

This doesn't solve the problem. Believe me. I had a sliding scale, and soon enough I can't get enough spots for people who are dying to pay full fee. I raised my full fee multiple times but still have endless inquiries. You can limit part of your practice as sliding scale, but that's more like contributing to charity. It's not "scalable".

Not sure I agree your conception that a good business is not a scalable business. I’m not sure why you think that, please elaborate if you can. Boutique doesn’t equal more revenue or more profit.

Yes it does. The partners at Watchtell Lipton Rosen make way more typically than a C-suite at a Fortune 500. Same is true for hedge funds, accounting, consulting. The elite private boutiques net much more per partner. Same is true for top psychiatrists in the country. Who do you think makes more, the top private pay psychiatrists in each metro markets, or the department chairs at the largest chains in the said markets? I KNOW for a fact that the former make typically 3x the latter.

Professional services as a practice the goal is elite, specialized, small operation, high-profit margin per unit economics (hour time). If you want to *practice* psychiatry, it's much better for your bottomline.

If you are talking about owning and operating a larger business, obviously you need to scale. But that's not practicing psychiatry. Not by a LONG shot. Do you want to be a psychiatrist or do you want to own a business? Figure that out.

From what I understand, the proliferation of NPs isn’t because alphabet soup providers are equivalent to cash PP psychiatric care, the proliferation of NPs is done exactly to scale and stretch one MD into 5 MDs. They simply function as forever residents with varying degrees in quality.

I would be very, very hard pressed to accept the idea that they have similar outcomes unless I see some demographic controlled studies on the two and I’m open to reading it.

Actually, the current tendency is for NP online practices to produce research to show SUPERIORITY. I happen to do executive consulting in this area and know several players that are publishing research on this topic ("mental health technology companies" as they are called). Do a google search and each of the websites have a section on their own papers. It's evident that a properly managed army of NPs might conform *better* to algorithmic practice. Be very careful what you wish for. It's very hard to actually prove that MDs deliver "better care" in the sense of managed-care style outcome evaluation, especially in sicker patients, where the value of care is often very hard to tease out through conventional implementation science.

This is by the way not a psychiatry issue. It's hard and controversial to prove many expensive surgeries and procedures are effective on a "cost adjusted basis".

If we’re talking about bags, I kind of don’t want to be Walmart or gucci, I want to be Kate Spade… lol I hope that metaphor translates

EDIT: I realize Kate Spade died by suicide and I’m actually not referring to that. I’m literally talking about quality of bag. Their bags are like $100-$500+ so not $20, not $2000. Just want to be clear about that.

Sure. This you can do by referring your patients for therapy at a PhD, etc. But just know that combined med + intensive, long term therapy in a personality-disordered patient from a well-trained MD IS the Gucci of mental health.

 

[splik]

Again, this is the BS attitude perpetuated by the academic world that patients are mere objects to be acted upon by psychiatrists, and if patients don't get better it's because their "psychiatrists are incompetent, lazy, and greedy (except for me, of course)."

It doesn’t matter how much time you spend or how thoughtful your case formulation, or if you're Becker or Linehan or Freud, the patient must be willing to undergo painful change on some level.


What the academic BS people don't understand is that proceduralists and surgeons screen for patients who are appropriate candidates for their intervention.

While psychiatry is not a procedural specialty, psychotherapy itself is a procedure. But not every patient who passes through clinic is appropriate for, or can tolerate, the surgeon's scalpel or the psychiatrist's gold standard intervention of actual psychotherapy.

Well I never said if pts don't get better it's because their psychiatrists suck, but a lot of patients who could get better DO receive sub-optimal care (and it's not just a problem in psychiatry, also with therapists, NPs etc). I get more frustrated with bad therapists than bad psychiatrists these days.

I will be the first to say the reason I have good outcomes is that I am highly, highly selective in the patients that I see. They aren't "easy patients" in terms of complexity but any means, but they are highly motivated and engaged. I'm also very frank with patients and families about what can be achieved and what the goals of our work is. You are absolutely right that we have to select patients who are able to benefit from our interventions, and nothing I said contradicts that.

 

[Orgone]

OP your questions have generated some great posts with quality information. And it is good to be thinking about the question "what actually is good treatment, and am I doing it?". But if you actually are a PGY1 as your profile says, and if it is true that you are ruminating on these topics to the point that they are stressing you about your future . . . then my honest and sincere advice that I would give to my sibling is to simply stop thinking about all this, do your work and develop your clinical skills, and do some fun things when you can.

At this point you do not have the experience to understand the pros and cons of what different practice options are out there, which might be better suited for your personality and interests, and to what extent you have the power to tailor them to your own choosing.

It would be like you're doing a research paper and struggling to write your conclusion before the data has even come in.

You'll be better able to start thinking about these issues more sometime end of 3rd and 4th years, but even then your experience will not have prepared you much for understanding what types of private practices you can develop.

 

[TexasPhysician]

In academics/training, you will mostly see how things are done in that program. You don’t see much about how the private world works. If possible, I’d recommend moonlighting in multiple environments. If you want to learn how to build a large, lucrative, scalable business, you need to understand the intricacies about the many different options and where you could fit in within your desired community.

What could work in 1 geographical area may not work elsewhere. Insurance can reimburse so poorly that you can’t even function well yourself in that arena. There are other areas that reimburse so well that accepting cash is a waste of time.

 

[Horners]

Horners, they weren't saying you have a personality disorder. I also wasn't saying that. Nobody here was name calling.

Candidate2017 was saying you introjected a component of the projective identification. The presence of splitting and any features of a cluster B personality disorder does not imply that you have a personality disorder. It's just that part of the challenge of talking to and providing care to patients who employ these defenses is that one can identify or introject. Rescue fantasies, collusion with the notion that all their problems are external, etc, are all things that occur in psychiatrically "normal" people who interact extensively with people who engender these feelings in us.

Blaming the insurance companies is another form of externalization of the problem. The presence of what was formerly an Axis II disorder does not preclude the presence of what was formerly an Axis I disorder. The presence of a not-as-lucrative icd-10 diagnosis does not mean that there isn't one that would be better for billing, prior authorization, or other purposes that can apply. Usually more inpatient days are covered if you code schizophrenia (F20.9), psychotic mania (F30.2), secondary mania, or substance-induced psychosis (F19.959) as unspecified psychotic disorder not due to a known substance or general medical condition (F29). Which one are your encounters typically coded as?

If you're addressing a problem, put it in the problem list, assessment, and plan. There will be plenty to bill insurance appropriately in an insurance-taking clinic. In one that takes private pay, it doesn't matter what diagnoses you put on the note unless you're planning to use it for insurance prior authorization for a prescription.

Okay I see… another example of not knowing what I don’t know, or maybe I just read that tone wrong and felt defensive.

But, I don’t know if the patients themselves see the issue as personality in nature. They come in and tell me “I have bipolar disorder and I was out on lithium and depakote in the past and it doesn’t help”

Turns out they never had true mania in the past and use stimulants sometimes. I think, well… your issue is BPD and sometimes you look manic, but your underlying issue is mood dysregulation. And I wonder why these patients get told they have bipolar disorder when I really think it’s something else.

I think your rationalization that there other problems to conquer alongside the underlying root issues is actually a sufficient answer for me.

Frankly, due to the fact that the majority of my experiences are seeing patients at their most acute and decompensated I guess makes me feel a little burnt out. Makes me feel like I’m churning through motions with no genuine satisfaction because I don’t get to see them when they’re thriving and doing well in life. But I received a lot of good advice here. I don’t think I’m the first or last psychiatrist to feel what I’m feeling regarding feeling powerless to try and improve people’s lives who may or may not want to be improved.

 

[PsyDr]

1) Yes. You're essentially selling a niche product. There are tons of businesses like that. Some are higher end, some lower end, some just do their own thing (e.g., Delaware Punch, Alpha Romeo). If you can define what you are selling, who you are selling to, and why they’d want to buy it… you’ll be fine.

2) You're missing a slightly more subtle aspect of the market competition. People have already mentioned the Dr. Feelgoods. That's simple to compete against. The more subtle aspect of competition is in what is not addressed.

a) Excuses for sale: Providers that say that almost all bad behaviors are caused by a mental illness. So those affected by the bad behavior shouldn’t be hurt by the bad behavior, they should be nicer to the misbehaved.
b) Dr. Superficial: Aka, the psychiatric equivalent of “don’t weight me”. Providers who keep the interview on the PHQ9 scores. This allows patients to avoid bringing up painful emotions, or really meaningful help. If everyone is giving out escitalopram 10mg, move it up to 20… why would you want to have to talk about how your traumatic childhood? Isn’t it better to have your psychiatrist treat your “depression” caused by romantic failures, instead of discussing how your weight, fashion sense, and hobbies are affecting your success rates?
c) Dr. No Axis II: Insurance won’t pay for a sole diagnosis of personality disorders. Despite evidence, they won’t pay for topiramate. So maybe you call it something else. A few years later, you’re answering questions like “why do I like John Dillinger history” with “you have depression”. It provides patients with an identity, based upon mental illness. And that identity requires repeated patronage.

There’s a ton of those types of things.

 

[Desired Member]

Okay I see… another example of not knowing what I don’t know, or maybe I just read that tone wrong and felt defensive.

But, I don’t know if the patients themselves see the issue as personality in nature. They come in and tell me “I have bipolar disorder and I was out on lithium and depakote in the past and it doesn’t help”

Turns out they never had true mania in the past and use stimulants sometimes. I think, well… your issue is BPD and sometimes you look manic, but your underlying issue is mood dysregulation. And I wonder why these patients get told they have bipolar disorder when I really think it’s something else.

I think your rationalization that there other problems to conquer alongside the underlying root issues is actually a sufficient answer for me.

Frankly, due to the fact that the majority of my experiences are seeing patients at their most acute and decompensated I guess makes me feel a little burnt out. Makes me feel like I’m churning through motions with no genuine satisfaction because I don’t get to see them when they’re thriving and doing well in life. But I received a lot of good advice here. I don’t think I’m the first or last psychiatrist to feel what I’m feeling regarding feeling powerless to try and improve people’s lives who may or may not want to be improved.

In this example, it appears a diagnosis was given in a rush without carefully considering substance use and timeline of symptoms. Psychiatrists may rush through an evaluation (perhaps due to pressure from insurance/hospital to fit X patients into the day, too many patients and not enough psychiatrists, etc) and give diagnoses that later appear inaccurate....though bipolar disorder is generally a difficult diagnosis to confirm.
It seems you want to have the time to give people accurate diagnoses and provide or refer them to appropriate treatment (which they would ideally be motivated to pursue and able to afford). But the reality is....this often doesn't occur. Just do your best. I understand how you feel.

 

[Stagg737]

So many great answers here and will try not to just parrot others, but some advice from someone finishing residency who has had similar thoughts at times along the way:

I often see patients coming in with the alphabet soup diagnoses “patient has a history of MDD GAD ADHD DMDD PTSD” when I see that, I immediately think, this is a traumatized patient with a personality disorder and some psychiatrist out there calls it MDD and gives the patient Zoloft with no real effect because the primary issue with the patient is personality, but the issue with treating personality is that it takes time, effort and addressing genuine catastrophic thought processes which are indeed super valuable but do not make economical sense to do as insurance doesn’t reimburse well for therapy.

Keep in mind how common co-morbidities with many of these disorders are. The endless alphabet soup is often a bad sign, but I have had a couple of patients where as we peeled away the onion layers new, legitimate diagnoses kept emerging. Example: patient legit MDE is stabilized then turns out they have PTSD, then turns out they've had GAD since before any of their traumas, then turns out all of that is well-controlled, but they also very likely have ADHD. This was an actual therapy patient of mine who I initially saw for depression/anxiety treatment after d/c from inpatient. I believe he ended up on Duloxetine + Wellbutrin, and Prazosin and was doing pretty well when I last saw him.

2. You can go into academics, community mental health, hospital based practices, etc. Each sector prioritizes different things. Usually the private practices are production based, "turn and burn" conveyor belt psychiatry (from my experience so far). Community mental health they get funding through other sources (im in this setting) and we have access to things like ACT team, substance abuse groups, supported employment, etc. I had a patient today, when i first saw him, was on 16 psych meds. I have him down to 3. Hes doing amazing. He had severe TD from all the antipsychotics they through on him, just from peeling away his meds and adding austedo his QOL has drastically improved. Some of the hospital systems seem to prioritize quality as well, each setting has its own pros and cons. Community setting will be your higher/possibly highest acuity setting in outpatient, as I definitely see the sickest of the sick

I will say that the bolded can vary significantly between practices/facilities within the same area. One of the CMHCs we rotated through (which our program dropped) was absolutely awful and it was a 3-4 month wait just for a case manager, and only thing they would get before CM was assigned was med appointments. Pretty awful set up.

but be ready to navigate offering what you can (accept what you can't) and accept the limited progress of patients that you know could have achieved so much more. You can't do it all, and you can't "fix" 'em all.

You are correct that treating personality takes time and effort. However, that time and effort must come from the patient not the psychiatrist.

I definitely don’t know what I don’t know and maybe that’s what I’m struggling with. Maybe it’s an ego thing for me to actually want to “help” the patient.

Quoting these because they reflect the best advice I got during 3rd year which I repeat on here regularly. "You should not be working harder than your patient is." For a while I felt like if I couldn't help that I was failing or at least not meeting my own expectations. It's important to realize that there are some people you just can't help because they don't really want to BE better, they just want a magic pill to FEEL better. There are also times when everyone is working their butts off, but because of social factors you just can't get them the help they need. The best way to address that is to know what the local resources are and know how to get your patients to them. For some, that will do far more good than you ever could.

Why are axis II not reimbursed? The quality of mental health care and actually efficiency at our jobs would greatly increase if we had sensible diagnoses such as “current major depressive episode secondary to underlying cluster B personality disorder/traits”

So that the patient and all providers reading can work on the patient’s actual problem which would be DBT focused interventions.

Admittedly, I am very cynical nowadays with my diagnostic approach and I am quick to believe really the majority of what I see is behavioral/personality issues that medications don’t fully address.

Again, remember that co-morbidities are common and that it's often easier to play the game (insurance and meds) by just listing MDD and BPD as separate diagnoses as long as they're meeting criteria. That should not change your recommended treatment for the personality/behavioral components, but it keeps things simple for non-psychiatrists and can easily be clarified in formulation.

Maybe at this stage in the game, I really see a ton of BPD and I get so frustrated because I am still mainly in the inpatient/ED/CL portions of my training and I feel so useless because I’ll spend time really talking to these patients and all of their destructive thought processes unravel in front of me and I see so much space to really work

At this point you do not have the experience to understand the pros and cons of what different practice options are out there, which might be better suited for your personality and interests, and to what extent you have the power to tailor them to your own choosing.

It would be like you're doing a research paper and struggling to write your conclusion before the data has even come in.

Orgone answered it perfectly, but to add an N to the sample size, there were a lot of things I didn't realize until I was actually rotating in our outpatient clinics. ED/Inpt/CL it's usually not difficult to figure out what a patient actually needs (meds, therapy, CM, housing resources, etc) if you spend enough time with them, but actually making that happen is very, very different. We're pretty spoiled with having great SW/CM on our inpatient unit who make a lot happen for our patients at d/c. When I rotated through our CMHC during 3rd year, it was very eye opening. Resources that seem basic and should be easy for patients to obtain may not exist. At the same time, in other clinics you'll see patients who are very motivated, have the means and access to resources, and genuinely get better thanks to your help and a little nudge in the right direction.

I do wish I could go back to my 2nd year and even 3rd year to give myself some advice on various settings and situations, but if you're at a decent program with good exposure, you'll get there as you progress.

Comparing doctors who have 5 minute OP follow-ups with the rare IP doctors with 30 minutes to talk to each patient is an apples and oranges comparison. I'm sure you have seen IP docs spend < 5 minutes with a patient. The goal of these short-term, acute-care IP facilities isn't to address the root cause of the patient's suffering. It's to stabilize them just enough that they can go out and get the outpatient treatment.

Agree, and to go a step farther it's important to keep in mind the purpose of the setting you're working in. In the ER, I'm basically just triaging patients to see where they go next and providing them with basic resources if we're discharging them. Our inpatient unit is more acute, so we're there to stabilize them, help develop safety plan and basic coping skills, and ensure they've got a safe plan for d/c with f/up. In our academic outpt clinic our patients are a bit higher functioning than the CMHC, so we're really "practicing" psychiatry and working to get them better utilizing meds, performing therapy, and collaborating with the rest of their outpt team and therapists. At the CMHC I was at it was basically the wild west, so we were mostly trying to ensure SPMI patients were taking their meds and remaining stable or just preventing them from needing to go inpatient. I also went a step farther and made sure their CM knew what resources they needed if anything new came up in the appointments.

Trying to do meaningful and in-depth psychotherapy on an acute psych inpt unit isn't very realistic, just like making med changes to their primary meds in the ER isn't usually a good idea. Know your role for your setting and it may help keep some of the things you're stressing out about in context.

I think it’s important to reality check my self. I’ll be sure to reflect on this.

This is great insight. Good for you for actually exploring these thoughts and seeking advice. Sounds like you're at least on the right path for personal growth.

 

[Stagg737]

They [NPs] simply function as forever residents with varying degrees in quality.

Oh sweet summer child, if only this were so...

 

[deleted456421]

"Despite evidence, they won’t pay for topiramate."

What evidence? I ask because I keep finding people on topiramate whose primary complaint is "I feel confused all the time" so I remove it and they feel better. All of the evidence I can find is crap (even for weight loss, it just isn't justifiable as a sole agent).

I don't mean to derail this thread, but I'm finding myself in an endlessly repeating pattern and I want to know your justification given the scant evidence. NPs are the only people who use it locally.

 

[PsyDr]

What evidence? I ask because I keep finding people on topiramate whose primary complaint is "I feel confused all the time" so I remove it and they feel better. All of the evidence I can find is crap (even for weight loss, it just isn't justifiable as a sole agent).

I don't mean to derail this thread, but I'm finding myself in an endlessly repeating pattern and I want to know your justification given the scant evidence. NPs are the only people who use it locally.

I completely agree with you. But there is RCT evidence.

Topiramate treatment of aggression in female borderline personality disorder patients: a double-blind, placebo-controlled study - PubMed

Topiramate appears to be a safe and effective agent in the treatment of anger in women with borderline personality disorder as defined by SCID criteria. Additionally, significant weight loss can be expected.

pubmed.ncbi.nlm.nih.gov

 

[deleted456421]

I completely agree with you. But there is RCT evidence.

Topiramate treatment of aggression in female borderline personality disorder patients: a double-blind, placebo-controlled study - PubMed

Topiramate appears to be a safe and effective agent in the treatment of anger in women with borderline personality disorder as defined by SCID criteria. Additionally, significant weight loss can be expected.

pubmed.ncbi.nlm.nih.gov

You'll have to forgive my skepticism as I review how a 24% change in an obscure and costly proprietary scale translates clinically. We all know that relative risk reduction is the standard for this sort of clinical study (because only decent studies report ARR), yet we're left with a 24% change in something I can't even access because it costs money.

Numerous trials of much higher quality have demonstrated absolutely no benefit for topiramate in mood stabilization (check out Maudsley's). Just like divalproex's disastrous use in treating "anger and agitation" in the elderly, I'm witnessing topirmate's devastating effects in those with borderline personality disorder.

Again, I apologize for derailing this thread, but I'm sick of dealing with crap like this. Granted, I have job security since patients come to me feeling miserable when they're put on concoctions based on studies with 29 patients, but good lord do they suffer.

 

[deleted456421]

In this example, it appears a diagnosis was given in a rush without carefully considering substance use and timeline of symptoms. Psychiatrists may rush through an evaluation (perhaps due to pressure from insurance/hospital to fit X patients into the day, too many patients and not enough psychiatrists, etc) and give diagnoses that later appear inaccurate....though bipolar disorder is generally a difficult diagnosis to confirm.
It seems you want to have the time to give people accurate diagnoses and provide or refer them to appropriate treatment (which they would ideally be motivated to pursue and able to afford). But the reality is....this often doesn't occur. Just do your best. I understand how you feel.

Despite my warnings about the waning role of physicians, I must admit I've found a good middle ground: I'm currently employed at a local mental health authority that affords me 1 hr initial appointments and 30 minute follow-ups at a great rate of $220/hr. I have a team of social workers and front office employees whom manage all of the referrals I request. Sure, CBT for pain and insomnia are still difficult to come by (as is CPT), but at least every patient has a dedicated clinician that can inform me about major changes in our patients. Not only that, I get about an hour of protected administrative time daily.

Don't get me wrong, though, I'm still angry about the NPs in my organization that see 4-5 patients daily compared to my 12-16 and get paid half as much despite 1/10 the training. However, this community mental health center has decided that psychiatrists are necessary for directing psychiatric care.

 

[Horners]

So many great answers here and will try not to just parrot others, but some advice from someone finishing residency who has had similar thoughts at times along the way:


Keep in mind how common co-morbidities with many of these disorders are. The endless alphabet soup is often a bad sign, but I have had a couple of patients where as we peeled away the onion layers new, legitimate diagnoses kept emerging. Example: patient legit MDE is stabilized then turns out they have PTSD, then turns out they've had GAD since before any of their traumas, then turns out all of that is well-controlled, but they also very likely have ADHD. This was an actual therapy patient of mine who I initially saw for depression/anxiety treatment after d/c from inpatient. I believe he ended up on Duloxetine + Wellbutrin, and Prazosin and was doing pretty well when I last saw him.



I will say that the bolded can vary significantly between practices/facilities within the same area. One of the CMHCs we rotated through (which our program dropped) was absolutely awful and it was a 3-4 month wait just for a case manager, and only thing they would get before CM was assigned was med appointments. Pretty awful set up.





Quoting these because they reflect the best advice I got during 3rd year which I repeat on here regularly. "You should not be working harder than your patient is." For a while I felt like if I couldn't help that I was failing or at least not meeting my own expectations. It's important to realize that there are some people you just can't help because they don't really want to BE better, they just want a magic pill to FEEL better. There are also times when everyone is working their butts off, but because of social factors you just can't get them the help they need. The best way to address that is to know what the local resources are and know how to get your patients to them. For some, that will do far more good than you ever could.



Again, remember that co-morbidities are common and that it's often easier to play the game (insurance and meds) by just listing MDD and BPD as separate diagnoses as long as they're meeting criteria. That should not change your recommended treatment for the personality/behavioral components, but it keeps things simple for non-psychiatrists and can easily be clarified in formulation.




Orgone answered it perfectly, but to add an N to the sample size, there were a lot of things I didn't realize until I was actually rotating in our outpatient clinics. ED/Inpt/CL it's usually not difficult to figure out what a patient actually needs (meds, therapy, CM, housing resources, etc) if you spend enough time with them, but actually making that happen is very, very different. We're pretty spoiled with having great SW/CM on our inpatient unit who make a lot happen for our patients at d/c. When I rotated through our CMHC during 3rd year, it was very eye opening. Resources that seem basic and should be easy for patients to obtain may not exist. At the same time, in other clinics you'll see patients who are very motivated, have the means and access to resources, and genuinely get better thanks to your help and a little nudge in the right direction.

I do wish I could go back to my 2nd year and even 3rd year to give myself some advice on various settings and situations, but if you're at a decent program with good exposure, you'll get there as you progress.



Agree, and to go a step farther it's important to keep in mind the purpose of the setting you're working in. In the ER, I'm basically just triaging patients to see where they go next and providing them with basic resources if we're discharging them. Our inpatient unit is more acute, so we're there to stabilize them, help develop safety plan and basic coping skills, and ensure they've got a safe plan for d/c with f/up. In our academic outpt clinic our patients are a bit higher functioning than the CMHC, so we're really "practicing" psychiatry and working to get them better utilizing meds, performing therapy, and collaborating with the rest of their outpt team and therapists. At the CMHC I was at it was basically the wild west, so we were mostly trying to ensure SPMI patients were taking their meds and remaining stable or just preventing them from needing to go inpatient. I also went a step farther and made sure their CM knew what resources they needed if anything new came up in the appointments.

Trying to do meaningful and in-depth psychotherapy on an acute psych inpt unit isn't very realistic, just like making med changes to their primary meds in the ER isn't usually a good idea. Know your role for your setting and it may help keep some of the things you're stressing out about in context.



This is great insight. Good for you for actually exploring these thoughts and seeking advice. Sounds like you're at least on the right path for personal growth.

This was great, appreciate your time in writing this out.

At the end of the day, these are all just selfish things from me. I want to actually do the “right” things for my patients, decrease human suffering, increase quality of life and build wealth on a great income. Maybe that’s asking for too much? But I’m willing to work to do all of that.

I’m praying that:

crap care + excellent $ or good care + poor $

Is a false dichotomy and I think I’ve had sufficient evidence from these discussions to prove that’s not true.

Really once again, appreciate your insights.

 

[Horners]

Despite my warnings about the waning role of physicians, I must admit I've found a good middle ground: I'm currently employed at a local mental health authority that affords me 1 hr initial appointments and 30 minute follow-ups at a great rate of $220/hr. I have a team of social workers and front office employees whom manage all of the referrals I request. Sure, CBT for pain and insomnia are still difficult to come by (as is CPT), but at least every patient has a dedicated clinician whom can inform me about major changes in our patients. Not only that, I get about an hour of protected administrative time daily.

Don't get me wrong, though, I'm still angry about the NPs in my organization whom see 4-5 patients daily compared to my 12-16 and get paid half as much despite 1/10 the training. However, this community mental health center has decided that psychiatrists are necessary for directing psychiatric care.

In your experience was this kind of job a unicorn? Or are they around?

 

[deleted456421]

In your experience was this kind of job a unicorn? Or are they around?

It was a surprising find since I recently finished residency, but several local community mental health organizations offer similar per diem rates. I don't want to give myself away, but you need to find Northeastern states with laws that make non-compete clauses unenforceable and offer robust Medicaid expansion. You also have to contact these organizations directly, although some do advertise locally, since they don't often seem to use major national recruiters.

Edit: I grossly under-appreciated the role of non-competes when I started residency. I've looked at Midwestern states since that's where I was told to go for decent jobs and found they have a difficult time besting opportunities in Eastern states that invalidate non-competes. It's a recent paradigm shift in psychiatry, but I don't think "flyover states" necessarily equate to higher salaries anymore. Blows my mind that employers in at-will states, which includes most states, are allowed to enforce non-competes when they can arbitrarily change your pay (if the same state allows non-competes).

In what world does it make sense that an employer can cut your salary by $50k without allowing you to change shops?

 

[bltzybltz]

I think having a strong referral network of therapists you trust can go a long way too in PP. You may not be able to help every patient yourself, but at the very least, you can have some faith in where they're going.

How do you build a referral network with therapists (and PCPs)?

 

[Jules A]

How do you build a referral network with therapists (and PCPs)?

Re therapists/social workers: be collegial with the team. Getting to know the social workers/therapists you are sharing patients with and being nice to the ED social workers presenting patients for admission to the unit is a good strategy whether you plan to open private practice or not. When your former teammates learn of your private practice if you were nice and a decent doc they will refer patients to you.

 

[Stagg737]

In your experience was this kind of job a unicorn? Or are they around?

I mean, I'm only looking in the midwest and have seen positions like that. I just haven't seen them from CMHCs so much, but I'm also not that interested in outpatient, so haven't really looked in depth.

It's a recent paradigm shift in psychiatry, but I don't think "flyover states" necessarily equate to higher salaries anymore.

Idk, the draw to a lot of the midwest for people I've talked to is the CoL and the overall spending power, not necessarily that the salaries were that much higher. I can say from several cities I've lived in or stayed in for extended periods of time that $250k goes a lot farther in the midwest than a lot of other places.

 

[Desired Member]

What evidence? I ask because I keep finding people on topiramate whose primary complaint is "I feel confused all the time" so I remove it and they feel better. All of the evidence I can find is crap (even for weight loss, it just isn't justifiable as a sole agent).

I don't mean to derail this thread, but I'm finding myself in an endlessly repeating pattern and I want to know your justification given the scant evidence. NPs are the only people who use it locally.

Dope-a-max

 

[futureapppsy2]

Careful here. I don't doubt that this is probably true in many circumstances, but it is always worth stepping back for a moment and examining whether you are getting drawn into the split. Folks with BPD are prone to generating rescuer/savior fantasies in clinicians who accept uncritically the idea that they'll finally be the ones to fix them, unlike all those other idiots they've seen in the past who were just too greedy or stupid to do their jobs right. Being on the good side of the split is intoxicating and sometimes you can leverage it for positive ends but it will not last forever.

Oooph, yes. The assumed competency cycle in patients with BPD is something, as is the "charming/suave" cycle in some ASPD/NPD patients.