Should I quit?

[F0nzie]

I am conflicted about my part-time job at a community mental health clinic. My contract is for 30 min med checks but now I am receiving a continuous stream of referrals that I am booked 4 months out. I can't even check on my patients for med changes ie. 1-2 weeks for mania/psychosis or 1 month for depression. Instead I have been scheduling patients with the nurses and doing driveby med checks between my 30 min med checks. I have spoken to my chief and the medical director and they were like "that's the system" What should I do now? I feel this is too much liability and I am not happy.

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[softballtennis]

I think you should do what you feel you need to do. If I were you I would quit , that's doing a disservice to your patients they deserve to get better care. But that's my opinion I just feel that the number one priority of a psychiatrist should be to help people not earn money. The system I do think is flawed I would rather earn less money and see my patients get better, than earn more money and be a med pusher. I do think it is a disservice to patients, to just send them off with a script and say they should talk to their therapist about that. How would a psychiatrist know by doing 15 minute med checks how the patient is doing and how the meds are working? I had a psychiatrist who just pushed meds and didn't listen to me. I left his practice and got a new psychiatrist who actually listens to what I am saying.

 

[daru1]

Honestly, my first job was like this as well. Started off the way they pitched it to me, then morphed into something much worse which was blamed on "the system." I quit. No regrets about it. I did help them find a replacement for me (which was just me being nice because I wanted to make sure the patients had someone competent treating them after I left). Full disclosure, my private practice was taking off at the same time, so it made things a little easier. Good luck with the choice, it's a hard one, but I would feel for any doctor that went through all the training/experience that we have to get caught up in 'system issues' and ends up burning out early.

 

[birchswing]

I've had worse. I started seeing a psychiatrist when I was 15 at a mill-type facility. I only saw him that one time, and from then on I saw different nurses who would continue writing my scripts. I'm not sure if he signed them or if they did, but I never saw him after that.

Obviously the psychiatrists here will give you better advice than I could, but I would say the ideal (not that's necessarily possible) is to change the system from within. Presumably if you quit, the person who replaces you will be tasked exactly as you are and he/she might not even care that they aren't seeing the patients enough. Caring and not being able to see patients enough is better than not caring and not being able to see the patients enough.

 

[freaker]

You might just say that you're not going to do any further intakes (or severely limiting them), and that if they don't like that, you'll leave. I guess you'll see how serious they are about keeping you. It's not exactly easy to replace psychiatrists. Your role as a provider is to provide excellent care around an effective business model to keep the doors open. If your head honcho isn't interested in providing excellent care, do you really want to be working for him or her? And no, shipping off complicated and sick patients to 1) a midlevel who 2) hasn't seen the patient before is not excellent care. At all.

 

[Ceke2002]

I would say do what you feel is in the best interest of the patients. If that means challenging the status quo, and the higher ups don't like it, then let them try and find a replacement for you - they might just find out the hassle isn't worth it, and decide to make changes instead (one can only hope).

 

[F0nzie]

I've been feeling extemely irritable at work and when I get home. I keep getting thrown SI, HI, borderline, psychosis, mania, and depression in 20 min intervals (half of these people I don't even know). On top of that I need to write up court order reports, sign a million things, write prior auths, doc-to-docs, answer case manager and nurse questions. I have to go testify in court on a guardianship case that I don't even know squat about. We have Next Gen EMR that requires a ton of clicks... I feel like I could use some Zyprexa to get the edge off. If i had a candy bowl of antipsychotics at work I seriously would take some. I appreciate the advice.

 

[PistolPete]

Your place uses Next Gen? Wow, I'm sorry! We use that at one of the clinics I work at and it's awful! And I echo above posters, sounds like it's time for a change: either they change or you leave.

 

[Jester25]

Business as usual at a typical CMHC. I would never take a job there for the reasons you listed. I would quit. You don't need the headache.

 

[vistaril]

I am conflicted about my part-time job at a community mental health clinic. My contract is for 30 min med checks but now I am receiving a continuous stream of referrals that I am booked 4 months out. I can't even check on my patients for med changes ie. 1-2 weeks for mania/psychosis or 1 month for depression. Instead I have been scheduling patients with the nurses and doing driveby med checks between my 30 min med checks. I have spoken to my chief and the medical director and they were like "that's the system" What should I do now? I feel this is too much liability and I am not happy.

I mean this is what community mental health is.......if you don't like it, then of course you should quit and find another job that you like more.
You are trying to jam a square peg into a round hole....not going to fit, so stop trying.

 

[dl2dp2]

I think you should drop out of that craze ASAP. Look, you shouldn't compromise your quality of care just because there's nothing set up to take care of these people. Plus, you are trying to set up a private practice, and you don't have to dichotomize your reputation like that and tier your own care.

While I'm very sympathetic to the fact that indigent patients get substandard mental health care, I don't think forcing clinicians to do a poor job for them is the answer.

The only alternative is if you can somehow smartly work out a system with the power above to make it a better arrangement. This takes a LOT of work though, and mostly political work. Whether you are interested and have the endurance and ambition to make it happen is up to you, but I don't think you should feel trapped.

 

[novopsych]

I know everybody's gonna give you some pithy advice saying stick-it-out or get-the-hell out. But you're a psychiatrist. Use your head. You've got to figure-it-out.

Let's use our problem-solving skills:

There is no problem with you (the psychiatrist).

There is no problem with the patients.

The problem is the bureaucrats in charge.

So, if you're willing to quit anyway and have already expressed the problem to your director, call your local ABC, NBC, or CBS affiliate and tell them you have a story about how you can't give proper mental health treatment to people who are in the most need because of the practices at this clinic. You can even sensationalize it by saying you don't know what these undertreated patients are liable to do. Now, be careful not to talk about your patients with specifics. Just tell the world what you've told us.

I guaran-damn-tee it'll be fixed overnight.

Now, go figure!

 

[vistaril]

I think you should drop out of that craze ASAP. Look, you shouldn't compromise your quality of care just because there's nothing set up to take care of these people. Plus, you are trying to set up a private practice, and you don't have to dichotomize your reputation like that and tier your own care.

While I'm very sympathetic to the fact that indigent patients get substandard mental health care, I don't think forcing clinicians to do a poor job for them is the answer.

The only alternative is if you can somehow smartly work out a system with the power above to make it a better arrangement. This takes a LOT of work though, and mostly political work. Whether you are interested and have the endurance and ambition to make it happen is up to you, but I don't think you should feel trapped.

Let's not act like the venue he is working in is some sort of weird/unusual/atypical job.....community mental health center jobs themselves don't make up a large percentage of the total jobs out there, but if you add them up along with the agency jobs that are very similar you get a pretty decent chunk of jobs.....all staffed by board eligible or board certified psychs(or psych nps)......

And then there are all the insurance based outpt practices that, depending on how they are run, May or may not be different from agency jobs or cmhcs....

Where I different from you is I don't necessarily know that most cmhc type care is substandard. According to what standard? That which a pt with blue cross gets in the outpt world? That which a private pay pt gets in an affordable cash pay practice? That which an uninsured pt gets in a busy ed? That which Barbara Streissand gets? Rather when one works at a cmhc it is only relevant to compare the level of care you are providing to other patients and providers in similar situations....I work an agency job now and think I do a damn good job. Would it be considered good in some other settings with a bunch more time and more resources? No....but that's not my reality so I don't worry about it.

 

[whopper]

I've moved around in jobs 4x since I graduated. Each job has it's pros and cons.

Community mental health can really suck if you don't work with people you like, there's not enough support, and the bureaucracy is driving you nuts. If that's the case get out.

I've figured out for myself that money is not the biggest factor for my satisfaction. It's going to be a mix of my colleagues, the money, being intellectually stimulated, not being bogged down by the system at work, and feeling effective as a healer.

For any new graduate, I recommend not feeling tied down in particular to anyone place because it may take a few jobs to figure out what you really like to do and what's a better place for you. Irony is I figured out the playing-field in Cincinnati and now I moved because of my wife.

I'd be willing to stay in a community mental health place if the staff members were very good, I felt we were a team, and the bureaucracy wasn't getting in my way. I'd also make it clear to the management I could leave and that my numbers have always consistently been in the area where I usually do much better than other psychiatrists....SO FREAKING PAY ME, and at the same time I'll work with them on doing what I can do to be more effective in structuring the system to be the best cost and healing effective place it can be. I'm not going to be at a place where I make just as much as another guy when I'm literally seeing 30% more patients than he is, my satisfaction rates are much better (and I'm not prescribing benzos), and the patient's need to see a psychiatrist once they get me goes down because I'm actually getting them better.

I see a lot of doctors just do what they feel is a minimum and not do much more. When I've worked in community places, after about 6 months when I've figured out the system, I've sat down with the management and mentioned we could, for example, see X more amount of patients (while still being effective) if we did Y and it would bring in more money and heal more people.

If you're at a place that doesn't work with you on this type of practice, get out. You're too smart to be in a place run by idiots that already has one hand tied around your back because you're dealing with Medicaid/Medicare.

 

[vistaril]

I've moved around in jobs 4x since I graduated. Each job has it's pros and cons.

Community mental health can really suck if you don't work with people you like, there's not enough support, and the bureaucracy is driving you nuts. If that's the case get out.

I've figured out for myself that money is not the biggest factor for my satisfaction. It's going to be a mix of my colleagues, the money, being intellectually stimulated, not being bogged down by the system at work, and feeling effective as a healer.

For any new graduate, I recommend not feeling tied down in particular to anyone place because it may take a few jobs to figure out what you really like to do and what's a better place for you. Irony is I figured out the playing-field in Cincinnati and now I moved because of my wife.

I'd be willing to stay in a community mental health place if the staff members were very good, I felt we were a team, and the bureaucracy wasn't getting in my way. I'd also make it clear to the management I could leave and that my numbers have always consistently been in the area where I usually do much better than other psychiatrists....SO FREAKING PAY ME, and at the same time I'll work with them on doing what I can do to be more effective in structuring the system to be the best cost and healing effective place it can be. I'm not going to be at a place where I make just as much as another guy when I'm literally seeing 30% more patients than he is, my satisfaction rates are much better (and I'm not prescribing benzos), and the patient's need to see a psychiatrist once they get me goes down because I'm actually getting them better.

I see a lot of doctors just do what they feel is a minimum and not do much more. When I've worked in community places, after about 6 months when I've figured out the system, I've sat down with the management and mentioned we could, for example, see X more amount of patients (while still being effective) if we did Y and it would bring in more money and heal more people.

If you're at a place that doesn't work with you on this type of practice, get out. You're too smart to be in a place run by idiots that already has one hand tied around your back because you're dealing with Medicaid/Medicare.

What you are describing though is a bit different than what fonzie has always wanted from these sorts of jobs though. He isn't interested in improving care to get to a point where he could improve efficiency, see more pts per hr, etc....yes he does want to provide patient centered good care, but he wants to do it at the rate of 2 follow ups per hour.

Fonzie goals, IMO, are just not compatible with what a well run cmhc can be....whereas what you write above could be.

 

[dl2dp2]

Where I different from you is I don't necessarily know that most cmhc type care is substandard. According to what standard? That which a pt with blue cross gets in the outpt world? That which a private pay pt gets in an affordable cash pay practice? That which an uninsured pt gets in a busy ed? That which Barbara Streissand gets? Rather when one works at a cmhc it is only relevant to compare the level of care you are providing to other patients and providers in similar situations....I work an agency job now and think I do a damn good job. Would it be considered good in some other settings with a bunch more time and more resources? No....but that's not my reality so I don't worry about it.

I agree. You make a legit point. I have no evidence that the care that Fonzie deliveries in his typical CMHC is less "quality" compared to the care he delivers in his cash private practice. However, we all know that, at least most of the time, both patients and clinicians PREFERS the latter. There might be some value in that preference, but just purely based on outcome, I agree with you and think there might not be a difference (and certainly not a large difference) in say treating someone's MDD at a CMHC vs. cash practice. Although, there's no evidence that has demonstrated that there isn't a difference either.

Be that as it may, your point, while legit, is somewhat irrelevant given that we are not talking about a standard universally applied as a care delivery issue. We are talking about Fonzie's personal standard. Everyone can get a JCPenny suit and we can say it's adequate and not substandard, but if Fonzie is committed to provide a Prada suit, that's his prerogative.

 

[vistaril]

I agree. You make a legit point. I have no evidence that the care that Fonzie deliveries in his typical CMHC is less "quality" compared to the care he delivers in his cash private practice. However, we all know that, at least most of the time, both patients and clinicians PREFERS the latter. There might be some value in that preference, but just purely based on outcome, I agree with you and think there might not be a difference (and certainly not a large difference) in say treating someone's MDD at a CMHC vs. cash practice. Although, there's no evidence that has demonstrated that there isn't a difference either.

Be that as it may, your point, while legit, is somewhat irrelevant given that we are not talking about a standard universally applied as a care delivery issue. We are talking about Fonzie's personal standard. Everyone can get a JCPenny suit and we can say it's adequate and not substandard, but if Fonzie is committed to provide a Prada suit, that's his prerogative.

I'm not sure I made myself clear earlier....I'm pretty sure that the quality of care he provides at his private clinic is better.

But I'm pretty sure I could drive a Porsche 911 turbo faster than Jeff Gordon can drive a ford tempo. But Jeff Gordon's delta over the average driver in that tempo is unquestionably better than mine in a 911. Which is one valid way to look at it.

When I leave an agency for the day and head home, I certainly don't worry that the care my patients received wasn't as good as the care Barbara Streissand received that day. That's not the reality of the task I chose to take on that day I signed up to work at the agency. Oh well. It is what it is.

The reality is whether I work at my agency or fonzie works at his cmhc, those patients are always going to be there and those jobs are always going to be there. As I said earlier, if fonzie doesn't like what those jobs are at their core he shouldn't do them. It's really not complicated.

 

[birchswing]

I'm not sure I made myself clear earlier....I'm pretty sure that the quality of care he provides at his private clinic is better.

But I'm pretty sure I could drive a Porsche 911 turbo faster than Jeff Gordon can drive a ford tempo. But Jeff Gordon's delta over the average driver in that tempo is unquestionably better than mine in a 911. Which is one valid way to look at it.

When I leave an agency for the day and head home, I certainly don't worry that the care my patients received wasn't as good as the care Barbara Streissand received that day. That's not the reality of the task I chose to take on that day I signed up to work at the agency. Oh well. It is what it is.

The reality is whether I work at my agency or fonzie works at his cmhc, those patients are always going to be there and those jobs are always going to be there. As I said earlier, if fonzie doesn't like what those jobs are at their core he shouldn't do them. It's really not complicated.

I don't disagree that there can be a bad quality of care in community health centers and, as you seem to relish, in prisons.

But is there really some Cadillac level of any type of medicine? No. All the money in the world couldn't save Robin Williams, Heath Ledger, Michael Jackson, Phillip Seymour Hoffman, Anna Nicole Smith, etc.

Now, I'm sure Barbara Streisand has more time with her doctors than do the people at the community clinics or in your prison. And things that get overlooked for the poor people with fast med checks are probably less likely overlooked to *some* degree with the wealthy. But it's not like Barbara Streisand is going to live to be 200. Nor Oprah. Oprah had that fancy test some years back; I think it's like a CT scan of every part of the body. She's not going to live longer because of that. And it's not like a mentally ill celebrity is that much better off than a middle-class person with mental illness. The biggest success story I've seen with psychiatry and celebrities is Britney Spears and that seems to be not a function of a brilliant, Cadillac-level psychiatrist (what would that even entail?) but of her father taking custody over her—the fact that a level-headed person cares and got the courts involved to mandate care.

What you're talking about is not the difference between Babs and a poor person. You're talking about the difference between a middle-class and poor person. And your lack of optimism that the care could not be equalized between the two is sad, but maybe helpful in that it'll get people to talk about it.

 

[vistaril]

I don't disagree that there can be a bad quality of care in community health centers and, as you seem to relish, in prisons.

But is there really some Cadillac level of any type of medicine? No. All the money in the world couldn't save Robin Williams, Heath Ledger, Michael Jackson, Phillip Seymour Hoffman, Anna Nicole Smith, etc.

Now, I'm sure Barbara Streisand has more time with her doctors than do the people at the community clinics or in your prison. And things that get overlooked for the poor people with fast med checks are probably less likely overlooked to *some* degree with the wealthy. But it's not like Barbara Streisand is going to live to be 200. Nor Oprah. Oprah had that fancy test some years back; I think it's like a CT scan of every part of the body. She's not going to live longer because of that. And it's not like a mentally ill celebrity is that much better off than a middle-class person with mental illness. The biggest success story I've seen with psychiatry and celebrities is Britney Spears and that seems to be not a function of a brilliant, Cadillac-level psychiatrist (what would that even entail?) but of her father taking custody over her—the fact that a level-headed person cares and got the courts involved to mandate care.

What you're talking about is not the difference between Babs and a poor person. You're talking about the difference between a middle-class and poor person. And your lack of optimism that the care could not be equalized between the two is sad, but maybe helpful in that it'll get people to talk about it.

well a lot of it comes down to who is paying....I'm a middle class person, and if I went to see a psychiatrist I would be paying for it. So you pay for what you get. I'd either be paying for it through my insurance premiums or out of pocket. Most people(not everyone) at these community health centers don't actually pay for their care but it is being subsidized by others(like myself).....so no I don't think it is 'sad'. Mental Health services are just that- services. There isn't an unlimited and free supply of care here to be doled out......if we let every mental health practitioner spend gobs of time with every med check at a cmhc, that's going to lead to more funding required(either directly or indirectly), which someone has to pay for. And when that someone who is paying for it isn't the consumer(as it usually isn't in cmhcs), then these issues come about....

 

[smalltownpsych]

I am conflicted about my part-time job at a community mental health clinic. My contract is for 30 min med checks but now I am receiving a continuous stream of referrals that I am booked 4 months out. I can't even check on my patients for med changes ie. 1-2 weeks for mania/psychosis or 1 month for depression. Instead I have been scheduling patients with the nurses and doing driveby med checks between my 30 min med checks. I have spoken to my chief and the medical director and they were like "that's the system" What should I do now? I feel this is too much liability and I am not happy.

Is there no way to stop the stream of referrals? Also, I'm surprised that there is a chief and a medical director at that clinic, are they seeing patients or are they just overhead? I don't agree with their, "that's the system" garbage. We are not hired labor, we are licensed healthcare providers and we need to be the ones designing the system. Not the beancounters and politicians. If this particular system does not allow for any of that, then the answer is pretty clear IMO. When I have been in similar situations, I have been able to institute some changes, but also eventually had to realize when it was time to vote with my feet and move on.

 

[vistaril]

Is there no way to stop the stream of referrals? Also, I'm surprised that there is a chief and a medical director at that clinic, are they seeing patients or are they just overhead? I don't agree with their, "that's the system" garbage. We are not hired labor, we are licensed healthcare providers and we need to be the ones designing the system. Not the beancounters and politicians.

lmao....this is hilarious stuff. Stop the stream of referrals? The WHOLE POINT of the darn place is to see referrals....that's the POINT FOR THEIR FUNDING. Sheeeesh.....what is your fantasy about what the purpose of cmhcs are- to provide slow paced cushy jobs for psychiatrists and counselors who want a safe salaried position? or to......SEE REFERRALS?

 

[smalltownpsych]

Obviously there is a point where there are more patients than one clinician can handle. If he leaves, like many providers would and do every day, how does that help the referrals get seen? I doubt that Dr. Fonz is naive enough to expect community mental health to be a cush job, after all, I doubt that his private practice is cush either.

 

[barzan]

there is a saying " if you don't like it move on, you're not a tree''

 

[vistaril]

there is a saying " if you don't like it move on, you're not a tree''

exactly.

 

[vistaril]

Obviously there is a point where there are more patients than one clinician can handle. If he leaves, like many providers would and do every day, how does that help the referrals get seen?

Yes, and in community mental health terms, he's not nearly at that point yet. He *is* at the point where he is seeing more patients in any given time period than he would prefer to see. Which means he needs to find another setting/job that is more amenable to his desires. There are jobs out there which allow you to see the volume of patients he desires. They may come with less guarantees, less money/benefits, less safeguards, less support, more pressure/demands from patients, etc.....hey those are the tradeoffs in life/work.

This is not a complicated situation people.

As for your last question, the clinic will find someone else. They may have to staff it with more nurse practitioners(which based on his previous posts they dont mind doing anyways). They may have to go through an agency or locums company and end up paying more temporarily than they want. But they will get someone to see the patients and work for them unless their demands are unreasonable(and Fonzie hasn't given us any indication they are). What fonzie has made clear is that this is not the type of setting/environment that he wants to work in.....which means he should start looking for a setting(almost certainly not a cmhc) which he prefers better.

 

[F0nzie]

I feel terrible about the prospect of quitting. I feel very attached to many of my patients, many of whom have had 2-3 psychiatrists/Nps per year before I started. Maybe I will try to put my foot down on the referrals and see what happens. They didn't want to give me full time benefits when I applied for a part-time position but I got it anyways because I was ready to walk on the offer. I kinda feel awkward taking it to the next level after clearly articulating my concerns but I guess I need to get over that feeling if I want change.

 

[whopper]

When I worked in community mental health, I didn't mind it at one place because they modified what I was allowed to do and we played up on each other's strengths. I eventually left because it wasn't what I wanted to do. I wanted to work in an academic setting, but if I stayed I would've been fine.

I compare that to another community place I worked at in fellowship, where I was going nuts due to the bureaucracy. I had to write the meds 5x, once in the progress notes, once in the med list, on the script, then on another form that went to the pharmacy, and on a separate form in an order section. If the patient was on a state-assistance in Ohio called Central Pharmacy, I had to write it yet again on a special form. This drove me nuts, especially when I had a patient on 5+ meds cause I was literally writing 25+ lines. About 15 minutes of the entire 30 minute session just went to the darned writing of those meds.

I wouldn't have stayed at the latter place. I mentioned to them dozens of times they needed to set up their EMR so that everything auto-populated.

Getting back to you Fonzie, from what you're telling me, I'd quit. What I would also do is with the patients you got better, do some final interviews with them where you educate them enough to keep up some hope that they can maintain their improvement.

 

[vistaril]

I feel terrible about the prospect of quitting. I feel very attached to many of my patients, many of whom have had 2-3 psychiatrists/Nps per year before I started. Maybe I will try to put my foot down on the referrals and see what happens. They didn't want to give me full time benefits when I applied for a part-time position but I got it anyways because I was ready to walk on the offer. I kinda feel awkward taking it to the next level after clearly articulating my concerns but I guess I need to get over that feeling if I want change.

If you keep working here, you are going to:

1) continue making concessions(either in salary or in the volume of patients you see vs what you were told you will see)
2) continue to be at odds with this system in an on again/off again pattern

That's just the way it is. iirc you're only getting about 110 dollars per hour as a board eligible(now board certified?) psychiatrist to do community mental health. That tells me that either your job market is really really crappy or you're already passing on 30% or so of market value for them to accomodate your reduced patient demands(I wouldn't work cmhc for less than 135-140/hr but then again I work with more patients per hour on followup).....

I just don't understand why you keep trying to force an awkward fit. There is a reason it is an awkward fit. Surely there are insurance based practices in your area where you could work 20 or so hours a week and see the volume of patients you want and make similar money(perhaps a touch less). That's what you need to do.

 

[F0nzie]

now board certified?

Taking the 2015 exam.

 

[F0nzie]

I compare that to another community place I worked at in fellowship, where I was going nuts due to the bureaucracy. I had to write the meds 5x, once in the progress notes, once in the med list, on the script, then on another form that went to the pharmacy, and on a separate form in an order section. If the patient was on a state-assistance in Ohio called Central Pharmacy, I had to write it yet again on a special form. This drove me nuts, especially when I had a patient on 5+ meds cause I was literally writing 25+ lines. About 15 minutes of the entire 30 minute session just went to the darned writing of those meds.

Wow...that sounds like a total nightmare...

 

[Ceke2002]

I feel terrible about the prospect of quitting. I feel very attached to many of my patients, many of whom have had 2-3 psychiatrists/Nps per year before I started. Maybe I will try to put my foot down on the referrals and see what happens. They didn't want to give me full time benefits when I applied for a part-time position but I got it anyways because I was ready to walk on the offer. I kinda feel awkward taking it to the next level after clearly articulating my concerns but I guess I need to get over that feeling if I want change.

I don't profess to know how the system works in America, but from what I've seen of you on these boards, and on your website, you are a fine Psychiatrist who I have no hesitation recommending. If you do decide to stay and challenge the way things are currently set up at the cmhc, and it doesn't work out could you take some of your patients with you across to your private practice? Maybe offer a sliding scale of fees or something? Personally I think it's a bit of a crime for a community mental health centre to have such a good physician on board and not be utilising you to the best potential.

 

[Armadillos]

I obviously have never worked an attending job, but if you get to the point where you have decided your going to quit anyway you might as well just first try making what you feel are somewhat drastic demands and the end outcome will be exactly the same if they say no.
Then you won't have to wonder "what if" as much, and who knows maybe the stars align and they actually give you what you want.

 

[birchswing]

well a lot of it comes down to who is paying....I'm a middle class person, and if I went to see a psychiatrist I would be paying for it. So you pay for what you get. I'd either be paying for it through my insurance premiums or out of pocket. Most people(not everyone) at these community health centers don't actually pay for their care but it is being subsidized by others(like myself).....so no I don't think it is 'sad'. Mental Health services are just that- services. There isn't an unlimited and free supply of care here to be doled out......if we let every mental health practitioner spend gobs of time with every med check at a cmhc, that's going to lead to more funding required(either directly or indirectly), which someone has to pay for. And when that someone who is paying for it isn't the consumer(as it usually isn't in cmhcs), then these issues come about....

I'm not sure if you're just arguing that this is how it is or also how it should be. I'd agree with the former and not the latter. Assuming it were really as simple as a person getting better care but it requiring more money from the public, then I would argue the money is well worth it both for humanitarian reasons but also because a more functional patient is more likely able to participate in society, work, etc.

The US government spends an enormous amount of money on healthcare per citizen; we just don't spend it efficiently because we have a very balkanized system. ObamaCare helps by pooling people together the way that a large employer can, but it's still balkanized. I've never understood this strong sentiment against extending public healthcare to more people. I personally would advocate Medicaid for everyone as a base level of insurance. And I'd also subsidize the cost of all medical school training (I think the cost of medical school is why we don't have enough doctors in primary care or competition and so many FMGs).

But in lieu of all that, when we talk about expanding who gets coverage and how much, I think it is so bizarre that people stick their feet in the sand because who gets what is already extremely arbitrary. There is nothing more socialistic about ObamaCare than Medicaid, Medicare, VA benefits, military hospitals, etc.

So to say that community clinic patients should get this level of care because that's their lot in life is arbitrary. They're already being assisted. What's the opposition to moving the needle? Why do people always happen to love exactly where the needle is at right now?

 

[Information Underload]

I have no evidence that the care that Fonzie deliveries in his typical CMHC is less "quality" compared to the care he delivers in his cash private practice.

That depends. There's plenty of evidence, for instance, that CBT plus meds (private practice) works better than meds alone (CMHC). If you're providing legit, evidence-based therapy in addition to medication in longer appointments, you're giving better care.

 

[vistaril]

I'm not sure if you're just arguing that this is how it is or also how it should be. I'd agree with the former and not the latter. Assuming it were really as simple as a person getting better care but it requiring more money from the public, then I would argue the money is well worth it both for humanitarian reasons but also because a more functional patient is more likely able to participate in society, work, etc.

The US government spends an enormous amount of money on healthcare per citizen; we just don't spend it efficiently because we have a very balkanized system. ObamaCare helps by pooling people together the way that a large employer can, but it's still balkanized. I've never understood this strong sentiment against extending public healthcare to more people. I personally would advocate Medicaid for everyone as a base level of insurance. And I'd also subsidize the cost of all medical school training (I think the cost of medical school is why we don't have enough doctors in primary care or competition and so many FMGs).

But in lieu of all that, when we talk about expanding who gets coverage and how much, I think it is so bizarre that people stick their feet in the sand because who gets what is already extremely arbitrary. There is nothing more socialistic about ObamaCare than Medicaid, Medicare, VA benefits, military hospitals, etc.

So to say that community clinic patients should get this level of care because that's their lot in life is arbitrary. They're already being assisted. What's the opposition to moving the needle? Why do people always happen to love exactly where the needle is at right now?

What's the matter with moving the needle in the other direction? Which is what I would argue for. IMO, far too. Ugh of my money is already confiscated at gunpoint by the federal govt to pay for services(daycare, housing stipends, health care, electricity bills, etc) for others.

You clearly have a different viewpoint.....fine. The only time I get irritated with liberals over issues like this is when they refuse to recognize the downside and cost to their desires. I respect leftist a a ton more when they just come out and shoot straight....

 

[vistaril]

That depends. There's plenty of evidence, for instance, that CBT plus meds (private practice) works better than meds alone (CMHC). If you're providing legit, evidence-based therapy in addition to medication in longer appointments, you're giving better care.

This is an oversimplification. Some cmhcs do offer decent therapy services. And many private practices offer crap for therapy services.

 

[dl2dp2]

I feel terrible about the prospect of quitting. I feel very attached to many of my patients, many of whom have had 2-3 psychiatrists/Nps per year before I started. Maybe I will try to put my foot down on the referrals and see what happens. They didn't want to give me full time benefits when I applied for a part-time position but I got it anyways because I was ready to walk on the offer. I kinda feel awkward taking it to the next level after clearly articulating my concerns but I guess I need to get over that feeling if I want change.

It seems like you are getting some stuff that you want from this job, which is entirely understandable. I actually think that there are ways to improve the way you are practicing at this job if you can think more globally. Maybe make a list of things that can use improvement, and go to the administrator and meet with him to see which of these things can be constructively improved, then set a time line and measurable outcomes to assess the improvement in time. This is classic Quality Improvement (QI) work, and the administration should know/understand why it's important.

The way to get over the feeling of awkwardness, in my experience, is: (1) having actual material and possible solutions to present and discuss, instead of simply complain. Now you may not have immediate answers, but at least brainstorm for answers can work in your favor. (2) take ownership of the work environment. Sure you are not a partner at this ? non-profit? but just an employee, but if you take ownership perhaps one day you WOULD be running the clinic, and at least you would feel like you have some semblance of control and voice in the process.

This is why I posted previously that while simplistically you can just quit as Vis says (yes you are not a tree, why don't you just move), but I totally understand why it's hard to sometimes and people feel stuck. I truly think there are always creative solutions in these scenarios, it just requires a certain degree of communication skills and confidence, as well as preparation. It's not rocket science and it doesn't take 80 hours a week, but it is real work. So if you don't want to do that kind of work, you should mentally prepare yourself to leave. But if you do, it might end up being kind of fun and rewarding.

 

[heyjack70]

If you're getting stretched to the point of falling below the standard of care, you need to make a change or quit. If there is a bad outcome, you're on super thin ice, and a defense of "my job told me I had to see this many patients" isn't going to get you very far. You're the doctor and if you can't provide safe care, it's on you to put your foot down.

 

[Therapist4Chnge]

Some considerations:
1. Check your contract…and see if they are abiding by the contract.
2. It may be "their system"…but it is YOUR license.
3. Consider what is the standard of care and work backwards. If you are not able to provide proper care within "their system", then that should be a strongly weighed.

 

[Information Underload]

This is an oversimplification. Some cmhcs do offer decent therapy services. And many private practices offer crap for therapy services.

In 15-20 minute appointments? Doubtful. Time alone constrains what can be done in most mental health centers, where it's spit out your symptoms while I spit out the script.

 

[whopper]

I apologize if this was already covered. At the MH community center I worked at that ran things smartly, they had a nurse interview all the patients before they saw me, and this cut through a lot of the time I needed. This only works if the person doing this is sharp and that nurse I worked with was extremely sharp.

If you work with the right person, they can effectively cut the time you need with a patient, but if you get the wrong person, it could make your situation worse. In such a situation, I'd tell the agency I need the right person and work on getting that person. Try one nurse or social worker, or therapist, then try another until the right duo is formed. This also makes the agency money because now two people are checking out the patient, and each can bill and it helps the system and community because it allows the doctor to cost-effectively extend him/herself to more patients.

Now only way I can see this not working is if the doc can't find the right partner or if the new healthcare laws and billing system don't allow for this to happen.

 

[keifernny2]

I work PT at a similar agency as Whopper is describing (also in Ohio, actually), and love it. I have a phenominal nurse who really balances all the patient issues very well.
One thing that I noticed was that I could initially bring back patients as frequently as I needed within 3-4 weeks (ie: SMI / Psychotic patients that need close monitoring), and it all went swimmingly until one of the other providers retired and left a patient load of 800 to be immediately absorbed by the rest of the staff.

The situation then began to resemble the first post. If it is temporary, that's one thing...but if it becomes persistent then it is a big problem and makes you want to quit. At my agency, we just started setting clear instructions with the admin staff, ie: "I only will take new referrals on Thursdays from 1-2pm." This would require your medical director to be on board.

It seems like medicaid expansion is kicking in full force w/r/t referrals at this point.

 

[whopper]

When I had the right nurse with me, my patient load-forgot exactly how big it was, went from about 80% of the patients having a GAF of 30+ (the reset were alright and just needed refills) to almost all of them having a GAF of 55+.

What happened was the place had a string of bad doctors before me. People prescribing benzos up the wazzoo, Namenda for ADHD and Wellbutrin for anxiety disorders. I wish I was joking. I got the job, put these people on the right meds and within 2-3 months > 50% of my patients were significantly better. They went from having to be seen monthly or more to once every few months. It actually got to the point where I started having too much free time on my hands so they had to divert patients away from other doctors that were not getting successful treatments.

No this was not me being the best doctor out there. It was me simply doing standard treatments while the rest of the docs there didn't know WTF they were doing. I wish I were joking on the Namenda for ADHD thing.

The agency started bending to do things I wanted to do once they saw I was getting them results and the nurse they had me with was a huge part of the treatment success. She streamlined everything for me.

By the time I left, I spent several hours telling the management what was going on and that the patients I got better had to stay on the same meds. I was fearing a new doctor would come in and start using the old, "I stopped their Citalopram even though it was working and gave them Seroquel because Seroquel works on everything" line.

 

[vistaril]

In 15-20 minute appointments? Doubtful. Time alone constrains what can be done in most mental health centers, where it's spit out your symptoms while I spit out the script.

huh? do you even know how most cmhcs work? Most all are staffed with lpcs, lcsws, etc who do the therapy. In fact this is one way they generate a decent portion of their reimbursement.
Most of the regular therapy provided in private practices these days is also provided by lcsws and lpcs, and I'm certain that a higher percentage of private practices lack such people to do therapy as compared to cmhcs(even excluding from the mix psychiatrists who actually see patients for therapy)

Look I'm not saying cmhcs provide good mental health care. They don't for the most part. Whether it makes a difference for many of their patients is debatable. But they do offer therapy services, sometimes in much greater abundance than private practices do.

 

[vistaril]

I apologize if this was already covered. At the MH community center I worked at that ran things smartly, they had a nurse interview all the patients before they saw me, and this cut through a lot of the time I needed. This only works if the person doing this is sharp and that nurse I worked with was extremely sharp.

If you work with the right person, they can effectively cut the time you need with a patient, but if you get the wrong person, it could make your situation worse. In such a situation, I'd tell the agency I need the right person and work on getting that person. Try one nurse or social worker, or therapist, then try another until the right duo is formed. This also makes the agency money because now two people are checking out the patient, and each can bill and it helps the system and community because it allows the doctor to cost-effectively extend him/herself to more patients.

Now only way I can see this not working is if the doc can't find the right partner or if the new healthcare laws and billing system don't allow for this to happen.

yeah, thats how a lot of cmhcs work and bill. But that's a very different type of care than Fonzie wants to provide.

And I'm not saying his version is better or worse. It's just that by definition his version is going to require a heavy time committment per pt of the psychiatrists time, whereas your version seeks to make things from the psychiatrists time required much more efficient.

your version is much better suited to the realities of cmhcs today(and it's not neccessarily bad care in that setting imo), but it's simply not what fonzie wants to practice.