Those who love their outpatient job

[Candidate2017]

To those who love their outpatient job, what type of environment do you work in? Is it your own private practice? A well run, psychiatrist-owned private practice? A cash practice that serves the worried well?

In residency, our main outpatient clinic was comprised of only 20% controlled substance seekers, who usually went elsewhere for goodies after a few visits. Otherwise, there was a lot of therapy involved, and I enjoyed the interactions with almost all my patients, who were actively trying to improve themselves. Some people described this clinic as a boutique practice. I've never worked in a boutique practice, but I imagine that is what it would be like.

In the "real world", my outpatient gigs are in Big Box shops for The Man. There is very little therapy because many patients just want a pill, a controlled substance, a disability letter, etc. Many are interested in what I can get or do for them, instead of what they can do for themselves. I feel my therapy skills atrophy. And every 2-3 months, I lose a patient to suicide, homicide, alcohol, opioids, or disease. It is draining, and not enjoyable at all. It is so draining that I lack energy to start my own private practice, even though I work part time. I also had a former colleague commit suicide. Though I can't say for sure, I wouldn't be surprised if it had something to do with their work at a similar Big Box shop, and frankly I was not shocked.

My former co-residents who do outpatient at Big Box shops feel kind of the same, though they seem to have experienced less severe pathology. Those who work at private practices find it not quite as bleak, but do feel it is all about grinding through 2-3 controlled substance patients per hour. So, I'm wondering if this a small sample set, or if this is the way it is, or if others who love outpatient have just found some niche of their own.

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[clozareal]

I love my work. I have my own private practice and that's all I do now. It's a cash practice treating CAP and adults. I have a nice mix of depression, anxiety, bipolar disorder, ADHD, schizophrenia, sleep disorders, oppositional behaviors. About half my weekly hours is individual or family therapy. Most are highly motivated and collaborative and if they're not, they often don't stay on as patients very long with me. Most of my patients schedule for one hour and the most I will see in one hour is two patients. Filled up in about a year.

Some are worried well, but most are sick enough to have significant impairment. They typically have family who are willing to help them out with logistics of appointments and getting them back on track or paying for the appointments. I have patients who've lost or at risk of losing their jobs, failing out of school, severe interpersonal conflicts, significant distress from their symptoms, social isolation, aggression, self-harm. Some need higher level of care at times.

I haven't written one disability letter and haven't been asked to. I also don't have controlled substance seekers as I have no problem telling them no if they don't meet criteria for it and aren't willing to put in work outside of the medication to help themselves get better. I do a lot of integrative work where I get labs, use supplements, incorporate a ton of lifestyle recommendations and have the time to do so. I do a lot of CBT-I, MI on exercise and diet, behavioral activation, exposure therapy, parent management training, and interventions in the schools/teachers.

I don't see more severe personality disorders or addiction as I know I'm not a good fit for them, but will do MAT and open ended therapy for personality disorder if they are motivated. I also don't see high conflict families, divorcing parents with the kid caught in the middle and refuse to co-parent diplomatically, and high acuity in terms of violence or active suicidality, although I do tend to take sicker patients such as those with suicidal ideation and plan without intent.

 

[Attending1985]

To those who love their outpatient job, what type of environment do you work in? Is it your own private practice? A well run, psychiatrist-owned private practice? A cash practice that serves the worried well?

In residency, our main outpatient clinic was comprised of only 20% controlled substance seekers, who usually went elsewhere for goodies after a few visits. Otherwise, there was a lot of therapy involved, and I enjoyed the interactions with almost all my patients, who were actively trying to improve themselves. Some people described this clinic as a boutique practice. I've never worked in a boutique practice, but I imagine that is what it would be like.

In the "real world", my outpatient gigs are in Big Box shops for The Man. There is very little therapy because many patients just want a pill, a controlled substance, a disability letter, etc. Many are interested in what I can get or do for them, instead of what they can do for themselves. I feel my therapy skills atrophy. And every 2-3 months, I lose a patient to suicide, homicide, alcohol, opioids, or disease. It is draining, and not enjoyable at all. It is so draining that I lack energy to start my own private practice, even though I work part time. I also had a former colleague commit suicide. Though I can't say for sure, I wouldn't be surprised if it had something to do with their work at a similar Big Box shop, and frankly I was not shocked.

My former co-residents who do outpatient at Big Box shops feel kind of the same, though they seem to have experienced less severe pathology. Those who work at private practices find it not quite as bleak, but do feel it is all about grinding through 2-3 controlled substance patients per hour. So, I'm wondering if this a small sample set, or if this is the way it is, or if others who love outpatient have just found some niche of their own.

How I feel waxes and wanes and lately I have felt very much like this. This combined with a push to see more and more patients is making me really seek an exit plan at least from a typical employee position.

 

[SmallBird]

To those who love their outpatient job, what type of environment do you work in? Is it your own private practice? A well run, psychiatrist-owned private practice? A cash practice that serves the worried well?

In residency, our main outpatient clinic was comprised of only 20% controlled substance seekers, who usually went elsewhere for goodies after a few visits. Otherwise, there was a lot of therapy involved, and I enjoyed the interactions with almost all my patients, who were actively trying to improve themselves. Some people described this clinic as a boutique practice. I've never worked in a boutique practice, but I imagine that is what it would be like.

In the "real world", my outpatient gigs are in Big Box shops for The Man. There is very little therapy because many patients just want a pill, a controlled substance, a disability letter, etc. Many are interested in what I can get or do for them, instead of what they can do for themselves. I feel my therapy skills atrophy. And every 2-3 months, I lose a patient to suicide, homicide, alcohol, opioids, or disease. It is draining, and not enjoyable at all. It is so draining that I lack energy to start my own private practice, even though I work part time. I also had a former colleague commit suicide. Though I can't say for sure, I wouldn't be surprised if it had something to do with their work at a similar Big Box shop, and frankly I was not shocked.

My former co-residents who do outpatient at Big Box shops feel kind of the same, though they seem to have experienced less severe pathology. Those who work at private practices find it not quite as bleak, but do feel it is all about grinding through 2-3 controlled substance patients per hour. So, I'm wondering if this a small sample set, or if this is the way it is, or if others who love outpatient have just found some niche of their own.

I don't think any of this is wrong, but there are many employed outpatient positions that will allow you to check some of the boxes, although perhaps not all. For example, in my system people could claim they feel a 'pressure' to see 3 patients an hour but that's tied to them having a very high salary expectation. Absolutely nothing would stop them from seeing all their patients for 30 - 40 minutes, they would just make more like an average salary. Part of the reason I prefer systems that have some relationship between productivity and compensation is that at least if you're super busy you are being paid well, and if you are making less money it should mean things are more relaxed. Systems that divorce this relationship can really take advantage of you.

 

[Sushirolls]

My private practice is the only thing still keeping me in practice.

 

[SmallBird]

I did hear from a colleague who took a full time job focused on psychiatric long-COVID and that is always a helpful reminder that it can always be worse.

 

[Monocles]

I did hear from a colleague who took a full time job focused on psychiatric long-COVID and that is always a helpful reminder that it can always be worse.

Wait, can you explain more on how this is bad? Is it the lack of current research or helpful evidence-based interventions?

 

[splik]

Wait, can you explain more on how this is bad? Is it the lack of current research or helpful evidence-based interventions?

havimg Worked in one of these clinics it’s very tedious. And I love somatoform pts but these clinics take the cake. I didn’t last long. The two people after me both lasted a month lol

 

[SmallBird]

Wait, can you explain more on how this is bad? Is it the lack of current research or helpful evidence-based interventions?

Although anyone who is interested in helping these patients deserves our thanks, they will be faced with a heterogenous groups of people with true inexplicable symptoms, a further group with histrionic tendencies who are attributing unrelated phenomena to COVID or the vaccine, and a further group that may have a true chronic brain problem from COVID that is no more well described than I just did here.

 

[splik]

Although anyone who is interested in helping these patients deserves our thanks, they will be faced with a heterogenous groups of people with true inexplicable symptoms, a further group with histrionic tendencies who are attributing unrelated phenomena to COVID or the vaccine, and a further group that may have a true chronic brain problem from COVID that is no more well described than I just did here.

My experience was:
1) people with problems of living and adjustment reactions that wanted to talk about having COVID and had no actual psychopathology
2) patients with pre-existing psychopathology not related to COVID that were not suitable for management in a PASC clinic
3) patients who probably never even had COVID
4) patients with somatoform disorders

All the interesting patients never make it to these clinics. When I was doing C-L we saw patients with COVID psychosis, mania, catatonia, autoimmune encephalitis, complications of steroids, delirium, PTSD etc. We didnt find a single patient with actual PTSD in our COVID clinic (though many of them thought they had it from having the flu lol) and of course the patients with more severe psychopathology were excluded by the pulmonologists. And the neurologists took the interesting pts.

 

[TexasPhysician]

Outpatient private practice: I am owner or part-owner in locations. Pay is productivity based for clinicians here. No demands on time or type of patient. Insurance is more patients and faster, but sometimes that is more fun than longer appts for me. Both have good success rates and good patients. Pay is higher with volume insurance. I prefer a mix of clinics.

I don’t treat much worried well or much schizophrenia.

 

[Stagg737]

How do the outpatient people deal with the pharmacy issues? I feel like I'm constantly getting requests to renew prescriptions that still have refills available, requests for med adjustments between appointments, or pharmacies just not having certain meds/saying they won't fill meds because X, Y, or Z; and I only do 6-8 hours of outpatient per week. How much time do all the FT outpatient docs spend on pharmacy stuff? I wonder if this is something I experience more d/t the nature of my clinic or if it's more widespread, because it's one of several reasons that I can't ever see myself going to outpatient full-time.

 

[Sushirolls]

I changed my policies to just auto deny all pharmacy requests.

During the appointments I make a task for myself in Luminello to refill XYZ on day ABC. I communicate this plan with the patient in the appointment, so all are on the same page.

New policy is for patients to message me (and/or assistant).

If I get a message I review my tasks, or the last note, or the pharmacy section to see if appropriate. 9 out of 10 times, patient has meds, but the pharmacy is giving them the shaft. I message the patient back, I sent off the sertraline 100mg on day ABC and you have 2 refills with that prescription, please go nudge/talk/WTF your pharmacy. If yo still have issues let us know. 9 of 10 times, problem solved.

I prescribe enough to get patients to their next appointment which is 3 months or less away.

I too got tired of the pharmacy refills. Waste of time.

 

[clausewitz2]

Like @Sushirolls , I completely ignore computer generated faxes from pharmacies. I tell all my patients to message me if they have any trouble getting the meds I have prescribed to them. When people message for refills, if they have refills already on their current script I ask for clarification as to whether the pharmacy is actually saying they have no script on file. This usually curtails that behavior after a few repetitions.

I usually aim to refill prescriptions during someone's appointment or very shortly thereafter. I spend perhaps 10 minutes a day dealing with pharmacy stuff otherwise.

 

[TheRightMedication]

I prefer inpatient, but not as much as I prefer being my own boss. Therefore, private practice.

 

[TexasPhysician]

I changed my policies to just auto deny all pharmacy requests.

During the appointments I make a task for myself in Luminello to refill XYZ on day ABC. I communicate this plan with the patient in the appointment, so all are on the same page.

New policy is for patients to message me (and/or assistant).

If I get a message I review my tasks, or the last note, or the pharmacy section to see if appropriate. 9 out of 10 times, patient has meds, but the pharmacy is giving them the shaft. I message the patient back, I sent off the sertraline 100mg on day ABC and you have 2 refills with that prescription, please go nudge/talk/WTF your pharmacy. If yo still have issues let us know. 9 of 10 times, problem solved.

I prescribe enough to get patients to their next appointment which is 3 months or less away.

I too got tired of the pharmacy refills. Waste of time.

I don’t do refill requests except to reach the next appt or deal with current stimulant shortage. This is quick and easy. Most calls are prompted to schedule an appointment. I almost never call or message a patient. I don’t refill requests from pharmacy. Staff complete all PA’s.

 

[clozareal]

I do maybe 2-3 calls to the pharmacy a month at the most, and that's for stimulant issues these past few months (they've asked me to verify telehealth/in person or why I'm prescribing to a pharmacy 20-30 miles away from my practice address when the patient can see a closer psychiatrist or be prescribed to pharmacy closer to my office. wtf? do they know about the shortage of psychiatrists let alone child psychiatrists?).

I also tell patients to contact me when their prescription is about to run out, but to contact the pharmacy first if there are refills left. It gives them ownership of their meds rather than me being the parent and holding their hand. I hate that and will educate my patients aggressively on that.

The next appointment is almost always scheduled for when the patient needs a next refill. If they don't contact me, they either don't need the med, are non-adherent, or drop off as a patient on my panel.

 

[clausewitz2]

I do maybe 2-3 calls to the pharmacy a month at the most, and that's for stimulant issues these past few months (they've asked me to verify telehealth/in person or why I'm prescribing to a pharmacy 20-30 miles away from my practice address when the patient can see a closer psychiatrist or be prescribed to pharmacy closer to my office. wtf? do they know about the shortage of psychiatrists let alone child psychiatrists?).

I also tell patients to contact me when their prescription is about to run out, but to contact the pharmacy first if there are refills left. It gives them ownership of their meds rather than me being the parent and holding their hand. I hate that and will educate my patients aggressively on that.

The next appointment is almost always scheduled for when the patient needs a next refill. If they don't contact me, they either don't need the med, are non-adherent, or drop off as a patient on my panel.

This is the attitude needed for surviving in outpatient with anything but a truly chronic SMI population. You do not do things for your (adult) patients that a grown adult is 100% capable of doing. You maybe provide education about what or how to do it a couple times, but you do not rescue them from basic tasks.

On this hangs all the outpatient laws and the prophets.

 

[Bartelby]

This is the attitude needed for surviving in outpatient with anything but a truly chronic SMI population. You do not do things for your (adult) patients that a grown adult is 100% capable of doing. You maybe provide education about what or how to do it a couple times, but you do not rescue them from basic tasks.

On this hangs all the outpatient laws and the prophets.

I second this excellent advice! Having the mindset shift to realize I am treating competent adults who have to at least meet me halfway decreased the stress of outpatient dramatically. If they don't put in the basic effort I'm not going to play parent for them.

 

[Dr. Pookie]

Recent residency grad and have only done my own solo outpatient practice so far. I take a mix of insurance and self-pay, though mostly insurance at the moment. Mix of depression, anxiety, and far fewer bipolar, couple of borderlines, no schizophrenia. Personality pathology hasn't really interfered with care so far. I have a small psychotherapy practice in which I don't take insurance. That has been fun so far as well. I don't miss being a resident obviously, but I have never worked a "real" job after residency, so don't really have anything to compare.

Some people talk about the dangers of isolation/loneliness in private practice, but I haven't gotten there yet.

 

[Candidate2017]

I don't think any of this is wrong, but there are many employed outpatient positions that will allow you to check some of the boxes, although perhaps not all. For example, in my system people could claim they feel a 'pressure' to see 3 patients an hour but that's tied to them having a very high salary expectation.

The responses seem to confirm that people who love outpatient, invariably have their own private practice.

OTOH, it could be selection bias because those who enjoy churning for The Man to make $450k-650k+ ain't got no time for SDN. Even so, maybe they enjoy the money but not the work. Personally, I don't do 3 an hour. I don't get push back from The Man for that, but pretty much everything else. I suppose that's what it boils down to. I have a friend that says the hardest and worst patient to treat is The Man because The Man is an invisible patient who shows up every day to every single patient appointment.

How do the outpatient people deal with the pharmacy issues? I feel like I'm constantly getting requests to renew prescriptions that still have refills available, requests for med adjustments between appointments, or pharmacies just not having certain meds/saying they won't fill meds because X, Y, or Z; and I only do 6-8 hours of outpatient per week. How much time do all the FT outpatient docs spend on pharmacy stuff?

Systemic, regularly occurring issues can be controlled by establishing boundaries.

Staff/patients (yes, staff are sometimes the equivalent of an additional patient) need to know refills/major med changes are addressed at visits. Write enough refills to get patients to the next visit. Thus, if a patient calls for refills, it means they are not compliant with follow up. Tell them to reschedule ASAP, and they will get a courtesy bridging refill. Discharge patients who routinely abuse this courtesy.

Staff can handle all of the above, but it takes a while to train them if no one has ever established boundaries. Even if solo, it doesn't take much work if you establish boundaries.

 

[FlowRate]

I wouldn't say that I 100% love my job. Honestly, my temperament is that I would probably never say that I love any job since jobs pretty much always have some aspect that's unpleasant. I am happy enough with my job that I am not entertaining any short or long term plans to change. I work for a Permanente Medical Group.

Clinically, I like that we get pretty much the entire spectrum of pathology minus very severe CMI. Although we do get (somewhat inappropriately from the HMO lens) some first-presentations for simple mood/anxiety concerns, I think our average acuity is very likely higher than the typical outpatient private practice and potentially higher than my residency caseload. While that can be trying at times, I also feel like I'm helping patients who really need the help.

I dislike that our patient population seems more entitled than average and I'm not sure if that's a regional thing or due to the particular types of employer groups that opt for our insurance. I think part of it is that high deductible plans are very common here and so those patients expect more since payments are coming directly out of their pocket.

We have good to great support staff (RN, MA, CPS, IOP, Crisis). We have somewhat more limited internal therapy availability than I'd like and adequate in-network therapy. But it's hard to get patients good insurance-paneled therapists in most parts of the country.

I wish there was some opportunity to carry at least a few therapy-proper cases but that's not in the cards at the moment.

There has been a push in some departments to see more patients in the same amount of time. So far, psychiatry has been able to prevent that from happening. The upper leadership beyond our department mostly understands that you need a certain amount of time to do a good job in psychiatry and psychiatrists are in significant demand so they also don't want to piss us off.

Working for a PMG/HMO, I am asked to balance/maximize value, access, and quality in a way that FFS outpatient docs are not. I think it's a nice way to practice medicine for the most part.

 

[MedMan80]

I love my work. I have my own private practice and that's all I do now. It's a cash practice treating CAP and adults. I have a nice mix of depression, anxiety, bipolar disorder, ADHD, schizophrenia, sleep disorders, oppositional behaviors. About half my weekly hours is individual or family therapy. Most are highly motivated and collaborative and if they're not, they often don't stay on as patients very long with me. Most of my patients schedule for one hour and the most I will see in one hour is two patients. Filled up in about a year.

Some are worried well, but most are sick enough to have significant impairment. They typically have family who are willing to help them out with logistics of appointments and getting them back on track or paying for the appointments. I have patients who've lost or at risk of losing their jobs, failing out of school, severe interpersonal conflicts, significant distress from their symptoms, social isolation, aggression, self-harm. Some need higher level of care at times.

I haven't written one disability letter and haven't been asked to. I also don't have controlled substance seekers as I have no problem telling them no if they don't meet criteria for it and aren't willing to put in work outside of the medication to help themselves get better. I do a lot of integrative work where I get labs, use supplements, incorporate a ton of lifestyle recommendations and have the time to do so. I do a lot of CBT-I, MI on exercise and diet, behavioral activation, exposure therapy, parent management training, and interventions in the schools/teachers.

I don't see more severe personality disorders or addiction as I know I'm not a good fit for them, but will do MAT and open ended therapy for personality disorder i they are motivated. I also don't see high conflict families, divorcing parents with the kid caught in the middle and refuse to co-parent diplomatically, and high acuity in terms of violence or active suicidality, although I do tend to take sicker patients such as those with suicidal ideation and plan without intent.

This is bang on what i want. I'm stuck in an employed clinic and have to see everything and it's kinda burning me out...

 

[tr]

The responses seem to confirm that people who love outpatient, invariably have their own private practice.

I love my job and I don't have a private practice but I'm not sure that's useful for you because what I do is not very replicable. I'm subspecialized in an area I love, don't see any patients outside my specialty area anymore, and have about an even split between research and clinic at an academic medical center, plus a fair amount of teaching - maybe 50/40/10 or so (clinic and teaching overlap somewhat). I think I would be very unhappy with a full time job of straight patient care, private or otherwise.

 

[Merovinge]

You need a new job, yours sounds like bottom 5-10% for sure. Lots of other options to consider such as joining an MD run group, PHP/IOP work, academics, permenante style, cash practices also serve a lot more than the worried well. Heck even something like jail based work I would take over your setup as at least their your mindset is one of limited expectations.