What is inpatient like in the private world?

[Trismegistus4]

Has anyone here taken an inpatient job in a private (i.e., non-academic, with no residents or med students) hospital? Or seen up close what these jobs are like? What is your schedule like? What are your actual duties? How are all the little things handled that in an academic center are handled by a resident always being on-site (e.g., a patient getting admitted at 2AM?)

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[heyjack70]

What are you a survivor of?

 

[whopper]

I worked at the Lindner Center, a private hospital. Lindner may have been different because they were very upscale on so many levels. Three of the top 100 doctors in the country work there-Susan McElroy, Paul Keck and Michael Keys. Many doctors there had top marks as physicians including people with national awards, or otherwise solid reps.

What I liked about the place is that I knew I was working with the best. Aesthetically the place was beautiful, it was specifically designed to be a psych facility (e.g. each room the water could be shut off from a master control area for patients with psychogenic polydipsia) and I knew if I had an issue the guy above me asking me the questions was also a clinician, not just some hospital administrator that didn't understand clinical practice.

They didn't have residents so everything had to be handled by the attendings. It felt odd to have Paul Keck be on call and admit patients. (Yeah I know, really weird surreal feeling cause residents do that in university hospitals). Other things happened that you have to get used to but not in a bad way. For example I'm walking down the hall and one of the guys in charge of the center is on the phone with another guy who also happens to be one of the top people in the field and while everyone there was always very nice to me, I just always had a "you're not worthy" feeling. (No one there ever had a condescending attitude. They always treated me with the utmost respect). Or around 2-3 PM they came in with a snack cart that had Starbucks quality coffee and snacks. Did I mention the patients had a chef prepare their food? Almost crusted chicken was an item on the menu.

Some odd things happened that did bug me but they were in no way the fault of the center. E.g. we'd get some very wealthy patients and it'd be annoying getting a call in the middle of the night from the patient's father because he just found out that his son isn't getting the organic-brand shampoo and he wants me to write an order so his son could use it. Comes with the territory of treating wealthy patients. I also had a very litigious husband of a patient who had a lawyer working for him full time and if anyone looked at him the wrong way he would call up the lawyer and ask her if there was any way he could sue the other person. You only see that type of thing with rich folks.

 

[cookymonster]

Has anyone here taken an inpatient job in a private (i.e., non-academic, with no residents or med students) hospital? Or seen up close what these jobs are like? What is your schedule like? What are your actual duties? How are all the little things handled that in an academic center are handled by a resident always being on-site (e.g., a patient getting admitted at 2AM?)

If you moonlight at a "private" hospital you will get a glimpse of what this is like.

Patients do not need to be seen by a psychiatrist at the moment. Where I work they are seen by crisis workers, at other places they are seen by ER docs, and then referred to psychiatrist on call, who gives basic orders by phone until patient is seen within 24 hours (perhaps 48 hours on the weekend).

As an attending, I do everything I did as a resident, with some exceptions. I defer most family contact to social workers, unless a face-to-face family meeting is scheduled (which I can bill for). Admission medical evaluations are performed by a mid-level.

Otherwise I do pretty much all the psychiatric evaluation and treatment from admission to discharge, unless the patient is in the hospital for so long that they need to be handed off to a colleague. This is different from training, in which most of the patients we saw on the unit had an extensive psych H&P done by a resident the night before, and sometimes were also seen by a different attending than the one on the unit the day before. I spend more time on average with my patients than we spent with them on the unit in residency (attendings in residency were probably paid primarily in salary, whereas I am 100% production).

 

[serimeri]

where I did my audition , the social workers saw the pts in the morning AM hours. it was a private unit

 

[milesed]

I can only comment on my past experience.

We had a usual census around 16-20 patients. It was split up between the hospitals' full-time doc and our part-time doc.Problem was our doc was only there for a 1/2 day and had 1/2 the patients. I always covered for him when he was out, we all shared 1 in 3 call during the week, weekends and all holidays. It sucked. We also had to do all medical H and P's and deal with all medical issues.

We were all paid salary, so extra work meant no extra pay.

The hospital doc got twice as much vacation time as we did (different employer) so we always had to cover his duties, call etc when he was out. He was also so slow that he couldn't see his half of the patients in 8 hours (we did it in 4). The ER docs also made it worse by consulting us on anything they didn't want to deal with (mostly drunks) we had to see them within 2 hours.

When our inpt doc left for another job, we pulled out of inpt completely and my life has been better ever since (2002 I think). Not a single doc employed by this hospital has stayed more than 2 years.

 

[Trismegistus4]

What are you a survivor of?

Medical school.

I worked at the Lindner Center, a private hospital...

All that is very interesting, but I'm really just interested in practical details, like what an inpatient psychiatrist's work schedule and hours are like and what their specific duties are.

I can only comment on my past experience.

We had a usual census around 16-20 patients. It was split up between the hospitals' full-time doc and our part-time doc.Problem was our doc was only there for a 1/2 day and had 1/2 the patients. I always covered for him when he was out, we all shared 1 in 3 call during the week, weekends and all holidays. It sucked. We also had to do all medical H and P's and deal with all medical issues.

We were all paid salary, so extra work meant no extra pay.

The hospital doc got twice as much vacation time as we did (different employer) so we always had to cover his duties, call etc when he was out. He was also so slow that he couldn't see his half of the patients in 8 hours (we did it in 4). The ER docs also made it worse by consulting us on anything they didn't want to deal with (mostly drunks) we had to see them within 2 hours.

When our inpt doc left for another job, we pulled out of inpt completely and my life has been better ever since (2002 I think). Not a single doc employed by this hospital has stayed more than 2 years.

So it sounds like the biggest problem for you was the conflict between your group and the other group. Also, I know not to take a job where I'd have to deal with all the medical issues.

What I really want to know is what kind of hours an inpatient doc works on a day-to-day basis? If you manage to get all your work done by, say, 2:30 PM, can you just leave? Also, what is call like? Do you ever have to actually go in?

 

[cookymonster]

In most jobs I'm aware of, you can come and go when you want. You aren't on the clock, and they can just call you if you need anything. We were forced to stay on the unit until 5pm as residents not because there was a good reason for it, but because that's the way residency works. Some of the most efficient docs in my group work from 7 - noon. I'm more a 9 - 4 type of person. You could probably see all of your patients after lunch if you wanted. There are plenty of "full-time" inpatient docs who find time to maintain a private practice on the side.

However, it's not like you can just wake up that day and decide what hours you feel like going in. Usually you have brief meetings with other treatment team members to plan around. You may do family meetings and occasionally have other scheduled stuff to do. More often than not, this is going to be in the morning.

Call is probably the biggest fly in the ointment for inpatient work, even though it's 1000x better than being on call in residency. You're mainly doing taking phone calls from ED to field (and block) admission, giving admission orders, and doing cross-cover on the unit you're covering. You shouldn't ever have to go in. Purely psychiatric exacerbations can be handled over the phone, and if the patient becomes medically unstable, you can probably either consult a doctor who's in the hospital, or if no one's on site, have them go to an ER. It's crucial to go over how often you're on call (less is better) and how you're compensated for it. No matter how light the call is, being stuck at home in your free time hurts your quality of life, and you deserve to get paid accordingly. Call frequency is more of a problem in smaller units, but if you're lucky there will be outpatient doctors who will be sharing the responsibilities.

 

[Doctor Bagel]

If you had more time, it might be a good idea to get a moonlighting job at the place you're thinking about working at. That would give you a picture of call and whatnot. I moonlight at a local hospital, and I can say that overnight call is way easier than residency overnight call in that you essentially never go in. Also, they streamline things so you're rarely paged for little things like laxatives at 3 am and have readily available 24 hour hospitalists who are actually nice and willing to see your patients as opposed to the ones in residency who argue with you. Other way to check things out would be to take a locums position. One of my classmates is doing full-time inpatient work, and he's pretty content.

Following up on that thought, what do you think about lifestyle of inpatient versus outpatient? I think outpatient in some big systems (umm, one that starts with a K), would constitute much harder work than inpatient putting together time with patients, documentation and administrative work.

 

[milesed]

Medical school.


All that is very interesting, but I'm really just interested in practical details, like what an inpatient psychiatrist's work schedule and hours are like and what their specific duties are.


So it sounds like the biggest problem for you was the conflict between your group and the other group. Also, I know not to take a job where I'd have to deal with all the medical issues.

What I really want to know is what kind of hours an inpatient doc works on a day-to-day basis? If you manage to get all your work done by, say, 2:30 PM, can you just leave? Also, what is call like? Do you ever have to actually go in?

I'd arrive around 7:30 am sit in with the nurses as they did there shift change/check out reports until about 8am, then see patients individually until done. I also had to see all new admits from overnite, see any consults the rest of the hospital had ordered and see anyone in the ER we were consulted on. I could get through my part by 12-1pm each day, but could be called back at any point. I had to leave the unit to see outpatients until 5pm so came back after 5 if need be.

Call was the worst part, but you can potentially set it up differently.The seclusion and restraint laws had just changed so that an MD had to see the patient face to face within 2 hours and come back every 4 hours if they remained secluded or restrained. I think this has changed now to allow nurses to do the face to face. Any ER patient they wanted seen had to be seen by me at any hour of the night. Calls from the unit for prn stuff were not bad. Admit calls from elsewhere were harder. You didn't have to see them, but had to wake up enough to take notes, then call in orders to hold them until you came in the next day. I rarely had a night w/o admits and usually had 3-4 at any hour. Feeling handcuffed to a pager every 3rd night is no fun.

We had no time off the next day or after a rough weekend of call.

My issues about how everything was structured were due to the admin. of the group that sub-contracted out the unit with the hospital. The workload was one thing, the inappropriate pressure to go against what patients needed was another. If a patient had decent insurance, they'd pressure you to keep them way past an appropriate d/c date. They also pressured me to d/c patients way too early when it was medically dangerous if their insurance was poor ( guy withdrawing from Xanax with DT's).

You can protect yourself somewhat from the excessive workload with PA or ARNP's if they will hire them for you. You can also be broken by poor nursing staff or techs. It will just vary by situation. I came from a high quality university setting and assumed it would be similar- my mistake.

I know I sound very negative. I just want to help keep others from a bad situation like I was in due to my ignorance. Others I did residency with are still doing inpt work and loving it at other hospitals.

 

[Trismegistus4]

I spend more time on average with my patients than we spent with them on the unit in residency (attendings in residency were probably paid primarily in salary, whereas I am 100% production).

If you're paid by productivity, wouldn't you spend less time with each patient? I thought productivity was based more on quantity than quality.

In most jobs I'm aware of, you can come and go when you want. You aren't on the clock, and they can just call you if you need anything. We were forced to stay on the unit until 5pm as residents not because there was a good reason for it, but because that's the way residency works. Some of the most efficient docs in my group work from 7 - noon. I'm more a 9 - 4 type of person. You could probably see all of your patients after lunch if you wanted. There are plenty of "full-time" inpatient docs who find time to maintain a private practice on the side.

I would love to have an inpatient job where I got there between 7:30 and 8 and it wasn't uncommon for me to be done at 2.

Other way to check things out would be to take a locums position. One of my classmates is doing full-time inpatient work, and he's pretty content.

I was previously almost embarassed to pursue locum tenens work, because I perceived it as something that semi-retired people did toward the end of their careers, and thought all my supervisors would be disappointed with me if I went that route. However, I'm starting to rethink it. One of our current interns just told me that his brother did locums right out of (child & adolescent psych) fellowship, and makes tons of money. And one of our other residents told me that her husband, who is also a psychiatrist, says that he regrets not doing locums while he was still single.

I know I sound very negative. I just want to help keep others from a bad situation like I was in due to my ignorance. Others I did residency with are still doing inpt work and loving it at other hospitals.

What would you say candidates should look out for, or what questions should we ask, to avoid getting into the kind of situation you were in?

 

[cookymonster]

If you're paid by productivity, wouldn't you spend less time with each patient? I thought productivity was based more on quantity than quality.

You can generate more RVUs per hour if you spend less time with your patients. But you will still generate more total RVUs if you spend more face to face time with them. You only have a set number of patients at the beginning of the day (at least that is the case with me... maybe at some jobs you can just keep seeing more patients instead), so it is up to you really how much work you want to do with them and at what point the returns are no longer worth it.

If you are getting paid by salary on the other hand, you're incentivized to spend the least time with the fewest patients.

Your colleagues and staffing are some of the most important predictors of satisfaction in this type of work. In that respect, it's not that different than evaluating prospective training programs. I interviewed at some places where I didn't meet any of the other inpatient doctors, which was an obvious red flag. How would I feel comfortable sharing call and handing off patients with these people?

Also, pay attention to the mission and culture of the institution where you work. Margins are so tight in mental health that if profit is the motive, a hospital has to cut costs any way they can to achieve it. That will show up in how they pay you, staffing issues (forcing nurses and techs to cover too many patients), giving out controlled substances to encourage repeat business, and differential treatment of patients based on their ability to pay. To practice the right way in an inpatient setting, we have to run in the red and rely on the support a larger academic-like hospital system that values us... or at least recognizes our necessity.

Locums (and especially if it could become permanent) is a great idea, because these jobs can be like a pig in a poke. I didn't do locums because I was too attracted to benefits, but if you're at all uncertain about what you want or have cold feet about a first job, it's probably the way to go.

 

[Igor4sugry]

Feeling handcuffed to a pager every 3rd night is no fun.
We had no time off the next day or after a rough weekend of call.

I'm just curious about why you took a job of this type? Was this your first job out of residency? Did you know about the every 3rd night call? Employers may have hard time recruiting current grads because night float systems have gotten rid of 24hour calls (I don't think there is a psych residency with every 3rd night call) and I would be hesitant to do it. At the state hospital here in Ohio there is no mandatory call. If you do call you get to leave at noon the following day and also get compensated for doing call.

 

[Trismegistus4]

Locums (and especially if it could become permanent) is a great idea, because these jobs can be like a pig in a poke. I didn't do locums because I was too attracted to benefits, but if you're at all uncertain about what you want or have cold feet about a first job, it's probably the way to go.

I'm attracted to benefits too, but not enough to rule out locums. If I had a wife and 3 kids, I'd need health insurance for 5 people, plus life insurance and a substantial disability policy. Being single with no dependents, I need only health insurance for myself and a modest disability policy. I realize there's the issue of funding retirement too, but presumably, making more money doing locums, I'd be able to put that additional money into my own retirement accounts.

One thing I need to figure out is what people who do locums full-time do about all the facets of life that require a permanent residence. I have no reason to keep my apartment after I graduate from residency. Where would I renew my driver's license, vote, pay taxes, etc.?

 

[milesed]

I'm just curious about why you took a job of this type? Was this your first job out of residency? Did you know about the every 3rd night call? Employers may have hard time recruiting current grads because night float systems have gotten rid of 24hour calls (I don't think there is a psych residency with every 3rd night call) and I would be hesitant to do it. At the state hospital here in Ohio there is no mandatory call. If you do call you get to leave at noon the following day and also get compensated for doing call.

Q3 call was at my first job out of residency. It was to be q5 when I accepted, but 2 docs left soon after I started. I was locked into the job for 2 years. Near the end of that contract,we pulled out of inpt work.

When interviewing, I'd ask questions about plans for back up if someone leaves or has extensive medical leave, mid-level support, ability to hire locums, etc. This sort of BS is why so many leave their first jobs quickly. The employers are out to make money and keeping you happy should, but may not be, a consideration in this.

I have friends doing inpt and loving it. They are pretty much the only option for their hospital, so they hold all of the power in decision making.