When does a heap become a pile

[lockian]

I seem to have some sort of trauma response to being singled out in a negative way. I was doing relatively ok mentally until recently, when I learned a patient had been directed to patient relations since they were unhappy. I don't know if it has gone anywhere yet or turned into a formal complaint. I shouldn't get into the particulars too much, but patient's situation and meds were a combination I was highly uncomfortable with, but I made some changes and referred them to a colleague who is good at that kind of thing, offering to support them until they establish with said colleague. Day of, patient seemed fine with it, but then expressed a high degree of distress to my staff, and insisted on seeing someone else (which was already being worked on).

Prior to this, I was already feeling in the dog house because a couple months prior our medical director had talked to me about getting more feedback than others about not running on time. He's actually a really nice and supportive person, and we worked on both systemic and behavioral changes that I could implement to avoid this. But being more comfortable ending sessions or doing less in session (I'm a complex thinker, relatively detail oriented and not confident) is going to take time, and some helpful changes to my schedule also cannot be made immediately due to already scheduled patients. I am doing 2 intakes a day (vs 3-4 before), and next month will be doing just 1 intake per day, and my admin time is later in the day when I need it more. But I still find myself overbooking myself and doing 10-12 old patients per day to get both routine and urgent follows up in.

Of course, like everyone I get the occasional lowest possible score on patient surveys, usually due to disagreements about whether a treatment plan is appropriate. The majority of scores are still relatively good. I think.

Bottom line is:
People say running late or lower scores or patient complaints are all par for the course, but it bothers me that I don't know and may never know when a heap becomes a pile and you're put on some sort of performance improvement plan or it gets to be enough to be fired or your contract non renewed. Colleagues have told me that the organization is pro-physician and wants you to succeed, and turnover is low. But there is always the voice in my head that says I can't do this job since I am already working as hard as I can, maybe too hard, and if I am told to do better I don't know how I'd do that.

I know a lot of people on this forum recommend private practice to escape all the worries about job security, and I guess I can always do it, but right now I see it as a last resort because of the uncertainty of it, and the need to essentially build all the systemic factors like billing, documenting, and between-appointment care yourself.


tl/dr, I still need to not run behind as often in clinic and negative patient or admin feedback makes me spiral about it adding up and losing my job (though I guess it takes more to make me do this than 1-2 years ago). Wondering if anyone has support or wisdom to share.

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[wolfvgang22]

I feel you, I'm also sensitive to complaints and criticism, because like you, I want to do a very good job.

You've got to look at this pragmatically, though. You have to care a less about bull**** like patients being angry you won't prescribe inappropriate meds. You did the right thing, documented why you did it, no one can dispute good medical practices. This will not get you in trouble.

Be pragmatic. Stop working harder than everyone else. Being slow, that hurts the bottom line and this will get you in trouble. So focus on getting patients in and out of your office quickly. When a patient has been offered treatment options, made a treatment plan with you, and been educated, the ball is now in their court to follow the treatment plan. If they won't make a plan with you, or wont adhere to a plan, or arent ready for the next step, stop wasting so much time on them. You cannot do their part for them. Listen to them a bit, and then bring up the options and plan each time, and if they are ambivalent move on with a smile. Stop banging your head on the wall. Stop writing long notes.

 

[smalltownpsych]

Sessions are shorter and more effective when you try to do less in each one, Change is incremental and some of it happens outside the office. Let time work for you. If you could devote an hour a week to learning some more psychotherapy type skills, especially from someone that understands the importance of boundaries and the therapeutic frame in the process, I think that would really help. Also, shorter notes are great advice! My patient outcomes are not correlated with documentation length. 😊

 

[WisNeuro]

Patient complaints for doing good work is par for the course in MH. As long as you are following standard of care and documenting appropriately, not a whole lot to worry about.

 

[Bartelby]

It sounds like they are working you very hard based on this and other posts. A lot of psychiatrists would not find this kind of position appealing, and I doubt they are eager to get rid of you!

I like seeing that you are backing down from 3-4 intakes and 10-12 follow ups with complex patients every day. I think that will help. In my mind, if you have 12 follow ups then one intake is plenty (assuming 8 hours worked per day)!

 

[splik]

I don't think going into private practice would be a good move for you right now and would likely make some things worse. I reiterate previous suggestion to seek supervision, consultation or mentorship to help you navigate some of these issues related to challenges with professional practice.

I think we can often take it personally when we receive negative feedback from patients. If you are having a very strong response to that, it means that you are experiencing this as an attack on your self worth, and likely catastrophizing that this means that your career is in jeopardy. It is always uncomfortable to receive negative feedback even when you know it is unreasonable. I have been worried in the past about how colleagues would view patients saying negative things about me and fearing the worst. However, it has not impacted my practice at all. One of the last pts I saw at my previous job was severely narcissistic patient who was extremely angry with me after the fact (was perfectly pleasant and in fact idealizing in the appt) and sent a scathing message that all could see in mychart. The patient also accused me of being sexually inappropriate in addition to other completely fabricated claims of professional misconduct. I also heard from the referring physician in the next visit the patient spent the whole time launching into a tirade about me. Honestly the whole thing made me feel physically sick even though I knew I had done nothing wrong (and fortunately I also had a resident in the room during this encounter to quash any accusations of impropriety). The referring physician did not see me any more negatively and actually apologized to me for sending me this severely personality disorder pt.

My point is the more experience you have with negative feedback that has no impact on how others see you, and no impact on your practice or job security, the less it will bother you. Though it will always bother you to some degree, which is okay and may reflect some degree of professional pride you take in your work.

 

[lockian]

It sounds like they are working you very hard based on this and other posts. A lot of psychiatrists would not find this kind of position appealing, and I doubt they are eager to get rid of you!

I like seeing that you are backing down from 3-4 intakes and 10-12 follow ups with complex patients every day. I think that will help. In my mind, if you have 12 follow ups then one intake is plenty (assuming 8 hours worked per day)!

I’m not sure *they* are working me too hard… I just volunteered to take those 3+ intakes at one point and nobody stopped me.

My patient contact time is 28 hours a week, 7 hours a day, 30 minute follow ups and 60 minute intakes. That’s actually very reasonable on face, which makes me think my problems are my fault.

But some intakes are really tough and some follow ups are also. If I could just say to those complex folks, “we need to stop, I will see you in 1-2 weeks because this issue we haven’t done justice to is very important” that would help and that is my goal to have that availability… but I don’t. My soonest urgent follow up is often 3-4 weeks out unless I overbook myself (extend my day, work though lunch, and other bad boundaries things).

You’re right in that they probably don’t want to get rid of me because the need is tremendous. With Covid, even at our very stable institution people are retiring or leaving a lot more than they once did.

 

[lockian]

I don't think going into private practice would be a good move for you right now and would likely make some things worse. I reiterate previous suggestion to seek supervision, consultation or mentorship to help you navigate some of these issues related to challenges with professional practice.

I think we can often take it personally when we receive negative feedback from patients. If you are having a very strong response to that, it means that you are experiencing this as an attack on your self worth, and likely catastrophizing that this means that your career is in jeopardy. It is always uncomfortable to receive negative feedback even when you know it is unreasonable. I have been worried in the past about how colleagues would view patients saying negative things about me and fearing the worst. However, it has not impacted my practice at all. One of the last pts I saw at my previous job was severely narcissistic patient who was extremely angry with me after the fact (was perfectly pleasant and in fact idealizing in the appt) and sent a scathing message that all could see in mychart. The patient also accused me of being sexually inappropriate in addition to other completely fabricated claims of professional misconduct. I also heard from the referring physician in the next visit the patient spent the whole time launching into a tirade about me. Honestly the whole thing made me feel physically sick even though I knew I had done nothing wrong (and fortunately I also had a resident in the room during this encounter to quash any accusations of impropriety). The referring physician did not see me any more negatively and actually apologized to me for sending me this severely personality disorder pt.

My point is the more experience you have with negative feedback that has no impact on how others see you, and no impact on your practice or job security, the less it will bother you. Though it will always bother you to some degree, which is okay and may reflect some degree of professional pride you take in your work.

One reason why you all might not have heard from me about my insecurities for a while is because I did find a mentor outside of my job, and they are helpful, particularly in talking through cases I am stuck on, but they also in private practice and one of the people who seems to think that that, along with cherry picking patients, is the ultimate solution to any systemic or personal issues. They are empathetic but at times it feels, to quote the move “As Good as it Gets” that “I’m drowning and they are describing the water.” Same happened with my old therapist, who was also an old school psychoanalytically trained MD psychiatrist. Maybe I expect too much, idk.

So I sometimes like to get a variety or perspectives. Thank you for sharing your experience I’m glad that there was a witness to support the fact that the accusations were unfounded. That’s incredibly scary, because if there is not a witness or recording, what can you really do?

 

[comp1]

You ARE in your own therapy, right?

 

[hallowmann]

I’m not sure *they* are working me too hard… I just volunteered to take those 3+ intakes at one point and nobody stopped me.

My patient contact time is 28 hours a week, 7 hours a day, 30 minute follow ups and 60 minute intakes. That’s actually very reasonable on face, which makes me think my problems are my fault.

But some intakes are really tough and some follow ups are also. If I could just say to those complex folks, “we need to stop, I will see you in 1-2 weeks because this issue we haven’t done justice to is very important” that would help and that is my goal to have that availability… but I don’t. My soonest urgent follow up is often 3-4 weeks out unless I overbook myself (extend my day, work though lunch, and other bad boundaries things).

You’re right in that they probably don’t want to get rid of me because the need is tremendous. With Covid, even at our very stable institution people are retiring or leaving a lot more than they once did.

You need to get more comfortable with delaying your next move and ending the visit. Its OK for a diagnostic to be stretched between 2 (or more) visits, even ones 3-4 wks apart. You can assess for safety and its OK not to prescribe or "do something" in that time. Alternatively you can even make a "small" (read: inconsequential) change if its something the patient wants and will build rapport/therapeutic alliance. Then truly finish the diagnostic at the next visit.

As an attending no one is going to stop you from volunteering to do more work. They assume you know your limits and will only take more if you can. You need to stop volunteering like that. When you are efficient, then you can volunteer for more. This isn't residency. Get rid of that "above and beyond" attitude and get your routine down to stay efficient. Go above and beyond for your current patients first by keeping them on time and actually having urgent follow-ups. If your urgent follow-ups are 3-4 wks out, those aren't urgent follow-up and you're sacrificing those slots for work you don't need to be doing.

 

[smalltownpsych]

I also resonate with your thought processes and the areas that you identify as difficulties. Boundaries, wanting to please people, wanting to feel like I was doing something. This job really hits hard on those and as someone in private practice, albeit slightly different as a psychologist, I can say that I agree with other poster that would not be a fix. Better to improve some of these areas first before you make that leap. I have a couple of interns working with me and they both are sensitive and achievement oriented and want to please both me and their patients and struggle with setting boundaries. Funny thing is that the one guy is ex-military so you’d think he’d be a bit better at it. 😉
Just one example is that I know that they have to get better at ending sessions on time, it’s good for them and it’s good for the treatment. First interviews are often the most challenging because patients can be all over the map and once they open up want to keep talking. It is tough to interrupt that process, but it needs to be done in order to get the background and diagnostic info needed. It also begins the therapeutic process as you begin to model for them how to contain and organize their thoughts and feelings.

 

[PsyDr]

1) Scenario: A patient is actively suicidal. They do not want to be hospitalized. You do it anyway. They are mad. Are you as upset as the patient complaint you're talking about? Both are instances where patients don't like your treatment plan. What is the difference? Where is the line on that continuum?

2) I've noticed that people who are chronically late, plan for the ideal scenario. If you're constantly late, you're doing too much. I'm guessing that you are planning for everything to go according to plan. Life never goes that way. Complications come up, a patient goes long, an urgent thing needs to be handled, a PA needs to be answered, etc. If you don't have space in your day for those extra things, you're gonna fail.

3) Boundaries. Everyone agrees you can't do that schedule. Why are you going back to overbooking yourself? You know you can't do it. Patients have their own responsibilities. It's not your job, to rush in, and fix things because a patient screwed up.

 

[Candidate2017]

I have a couple of interns working with me and they both are sensitive and achievement oriented and want to please both me and their patients and struggle with setting boundaries. Funny thing is that the one guy is ex-military so you’d think he’d be a bit better at it. 😉

Other than non-fraternization, the military does not respect one's boundaries. You owe them a fixed period of your life and do as you are told (hello, medical residency). Heck, look at the VA.

If your urgent follow-ups are 3-4 wks out, those aren't urgent follow-up and you're sacrificing those slots for work you don't need to be doing.

The flip side is if an outpatient psychiatrist truly thinks a patient requires visits more frequently than q4 weeks, the patient needs a higher level of care, for which a clinic psychiatrist cannot provide. Of course, if they are having a true emergency (SS, SJS, NMS, SI, HI, etc), they need immediate medical and/or custodial care (ER, hospital, psych ward, jail, etc).

On the other hand, if a clinic patient FEELS they need to be seen sooner than q4 weeks, they are really asking for DBT or a therapist they can see daily.

 

[Candidate2017]

I’m glad that there was a witness to support the fact that the accusations were unfounded. That’s incredibly scary, because if there is not a witness or recording, what can you really do?

This is another reason to be on time and finish notes by the end of session.

Although in this instance there may not be anything to document in the MSE about the patient being hostile, threatening, or flirtatious, it would still be documented you declined/disagreed with the patient's request and had some inkling of personality disorder. At the very least, the EMR records metadata that you were typing away and crafting a magnificient note the entire time, which it makes it pretty darn hard to assault anyone or leave any bandwidth to be sexually inappropriate.

OP, to answer your question, heap and pile are synonyms. Hold your breath, grab a shovel and get to work because that's how we earn our living.

 

[lockian]

1) Scenario: A patient is actively suicidal. They do not want to be hospitalized. You do it anyway. They are mad. Are you as upset as the patient complaint you're talking about? Both are instances where patients don't like your treatment plan. What is the difference? Where is the line on that continuum?

2) I've noticed that people who are chronically late, plan for the ideal scenario. If you're constantly late, you're doing too much. I'm guessing that you are planning for everything to go according to plan. Life never goes that way. Complications come up, a patient goes long, an urgent thing needs to be handled, a PA needs to be answered, etc. If you don't have space in your day for those extra things, you're gonna fail.

3) Boundaries. Everyone agrees you can't do that schedule. Why are you going back to overbooking yourself? You know you can't do it. Patients have their own responsibilities. It's not your job, to rush in, and fix things because a patient screwed up.

1) the difference is when it turns into an official complaint and there’s a third party, possibly not a medical professional, who makes decisions about my fate

2) you’re exactly right. I have admin and lunch time but they often get overrun by patients that run long, phone calls, refills, fires that need to be put out, so it still does not feel like enough buffer time. I have support staff but still need to tell them what to do. I’ve gotten a bit better at ending sessions on time or even early if things are stable (clawing back some time), because someone told me that the main things to cover in a follow up are “are you better, are you worse, are there side effects?” But when things are complex or higher risk, my defense mechanism is to be more thorough: ask more questions, do more explaining. To not do that, I need to tolerate the discomfort of having potentially missed something or not considered something. It’s constant exposure therapy and exhausting.

3) decreasing how many patients I take on and therefore having a less tight schedule does take time due to intakes already scheduled. It will be down to one per day in the new year. Right now with the holiday break my routine follow ups are more like 6-8 weeks out, and sooner visits that are available for myself or my nurses to use to schedule are sparse and need to be reserved for patients who are struggling. So I’m not sure what to do if there’s a new patient I see who is complex or an existing patient who is acute and I don’t know what to do with them.

I need time, energy and support to turn this around. Every day I come in with the intention to do less, be more comfortable with leaving things unresolved and being more decisive, and something still happens to undo that. Maybe I should keep a log of how many sessions I start late. I think it’s less than earlier this fall?

Anyway, I’m afraid I will get let go or my contract non renewed before I manage to get substantially better.


PS:
Notes are getting better. I finish most of the hpi and plan while speaking to the patient and then return to clean them up and close the encounter after hours. I just need to prevent myself from making the cleanup too long a process.

 

[lockian]

You ARE in your own therapy, right?

Looking for a therapist who would be a good fit. Experiences with therapy for me have been all over the map and honestly more either useless or actively harmful. I honestly find it most helpful to talk to friends who can jog me out of my stuck points with a well placed invalidation of my worries that gives perspective and hope. I also find it more therapeutic to do a yoga, sauna, or acupuncture session than talk to my latest therapist. Exercise too, if I can get over the hump and do it.

 

[PsyDr]

1) the difference is when it turns into an official complaint and there’s a third party, possibly not a medical professional, who makes decisions about my fate

2) you’re exactly right. I have admin and lunch time but they often get overrun by patients that run long, phone calls, refills, fires that need to be put out, so it still does not feel like enough buffer time. I have support staff but still need to tell them what to do. I’ve gotten a bit better at ending sessions on time or even early if things are stable (clawing back some time), because someone told me that the main things to cover in a follow up are “are you better, are you worse, are there side effects?” But when things are complex or higher risk, my defense mechanism is to be more thorough: ask more questions, do more explaining. To not do that, I need to tolerate the discomfort of having potentially missed something or not considered something. It’s constant exposure therapy and exhausting.

3) decreasing how many patients I take on and therefore having a less tight schedule does take time due to intakes already scheduled. It will be down to one per day in the new year. Right now with the holiday break my routine follow ups are more like 6-8 weeks out, and sooner visits that are available for myself or my nurses to use to schedule are sparse and need to be reserved for patients who are struggling. So I’m not sure what to do if there’s a new patient I see who is complex or an existing patient who is acute and I don’t know what to do with them.

I need time, energy and support to turn this around. Every day I come in with the intention to do less, be more comfortable with leaving things unresolved and being more decisive, and something still happens to undo that. Maybe I should keep a log of how many sessions I start late. I think it’s less than earlier this fall?

Anyway, I’m afraid I will get let go or my contract non renewed before I manage to get substantially better.


PS:
Notes are getting better. I finish most of the hpi and plan while speaking to the patient and then return to clean them up and close the encounter after hours. I just need to prevent myself from making the cleanup too long a process.

. Just document that your plan is consistent with the community standard of care.

“I will start escitalopram 10mg, qd, for MDD, which is consistent with the community standard of care.”

If a non-licensed person says ANYTHING about your treatment plan, you respond with, “Are you saying that I should violate the community standard of care, which is the first step of malpractice? Because my contract says the exact opposite.”

Stand up for yourself.

 

[lockian]

@wolfvgang22 did you delete your post? It had some gold! I like to try to aim to view a 30 minute visit as really a 20 minute visit.

 

[SmallBird]

1) the difference is when it turns into an official complaint and there’s a third party, possibly not a medical professional, who makes decisions about my fate

2) you’re exactly right. I have admin and lunch time but they often get overrun by patients that run long, phone calls, refills, fires that need to be put out, so it still does not feel like enough buffer time. I have support staff but still need to tell them what to do. I’ve gotten a bit better at ending sessions on time or even early if things are stable (clawing back some time), because someone told me that the main things to cover in a follow up are “are you better, are you worse, are there side effects?” But when things are complex or higher risk, my defense mechanism is to be more thorough: ask more questions, do more explaining. To not do that, I need to tolerate the discomfort of having potentially missed something or not considered something. It’s constant exposure therapy and exhausting.

3) decreasing how many patients I take on and therefore having a less tight schedule does take time due to intakes already scheduled. It will be down to one per day in the new year. Right now with the holiday break my routine follow ups are more like 6-8 weeks out, and sooner visits that are available for myself or my nurses to use to schedule are sparse and need to be reserved for patients who are struggling. So I’m not sure what to do if there’s a new patient I see who is complex or an existing patient who is acute and I don’t know what to do with them.

I need time, energy and support to turn this around. Every day I come in with the intention to do less, be more comfortable with leaving things unresolved and being more decisive, and something still happens to undo that. Maybe I should keep a log of how many sessions I start late. I think it’s less than earlier this fall?

Anyway, I’m afraid I will get let go or my contract non renewed before I manage to get substantially better.


PS:
Notes are getting better. I finish most of the hpi and plan while speaking to the patient and then return to clean them up and close the encounter after hours. I just need to prevent myself from making the cleanup too long a process.

It feels like constant exposure therapy and is exhausting? I'm sorry, that seems uncomfortable and not-the-same as just being detail oriented. That sounds like me trying to do a sport, and I just wouldn't be able to do that all day. Maybe you should consider a different form of practice where you don't have the need to operate in a way that activates your fear system with every appointment? You could do like an inpatient job and ask for a half case load and spend as much time as you want with 5 patients and still make double the median US income. Just a thought.

 

[lockian]

It feels like constant exposure therapy and is exhausting? I'm sorry, that seems uncomfortable and not-the-same as just being detail oriented. That sounds like me trying to do a sport, and I just wouldn't be able to do that all day. Maybe you should consider a different form of practice where you don't have the need to operate in a way that activates your fear system with every appointment? You could do like an inpatient job and ask for a half case load and spend as much time as you want with 5 patients and still make double the median US income. Just a thought.

You may be right…

Although constant is an exaggeration. It’s only some appointments and some situations and it’s getting to be less often, because exposure does work. But maybe it’s a sign — it should not be this hard.

In inpatient I’d have to discharge high acuity people, so I was thinking maybe PHP. But then if I don’t have the structure of clinic to motivate me I might be even slower.

 

[SmallBird]

You may be right…

Although constant is an exaggeration. It’s only some appointments and some situations and it’s getting to be less often, because exposure does work. But maybe it’s a sign — it should not be this hard.

In inpatient I’d have to discharge high acuity people, so I was thinking maybe PHP. But then if I don’t have the structure of clinic to motivate me I might be even slower.

PHP is the setting in which I find efficiency to be most important because at 2 or 3pm everybody goes home and if you haven't seen them by then there is no staying late. Going slower because you're on inpatient would be a choice that you would make.

 

[lockian]

PHP is the setting in which I find efficiency to be most important because at 2 or 3pm everybody goes home and if you haven't seen them by then there is no staying late. Going slower because you're on inpatient would be a choice that you would make.

I want to get faster and be more ok with letting things go, whatever practice setting I am in. I also do like the job I have for the most part. I guess I’ll keep thinking about it but I recall in residency the acuity of inpatient had its own share of exposure therapy. The only real solution is probably to fill my practice with high functioning “worried well” and ADHDers with no history of CD.

 

[SmallBird]

I want to get faster and be more ok with letting things go, whatever practice setting I am in. I also do like the job I have for the most part. I guess I’ll keep thinking about it but I recall in residency the acuity of inpatient had its own share of exposure therapy. The only real solution is probably to fill my practice with high functioning “worried well” and ADHDers with no history of CD.

Of course that isn't the only real solution. But, I don't actually feel good about giving you advice, except to say, it sounds like you need very different kind of support to what can be offered here.

 

[clausewitz2]

Just one example is that I know that they have to get better at ending sessions on time, it’s good for them and it’s good for the treatment. First interviews are often the most challenging because patients can be all over the map and once they open up want to keep talking. It is tough to interrupt that process, but it needs to be done in order to get the background and diagnostic info needed. It also begins the therapeutic process as you begin to model for them how to contain and organize their thoughts and feelings.

This is something I struggled with for the longest time. Ultimately in intakes especially but also in regular appointments with the chatty folks at a certain time (15 minutes before end for intakes, 5-10 minutes for 30 minute appointments) I now just force myself to ask explicitly if there is anything else they feel absolutely has to be covered today or we can't discuss in the future. It's not foolproof but my experience is a majority of my patients can prioritize things at least somewhat when explicitly prompted to do so. For those who can't manage that I will then just interrupt in the last few minutes to ask about scheduling our next appointment to continue the conversation "since I think there's clearly a lot more we could talk about here and it deserves more than a couple minutes." I have one or two people who I ultimately have to repeat "I will see you on the Xth" several times before hanging up, one major advantage of telehealth.

 

[clausewitz2]

. Just document that your plan is consistent with the community standard of care.

“I will start escitalopram 10mg, qd, for MDD, which is consistent with the community standard of care.”

If a non-licensed person says ANYTHING about your treatment plan, you respond with, “Are you saying that I should violate the community standard of care, which is the first step of malpractice? Because my contract says the exact opposite.”

Stand up for yourself.

Better yet, send it in an email. Unless they're extremely stupid as well as clueless, this should put a stop to meddling like this. The CMHC I worked for for a while insisted that I do some nonsense pro forma documentation that claimed certain things were done that were never, ever done, and the moment I sent an email saying "sorry, I think I must be confused, this seems like insurance fraud" . . .

Crickets.

 

[smalltownpsych]

One thing I do is try not to spend extra time or effort with people with active chemical dependency in an outpatient setting unless it is to make a referral to the appropriate level of treatment. These patients are better at deflecting treatment than we are at providing it. I say this as someone with a high amount of expertise in treating substance abuse that has actually been in charge of a couple of programs. Since I grew up in a family system with a lot of substance use issues I have had to do some extensive personal work in this area and am of course still working on it.

 

[annoyedpsychiatrist]

Consider the alternative: what could you have done realistically to make the patient give you a good review? I know my intake today will for sure give me a bad review. I know that it bothered me initially, but ultimately the patient had very clear traits of a personality disorder, she didnt want to come in the first place (PCP urged her to), and she was self medicating with substances. In situations like these, how does someone make the patient leave satisfied?

The patient was upset about their medication regimen not being what they want. You knew deep down that it may of not been the best regimen, and something was wrong with it. You held firm in your decision and gave them the benefit of a second opinion. Should you have gone against your own beliefs/knowledge to please that patient? And even if that pleased them now, we both appeasement only works in the short term. Give an inch and patients with personality disorders/severe SUD/etc will take a mile from you. You set boundaries. You didnt call the patient names, act in a codenscending manner or attack the patient. Because the patient is seeing you shows that something in their life is not functional and that they need your guidance on something. Often what makes patients happy isnt whats actually best for them. Sometimes by making them unhappy, youve done the right thing.

There are periods where you just cant win no matter what you do unless you make yourself a doormat for a maladaptive patient. Remember if you're getting these bad reviews, others are too. I get the occasional bad review, but i know deep down that what could i have done? Some days it certainly affects me more than other days but when that happens i slow myself down and ask "Did I do what I felt was right at the time? Did I act without bias? Would I have done anything differently?"

 

[hallowmann]

The flip side is if an outpatient psychiatrist truly thinks a patient requires visits more frequently than q4 weeks, the patient needs a higher level of care, for which a clinic psychiatrist cannot provide. Of course, if they are having a true emergency (SS, SJS, NMS, SI, HI, etc), they need immediate medical and/or custodial care (ER, hospital, psych ward, jail, etc).

On the other hand, if a clinic patient FEELS they need to be seen sooner than q4 weeks, they are really asking for DBT or a therapist they can see daily.

I mean, you're not wrong, but I have a lot of patients that short of being enrolled in ACT, they can't really manage the requirements to adhere to a PHP/IOP schedule, and many would only go inpatient on holds/commitment, so when they decompensate, I like to know I can see them again relatively soon. For me, ideally that's 2 wks.

To be clear, I'm working community psych, lots of SMI/SUD/dual-diagnosis and resource poor patients.

 

[Stagg737]

One reason why you all might not have heard from me about my insecurities for a while is because I did find a mentor outside of my job, and they are helpful, particularly in talking through cases I am stuck on, but they also in private practice and one of the people who seems to think that that, along with cherry picking patients, is the ultimate solution to any systemic or personal issues. They are empathetic but at times it feels, to quote the move “As Good as it Gets” that “I’m drowning and they are describing the water.” Same happened with my old therapist, who was also an old school psychoanalytically trained MD psychiatrist. Maybe I expect too much, idk.

Maybe they're trying to make sure you're aware of the situation and general environment of psych since you're a younger attending. If you have a good understanding of "the water", the question becomes why aren't you doing anything about it? (rhetorical, sounds like you are trying).

It sounds like you still hold yourself heavily responsible for your patients. Don't. It's important to be empathetic and care, but you cannot make decisions for them and it's not your job to "fix" them. Your job is to educate them and provide them with the tools they need to help themselves (or refer them to SW/CM/others who can provide the help they need), if you've done that then you've done what you can. I struggled with that in residency and sometimes find myself going down that rabbit hole, but at the end of the day it's on the patient to implement treatment plans. I'll reiterate my favorite advice from one of our older and wiser attendings in residency that has helped keep me in line and sane, "You should never be working harder than the patient."

Anyway, I’m afraid I will get let go or my contract non renewed before I manage to get substantially better.

Unless you love your job, don't worry about this. Take a look at some job boards and realize there are a plethora of opportunities pretty much everywhere and you can even create jobs places if you have a reasonable proposal.

 

[annoyedpsychiatrist]

Maybe they're trying to make sure you're aware of the situation and general environment of psych since you're a younger attending. If you have a good understanding of "the water", the question becomes why aren't you doing anything about it? (rhetorical, sounds like you are trying).

It sounds like you still hold yourself heavily responsible for your patients. Don't. It's important to be empathetic and care, but you cannot make decisions for them and it's not your job to "fix" them. Your job is to educate them and provide them with the tools they need to help themselves (or refer them to SW/CM/others who can provide the help they need), if you've done that then you've done what you can. I struggled with that in residency and sometimes find myself going down that rabbit hole, but at the end of the day it's on the patient to implement treatment plans. I'll reiterate my favorite advice from one of our older and wiser attendings in residency that has helped keep me in line and sane, "You should never be working harder than the patient."


Unless you love your job, don't worry about this. Take a look at some job boards and realize there are a plethora of opportunities pretty much everywhere and you can even create jobs places if you have a reasonable proposal.

this x10000000. Medication doesn't necessarily solve problems, it improves symptoms of a problem. Patient's actions/thoughts/etc are often what exacerbate their own systems, we cant force them to make the right choices.

Also patients present to us depressed, anxious, angry, psychotic, etc. Its hard to generate nonstop good reviews when the people you see are unhappy people.

 

[the5thelement]

The patient is the one with the disease. Learn to be kind to yourself. Its not an easy job at the best of times. Dont compound the problems by overbooking.

 

[lockian]

Of course that isn't the only real solution. But, I don't actually feel good about giving you advice, except to say, it sounds like you need very different kind of support to what can be offered here.

Well, the only real solution that does not involve behavior or attitude change on my part.

This space has its use. I don’t see my colleagues practice directly, barring whatever intermittent shadowing occurred in residency. So it’s helpful to see how people approach fairly ubiquitous challenges like staying on time and patient complaints. It’s also helpful to know that if others think or operate a certain way, then it’s ok for me too.

 

[lockian]

It sounds like you still hold yourself heavily responsible for your patients. Don't. It's important to be empathetic and care, but you cannot make decisions for them and it's not your job to "fix" them. Your job is to educate them and provide them with the tools they need to help themselves (or refer them to SW/CM/others who can provide the help they need), if you've done that then you've done what you can.

True. Ascribing too much accountability to myself and running late are related issues because I put pressure on myself to “figure it out” or “fix things.” Putting this pressure on myself can also result in “paralysis by analysis.” In reality, the answer might be “I don’t know,”“this is too complex to figure out today,” but then it’s… see you in another month? Ugh.

The cases that most slow me down are:
—wtf is going on here? Is it a symptom or a side effect? I’ve never seen this before. Still happens since I am not yet very experienced. Best plan here i think is actually to give myself more time but if I can’t do that in the next month figure out if there’s any safety concerns today.
—I make recommendations. They give pushback. “This won’t work, I already tried it, i don’t like the potential side effects, I can’t access this service.” Excuses abound. The answer is probably some version of “this is what’s known to be effective, this is the best treatment plan I can offer at this time.” These are NOT cases where more time will help.
—variant of number 2: limited options but not because the patient is pushing back. Maybe lots of meds have been tried. Maybe there are med options but legitimate medical barriers exist. Maybe the necessary resources are actually unavailable. Paralysis by analysis may set in because the case is on face complex. Maybe the answer here is to just see what small difference can be made today.

It’s probably the pandemic but getting people into therapy is a real bear in this community right now. In my institution therapists are so overworked they can see people maybe once a month. It’s not even a poor resource community either! I could also start a whole thread about bad therapists my patients have worked with. And I’ve worked with. (You’ve taken an EMDR course and you think you’re a trauma therapist now?) PHP/IOP is tricky too. It’s really disruptive for most people with jobs, school, kids etc to take 5 weeks out if their lives.

But. I can’t fix the above issues. I can only change my MO.

 

[mistafab]

True. Ascribing too much accountability to myself and running late are related issues because I put pressure on myself to “figure it out” or “fix things.” Putting this pressure on myself can also result in “paralysis by analysis.” In reality, the answer might be “I don’t know,”“this is too complex to figure out today,” but then it’s… see you in another month? Ugh.

The cases that most slow me down are:
—wtf is going on here? Is it a symptom or a side effect? I’ve never seen this before. Still happens since I am not yet very experienced. Best plan here i think is actually to give myself more time but if I can’t do that in the next month figure out if there’s any safety concerns today.
—I make recommendations. They give pushback. “This won’t work, I already tried it, i don’t like the potential side effects, I can’t access this service.” Excuses abound. The answer is probably some version of “this is what’s known to be effective, this is the best treatment plan I can offer at this time.” These are NOT cases where more time will help.
—variant of number 2: limited options but not because the patient is pushing back. Maybe lots of meds have been tried. Maybe there are med options but legitimate medical barriers exist. Maybe the necessary resources are actually unavailable. Paralysis by analysis may set in because the case is on face complex. Maybe the answer here is to just see what small difference can be made today.

It’s probably the pandemic but getting people into therapy is a real bear in this community right now. In my institution therapists are so overworked they can see people maybe once a month. It’s not even a poor resource community either! I could also start a whole thread about bad therapists my patients have worked with. And I’ve worked with. (You’ve taken an EMDR course and you think you’re a trauma therapist now?) PHP/IOP is tricky too. It’s really disruptive for most people with jobs, school, kids etc to take 5 weeks out if their lives.

But. I can’t fix the above issues. I can only change my MO.

For scenarios 1-3 there is an easy solution. Step back and say "wow, there is a lot to cover. Let us revisit this next visit. For now, we can either keep things the same or make change X, what would you prefer?" and see them in a few weeks. If they stall or keep putting up barriers, then say "okay, lets keep things the same. I'll have to get your follow up scheduled" and walk them to the door.

Problem solved. You're not a miracle worker. You can't fix these problems in 20 minutes.