working in a state mental hospital

[Igor4sugry]

We have rotations at the state mental hospital, and my experience was good.
Its much different from private hospitals for sure, for examples attendings don't need to see patients every day (1-2x per weak is required). The job has more controlled hours.
The one thing lacking is rigor of being in academic center and being immersed in latest treatments. Acuity seems higher as well.

Would love to hear of opinion from some attending working at a state mental hospital system.

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[michaelrack]

We have rotations at the state mental hospital, and my experience was good.
Its much different from private hospitals for sure, for examples attendings don't need to see patients every day (1-2x per weak is required). The job has more controlled hours.
The one thing lacking is rigor of being in academic center and being immersed in latest treatments. Acuity seems higher as well.

Would love to hear of opinion from some attending working at a state mental hospital system.

I have worked at several state psych hospitals (Mississippi). There variability state to state, as well as type of unit (long term vs acute) regarding how often patients are seen. Would agree about the controlled hours.

 

[notdeadyet]

I have worked at several state psych hospitals (Mississippi). There variability state to state, as well as type of unit (long term vs acute) regarding how often patients are seen. Would agree about the controlled hours.

Ditto this. Also, one of the biggest factors in clinical culture is whether the state hospital is a training site for residencies...

 

[whopper]

They vary state by state but here are the general trends I see even across states. There are exceptions.

1) Doctors in general tend to be worse as a whole vs academic centers. Of course, this is as a whole. There are some great doctors in the state system.

2) Incredibly good benefits. Several will give you half your salary for the rest of your life plus health benefits if you work for them about 25 years. Even more than that if you work longer.

3) The facilities tend to be physically bad. There are exceptions. Where I worked, the facility was one of the best in the country in terms of physical design because it was built in the 90s during the economic boom.

4) Sicker patients with worse prognosis.

Feel free to post if you see opposing trends. I'm basing this off of a mass total of about 9 state hospitals I know of across several states.

 

[vistaril]

We have rotations at the state mental hospital, and my experience was good.
Its much different from private hospitals for sure, for examples attendings don't need to see patients every day (1-2x per weak is required). The job has more controlled hours.
The one thing lacking is rigor of being in academic center and being immersed in latest treatments. Acuity seems higher as well.

Would love to hear of opinion from some attending working at a state mental hospital system.

Dont work at one, but the pay(in most states) for working at these is subpar...think 145ish starting. If you have student loans and are making that sort of money, you won't be buying the new m3 anytime soon. Yeah, there are exceptions...I think someone posted a link not too long ago of some high salaries, but I've also heard of lower than 145....some state mental systems still hire foreign psychs(who never did a residency in the US) for like 120-130k under a special license that only allows them to work as an inpatient state mental health doc. That obviously is one factor that depresses salaries....

Given the choice between working at a state mental hospital vs a VA, I'd take the VA job.

 

[Igor4sugry]

This particular state hospital starts at 180k. No call (get paid if sign up for call). Full state benefits; Defined benefit pension vs Defined contribution pension. Benefits are nice; health insurance is cheap; unused vacation days can be converted into pay. Retirement plan options are very nice with very low expense ratios and have access to 403 and 457 plans. They give loan forgiveness at $22k/yr x4yrs. Work till 4:30pm; 1hour for lunch.

Sounds like this may be in the top range of state jobs.

 

[whopper]

In Ohio the pay was dirt cheap--155K per year, but it was freaking easy. I'm taking you finished your work about 2-3 hours into the day and then had nothing to do but you were trapped there because you had to be there 40 hours a week.

Yes, most state jobs pay better but you could be working your tail off. E.g. while I was a resident in NJ, the state hospital system paid 200K/year but you worked all day long.

But a benefit with the Ohio system was if you did private practice on the side, it married well with the state job because you got benefits and during that free time, you could've gotten some of the private practice stuff out of the way. I'm not talking double-dipping because there was literally nothing else to do.

I've thought about retiring to the state later on....when I can't handle a 40 hour a week job anymore because that was the equivalent of part time work for a low full-time salary. You just had to sit there in your office doing something. I caught up on Deadwood (the HBO series), got a set of weights for my office, and should've gotten an inflatable bed.

 

[st2205]

State hospital I rotated through was very slow-paced and laid back. Saw some very sick people, though. Hours were light and I think most of the time was spent in the office. No call and no weekends, unless you wanted to earn more. Everyone made over 250. Half the people made over 300.

 

[PistolPete]

Anyone know if the California state hospital system is planning on moving to electronic medical records any time soon? The paper c harts and volumes (due to patients being there for like 10 or 20 years) is the biggest drawback at this point for me in terms of possibly accepting a job there. Any idea from anyone in the know?

 

[notdeadyet]

Anyone know if the California state hospital system is planning on moving to electronic medical records any time soon? The paper c harts and volumes (due to patients being there for like 10 or 20 years) is the biggest drawback at this point for me in terms of possibly accepting a job there. Any idea from anyone in the know?

I'd take any "plan" with a big grain of salt. They've been talking about doing it for eons. And given the state budget, and particularly how its affecting places like Napa, Atascadero, etc., I doubt it's high on anyone's list.

An EMR would be great, but it would be particularly painful for the first 5-10 years. I can almost guarantee that if they manage to get an okay for an EMR implementation, they aren't going to opt for the huge fee that would be scanned paper records. So post-EMR, you're going to wind up with duplication of efforts: look in the EMR, not find what you need, dig through the paperchart. It'll be handy for orders and paper labs, but the charts won't be going anywhere for many years.

 

[PistolPete]

What's the problem with Napa and Atascadero?

 

[notdeadyet]

What's the problem with Napa and Atascadero?

The state budget has not treated them kindly. California has a few counties that are great for mental health issues (this is why services vary so much from county to county), but as a state we don't have the best track record. Even in flush times, we didn't push a lot of state money to mental health. When times are tight, we REALLY don't do it. And when we do, the last thing they will put money towards is facilities.

I'm not as familiar with Atascadero, but Napa can be tough to work. Their security has been a point of contention among staff for a looong time. There are areas that the panic buttons do not work. The institutional police response times was pretty rotten. A DoJ investigation slapped them for violations several years ago, several about safety. A nurse was killed by a patient there 2-3 years ago and there were a lot of promises about improvements but I don't know if anything changed.

It was first built in the late 1800's. This is not one of those bright, antiseptic state hospitals built recently. I wouldn't mind working there, because there is great pathology and they have a great mission, but I would be cautious doing so.

 

[gibits]

Seems like there a lot of CA docs here. I spent about 1.5 years at Patton State and found it incredibly dull. You see the patients about once a month, do a monthly note and that's about it. The medications made no sense at all. You'd see mega doses and polypharmacy all over the place. The most stimulating thing was wondering if the note was a quarterly note, monthly or annual note.
It's a morally bankrupt system. I personally treated the guy involved in the Isla Vista massacre. There was nothing wrong with him. He was just a rich kid with a good lawyer that only got 4 years for killing 4 people.
In my 1.5 years there 2 psychiatrists were badly assaulted.

Honestly, it was not a good experience. One of my seniors took a job there and they cut him after only 5 months. So much the security of state jobs huh?

The good news is you have great benefits, only work 4 days a week and can leave at 3:30 if you want to. I highly doubt Metro, or Napa would be much different.

 

[whopper]

The medications made no sense at all. You'd see mega doses and polypharmacy all over the place

Same going on in Ohio.

Plenty of very sick patients on some medication regimen that made no sense at all but the treating doctor was a freaking idiot and did nothing to fix it.

This led to a phenomenon where the psychologist and nurse, even social workers and occupational therapists could tell this guy didn't know squat but they weren't the prescriber and couldn't change the meds themselves. Everyone would sit at the treatment team table knowing this medication regimen was wrong but each was trapped by the limitations of their profession in doing anything about it.

It was to the degree where I believed a monkey rolling a die would've given better treatment.

One thing about that job that my wife reminded me to do was to cope with this, I had to come home not allowing it to bother me because coming home, complaining about it for about 2-3 hours, especially given that I couldn't do much about it other than only fix my own patients was incredibly frustrating. I've seen cases where someone would be in the unit for literally years that wasn't even that sick but I couldn't do anything about it because it wasn't my own patient.

To answer those who will ask,
Why couldn't I do anything about it? Can't do anything to a patient that's not yours unless it's an emergency, but I did report the problem I saw to the administration that was well aware of these problems. Their attitude was they couldn't easily replace the doctor and if they did replace him/her they'd get someone just as bad. Unfortunately this philosophy was very much true.

One thing the administration started doing was they noticed my turnover rate was pretty good because I don't believe giving 8 meds out and Risperdal at 1 mg a day among a regimen you wouldn't expect to work anyways would treat psychosis. They started transferring a bunch of the patients from other units to my own unit because they knew that other doctor was good for nothing.

And this led to a new frustration. I was doing much better work and more work than most of my colleagues but wasn't getting paid anymore than they were.

 

[bashir]

Same going on in Ohio.

Plenty of very sick patients on some medication regimen that made no sense at all but the treating doctor was a freaking idiot and did nothing to fix it.

This led to a phenomenon where the psychologist and nurse, even social workers and occupational therapists could tell this guy didn't know squat but they weren't the prescriber and couldn't change the meds themselves. Everyone would sit at the treatment team table knowing this medication regimen was wrong but each was trapped by the limitations of their profession in doing anything about it.

It was to the degree where I believed a monkey rolling a die would've given better treatment.

One thing about that job that my wife reminded me to do was to cope with this, I had to come home not allowing it to bother me because coming home, complaining about it for about 2-3 hours, especially given that I couldn't do much about it other than only fix my own patients was incredibly frustrating. I've seen cases where someone would be in the unit for literally years that wasn't even that sick but I couldn't do anything about it because it wasn't my own patient.

To answer those who will ask,
Why couldn't I do anything about it? Can't do anything to a patient that's not yours unless it's an emergency, but I did report the problem I saw to the administration that was well aware of these problems. Their attitude was they couldn't easily replace the doctor and if they did replace him/her they'd get someone just as bad. Unfortunately this philosophy was very much true.

One thing the administration started doing was they noticed my turnover rate was pretty good because I don't believe giving 8 meds out and Risperdal at 1 mg a day among a regimen you wouldn't expect to work anyways would treat psychosis. They started transferring a bunch of the patients from other units to my own unit because they knew that other doctor was good for nothing.

And this led to a new frustration. I was doing much better work and more work than most of my colleagues but wasn't getting paid anymore than they were.

I've spent a lot of time visiting my brother in a state mental hospital. Witnessing the frequently incompetent care he received there has led me to consider working there myself someday, but this post validates my concern that this would likely be a thankless, soul-sucking job with little hope of enacting systemic change. Of course helping the people under your direct care is no small achievement and should be valued in its own right, but I don't know how long any one can keep that up before burning out.

Whopper, or anyone else, do you have any advice for how a future psychiatrist (M3) might set herself up for a career that includes improving the quality of care at the local state mental hospital? I toyed with the idea of getting an MPH during medical school but my husband vetoed that idea for what I had to concede were valid financial considerations.

 

[Fermata]

My experience has been the following:
1.) Generally sicker patients with worse prognosis as noted previously
2.) Generally more run-down facilities - this has been changing in my state as the major facilities are all being rebuilt but still the digs in the current state leave a lot to be desired (with one building at the nearest local state psychiatric facility having to be closed due to a bat infestation)
3.) The staff - it seems like those who have been employed at a state facility are less apt to do anything more than required to be helpful which seems less common than at a private or academic center. It seems to extend beyond just a person-to-person point of interaction but seems more systemic.
4.) More laid back - when patients stay longer, when there is not really a higher level of care, when notes have to not be done every day, when you are only required to work at more defined hours - it lends itself to a slower pace (which can be good and bad)

 

[whopper]

Whopper, or anyone else, do you have any advice for how a future psychiatrist (M3) might set herself up for a career that includes improving the quality of care at the local state mental hospital? I toyed with the idea of getting an MPH during medical school but my husband vetoed that idea for what I had to concede were valid financial considerations.

Unfortunately the solution IMHO is more people have to go into this field. When I mentioned the administration didn't do anything, I didn't mean it as if they were uncaring or evil. Out of all of the people I saw in the state hospital's administration, the overwhelming majority of them were good and cared. The problem was that they couldn't fix the patient themselves either for the same reason I couldn't. If you're the CCO of a hospital, you're not supposed to all of a sudden treat every single patient that's already assigned to a new doc. Several of these guys are my good friends and we've had discussions over a beer venting our frustrations over this.

And if they fired the doc, the replacement would likely be just as bad. Politically, if a hospital fires docs left and right, the general talk around town from the doctors is to not work for the place because, of course, plenty of docs want an easy job.

There is a general shortage of doctors across the country. It's to the degree where I know the administration of several of the hospital systems know each of the psychiatrists working as if they have a mental map of almost all of them, and getting the good ones is like trying to get a highly valued baseball player. The problems with the state also lie in that they can't pay you much more than what the state offers, so if there is a prize player, they can't pay them usually anything more and if so, they can only do so on the order of a few percentage points more. The number of players is limited, and if you dip your hand into the social network now and then, within 1-2 years you'll know who all the players are--and let me tell you, it ain't much!

I have mentioned my identity on the board in the past and it's not like I try to keep is secrete but I don't exactly want it plastered everywhere....and here's a reason why.

After I left the state hospital, someone in the administration offered me to come back and offered 25K more so than I was given before despite that the pay for all the docs is determined by an equation in the state handbook. Turned out the state was willing to hire some docs at a significantly inflated salary if they left but had a known track record of doing phenomenally better work than the other docs. I was told something to the effect that if I came back and took the extra 25K a year to not exactly announce it publicly. I was told something to the effect that higher ups in the state system knew I pretty much saved them several hundred thousands of dollars a year because I actually got patients moving.

I haven't gone back.....yet. The bonus of the state job was the good benefits, and it was darned easy. If I decided to make a private practice and mixed it with the state job, I'd have a job that married with PP well, would have benefits, a retirement to look forward towards, and make good money in PP (cause the state don't make much). I could come home less stressed and spend more time with my kids . The negative was having to deal with the chronic ineptitude from docs giving things like Neurontin to treat bipolar disorder and if I told them it doesn't work for that disorder they'd give me the evil eye and ignore me.

But the benefit I got with the university is I get to work with some of the best docs in the country---but I work my tail off and come home feeling stressed and blown away.

 

[Igor4sugry]

One way state hospitals can be more attractive is to increase loan repayment benefits. For example at least $100k over 4yrs of work.

Still, starting salary at state hospital is somewhat higher than starting salary at an academic center. Yet residents go for academic centers.
One thing state hospitals haven't done (at least to my knowledge) is higher psychNPs. They have psych NPs in community psych sites, but I'm not sure why not at state level, since this is a cheap way to get more providers.

Can you qualify for PSLF while working for a state hospital?

 

[whopper]

I've seen the state hire NPs, but for whatever reason it's generally shunned, so I don' t know if the shunning is due to a codified policy in the state books or because the hospital just wants doctors out of the preferences of people in the administration.

But I'm only talking Ohio.

 

[michaelrack]

One thing state hospitals haven't done (at least to my knowledge) is higher psychNPs. ?

I haven't seen state hospitals get NP's high, but I have seen them hire them in Mississippi

I supervised psych NP's at both the state psych hospital in Jackson MS and the state psych hospital in Meridian MS.

 

[vistaril]

One way state hospitals can be more attractive is to increase loan repayment benefits. For example at least $100k over 4yrs of work.

Still, starting salary at state hospital is somewhat higher than starting salary at an academic center. Yet residents go for academic centers.
One thing state hospitals haven't done (at least to my knowledge) is higher psychNPs. They have psych NPs in community psych sites, but I'm not sure why not at state level, since this is a cheap way to get more providers.

well yeah, but how good is state govt at doing things in a cost effective way??

Eventually, the dam is going to break(and soon) and they will have to though.

But in general, governments do not spend money effectively. The only solution is to give them less money to spend.

 

[whopper]

Not really though unfortunately the only way you're going to get more effectiveness is by being smart and creative but I wouldn't expect that from the state, cause it's the state.

What am I talking about?

A good doctor could save the state hundreds of thousands to millions vs the bad doctors. If the state upped the salary in Ohio from $155 to 190, they would get good docs and those good docs would save far more than the 40K price increase.

To give you a quick example, when I worked for the state, I got patients better in about a month that were there for years and did not get better. Was it because I was a unique genius? No. I am currently working with several docs in the university that IMHO are just as good as me and they too would've accomplished this feat. There's so many bad doctors in the state and several good doctors in a university setting.

Take one of those university docs and put him in the state system, he'd save at least several hundred thousands of dollars if he merely got 10 patients better in a month that were there for years. Each patient cost the system something on the order of $700 day (I'm off somewhere around $50-100/day) $700 x 365= $255,500 per patient. Now granted, if that person was put in a group home that too would cost money but the cost would be far less, more on the order of a few thousand per month.

But to implement this in a manner to get the better docs, they'd have to do things to make sure those docs were better and expect better work out of them. This is where the plan could fail cause it would involve people to actually give a damn and care and this is hard to make sure in happening in a state system.

In other states where state docs make good money, they've tried to decrease salaries before. I've seen it happen in the 80s. I was a teenager back then but a bunch of doctors are in my family. What happened is it got to the point where docs and nurses left because by cutting costs, the hospital went from semi-unsafe (e.g. dangerous patients but good guards appropriate measures in place) to very unsafe to the point where no one would work in the hospital to a degree where the state either HAD TO SHUT IT DOWN or raise pay to get more people to work there.

Bear in mind, there are constitutional/legal minimum standards a hospital has to abide be (established in the court-case Wyatt v. Stickney. http://www.treatmentadvocacycenter.org/component/content/article/345

If it's cut too much, it won't reach that minimal legal standard.

Where I worked, a guy just a few months ago became the new chief clinical doctor, Douglas Lehrer, and he's a phenomenal doctor. IMHO this guy could actually be that type of guy that could implement something that could work. He's good enough to be a private good doctor but for whatever reason wants to work for the state (IMHO likely because of his forensic interests and he's already heavily invested in the state retirement system but I'm speculating here).

 

[vistaril]

Not really though unfortunately the only way you're going to get more effectiveness is by being smart and creative but I wouldn't expect that from the state, cause it's the state.

What am I talking about?

A good doctor could save the state hundreds of thousands to millions vs the bad doctors. If the state upped the salary in Ohio from $155 to 190, they would get good docs and those good docs would save far more than the 40K price increase.

But to implement this in a manner to get the better docs, they'd have to do things to make sure those docs were better and expect better work out of them. This is where the plan could fail cause it would involve people to actually give a damn and care and this is hard to make sure in happening in a state system.

In other states where state docs make good money, they've tried to decrease salaries before. I've seen it happen in the 80s. I was a teenager back then but a bunch of doctors are in my family. What happened is it got to the point where docs and nurses left because by cutting costs, the hospital went from semi-unsafe (e.g. dangerous patients but good guards) to very unsafe to the point where no one would work in the hospital to a degree where the state either HAD TO SHUT IT DOWN or raise pay to get more people to work there.

Bear in mind, there are constitutional/legal minimum standards a hospital has to abide be (established in the court-case Wyatt v. Stickney. http://www.treatmentadvocacycenter.org/component/content/article/345

If it's cut too much, it won't reach that minimal legal standard.

starving the beast wouldn't be a bad thing imo......and not just for state mental health services but for govt services in general(but that's going off on a tangent/rant)

We know there are large discrepancies in what state hospital psychs are paid from state to state as you indicate. Some states have staff have base salaries of 130-5k. Some have starting salaries of 200k. I don't know that there is any evidence that the state hospitals with higher pay have psychiatrists doing a much better job. You've complained a lot about the staff psychiatrists at the place in Ohio you worked, but there are stories all across the country of the same variety at state hospitals.......

State hospitals are still being closed in massive numbers across the country anyways, so in 10 years I'm not sure how much it will matter. In my state the plan was to close ALL non forensics beds. Every single one. That is a little behind schedule and hasn't happened quite yet, but the number of state hospital beds is getting very very low. Seems that states are moving to a model where they are contracting out 'commitment beds' to private hospitals in piecemeal....which is almost certainly a good idea from a $ perspective as long as they keep the numbers below a certain number.

 

[whopper]

Well starving the beast could work in certain ways.

E.g. there has been talk of privatizing the state hospitals. IMHO, with good doctors, you could vastly decrease the expenses and actually increase the quality of care--but again with good doctors. That's the problem. It's hard enough as it is just to get doctors.

In the current state system, you do a good job, you really don't get paid more. Yeah I know I mentioned they offered me a deal where I got more, but I was told to keep it hush-hush, I was the only one I knew about that had this offer, and while there is an equation in the state salary to offer more pay to better docs it's only on the order of about 4-5% points and the former chief doctor never implemented it because he didn't want to deal with the worse docs complaining at him, so he gave everyone the same exact pay.