Avoiding outpatient burnout

[kookfu]

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Question for those with long term attending experience. What are some job tips/hacks you added later in your career to avoid burnout?

 

[Sushirolls]

Getting away from employed jobs. Doing PP.
Having a quality assistant / front desk.
Not taking UHC or other insurance that routinely scat on you.

 

[Bartelby]

Some things that help for me (whether in private practice or employed):

-Do 90 minute intakes and 30-minute follow ups
-Build in admin time, even if it is a lunch hour. Try to use time efficiently so that you can typically go for a walk, scroll SDN, or do whatever you want in that downtime.
-Manage your panel so that you have schedule openings for urgent cases. Having several acute patients with no way to manage them except working them in before or after-hours is stressful (and so is ignoring the issue and dealing with a bad outcome).
-If you have a niche interest consider building a practice geared toward that (for example, psychosis, trauma, substance abuse). If in private practice, consider developing a therapy panel (interesting work that decreases the overall panel size significantly).
-Maintain good boundaries. Avoid doing lots of out-of-session work or after hours work. For example, try to fill out paperwork with the patient in session where they can provide additional info and clarification.

I also recommend varying things up. If you have some time dedicated to another activity like research, leadership, or clinical care in another setting that can break up the "grind."

If I worked only outpatient clinical, I would do 0.8 FTE and work four eight-hour days if finances allowed. I think five days of a close to fully-booked schedule would likely burn me out. With a slower, gentler pace I find outpatient work to be pretty rewarding and probably the best practice setting in psychiatry.

 

[finalpsychyear]

Question for those with long term attending experience. What are some job tips/hacks you added later in your career to avoid burnout?

Work hardest early in your career like first decade then naturally you can scale back. Nothing beats this. This is what my attending told me and too many around me were crusiing around doing 20-25 hr work weeks for a few years post residency now they are in late 30s/early 40s realizing they should have done more early on and its been more challenging to get high paying jobs vs when they were in highest demand when first out.


Compound working leads to compounded investing which leads to sub 50 FIRE and work for fun lifestyle. Good luck it def wasn't easy but 0 regrets working my tail off then the stock market further compounded all that so a little luck never hurts.

 

[Ironspy]

Off the top of my head:
1. Boundaries for yourself, patients and admin
2. Clear expectations for patients about communication btwn appts, refills, fees etc (much easier in private practice v employed)
3. Schedule send all messages M-F 8-5 so no one expects an answer after hours
4. Max 6h of direct patient care in a day (5 is better)
5. Last hour of the day for admin. Never stay late.
6. Follow ups 30 minutes. Never shorter
7. Comprehensive screening of new patients to optimize doctor-patient compatibility
8. Don’t do things that make you resentful

 

[splik]

"Burnout" is really about systemic issues rather than things you can necessarily control in a given system. Interestingly, one of the biggest determinants of burnout in physicians is the level of student debt. This is why IMGs have lower rates of burnout, because they tend to have dramatically lower levels of student debt. So one of the big factors is for students to do their best to avoid accruing high levels of debt, and for those in practice to work hard at eliminating that quickly.

Other things that seem to track with burnout are features of late capitalistic healthcare including "productivity targets", high volume practice, quality metrics, patient satisfaction scores, low levels of autonomy, documentation/EMR bloat, and moral injury from feeling like you cannot provide the standard or quality of care that patients deserve. Dealing with monotonous tasks that alienate us from the actual practice of psychiatry (like doing prior authorizations, interacting with insurance companies, pharmacies etc) can all contribute to burnout.

Always have one foot out of the door. Always keep looking at other opportunities and jobs so you don't feel trapped. Take long weekends, take vacations, pivot to what you are passionate about and find a way to focus on that. The more control you have over how you practice (e.g. appointment lengths, frequency of visits, which patients you see) and the more you can farm out things like doing PAs, the more fulfilling a career you can have. Also, don't compare yourself to others. The most miserable people are the ones who feel upset they don't make as much as such and such, or gripe about NPs taking "our jerbs" etc. Be content with your lot in life and if you want more then put in the work and make it happen.

 

[finalpsychyear]

"Burnout" is really about systemic issues rather than things you can necessarily control in a given system. Interestingly, one of the biggest determinants of burnout in physicians is the level of student debt. This is why IMGs have lower rates of burnout, because they tend to have dramatically lower levels of student debt. So one of the big factors is for students to do their best to avoid accruing high levels of debt, and for those in practice to work hard at eliminating that quickly.

Other things that seem to track with burnout are features of late capitalistic healthcare including "productivity targets", high volume practice, quality metrics, patient satisfaction scores, low levels of autonomy, documentation/EMR bloat, and moral injury from feeling like you cannot provide the standard or quality of care that patients deserve. Dealing with monotonous tasks that alienate us from the actual practice of psychiatry (like doing prior authorizations, interacting with insurance companies, pharmacies etc) can all contribute to burnout.

Always have one foot out of the door. Always keep looking at other opportunities and jobs so you don't feel trapped. Take long weekends, take vacations, pivot to what you are passionate about and find a way to focus on that. The more control you have over how you practice (e.g. appointment lengths, frequency of visits, which patients you see) and the more you can farm out things like doing PAs, the more fulfilling a career you can have. Also, don't compare yourself to others. The most miserable people are the ones who feel upset they don't make as much as such and such, or gripe about NPs taking "our jerbs" etc. Be content with your lot in life and if you want more then put in the work and make it happen.

Good points here for sure. Have a vision of the roadmap of what your career will sorta look like since it wont necessarily hold. If your single, married, and/or have kids that will impact your "tank" so you have to manage with that in consideration. My first 5 years i was single and could put most of my tank into the career. My roadmap was not to be the doc that worked till 65 unless I was doing it for some reason not financially related at that point.

Once those variables were laid out, I simply mapped out my career in 3 phases. The first decade was the foundation base where investing till it hurt and working more than 1.0 FTE to have the money to invest compounded each other and would allow me to ease up in the following decades. I def live in the moment and have a ton of fun and travel thus working extra helps to have both things.

Im going to begin the 2nd phase next year where I am cutting hours and giving myself fridays off.

 

[FlowRate]

Live below your means and have solid emergency savings. This gives you short-term FU money if ever needed.

For me, having a significant admin role is a huge plus. Gives me more varied and interesting work and less clinic grind.

Know when to tell patients they need an appointment rather than another round of unanswered portal questions.

I wish I could be this way, but I'm not: some of our docs who are 1.0 clinical for many years and still happy with it are relatively more permissive--they choose less battles. I imagine things feel nicer when you're making more people happy with you, even if that might not be a system, quality, or epistemologically optimal outcome.

 

[calvnandhobbs68]

Different people are different in terms of motivation but I honestly think one of the best things for me outpatient is essentially being "productivity based" with private practice. Means that I actually get paid more to deal with an urgent patient issue or squeezing in a followup appointment.

I'm also pretty clear with patients that I don't make many medication changes unless we've previously talked about it or scheduled a followup appointment to discuss it....both so I get paid for my time and effort but also safety reasons. Will always have the story about the time that a parent wanted to stop a medication between appointments because a patient started 'hallucinating with it' but got the kid in the next day and found out guess what the hallucinations last week were from a benadryl OD that wasn't disclosed.

 

[Merovinge]

Good points here for sure. Have a vision of the roadmap of what your career will sorta look like since it wont necessarily hold. If your single, married, and/or have kids that will impact your "tank" so you have to manage with that in consideration. My first 5 years i was single and could put most of my tank into the career. My roadmap was not to be the doc that worked till 65 unless I was doing it for some reason not financially related at that point.

Once those variables were laid out, I simply mapped out my career in 3 phases. The first decade was the foundation base where investing till it hurt and working more than 1.0 FTE to have the money to invest compounded each other and would allow me to ease up in the following decades. I def live in the moment and have a ton of fun and travel thus working extra helps to have both things.

Im going to begin the 2nd phase next year where I am cutting hours and giving myself fridays off.

Really like the roadmap/phases of a career in psychiatry perspective. I don't know how people have kids in med school/residency, as I did the same thing where I grinded hard in fellowship/first few years of attendingdom with moonlighting and cashing out PTO. Then I settled into a regular 1.0 FTE once I had progeny. I will probably drop down to 0.8 FTE at some point in time in the next few years unless the markets go into extended stagnation/recession.

 

[Stagg737]

Really like the roadmap/phases of a career in psychiatry perspective. I don't know how people have kids in med school/residency, as I did the same thing where I grinded hard in fellowship/first few years of attendingdom with moonlighting and cashing out PTO. Then I settled into a regular 1.0 FTE once I had progeny. I will probably drop down to 0.8 FTE at some point in time in the next few years unless the markets go into extended stagnation/recession.

Me as example, I had my first kid at 29 at the start of my intern year. Wife was desperate to have kids and I also wanted to before 30. My parents had me when they were 35 and I was beating my dad in most sports by the time I was 8-9 because of his spinal issues (DDD). I wanted to make sure I could do all the activities with my kiddos when they were young and not miss out on some prime years of physical activity with them like my dad did.

Yes, it significantly changed my retirement/FIRE trajectory, but I’m far more likely to be able to make more money down the road than get those years I’d lose with my kids back.

 

[Stagg737]

As for the OP, agree with staying flexible and making time for what you love by scaling back later, even if that is just going down to 20-25 hours a week or doing 4 day work weeks.

I’d add that doing job cobbling/experimenting early is good to explore with what you really enjoy most. If you’re planning to work long term don’t worry about FIRE as much as finding something you really want to do. If you want to retire at 45 then just focus on maximizing income and accept that burnout to some extent is going to be very likely.

 

[Merovinge]

Me as example, I had my first kid at 29 at the start of my intern year. Wife was desperate to have kids and I also wanted to before 30. My parents had me when they were 35 and I was beating my dad in most sports by the time I was 8-9 because of his spinal issues (DDD). I wanted to make sure I could do all the activities with my kiddos when they were young and not miss out on some prime years of physical activity with them like my dad did.

Yes, it significantly changed my retirement/FIRE trajectory, but I’m far more likely to be able to make more money down the road than get those years I’d lose with my kids back.

I admire you and anyone else who can do this. It certainly wasn't for me to have kids with multiple 6 figures in loans but I love that people have the strength to do this.

 

[hamstergang]

I avoided outpatient burnout by changing to a residential job. Different levels of care and treatment settings will be a better fit for different people.

 

[Stagg737]

I admire you and anyone else who can do this. It certainly wasn't for me to have kids with multiple 6 figures in loans but I love that people have the strength to do this.

Yea, felt like with my age, family history, and wife’s insistence on starting the family don’t have a ton of choice. Fortunately, I was also non traditional and paid for a good chunk of school on my own, so graduated with well under $50k in debt at graduation.

 

[comp1]

Concur that if the OP is already looking for advice specific to stopping burnout in outpatient, maybe outpatient isn't for them. It certainly isn't for me. I was burnt out on it in residency. Fortunately there is a whole world of more structured patient environments out there with a lot more team work involved.

 

[Merovinge]

Concur that if the OP is already looking for advice specific to stopping burnout in outpatient, maybe outpatient isn't for them. It certainly isn't for me. I was burnt out on it in residency. Fortunately there is a whole world of more structured patient environments out there with a lot more team work involved.

Oddly enough I will say that I did not like outpatient in residency/fellowship and I took an IP job coming out of training. I was forced to move due to my partner's situation and ended up taking an OP job as it was all that was available. It ended up being much better as an attending than I had previously predicted and while I was very happy to move after 3 years there were definitely parts of that job I missed.

I have since put in 5 years at the PHP/IOP LoC and now am going into my own non-insurance based outpatient practice. I am not sure I would have made the decision to do that had I not been forced to do an OP job for 3 years earlier in my career.

 

[lockian]

Question for those with long term attending experience. What are some job tips/hacks you added later in your career to avoid burnout?

For me, variety has actually been helpful. Working across two different clinics with very different populations was a game-changer that helped me reconnect with my passion for the job.

Also, getting really efficient with documentation. Having it done or mostly done by the time you leave work for the day is a very liberating feeling. One of those AI scribes was actually helpful. I was efficient before I adopted it, but it still cut down on effort, helped me focus more fully on the patient, and cut down the amount of pressure I felt throughout my day.

 

[Dr. Pookie]

I avoid outpatient burnout by working part-time and leveraging the time of an associate along with ancillary services such as ketamine, etc.

I run a tight ship, have very clear boundaries with patients/staff and enforce them. Most importantly, I do not allow myself to check work emails when I'm in bed.

 

[kookfu]

Oddly enough I will say that I did not like outpatient in residency/fellowship and I took an IP job coming out of training. I was forced to move due to my partner's situation and ended up taking an OP job as it was all that was available. It ended up being much better as an attending than I had previously predicted and while I was very happy to move after 3 years there were definitely parts of that job I missed.

I have since put in 5 years at the PHP/IOP LoC and now am going into my own non-insurance based outpatient practice. I am not sure I would have made the decision to do that had I not been forced to do an OP job for 3 years earlier in my career.

How was PHP/IOP?

 

[Merovinge]

How was PHP/IOP?

I like it a lot, if you happen to enjoy acuity it's likely the best type of employment position. I do think insurance may squeeze down rates in the future as it's likely the most profitable area in all of psychiatry for the business owners. It also can work out for people to work part-time PHP/IOP and part-time OP practice, many of the docs I worked with have done this to add variety to their week. I find it easier to be 100% all-in on a particular position, but I do think it's quite valuable to work at different levels of care moonlighting or as an attending in psychiatry. People who only ever work OP (or IP) I find have some blindspots in their practice.

 

[Stagg737]

I like it a lot, if you happen to enjoy acuity it's likely the best type of employment position. I do think insurance may squeeze down rates in the future as it's likely the most profitable area in all of psychiatry for the business owners. It also can work out for people to work part-time PHP/IOP and part-time OP practice, many of the docs I worked with have done this to add variety to their week. I find it easier to be 100% all-in on a particular position, but I do think it's quite valuable to work at different levels of care moonlighting or as an attending in psychiatry. People who only ever work OP (or IP) I find have some blindspots in their practice.

I find the bolded fascinating as PHP/IOP where I'm at is notoriously NOT profitable resulting in there only being 2-3 real programs in my city. Our academic center has been talking about this for years but it's never materialized because of the financial downside as most insurances and CMS barely cover it at all where I'm at. I wonder if this is a geographic thing or if it's just specific insurances in different areas providing different coverages...

 

[Merovinge]

I find the bolded fascinating as PHP/IOP where I'm at is notoriously NOT profitable resulting in there only being 2-3 real programs in my city. Our academic center has been talking about this for years but it's never materialized because of the financial downside as most insurances and CMS barely cover it at all where I'm at. I wonder if this is a geographic thing or if it's just specific insurances in different areas providing different coverages...

Opposite problem by me. There are so many PHP/IOPs that have emerged over the past 10 years. It's great for patients as you can get in (if you have any commercial insurance) usually within a day or two and there are enough programs to have different niche's such that most patients can find a good fit.

Now if you are trying to provide these services to publicly or unfunded patients that is a very different story, but there is a high enough density of private insurance in this country to make the money wheels turn where I am.

 

[Monocles]

Live below your means and have solid emergency savings. This gives you short-term FU money if ever needed.

This is probably THE singular best advice for any newly minted attending in any specialty or working setting, full stop.

 

[clausewitz2]

Opposite problem by me. There are so many PHP/IOPs that have emerged over the past 10 years. It's great for patients as you can get in (if you have any commercial insurance) usually within a day or two and there are enough programs to have different niche's such that most patients can find a good fit.

Now if you are trying to provide these services to publicly or unfunded patients that is a very different story, but there is a high enough density of private insurance in this country to make the money wheels turn where I am.

Very much the same here, our local big academic center is up to I think 15 different IOPs/PHPs in various specialized tracks and counting. They do take medical assistance but Medicaid in Allegheny County is administered by an outfit that is a subsidiary of the self-insuring academic center so of course they cover it.

On a strictly fiscal basis, it is in fact an insurance company that happens to run a bunch of hospitals, just like in the 2005 era General Motors was a bank that had a sideline in making automobiles.

 

[Stagg737]

Opposite problem by me. There are so many PHP/IOPs that have emerged over the past 10 years. It's great for patients as you can get in (if you have any commercial insurance) usually within a day or two and there are enough programs to have different niche's such that most patients can find a good fit.

Now if you are trying to provide these services to publicly or unfunded patients that is a very different story, but there is a high enough density of private insurance in this country to make the money wheels turn where I am.

Very much the same here, our local big academic center is up to I think 15 different IOPs/PHPs in various specialized tracks and counting. They do take medical assistance but Medicaid in Allegheny County is administered by an outfit that is a subsidiary of the self-insuring academic center so of course they cover it.

On a strictly fiscal basis, it is in fact an insurance company that happens to run a bunch of hospitals, just like in the 2005 era General Motors was a bank that had a sideline in making automobiles.

Crazy how different it is. We have plenty of private insurers, they just don’t reimburse well for it (apparently). I only know 3 PHP/IOP programs in our city excluding the adolescent IOP our child psych hospital just started.

 

[hallowmann]

Very much the same here, our local big academic center is up to I think 15 different IOPs/PHPs in various specialized tracks and counting. They do take medical assistance but Medicaid in Allegheny County is administered by an outfit that is a subsidiary of the self-insuring academic center so of course they cover it.

On a strictly fiscal basis, it is in fact an insurance company that happens to run a bunch of hospitals, just like in the 2005 era General Motors was a bank that had a sideline in making automobiles.

I mean, UPMC is a behemoth whose leaders seemed to have always pictured themselves as businessmen before any other priorities related to healthcare delivery. Honestly, that's true for most big centers, but it seems so transparent, ingrained/baked in to everything UPMC does.

 

[Merovinge]

I mean, UPMC is a behemoth whose leaders seemed to have always pictured themselves as businessmen before any other priorities related to healthcare delivery. Honestly, that's true for most big centers, but it seems so transparent, ingrained/baked in to everything UPMC does.

While you or Clause are on the topic, how did UPMC become such a juggernaut in psychiatry specifically? Was there a particular focus on mental health in the past or some huge chair/researcher? I could be wrong, but it feels like psychiatry is their relatively strongest specialty.

 

[clausewitz2]

While you or Clause are on the topic, how did UPMC become such a juggernaut in psychiatry specifically? Was there a particular focus on mental health in the past or some huge chair/researcher? I could be wrong, but it feels like psychiatry is their relatively strongest specialty.

UPMC was started by Thomas Detre, who came from Yale to take over as chair of the Department of Psychiatry at Pitt and become head of the Western Psychiatric Institute and Clinic. He pursued a deliberate strategy of recruiting faculty from other institutions and aggressively pursuing NIMH grants, one of the first departments to do so systematically. He persuaded two nearby hospitals, Presbyterian and Montefiore, to pool resources with WPIC to pursue federal research dollars more broadly. And thus it began.