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How many gigs do you have? What are your hours like? Any midlevel responsibility?
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How many gigs do you have? What are your hours like? Any midlevel responsibility?
What’s NH work? Non hospital?
Nursing home. Can be a great gig, but also very easy to be exploitative as a lot of them will hire an NP or doc to come by once a month to essentially sign off on continuing meds that are often inappropriate or to basically sedate agitated patients. It can be done well and be a nice side hustle that adds a decent amount to income with flexibility. It is often done very poorly.
I say this as a C/L doc who often sees the NH patients that get sent to us when they get too agitated or violent and the med lists of some of these patients are legitimately shocking. I think the only actual board complaints I've filed were against NPs/physicians wildly mismanaging NH patients (for example starting 3 antipsychotics including clozapine and depakote at once without any labs or f/up for 4 weeks in a patient with no previous psych hx).
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I have two main gigs both IP hospitals that fully revolve around good teams of support so that I don’t need to be on site other than seeing my patients. I specialize in the sickest of the sick so spending 30min a patient is not really needed. I’m efficient at my notes and orders. I do have an NP collaboration at one hospital which is a small stipend plus small boost to my list as I see small subsets of his patients each day. And I do collaborate at another 3rd hospital. Then I have stipends for being a medical director and vice chair of the psych department at one of my main gigs and the medical staff president at my other gig. Overall hours in a week after I do all my stupid billing to biller etc hits 35-40 hours normally not more
There are some wild regimens that come in from the nursing homes. I catch them on the IP and CL side and many times wonder what is happening.
I don't think it's all just laziness. Sometimes it is, sure, but I don't think all the time. I did some nursing home rotations in residency and that is never, ever a job I would consider. The fact of the matter is that we have no effective medications that manage dementia related agitation. We're all just desperately grasping. The standard of care is "behavioral interventions." Behavioral interventions also have somewhat limited efficacy even when implemented well, but more importantly they require MASSIVE amounts of staffing. Full on inpatient acute medical floors often have significant problems appropriately implementing behavioral interventions and they have 2-3x the staff of a nursing home, usually along with straight up security or dedicated police services. You're absolutely setup for failure as a RN or MD and that's just soul crushing.
I’m going to push back hard on this one. We successfully treat dementia related agitation every day. As much as I don’t like geriatrics, it is a significant portion of what I do. I will agree that frequently meds by themselves may not be enough, but it is not difficult for staff to implement “behavioral interventions” in combination with meds to effectively treat 90% of the cases that come through our doors without need for a memory unit or some higher level of care.
That said, there are some patients who aren’t manageable. Those are the people either in end stage dementia, those who have other severe medical problems interfering with care, or those who were frankly jerks with major personality problems or TBIs before the dementia hit.
It also doesn’t matter what we do if the NH we send them back to sucks and doesn’t implement appropriate behavioral modifications or just changes the meds again anyway. But I disagree that dementia related agitation is difficult to treat. It can be, but most of the time it’s actually not.
Ah man I totally forgot about you and your insistence that you can provide expert care to inpatients in 10 minutes.
Yeah you must be the guy who wrote the garbage admit note for my young adult ASD patient who came in with SI due to religious perseveration, said this was a delusion and diagnosed him with "psychosis", started him on Abilify and cranked it up until he had akathisia and EPS and said he didn't have SI anymore and then discharged him. Must be that expert diagnostic capability you get on inpatient that makes you able to fully assess someone in 10 minutes.
It takes a lot of effort to not start a med and even more to not admit in the first place. It's certainly not the way to make money in a fee for service world. This is why I advocate for salaried only positions with set tours of duty for inpatient positions. You're already stuck there; you might as well provide something resembling care. And they should be handling all internal and external referrals too. If you don't admit the person, you don't have to see them the next day. It really leads to the best use of resources and the involuntary patients can never say "you're just keeping me here to make money."
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Wait, so you have 2-3 full time jobs but are able to get them done with less than 40 hrs of work per week? Is this a very underserved area you are in where they are dying for psychiatrists? I know people do this but where I live and where I trained, there's hardly a chance one gets a pure IP role as it is, let alone 3 of them stacked. To be fair to you, most people who do this know they aren't providing good care but probably wouldn't post about it since it's a really bad look for psychiatry.
Believe has you wish. I have no need to confirm my quality of care with someone who doesn’t see me nor my patient IRL. Remember just because you can’t do something doesn’t mean it’s not possible.
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Two not 3. And no it would not be underserved per se but all three hospitals are safety net and have 70+% of the population as Medicaid or unfunded so the population is underserved. I’d put my care next to anyone else’s. And the population I specialize in is as high acuity as they come which is much more interesting to me. But, it makes it hard to find people that want to cover my caseload when I’m gone and nursing staff and SW also dislikes it because it’s hard to find someone to manage these patients well. I don’t generally work with high functioning or high socioeconomic patients, whom do take more time. I also have students with me from a medical school and thankfully they also find the rotation and learning to be beneficial. I opened up taking 4th years this year because of demand
Just curious, how long do you spend on a typical intake interview for someone who is able to appropriately communicate?
Fair enough. Sounds like a place with med students/residents around, so from a market perspective why wouldn't one of those hospitals not just hire a new grad rather than someone already working another full time role? Asking because IP and the patient demographics you work with are primarily what I prefer too, but it took me a long while to find a pure IP role and even that is at risk as psychiatrists are getting laid off. And there's no chance I could round and bounce, it would be a really bad look and admin has cracked down on that
Honestly the vast majority of inpatient psychiatrists I've worked with, from med school through residency, do their follow ups on inpatient in about 3-5 mins per patient. Sometimes even less. Not defending it. Intakes longer unless the patient can't engage in the interview. We've always had access to the ER psych assessment which does a lot of the leg work for the eval.
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They’ve got what are essentially executive positions (dept vice chair and president) at both positions. When you’re in higher admin roles you get a lot more leeway regarding what you’re allowed to do clinically.
We have quite a few of those people around where I live. I remember signing the forms when our psychER patients were accepted to some outside hospital, and having to put the accepting doctors name - it was always one of like 5 or 6 people, even though we sent patients to 10+ different facilities. Some of our nurses who also did shifts at some of these places talked about these psychiatrists and the care provided. Gist I got was that if my family needed help, I wouldn't want them to go to those places. Granted, the majority of patients are Medicaid, uninsured etc, so beggars can't be choosers.
With that being said, the majority of the treatment effect for that patient population IMO is getting off the streets and extended sobriety from meth and other drugs, so I don't think it really matters if the psychiatrist spends 0 minutes or 20 minutes with the patient - they're gonna give Zyprexa/Risperdal/Haldol or some combination along with some Depakote, Cogentin etc. The vast majority of useful information is from chart review and asking the nurse if the patient hit anyone last night. Not great care obviously. Works "fine" for most of these patients as they end up generally in a better condition than when they came in. But then again the psychiatrist actively worsens the patients like calvnandhobbs68 talked about - there is no Autism on these units, its all Schizoaffective, and if someone with real Autism did get admitted, the accepting admin dun goofed (or the psychER team successfully sneaked one through by creative documentation - high-fives!), well they also seemed like they were responding to internal stimuli when they were looking around the unit all weird so yeah we're going with Schizoaffective - zyprexa 10mg BID.
If we're just going to talk about incentive design, the flip side of salaried only positions with set tours of duty means that physicians in question may be strongly motivated to do as little as they can get away with or fill their hours with the most enjoyable or least strenuous aspect of their job duties. You also have an incentive to keep as many rocks as possible to make things easy on yourself and minimize churn.
Depends on the patient and how much they wanna go through. But 10-20min if we are talking a true high functioning. Cover their past treatments meds and therapy and what do they have already set up and discuss what they have goals. Then start to go through how we will tackle that. Then allow them to dictate the length of what we discuss more or less since I’ll be seeing them every day until they are stabilized to 80% of good and trending up along with having their follow up and dispo nailed down. On IP I’ve never understood the idea that you should be spending 20-45 min a day with patients. There is no chance you need that as you’re moving into donning Therapy which will take nearly the entire hospitalization length just to get the rapport needed for you to hit the true pain points. Outcomes unfortunately dont reflect IP does much past stabilizing. So the biggest effort needs to be on a meds that make sense, work, no side effects as well as they can pay for l/have insurance cover those meds, and then getting their dispo truly nailed down with easy follow up, nursing home or rtc if they need it.
I’m not employed at either place. My main hospital they don’t pay me a dime so I am free to them so there isn’t anything less to pay. The other hospital pay is the same for anyone working there. And no generally a new grad won’t be useful with my patients. Even people a decade in don’t really like my caseload and staff doesn’t either. Luckily both jobs I’m quite embed and difficult to replace given the complexity and severity both places have which no one likes to see yet I love it and thankfully do well with it. I do plenty of petitions for meds against their will if needed which also a lot in my area don’t want to do. And I don’t get paid for that either. Just messes up my schedule but when needed it’s effective. And both jobs fully expect all providers to have some other job whether that’s Op or IP somewhere else.
Anything past two is wild to me. I’d be curious if some of those have Nps they oversee. So they are the attending but not actually seeing them. I know a couple docs that fully do 3-4 and their care is **** overall. Barely know what’s going on with the patients and just put on the same meds for everyone.
I’m thankful a few of the nurses have had family members with some severe issues and have brought them to the facility and specifically had asked me to take on the cases. I can’t say that pressure was fun but nice to know the trust is there. But generally I’d agree I’d want a family member elsewhere though I don’t truly know where I’d want them
That does help but both places fully expect everyone to have multiple jobs. And I had the flexibility from the start because I was a moonlighter and they recruited me heavily at one to the point they made it so good for me I couldn’t say no. The other I started as just coverage and slowly word got around about the work from nursing and families and I just slowly took over from multiple providers and the vice chair thing is truly just some BS the position was vacated and the Chair is someone I had done a ton of work with his patients so he offered me the spot. But, I do agree that making the admin happy along with supper staff and get lots of good feedback moving upward from multiple areas will help you gain flexibility
I'm not saying salaried positions can't have incentives. I think stretch goals like reducing length of stay and repeat admissions to the same or other facilities are very important. Bonus structure systems everywhere should include some quality metrics, of course. And I do concur with the above that the VAST majority of benefit in psychiatric admissions for most patients is the structure of the admission itself. Medications are usually a very distant second (or third). For most inpatient admission days you should be spending at least as much time with the chart as you do with the patient, sometimes much more depending on the amount present. That said, I work somewhere where most patients have inpatient and outpatient history available going back to 1995, so it's a little different than usual.
I am not sure what people are doing on inpatient. When I did inpatient at a mostly medicare/medicaid or uninsured pop (i.e. very sick), you at most have 5-10 minutes with a patient. Low functioning patients with severe SCAD or SZ really don't have much to say for follow ups. Most have poverty of speech and poverty of content, or are so manic that half the interview is done before you even talk to them. I never understood a 15-20 minute follow up in that setting. And usually an intake is like 30 minutes tops face to face with the patient, 1 hour tops start to finish with documenting and chart review.
Inpatient is generally pretty easy to do quality work and be in and out from 7am-1pm or 2pm at the latest if you have a family meeting or two. If we say 10 minutes F2F with a patient, 5 minutes documenting per patient, and 16 f/us a day with 2 intakes/ 2 discharges, that is 6-7 hours a day of work if you are efficient and doing good work. A lot of what's carrying the load of the work is sobriety, the meds, and the social work dispo plans. Just getting the diagnosis right and the initial plan right is the majority of our job on inpatient. We do a few tweaks here and there with side effects, but it is unusual to be so wrong on your initial plan that you have to reinvent the wheel. Many of these inpatients are not private pay patients with high functioning problems. It is polysubstance use disorders, SCAD, SZ, and bipolar in the setting of homelessness and poor social support. Dispo plans are mostly the same 4 sober living programs, and the same 8 shelters. It's also like the same 12 meds. There's no need to reinvent the wheel every time.
What is even going on in the room if you spend 20 minutes with a severe poverty of speech/ poverty of content patient follow up? Are MDs just sitting there getting yes no answers for 20 minutes, staring at the patient?
Inpatient is generally pretty easy to do quality work and be in and out from 7am-1pm or 2pm at the latest if you have a family meeting or two. If we say 10 minutes F2F with a patient, 5 minutes documenting per patient, and 16 f/us a day with 2 intakes/ 2 discharges, that is 6-7 hours a day of work if you are efficient and doing good work. A lot of what's carrying the load of the work is sobriety, the meds, and the social work dispo plans. Just getting the diagnosis right and the initial plan right is the majority of our job on inpatient. We do a few tweaks here and there with side effects, but it is unusual to be so wrong on your initial plan that you have to reinvent the wheel. Many of these inpatients are not private pay patients with high functioning problems. It is polysubstance use disorders, SCAD, SZ, and bipolar in the setting of homelessness and poor social support. Dispo plans are mostly the same 4 sober living programs, and the same 8 shelters. It's also like the same 12 meds. There's no need to reinvent the wheel every time.
What is even going on in the room if you spend 20 minutes with a severe poverty of speech/ poverty of content patient follow up? Are MDs just sitting there getting yes no answers for 20 minutes, staring at the patient?
As a supervisor, employed clinicians tend to overspend in patients with severe Cluster B personality pathology (borderline and higher IQ antisocial), not schizophrenia. It's been a consistent area of education for my employees and trainees. It is typically a lot more actively harmful than it might be with schizophrenia. However, acknowledging your countertransference about why you're drawn to do that can also aid diagnosis.
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It's definitely true you don't *need* as much time on an inpatient unit, and I know psychiatrists who get paid a full time salary for 7am-10AM of on site work. But that's just what I was getting at, in many places I have interviewed the admin have literally said they are tired of paying doctors who leave that early. I mean it makes sense as an administrator, you're expecting a full time employee to work full time, and if the work gets done then why not throw more work at them? That's the trend I've noticed with these types of gigs. And going off of what FatherPsychiatry mentioned, yeah with the vast majority of these types of patients, it's not rocket science. I've known half decent NPs that can do the exact same thing at less than half the cost of a psychiatrist. I guess I'm just not convinced pure IP roles like that can be sustainable, some people don't like the patient population psychmd03 works with but a LOT more people would happily suck it up and work that job given the pay and the hours.
Come on you gotta be hitting CBT giving them some worksheets to follow up on daily even though they can’t even explain what planet they are on but the fbi for sure found them.
When I worked at the VA it was one FTE but yeah you had to stay. And there are jobs like that around salaried but they won’t allow the docs to be jumping around during the day. It is wild to me to pay a salary and allow a doc to jump. If you’re having a job like that it should be incentive based plus quality of work.
