Adjusting to being an attending

[elbandito1]

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So I just finished residency and started an acute inpatient psych unit not that long ago. I feel like I’m struggle but I’m not even sure how. The clinical management is not an issue (though at times I do feel hesitant to make changes on even minor things), but more so the logistics of learning so much that I feel residency hasn’t taught me. I feel like I’m taking forever to write notes, and learning disposition planning is a nightmare with all these programs and acronyms, etc. I feel as though everyone has been very supportive and helpful, and nothing specific or anyone specific is making me feel inadequate, it’s a feeling I currently have. I’d love if anyone could provide any helpful suggestions on how to get myself quickly up to speed. I know it’ll take a while but this feeling is uneasy. Also having to study for the boards adds to the stress. Thoughts and suggestions would be much appreciated!

 

[robellis]

Very normal you will feel much better in one year, this transition is akin to starting intern year from medical school, they say you learn more in the first 6 months of being an attending than at any other time in your career, good luck and enjoy as I’m right there with you 😀

 

[comp1]

It gets easier! I do worry that we protect residents a bit too much from discharge planning which is actually the vast majority of day to day inpatient work. They do not pay you the big bucks to decide between fluoxetine and sertraline. EVERYONE has social work responsibilities including social workers, psychologists, addiction therapists, nurses, occupational therapists, etc, but it often does fall onto the attending to be the conductor of the symphony. Understand at least a little about everyone's job and a little about any given program you refer to. You'll gradually get to the point of knowing where a patient is going at discharge as soon as you meet them (or more often, see them again). Develop really good relationships with nurses. Find ways to ask for their opinions on discharge planning without promising anything in particular. Spend LOTS of time in chart review when all of the patients are new to you. Trust, but verify anything a patient says and preferably know their story before you even hear this admission's version of it. Your interviews should ideally be brief and focused on verifying information related to the current admission and how it might impact a discharge plan. Much of inpatient work is repeating the same discharge plan over until it sticks. Realize that part of what you're going through now is learning your "panel," the same as any outpatient provider. When you see the same person again, you won't be starting from scratch. Also, never forget that no matter the illness, patients still have at least some responsibility for their own recovery.

 

[J ROD]

If you have never been the boss, then it makes the transition worse. You are now the leader. Make decisions and own them. You will mistakes....fix them. Since you have residents let them do the work and teach. They can make medication decisions with guidance. Write the notes, make the phone calls to family, collateral, etc. Allow case management to do their job or make them. They should come up with discharge plan. You just have to make sure it makes sense. Every time you move to a new area you have to learn the boarding homes, homeless shelters, etc. Learn to take over the manager role and hold folks accountable.

 

[michaelrack]

If you have never been the boss, then it makes the transition worse. You are now the leader. Make decisions and own them. You will mistakes....fix them. Since you have residents let them do the work and teach. They can make medication decisions with guidance. Write the notes, make the phone calls to family, collateral, etc. Allow case management to do their job or make them. They should come up with discharge plan. You just have to make sure it makes sense. Every time you move to a new area you have to learn the boarding homes, homeless shelters, etc. Learn to take over the manager role and hold folks accountable.

Is Elbandito working in an academic setting in which he has residents?

 

[Stagg737]

Set up a meeting with your social workers to ask about what types of programs are available in the area, their names, how difficult/easy it is to get patients into them, what the CMHCs are, etc. sitting down for an hour or two with them up front will likely save a lot of time and stress down the road trying to learn everything on the fly.

 

[dl2dp2]

Have to say, discharge planning is perhaps *the reason* I hated inpatient, even as a medical student. Frankly, it's not a physician's job to figure out these programs and acronyms, and at a well-developed facility, it often isn't. At the time (as a medical student) in my head I was constantly like what is this weird medical specialty that's half social work?

There is very little of this nonsense outpatient, especially if your work is highly specialized. It's just not money/time efficient.

 

[deleted1100659]

Have to say, discharge planning is perhaps *the reason* I hated inpatient, even as a medical student. Frankly, it's not a physician's job to figure out these programs and acronyms, and at a well-developed facility, it often isn't. At the time (as a medical student) in my head I was constantly like what is this weird medical specialty that's half social work?

There is very little of this nonsense outpatient, especially if your work is highly specialized. It's just not money/time efficient.

this x100000000000. Calling various family members, such as second cousin jimmy, or great aunt jane to see if theyll take the patient after discharge. Which quite often pt has burned many bridges anyways. Then in residency, i was often scheduling the follow ups myself because we often didnt have a dedicated social worker. Made me hate inpatient. A lot of facilities have support for this at least, mine didn't at the time.

I do prefer outpatient because chances are if they made it to my office, they usually have a way to leave the office when finished.

 

[NickNaylor]

Your efficiency will improve with time as you do the same things over and over. It can be frustrating initially, but rest assured that things will improve.

 

[Copper_Tracker]

I actually disagree with the notion that outpatient is free of scutwork/and that inaptient suffers from the discharge planning process. Sure, many inpatient units have poor case management teams and thus the onus falls to the attending, etc. But if you are careful in your search process when you are ultimately looking for a full time attending job, you can land a gig where (*gasp*) case management actually does their job and you can focus on the clinical side. If these conditions are met, inpatient is a dream job

 

[Stagg737]

this x100000000000. Calling various family members, such as second cousin jimmy, or great aunt jane to see if theyll take the patient after discharge. Which quite often pt has burned many bridges anyways. Then in residency, i was often scheduling the follow ups myself because we often didnt have a dedicated social worker. Made me hate inpatient. A lot of facilities have support for this at least, mine didn't at the time.

I do prefer outpatient because chances are if they made it to my office, they usually have a way to leave the office when finished.

Yikes, only thing of this I've had to do was call/skype the outpatient clinic at the VA to make sure they scheduled the patient's f/up. I feel like the attending should know what resources may be available, but even a semi-competent CM/SW should be making the calls for d/c.

I actually disagree with the notion that outpatient is free of scutwork/and that inaptient suffers from the discharge planning process. Sure, many inpatient units have poor case management teams and thus the onus falls to the attending, etc. But if you are careful in your search process when you are ultimately looking for a full time attending job, you can land a gig where (*gasp*) case management actually does their job and you can focus on the clinical side. If these conditions are met, inpatient is a dream job

Agree with this. My experience has been that I've done FAR less paperwork and scutwork on the inpatient side than outpatient. Especially with our CMHC where CMs wanted forms filled out or signed for every random benefit under the sun.

 

[Monocles]

I actually disagree with the notion that outpatient is free of scutwork/and that inaptient suffers from the discharge planning process. Sure, many inpatient units have poor case management teams and thus the onus falls to the attending, etc. But if you are careful in your search process when you are ultimately looking for a full time attending job, you can land a gig where (*gasp*) case management actually does their job and you can focus on the clinical side. If these conditions are met, inpatient is a dream job

100% this! I am inpatient with a phenomenal team and it runs like butter. Also with any sort of inpatient gig, the dispositional roles are *built in* to your daily schedule whereas with outpatient you are expected to see pts every 30/60 mins and often have to deal with all the collateral work yourself, on your own time.

 

[NickNaylor]

I actually disagree with the notion that outpatient is free of scutwork/and that inaptient suffers from the discharge planning process. Sure, many inpatient units have poor case management teams and thus the onus falls to the attending, etc. But if you are careful in your search process when you are ultimately looking for a full time attending job, you can land a gig where (*gasp*) case management actually does their job and you can focus on the clinical side. If these conditions are met, inpatient is a dream job

Also agree. If anything, I find that the amount of scut I have to deal with on a daily basis is actually pretty limited, but we have a great case management and utilization review team. Really the only annoying thing that I have to do is the rare peer-to-peer. I also do some intermittent outpatient work as part of my job (TRD evaluations), and despite these being one-time consultations, they are WAY more burdensome from a scut perspective. I couldn't imagine dealing with a full panel of patients as a full-time, large-health-system psychiatrist.

 

[comp1]

It's nice to hear so many people extol the virtues of inpatient work!!

 

[AD04]

OP,

One of my friends from residency told me about another psychiatrist he works with who needed about a year to get used to the work. The guy would take a day to see 3 patients and document and bill. Granted, he's on the lower end of the bell curve starting out but now he's productive enough to make $400k / year. You'll get comfortable soon enough as long as you keep at it.

The trickiest part for me is adjusting to the EMR. It took a week for me to get comfortable with it. Then I also had to get used to state law and resources in the area. What helped me get up to speed quickly was asking a lot of question and documenting the answers. If I ever forgot, I had notes to refer to instead of asking the same questions over and over.

It helps if you work with a senior psychiatrist that is excellent clinically and efficient or better than you in some way. Then you can emulate them and better yourself. I discuss difficult cases with my partners from time to time.

It's ok to look dumb. Taking risks and making mistakes and learning from them is key to getting better. What may be more important than your ability is your likability. Be polite and kind to those you work with, including support staff. Be dependable. If people like you, you can make a lot of mistakes and get away with it.