Best corner of psychiatry for lifestyle

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NeuroKlitch

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I understand it's all relatively good compared to other specialities. In your experience , what area of psychiatry is the least challenging corner of psychiatry with good lifestyle (think admin work , redundant legals and notes, difficult patients). Does child or addiction work ?

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I understand it's all relatively good compared to other specialities. In your experience , what area of psychiatry is the least challenging corner of psychiatry with good lifestyle (think admin work , redundant legals and notes, difficult patients). Does child or addiction work ?
Ha no!

Least stressful, probably working 0.8 FTE adult outpatient in private group or employed clinic with good support staff taking only commercially insured patients. 90 minute intake, 30-40 minute followups. You will make less money, but be less stressed.
 
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I don't think the answer to your question is universal - figure out what you actually enjoy doing in psychiatry and do that for however many hours/week you feel is sufficient to meet financial goals and still allow time for family, hobbies, etc.

I actually find child psych less stressful than adult (in my limited experience, less personality/SUD stuff which I don't particularly enjoy) but it really does depend on the population. I think higher-functioning patients (middle to upper SES usually) tend to be more rewarding to work with for a lot of people and consequently seem "less challenging", but some folks only find meaning in working with those with SPMI.

If you're a med student like it says, rotate through as many different things as you can to get a sense for what you enjoy and what you don't. The "easiest" job won't mean much if after 6 months you're bored and don't find any meaning in your work...you want something that is the right balance of easy/challenging and doesn't result in burn out.
 
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It's going to be so specific to you! For me, it's inpatient that gets me up and excited every day, putting people's lives back together when they are at their lowest and even ferreting out the malingering and other manipulation is exciting. This may not be shared by a large number of people. :)
 
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Private practice outpatient. Child only. Set yourself up in a posh suburban corner near a major city. Cash only. Screen out complex/high risk patients.

Yesterday I was working an ER shift at a public hospital and some family told me every single PP in their suburb was closed to new intakes, and the only one open was charging $2500 for an hour long eval, and get this - next opening is in SEVEN MONTHS.

As an economist I think my jaw fell through my mask as it hit the floor. Anecdotes like these is why I laugh at all the panic over midlevel encroachment.
 
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Private practice outpatient. Child only. Set yourself up in a posh suburban corner near a major city. Cash only. Screen out complex/high risk patients.

Yesterday I was working an ER shift at a public hospital and some family told me every single PP in their suburb was closed to new intakes, and the only one open was charging $2500 for an hour long eval, and get this - next opening is in SEVEN MONTHS.

As an economist I think my jaw fell through my mask as it hit the floor. Anecdotes like these is why I laugh at all the panic over midlevel encroachment.
Where are you located?! That seems well beyond what the norm is but I guess if the supply/demand curve fits...my area is more like $3-400 for an initial eval.
 
Private practice outpatient. Child only. Set yourself up in a posh suburban corner near a major city. Cash only. Screen out complex/high risk patients.

Yesterday I was working an ER shift at a public hospital and some family told me every single PP in their suburb was closed to new intakes, and the only one open was charging $2500 for an hour long eval, and get this - next opening is in SEVEN MONTHS.

As an economist I think my jaw fell through my mask as it hit the floor. Anecdotes like these is why I laugh at all the panic over midlevel encroachment.

Which suburb? I don’t believe it.
 
Where are you located?! That seems well beyond what the norm is but I guess if the supply/demand curve fits...my area is more like $3-400 for an initial eval.
Which suburb? I don’t believe it.
Boston area. I certainly don't think it's the *norm* by any means. Perhaps the family was exaggerating after calling a handful of places. However, doing a cursory search on psychology today shows mostly $200-600 evals but in checking the sites many of them show that they are not accepting new intakes at this time. Given the astronomical MH demand of kids and adolescents in the area this year, I would not be surprised if the demand/supply curve has pushed hour long evaluations into the 4 digit territory - esp. for famous celebrity psychiatrists or for families willing to shell out $$$ for immediate care.

Texas I'll PM you the exact suburb b/c I don't want to dox the family. Actually I've shared no clinical information other than saying it's a family seeking care at a public hospital so I think it's fine. Brookline MA. For the unfamiliar here's a very culturally relevant and interesting article about Brookline.


"In Brookline, a single-family house rarely goes for anything under $1.5 million. The town even seems to pride itself on how much people stretch to live there; the city’s website highlights that half of all renters and more than a quarter of residents pay more than 30 percent of their income in housing, which is generally considered financially imprudent. But this isn’t spending on a watch or a car. This is spending on your child’s future.

As a class, Brookline parents might be summed up as: people who can and will fluently cite to you the data about how a child’s socioeconomic circumstances and parents’ educational background actually matter more for their achievement in the long term than the specifics of their schooling. And yet they still can’t stop themselves from trying to maximize their own kid’s shot. Because, mostly, people move to Brookline for the schools."
 
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Boston area. I certainly don't think it's the *norm* by any means. Perhaps the family was exaggerating after calling a handful of places. However, doing a cursory search on psychology today shows mostly $200-600 evals but in checking the sites many of them show that they are not accepting new intakes at this time. Given the astronomical MH demand of kids and adolescents in the area this year, I would not be surprised if the demand/supply curve has pushed hour long evaluations into the 4 digit territory - esp. for famous celebrity psychiatrists or for families willing to shell out $$$ for immediate care.

Texas I'll PM you the exact suburb b/c I don't want to dox the family. Actually I've shared no clinical information other than saying it's a family seeking care at a public hospital so I think it's fine. Brookline MA. For the unfamiliar here's a very culturally relevant and interesting article about Brookline.


"In Brookline, a single-family house rarely goes for anything under $1.5 million. The town even seems to pride itself on how much people stretch to live there; the city’s website highlights that half of all renters and more than a quarter of residents pay more than 30 percent of their income in housing, which is generally considered financially imprudent. But this isn’t spending on a watch or a car. This is spending on your child’s future.

As a class, Brookline parents might be summed up as: people who can and will fluently cite to you the data about how a child’s socioeconomic circumstances and parents’ educational background actually matter more for their achievement in the long term than the specifics of their schooling. And yet they still can’t stop themselves from trying to maximize their own kid’s shot. Because, mostly, people move to Brookline for the schools."
I'm from the area, and, oh, what an interesting space.
 
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Boston area. I certainly don't think it's the *norm* by any means. Perhaps the family was exaggerating after calling a handful of places. However, doing a cursory search on psychology today shows mostly $200-600 evals but in checking the sites many of them show that they are not accepting new intakes at this time. Given the astronomical MH demand of kids and adolescents in the area this year, I would not be surprised if the demand/supply curve has pushed hour long evaluations into the 4 digit territory - esp. for famous celebrity psychiatrists or for families willing to shell out $$$ for immediate care.

Texas I'll PM you the exact suburb b/c I don't want to dox the family. Actually I've shared no clinical information other than saying it's a family seeking care at a public hospital so I think it's fine. Brookline MA. For the unfamiliar here's a very culturally relevant and interesting article about Brookline.


"In Brookline, a single-family house rarely goes for anything under $1.5 million. The town even seems to pride itself on how much people stretch to live there; the city’s website highlights that half of all renters and more than a quarter of residents pay more than 30 percent of their income in housing, which is generally considered financially imprudent. But this isn’t spending on a watch or a car. This is spending on your child’s future.

As a class, Brookline parents might be summed up as: people who can and will fluently cite to you the data about how a child’s socioeconomic circumstances and parents’ educational background actually matter more for their achievement in the long term than the specifics of their schooling. And yet they still can’t stop themselves from trying to maximize their own kid’s shot. Because, mostly, people move to Brookline for the schools."

That sounds like a miserable area with miserable people.
 
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Best psychiatry gigs I've ever seen:

1) Nocturnalist for a psych hospital that allowed standing orders, and never had an open bed. Guy covered nights 7 days a week. Said he usually got called 5 times a week. IIRC, his income was about average. Basically 5hrs of work/week. Spent his days playing golf.

2) Super high end psychoanalyst that required patients to come 3x/week @ ~250/hr. He also did not work the entire month of August, but patients still had to pay for that month. Taking care of 7-10 patients/year that are stable enough to have $37k/yr for treatment that would mess up most jobs.... Not bad. I don't remember if he actually prescribed anything.

3) "Program director" for a chain of private psych hospitals. Office was in a nice complex, nowhere near a hospital. If you watched that office, the psychiatrist was the only person there. He came in around 10am, took a long lunch, and left before 4pm. Wore really nice suits, drove a nice car.
 
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I had an inpatient attending in medical school that would get to the hospital at 7am and be out by 10am, seeing 10-12 patient/day with medical student help. He took phone-call once a week. $300k/year. Worked one weekend a month where he had to stay "late" aka 1pm.

I remember one day we were in the elevator together heading towards the parking lot and I asked, "So, what are you going to do the rest of the day?" He goes, "Probably watch Netflix and order Thai for lunch." Seemed like a reasonably chill gig...which is how I ended up in inpatient psych.
 
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I had an inpatient attending in medical school that would get to the hospital at 7am and be out by 10am, seeing 10-12 patient/day with medical student help. He took phone-call once a week. $300k/year. Worked one weekend a month where he had to stay "late" aka 1pm.

I remember one day we were in the elevator together heading towards the parking lot and I asked, "So, what are you going to do the rest of the day?" He goes, "Probably watch Netflix and order Thai for lunch." Seemed like a reasonably chill gig...which is how I ended up in inpatient psych.

This kind of set up doesn't seem that unreasonable to obtain. I have a couple attendings in residency who essentially do this. Though they both then leave and do outpatient clinic second half of the day.
 
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This kind of set up doesn't seem that unreasonable to obtain. I have a couple attendings in residency who essentially do this. Though they both then leave and do outpatient clinic second half of the day.

Yea, I would agree that this is the standard with patient psych. I don't see the allure of outpatient. I hated the constant grind of outpatient in residency. Even with 30 min follow-ups.
 
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He also did not work the entire month of August, but patients still had to pay for that month.
Charging for the August angst? He must have had them under a spell.
 
Yea, I would agree that this is the standard with patient psych. I don't see the allure of outpatient. I hated the constant grind of outpatient in residency. Even with 30 min follow-ups.
I work outpatient in part because I don't want the constant fight about discharge dates while inpatient (from both patients and insurance).
 
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Yea, I would agree that this is the standard with patient psych. I don't see the allure of outpatient. I hated the constant grind of outpatient in residency. Even with 30 min follow-ups.

I like both, which is nice. I'm just trying to figure out what will be most lucrative once I get out of residency and start a first job.
 
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I had an inpatient rabbit in Easter basket that would get to the hospital at 7am and be out by 10am, seeing 10-12 patient/day with egg help. He took phone-call once a week. $300k/year. Worked one weekend a month where he had to stay "late" aka 1pm.

I remember one day we were in the elevator together heading towards the parking lot and I asked, "So, what are you going to do the rest of the day?" He goes, "Probably watch Netflix and order Thai for lunch." Seemed like a reasonably chill gig...which is how I ended up in inpatient psych.
This is the way! 😲
 
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I like both, which is nice. I'm just trying to figure out what will be most lucrative once I get out of residency and start a first job.

"Most lucrative" will all depend on how many patients you want to see per day, doesn't matter whether you choose inpatient or outpatient. I have inpatient friends that average 25-30pts a day (+ ECT + IOP rounding 1x/week) that make >$600k first year out of residency (Midwest area, medium sized city). I wish I could tell you "yea, but those guys must be working all the time and on call all the time and never see their families," but that's not true. None of it is. Reality is they're still home by 1-2pm most days and work the same 1 in 4 type weekend call I do. End of the day though, that was just a daily grind I didn't want and an amount of liability I didn't want, so I chose a lower paying job averaging 10-13 pts per day. Take home will still be over $400k...but man those jobs were tempting.
 
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The inpatient versus outpatient debate is so interesting to me now, having seen a little bit of both sides.

Obviously the academic resident outpatient clinic is not exactly PP. But for the life of me, I can’t understand how outpatient work could ever be easier than inpatient. The inbox messages, the calls, the admin, the complaints, the crisis situations, the prior auths, the lab orders... and that’s with MA’s and RN’s and a full time social work team. It’s insane.

Meanwhile, inpatient involves rounding and writing notes. Yes there are discharge fiascoes, But the bull**** burden seems to pale in comparison to outpatient.

I’m going into forensics, so the treatment portion will likely be in an inpatient setting. Right now (haha), I’m very happy about that future.
 
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I have inpatient friends that average 25-30pts a day (+ ECT + IOP rounding 1x/week) that make >$600k first year out of residency (Midwest area, medium sized city). I wish I could tell you "yea, but those guys must be working all the time and on call all the time and never see their families," but that's not true. None of it is. Reality is they're still home by 1-2pm most days and work the same 1 in 4 type weekend call I do.

What is the secret to the speed? Does he finish 25 - 30 notes by 2 PM?
 
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The inpatient versus outpatient debate is so interesting to me now, having seen a little bit of both sides.

Obviously the academic resident outpatient clinic is not exactly PP. But for the life of me, I can’t understand how outpatient work could ever be easier than inpatient. The inbox messages, the calls, the admin, the complaints, the crisis situations, the prior auths, the lab orders... and that’s with MA’s and RN’s and a full time social work team. It’s insane.

Meanwhile, inpatient involves rounding and writing notes. Yes there are discharge fiascoes, But the bull**** burden seems to pale in comparison to outpatient.

I’m going into forensics, so the treatment portion will likely be in an inpatient setting. Right now (haha), I’m very happy about that future.

You really have to test things out for yourself. A lot of people in my residency and on SDN talk about private practice being the golden land of opportunity in terms of autonomy and income. But that may not be the case. I don't think outpatient is better. I mainly don't like my schedule being dictated by when patients show up. I prefer to dictate my own schedule, which you can do much better doing inpatient. I also enjoy running around instead of sitting all day, which you can better do with an inpatient job. For me, both inpatient and outpatient are equal when broken down by productivity / hour. Doing good outpatient work keeps my readmission rates quite low.

When I "retire", I may consider working inpatient with long admissions. That would be such an easy job.
 
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What is the secret to the speed? Does he finish 25 - 30 notes by 2 PM?
Just an efficient psychiatrist, invariably spending 2 minutes on follow up and writing one sentence notes.
 
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Just an efficient psychiatrist, invariably spending 2 minutes on follow up and writing one sentence notes.

Yep. I've read some of those progress notes, and *gasp* the discharge summaries. Don't be that psychiatrist.
 
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Yep. I've read some of those progress notes, and *gasp* the discharge summaries. Don't be that psychiatrist.
I've gotta say, I'm a pretty quality oriented doc, I value a detailed assessment and differential when appropriate. I like seeing a narrative that actually details MDM and what's happening in the patient's life. However, I cannot wrap my head around the emphasis on long DC summaries in psych and what I did in residency and fellowship for them. I see hospitalists or surgeons discharge summaries and they are shockingly appropriate, turns out 5-10 sentences can encapsulate 99% of the necessary information for stays ranging from 4 to 24 days. Nobody has time to read a self aggrandizing 5 page DC summary, no one will, and no one cares. I used to dread patients being discharged due to the writing of the DC summary, inpatient medicine does not need to be this way.
 
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I've gotta say, I'm a pretty quality oriented doc, I value a detailed assessment and differential when appropriate. I like seeing a narrative that actually details MDM and what's happening in the patient's life. However, I cannot wrap my head around the emphasis on long DC summaries in psych and what I did in residency and fellowship for them. I see hospitalists or surgeons discharge summaries and they are shockingly appropriate, turns out 5-10 sentences can encapsulate 99% of the necessary information for stays ranging from 4 to 24 days. Nobody has time to read a self aggrandizing 5 page DC summary, no one will, and no one cares. I used to dread patients being discharged due to the writing of the DC summary, inpatient medicine does not need to be this way.

A solid discharge summary actually saves a lot more time, as I don't have to go back and read the whole freakin chart to understand what was the admission about. I don't need to know every medication dosing, every restraint..etc. But it is definitely important to include a general picture of how the admission evolved, what meds were trialed and what the pt best responded to (meds or otherwise) or any noteworthy side effects. It also helps to include what happened on admission and the discharge planning. Haven't counted sentences, but my guess a decent paragraph or two would do the job. IMO a well written discharge summary can go a long way.

Yesterday I read a DC summary that pretty much didn't say anything. HPI copy/pasted. My guess is that that's how you take care of 25 pts and leave by 1 pm.
 
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Yesterday I read a DC summary that pretty much didn't say anything. HPI copy/pasted. My guess is that that's how you take care of 25 pts and leave by 1 pm.

In facilities without an emr, it's common practice for the psychiatrist to pay someone (often a nurse or moonlighting resident) to do the discharge summary)
 
A solid discharge summary actually saves a lot more time, as I don't have to go back and read the whole freakin chart to understand what was the admission about. I don't need to know every medication dosing, every restraint..etc. But it is definitely important to include a general picture of how the admission evolved, what meds were trialed and what the pt best responded to (meds or otherwise) or any noteworthy side effects. It also helps to include what happened on admission and the discharge planning. Haven't counted sentences, but my guess a decent paragraph or two would do the job. IMO a well written discharge summary can go a long way.

Yesterday I read a DC summary that pretty much didn't say anything. HPI copy/pasted. My guess is that that's how you take care of 25 pts and leave by 1 pm.

For me it depends on the person writing the discharge summary. Are they a generally thoughtful person thinking about the patient in some kind of coherent psychological framework? Are they old-school psychopathology types? Then bring on the incredibly detailed observations about what the patient did and how they interacted with staff and team during admission!

Would I get the same information by putting the nursing notes in a blender? F**k off, just tell me the meds they left on.
 
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I adore long discharge summaries!! Of course you don't need to document every little thing done, but when a psychiatrist really puts the time in to justify the diagnosis, particularly a personality disorder diagnosis, I'm immensely grateful.
 
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I understand it's all relatively good compared to other specialities. In your experience , what area of psychiatry is the least challenging corner of psychiatry with good lifestyle (think admin work , redundant legals and notes, difficult patients). Does child or addiction work ?
Child and addiction are probably the most stressful areas aside from maybe eating disorders

The least stressful would probably be forensics or utilization review, but it really depends on your personality
 
I've gotta say, I'm a pretty quality oriented doc, I value a detailed assessment and differential when appropriate. I like seeing a narrative that actually details MDM and what's happening in the patient's life. However, I cannot wrap my head around the emphasis on long DC summaries in psych and what I did in residency and fellowship for them. I see hospitalists or surgeons discharge summaries and they are shockingly appropriate, turns out 5-10 sentences can encapsulate 99% of the necessary information for stays ranging from 4 to 24 days. Nobody has time to read a self aggrandizing 5 page DC summary, no one will, and no one cares. I used to dread patients being discharged due to the writing of the DC summary, inpatient medicine does not need to be this way.
For all but the most complicated of patients their course of care can be summarized in three paragraphs or less. Anything beyond that is often either ignored or skimmed by most. I usually do one paragraph to sum up the major diagnoses and how they were arrived at, one paragraph for medication course (with indications, responses, doses, side effects, etc), and one paragraph that covers the major points of the hospital course. I have a separate paragraph in the note that covers the discharge plan and safety.
 
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I've gotta say, I'm a pretty quality oriented doc, I value a detailed assessment and differential when appropriate. I like seeing a narrative that actually details MDM and what's happening in the patient's life. However, I cannot wrap my head around the emphasis on long DC summaries in psych and what I did in residency and fellowship for them. I see hospitalists or surgeons discharge summaries and they are shockingly appropriate, turns out 5-10 sentences can encapsulate 99% of the necessary information for stays ranging from 4 to 24 days. Nobody has time to read a self aggrandizing 5 page DC summary, no one will, and no one cares. I used to dread patients being discharged due to the writing of the DC summary, inpatient medicine does not need to be this way.
I continually get disappointed in my area by discharge summaries. They should just be renamed to discharge sentence or discharge check box [for profit psych hospitals].

I get these records and use them in the outpatient to further support and educate to the patient, that yes they have a bipolar diagnosis, or no they don't.

But usually, it's sorry, this hospital didn't document Scat and we are still left with no supporting clarity as to why you were given a bipolar, or schizoaffective diagnosis or even both.... or even why you were placed on the meds you were.

Conversely when I was doing inpatient work I was equally frustrated when patients returned and review of the internal hospital records (not for profit hospital) was sparse. So I couldn't speed my work up and do cut/paste/verify with patient on key details, because the key details weren't there. So I'd spend the time to muster up a quality note that could be the note to reference for future admissions.
 
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I continually get disappointed in my area by discharge summaries. They should just be renamed to discharge sentence or discharge check box [for profit psych hospitals].

I get these records and use them in the outpatient to further support and educate to the patient, that yes they have a bipolar diagnosis, or no they don't.

But usually, it's sorry, this hospital didn't document Scat and we are still left with no supporting clarity as to why you were given a bipolar, or schizoaffective diagnosis or even both.... or even why you were placed on the meds you were.

Conversely when I was doing inpatient work I was equally frustrated when patients returned and review of the internal hospital records (not for profit hospital) was sparse. So I couldn't speed my work up and do cut/paste/verify with patient on key details, because the key details weren't there. So I'd spend the time to muster up a quality note that could be the note to reference for future admissions.

"Check box" discharge summaries are bad, but have you ever read a checkbox H&P? Less than useless. But hey, how else are you supposed to see 25-30+ patients per day?
 
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"Check box" discharge summaries are bad, but have you ever read a checkbox H&P? Less than useless. But hey, how else are you supposed to see 25-30+ patients per day?
The "psychiatrist" in my organization, if you can call them that, whom I referred to in another thread, does this. When I assume care of a patient they "admitted," I just read the ER consult note; I don't even bother to glance at the H&P because it's completely useless.

My experience so far with these "efficient" (i.e., corner-cutting) psychiatrists is that, while of course the amount of time they spend face-to-face with patients is laughable too, the main way they squeeze what should be a full-time job into a half day is by essentially not doing documentation. The note is a mere placeholder, following the letter of the law but not the spirit of the law, consisting only of copy-forward, dot phrases, and check boxes, containing all the elements necessary for billing but providing absolutely no useful information clinically. A few clicks of the mouse and they've "done" a note. Takes about 30 seconds.
 
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The "psychiatrist" in my organization, if you can call them that, whom I referred to in another thread, does this. When I assume care of a patient they "admitted," I just read the ER consult note; I don't even bother to glance at the H&P because it's completely useless.

My experience so far with these "efficient" (i.e., corner-cutting) psychiatrists is that, while of course the amount of time they spend face-to-face with patients is laughable too, the main way they squeeze what should be a full-time job into a half day is by essentially not doing documentation. The note is a mere placeholder, following the letter of the law but not the spirit of the law, consisting only of copy-forward, dot phrases, and check boxes, containing all the elements necessary for billing but providing absolutely no useful information clinically. A few clicks of the mouse and they've "done" a note. Takes about 30 seconds.
This is pretty much standard practice in many other specialties for anyone focused on higher numbers of patients/day, which is the system that has been heavily incentivized by the government, employers, and insurance (none of which incent documentation or collaboration). I have a bit of a hard time telling my parent's all day about how behavioral reinforcement/incentives work to mold human behavior and then getting upset when seeing these things, as though having an MD is supposed to make you take the moral high ground and ignore incentive. We never ask people from other high income careers to do this, in fact we generally praise the businessmen who gut the environment or lower SES folks lives to eek out extra quarterly returns. On the other hand, I do think MDs should take the moral high ground and ignore incentives, so around the Marry-Go-Round my thoughts go on this topic.
 
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In my opinion, inpatient > outpatient.
Show up, write notes, do good evidenced based psychiatry, go home and don't worry about somebody bothering you.
Leave by 4pm at the latest.
Catch your kids baseball game. Enjoy life. Be well paid to do the above.
Pretty cush if you ask me.
 
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This is pretty much standard practice in many other specialties for anyone focused on higher numbers of patients/day, which is the system that has been heavily incentivized by the government, employers, and insurance (none of which incent documentation or collaboration). I have a bit of a hard time telling my parent's all day about how behavioral reinforcement/incentives work to mold human behavior and then getting upset when seeing these things, as though having an MD is supposed to make you take the moral high ground and ignore incentive. We never ask people from other high income careers to do this, in fact we generally praise the businessmen who gut the environment or lower SES folks lives to eek out extra quarterly returns. On the other hand, I do think MDs should take the moral high ground and ignore incentives, so around the Marry-Go-Round my thoughts go on this topic.

Yeah but the level of info needed in an HPI/DC summary is definitely different from psychiatry (or other things like medicine, infectious disease, etc) and say general surgery or ortho.

Ortho d/c summary: "X bone broken. We fixed X bone with X surgery and hardware. No post op complications. Patient to wear X cast/brace/etc. Patient come back in X weeks for checkup. X activity restrictions".

I also think carrying over this mentality from surgery or medicine to psychiatry is just incorrect. The reason ortho or surgery can do 10 minute visits is because almost their entire MDM is based on a physical exam they can obtain completely in 4-5 minutes and limited history/ROS they can obtain in 4-5 minutes. They can round on 30 patients in a morning in the hospital because most of them are post-ops who just need their surgical site checked and vitals/meds reviewed. Physical exam is by far the most efficient route to diagnosis for most specialities and the less in terms of a direct physical exam you can do to figure out a diagnosis, the more you have to rely on history, which takes much longer to obtain. So to say that you're practicing good psychiatry while also seeing patients and writing a note in 10 minutes total (unless its someone you've seen for 3-4 days straight already on an inpatient unit) is just not correct to me. I've also seen these notes/types of people rounding and while it's fun to get out by 12, I can't say I'd want my family member under that type of care if they were severely mentally ill.
 
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.... I can't say I'd want my family member under that type of care if they were severely mentally ill.
This. So much this. I don't want my family cared for by midlevels, nor docs who do quick notes. Even in my local area I'm hard pressed to think who I would want my own family to be seen by. There is one doc, but this one only does C/L. It pains me to think about the greater influences on health care and the increase in midlevels and Big Box shops that encourage these cursory encounters.

Hope I don't have an illness filled aging. Dark days ahead in the coming decades.
 
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In my opinion, inpatient > outpatient.
Show up, write notes, do good evidenced based psychiatry, go home and don't worry about somebody bothering you.
Leave by 4pm at the latest.
Catch your kids baseball game. Enjoy life. Be well paid to do the above.
Pretty cush if you ask me.

Hmm, I guess this is all very variable on particular units, like outpatient. i.e administrators who are pushing you to discharge patients, dealing with nurses and SW who are often more problematic than patients lol, the pressure of discharging someone early and always fearing that they would bounce back or something horrible would happen, insurance companies who keep badgering for a 24 hour extension...etc.

And if we truly were following "evidence based" inpatient psychiatry, the average length of stay wouldn't be 7-10 days (even shorter in some places). This is so to each his own. I don't think an inpatient setting is necessarily 'cush'. Of course if you don't care, see 30 patients in a couple of hours and leave by noon, then yeah it's "cush".
 
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How much time are you guys really spending on the acutely psychotic or manic patient when you see them? How different are your daily notes when you're just kind of waiting for them to marinate on the medications before you see any improvement?

At our hospital we have an acute floor, PD floor, substance floor, etc. The docs on the acute floor are routinely finished earlier and I could see how you could practice good medicine but spend much less time per patient/note. But what do I know, I'm just a resident.
 
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How much time are you guys really spending on the acutely psychotic or manic patient when you see them? How different are your daily notes when you're just kind of waiting for them to marinate on the medications before you see any improvement?
A valid point, but I still think it's important for the note to include some narrative describing what has actually gone on with the patient over the past 24 hours, not just a blatant copy-forward of the little blurb you cobbled together from dot phrases the first day you saw them, which you've copied-forward every day, making your notes read as though you and the patient have said and done the exact same things every day--i.e., the grievous sin of "documenting something you didn't do."*

I guess that's the point of @Merovinge's post above. We're the last specialty which contains at least some docs who still think the note should include a narrative.

Another thing is that I think the "plan" section should mention which meds are being increased/decreased/added/discontinued that day and why, not just be smart text dropping the current med list from the EMR into the note.

*Edited to add: and it's not like it takes more than 5 minutes to do a note including such a narrative. It's just that it takes more than the 30 seconds it takes to do a drag-and-drop, copy-forward nothing note.
 
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How much time are you guys really spending on the acutely psychotic or manic patient when you see them? How different are your daily notes when you're just kind of waiting for them to marinate on the medications before you see any improvement?

At our hospital we have an acute floor, PD floor, substance floor, etc. The docs on the acute floor are routinely finished earlier and I could see how you could practice good medicine but spend much less time per patient/note. But what do I know, I'm just a resident.
Document sleep, appetite, self care habits.
Explore delusions, any change fixed, less fixed. Are there new delusions.
Ask about their perceptions of meds and compliance. Trouble shoot personal buy in for enhancing med compliance.
Explore from their persecpectve what led to med non compliance.
physical ROS, are their symptoms of side effects, as the population tends to be minimalistic in responses. Ask more questions to assess tolerability.
Dive in to how they view the hospital are they tired of coming back?
 
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Document sleep, appetite, self care habits.
Explore delusions, any change fixed, less fixed. Are there new delusions.
Ask about their perceptions of meds and compliance. Trouble shoot personal buy in for enhancing med compliance.
Explore from their persecpectve what led to med non compliance.
physical ROS, are their symptoms of side effects, as the population tends to be minimalistic in responses. Ask more questions to assess tolerability.
Dive in to how they view the hospital are they tired of coming back?

I also have to say I have no love for these doctors when they complain about how insurance companies want justification for an inpatient. Well, when your note says literally nothing besides what your last 3 days of notes said with no explanation of any treatment or improvement/progression by the patient, what do you expect?
 
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I also have to say I have no love for these doctors when they complain about how insurance companies want justification for an inpatient. Well, when your note says literally nothing besides what your last 3 days of notes said with no explanation of any treatment or improvement/progression by the patient, what do you expect?

So much this. If I can't tell what the hell you're up to, why do you think the UR people should be able to do it?
 
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