Can you tailor your Practice?

[fj25]

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changed my mind about what I wrote

 

[OldPsychDoc]

I'm doing a SubI in E.R. and just saw a Schizo and a Suicidal, I dont like it. It gave me a headache. Is this what real psych is like? I thought I would just talk to people and help them through their problems. Not trying to figure out jibberish. I'm not sure I would like to deal with depression.

I think you'd better do an elective or two in psychiatry and see what it is really like. Because if you think you're going to avoid depression, suicide, schizophrenia, and other disorganized thought patterns...well, I'm really wondering if you have a realistic view of psychiatry at all. 🙁

 

[50960]

2/3 of primary care visits are depression/anxiety related. If you are not able to deal with this stuff you can 2 things: 1 choose a different job, 2 get some support in how to deal with such things and not go crazy. Most MH providers see 5-20 pts per day in private practice, and more in residency/hospital work, and we have to go home at the end of the day relatively OK...it is not easy. 😎

 

[Anasazi23]

It's hard to tell if your post is serious or not. "Helping people through their problems" and nothing else relegates you to a career in counseling psychology or something similar.

Untreated psychosis dealt with in the ER can be challenging. It is the ER after all.

I agree with OldPsychDoc. You'd better do a couple psych electives if you're considering it as a field, and if this whole post is serious.

The title of your post is whether or not you can tailor your practice. The simple answer is yes, though it will likely take time before you are easily able to do so. Many psychiatrists choose to not work with the severely mentall ill or unstable patients as much as they can. And, many psychiatrists choose to not work in hospitals, where sicker patients can be found.

Moaning 60 year-olds with substernal chest pain tend to give me a headache too. So I'm not doing IM, ER, or cards.
: )

 

[OldPsychDoc]

It's hard to tell if your post is serious or not. "Helping people through their problems" and nothing else relegates you to a career in counseling psychology or something similar.

Untreated psychosis dealt with in the ER can be challenging. It is the ER after all.

I agree with OldPsychDoc. You'd better do a couple psych electives if you're considering it as a field, and if this whole post is serious.

The title of your post is whether or not you can tailor your practice. The simple answer is yes, though it will likely take time before you are easily able to do so. Many psychiatrists choose to not work with the severely mentall ill or unstable patients as much as they can. And, many psychiatrists choose to not work in hospitals, where sicker patients can be found.

Moaning 60 year-olds with substernal chest pain tend to give me a headache too. So I'm not doing IM, ER, or cards.
: )

Maybe I'm feeling a bit more testy than usual this weekend, but I can't help but wonder if part of the reason that our ERs are full of untreated psychosis is because so many psychiatrists, with all of their vaunted medical and psychopharmacological training, just want to sit in suburban offices and coddle the worried well. Meanwhile, we're lucky if we can get a partially qualified PA or CNS (or prescribing psychologist, Sazi?) to see the really sick patients in ERs and community clinics.

Frankly, I like the acuity in the hospital--and you can usually get someone well enough to go home (for awhile at least...). Maybe once a month I save a life, too. I'd claw my eyes out with a rusty pitchfork if I had to hand hold middle-class middle managers through midlife crises all day long.

 

[Anasazi23]

I understand your point, though I must say that if there truly is the severe crisis in mental health care as some would have us believe, it is because of the relatively few psychiatrists compared to other graduating medical specialists in general.

A comparison might be dermatology doctors. Relatively few will work in medicaid clinics if they can have a posh practice. Not saying it's right. Just a force of lifestyle and economics.

I've been on my own rant lately as well. I'm currently finishing up my "senior resident/administrative psychiatry" rotation in our inpatient unit. I've come home at times so unbelievably sick and tired of hospital politics, deflecting malingerers and reversions to being an intern again (the hospital will use you as an intern to cover those on vacation), that I've definitively sworn off hospital work as a career choice for me. We have meetings, then meetings about the previous meeting, followed by the other, unrelated meeting after the post meeting. It sucks and isn't for me. Unending somatic complaints, long calls, being screamed at and insulted daily by psychotic patients, being assaulted on occasion, high turnover associated with admission and discharge paperwork, unrelenting calls from pharmacy, medically unstable patients with constant chest pain, productive cough, SOB, uncontrolled diabetes, leg ulcers, falls, violent episodes, seclusions, restraints, transfers, and never-ending paperwork make it even more unbearable at times. A long day in the inpatient unit - then they expect you to simply shut it off instantly so that you can see your high-functioning outpatients in the evening make the difference all the more visible.

Can't blame some people for not wanting a life filled with this. Especially when there are folks that don't mind doing it.

 

[PublicHealth]

Meanwhile, we're lucky if we can get a partially qualified PA or CNS (or prescribing psychologist, Sazi?) to see the really sick patients in ERs and community clinics.

It's already happening in LA.

From a prescribing psychologist in LA (copied from Div 55 listserv):

"My experiences are very similar to Jim Q's experiences. My patient mix has
actually shifted as well. I am on medical staff at one LTAC that has two
campuses and another LTAC. In addition, I am the only psychologist on medical
staff at a free standing Rehab Hospital (30 beds) and on medical staff at two
general hospitals...both one with rehab unit and the other with both rehab and
psych units. At each of the above, I am the only neuropsych.

My prior patient load tended to be chronic pain, TBI, spinal cord injury, and
geriatric stroke. In addition, I tended to see consults in the general
hospital for general psych issues. Because the wait time, even in the hospitals,
is rather long for a psychiatry consult (and psychiatrists are not on staff in
some of the LTACs and Rehab Hospital), I started getting more and more med
management for patients with psych issues and more serious psych issues. I, too,
started getting more SMI patients in the general hosp. on the med-surg
floors and in private practice as more and more primary care physicians seek to
have someone help with the care of these patients. At the present time, the
psychiatric unit still requires (per hospital policy) a psychiatrist to be the
attending. However, I am working slowly but surely to get that changed. With a
20 bed psych unit and three psychiatrists admitting, there has definitely been
no problem keeping the unit at capacity...especially since there are
virtually no services available in New Orleans. The problem has been finding and
keeping nursing staff. We are in a severe shortage. So, there is no incentive at
this time to have psychologists as attending...its not a matter of filling
beds. While the psychiatrists are busy taking care of the psych patients on our
20 bed unit, I have been taking care of the patients in the rest of the 320
beds of the hospital.

In my experience, since being able to write prescriptions (Feb '06), I have
written approximately 500 including refills. My experience is also similar to
John Bolter's. I would say I have discontinued, reduced (simplified), or
"corrected" about half that many as well. The most frequent medication I have
prescribed has been Lexapro (in the hospital setting). I have prescribed some
atypical antipsychotics, several antidepressants, several benzos, on a couple of
occasions...mood stabilizers, antihypertensives (akathisia), hypnotics
(sleepers), and others. I have ordered lab work...including CBC, electrolytes,
lipid profiles, LFTs, testosterone level (geriatric men), urine drug screen, and I
have ordered speech therapy, EEG, X-ray, CT, and very recently MRI and other
stuff I may be forgetting now.

Having said some of the above, there are some caveats here. As soon as
psychologists are eligible to become attendings that will in all probability mean
that we will have to take "call." Since there are no other medical
psychologists on staff at the hospitals where I work, that will mean I will have to be in
the call rotation with the psychiatrists and their nurse practitioners. That
sounds great and like a huge step forward for psychologists. HOWEVER, that
means that I will then have to take any patient that comes through our
emergency room and needs psych care...REGARDLESS of ability to pay. In Louisiana,
psychologists are not reimbursed by MEDICAID and, of course, collect nothing on
"self-pay" (interpret "no-pay") patients. This has been the cry of physicians
for a long time. The must take these patients with all of the liability and
no reimbursement. For psychologists that will be even worse.

So, while I can control the amount of "pro bono" I do now, as soon as I begin
taking emergency room call, that control will be out of my hands.

As is typically the case, nothing is ever as simple as it sounds."

 

[PublicHealth]

From another medical psychologist in LA (copied from Div 55 listserv)

"As the
current Chair of the licensing board that regulates all medical
psychologists in LA, I am pleased we have not received a single complaint
during the past two years. It is estimated that about 20,000 prescriptions
have been ordered in that time period. My experience tells me there are
fundamental differences between medical psychologists and their prescribing
activities, which seems to be largely related to the pathology they
typically see in their practice, as well as the practice setting. For
instance, in a standard outpatient practice with medically healthy adults, I
believe the incidence of prescribing is much less. However, if the medical
psychologist is managing a significant number of bipolar, major depression
or schizophrenia, there is typically a high incidence of prescription
writing.

In my practice, approximately 90% of the patients have serious medical
problems and many of them are already on medications for psych related
problems. A significant portion of my time is spent addressing problems
with their prescriptions (i.e., wrong med, wrong dose, poor compliance,
wrong diagnosis, drug-drug interactions, side-effects, poor patient
education, etc.). Additionally, I often initiate meds as necessary but
continue to maintain a healthy belief in the value of psychotherapy.

I spent 5 years in the Army as a psychologist, working both inpatient and
outpatient services. In my experience, there are significant differences
between working within the military and civilian practice. Directly
comparing the two is not as simple as people may wish to think. So, the
message would be simply focus more on what we know from the LA and NW
experiences as sources for information. LA currently represents the largest
collection of prescribing psychologists, 31 in total to date. We anticipate
that number will easily reach 50 by the end of this next year."

 

[fj25]

I agree that I do need to do more rotations but the way everything is set up, you have to make a choice fairly early without really knowing what the field entails.

My original post was totally for real. That was how I felt. Maybe I have been burnt out from the E.R. but when I wrote my personal statement, Psych sounded like a real good choice considering my personality. After experiencing some difficult patients I felt really drained and kind of annoyed.

I was wondering if it was like this the rest of my life. I already put in my applications and have already been offered interviews, so I'm already deep in the process.