contemplation stage - PP? join group? websites, reading recs, opinions, humor and snark all welcomed

[singasongofjoy]

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Getting beyond burnt out, contemplating a shift out of AMC into PP or possibly group; also not sure if burnout is the right reason to make such a move or if that is more running away from something rather than toward (and too tired to will myself into pondering it). I think I'm fairly familiar w/ the basic common pros/cons from following this forum; curious for any recommended reading materials etc. (or food for thought generally). I did run across "The Paper Office in the Digital Age" recommended by @AcronymAllergy while searching threads. Also purchased a couple of books on Amazon. Thank you for any further suggestions!

Anyone interested in feedback / thoughts on specifics, providing hard reality checks or whatnot, read on:

Possibly relevant factors I am weighing: there's certainly a demand for what I do; wait lists are long everywhere around here (ASD/IDD + psych diagnostics, I've further built a reputation for myself as adolescent/adult and/or 'give me the fun tricky cases' person in the area. also do a bit of therapy. Con: insurance sounds like a pain to deal with in PP whereas currently I have fairly limited need for interfacing w anything more than completing auth forms which are mostly medicaid and really easy. If preferable to not take insurance in PP how many people in target group would be able and also willing to pay out of pocket for 8 hours of eval + report writing etc.?

I love seeing my mostly medicaid folks currently. Possible to schedule periodic slots for medicaid specific sliding scale or probono etc or would there be some kind of red tape I'm unaware of?

I don't really want to work much more than my current 55-60 hours. I just want a different ratio of / a bit more control over how I spend my time (some of which relates to beign part of a much bigger system, some of which relates to being also in admin role). I don't even really care to make more than my current pay (not much comparatively) + benefits (good) but is it possible to do that with no more than 60 hrs wk PP?

When I have good supports and routines and strategies established, I can manage daily executive fx demands of current role (shout out to EF / bx coaching + adderall). But the idea of starting all sorts of different types of tasks etc. with high EF demand makes me moderately to a lot anxious at the moment (possible that might change as I get a better understanding of how others manage PP.?) Joining a group would, I assume, remove a fair amount of that though? Is it worth the tradeoff?

If I end up moving past contemplation stage, still thinking like a 2-4 yr planning time here. Would want to have as many details ironed out as possible - and no longer have to pay daycare monthly, build up some additional buffer (no loans other than mortgage, just financially pretty cautious I suppose). Thanks to anyone willing to give me food for thought that feels more positive / nice change from continually trying with relatively little success to address burnout contributors.

 

[WisNeuro]

Getting beyond burnt out, contemplating a shift out of AMC into PP or possibly group; also not sure if burnout is the right reason to make such a move or if that is more running away from something rather than toward (and too tired to will myself into pondering it). I think I'm fairly familiar w/ the basic common pros/cons from following this forum; curious for any recommended reading materials etc. (or food for thought generally). I did run across "The Paper Office in the Digital Age" recommended by @AcronymAllergy while searching threads. Also purchased a couple of books on Amazon. Thank you for any further suggestions!

Anyone interested in feedback / thoughts on specifics, providing hard reality checks or whatnot, read on:

Possibly relevant factors I am weighing: there's certainly a demand for what I do; wait lists are long everywhere around here (ASD/IDD + psych diagnostics, I've further built a reputation for myself as adolescent/adult and/or 'give me the fun tricky cases' person in the area. also do a bit of therapy. Con: insurance sounds like a pain to deal with in PP whereas currently I have fairly limited need for interfacing w anything more than completing auth forms which are mostly medicaid and really easy. If preferable to not take insurance in PP how many people in target group would be able and also willing to pay out of pocket for 8 hours of eval + report writing etc.?

I love seeing my mostly medicaid folks currently. Possible to schedule periodic slots for medicaid specific sliding scale or probono etc or would there be some kind of red tape I'm unaware of?

I don't really want to work much more than my current 55-60 hours. I just want a different ratio of / a bit more control over how I spend my time (some of which relates to beign part of a much bigger system, some of which relates to being also in admin role). I don't even really care to make more than my current pay (not much comparatively) + benefits (good) but is it possible to do that with no more than 60 hrs wk PP?

When I have good supports and routines and strategies established, I can manage daily executive fx demands of current role (shout out to EF / bx coaching + adderall). But the idea of starting all sorts of different types of tasks etc. with high EF demand makes me moderately to a lot anxious at the moment (possible that might change as I get a better understanding of how others manage PP.?) Joining a group would, I assume, remove a fair amount of that though? Is it worth the tradeoff?

If I end up moving past contemplation stage, still thinking like a 2-4 yr planning time here. Would want to have as many details ironed out as possible - and no longer have to pay daycare monthly, build up some additional buffer (no loans other than mortgage, just financially pretty cautious I suppose). Thanks to anyone willing to give me food for thought that feels more positive / nice change from continually trying with relatively little success to address burnout contributors.

On this point, all depends on your patient population and those waitlists. I only take 4 insurances in my area, as the rest pay terribly, or are a huge PITA to work with. I keep my waitlist artificially low, generally by only seeing patients from one neurology practice. When someone calls me and I am out of network, the choice is to usually pay my fee out of pocket, or wait 5-9 months depending on which other practices they call. I generally only get a few people willing to pay out of pocket to be seen in a few weeks as opposed to half a year plus. But, I also mostly see 65+. I'd have to think that people may be willing to pay a premium for their kids to be seen depending on how low in age range you go.

 

[smalltownpsych]

My first thought is that if you are willing to work 60 hours a week, then you will likely succeed. I just made the leap myself and I can tell you that there are a lot of little details to keep track of and when you mention EF issues that does make me think that some of those could be what you might need to really get a handle on. I’m not a detail oriented person so I was shocked at how hard it was to organize what steps to do first and would become overwhelmed by all of it at times. My strategy has always been to just simplify and do anything productive even if it isn’t the most productive task. My office looks amazing because when I got stuck I put energy into the physical layout. The electronic infrastructure is solid and incredibly efficient as that is also a skill of mine. Navigating insurance paperwork is not so that was an issue until I decided to go strictly cash. That was when my meager networking skills started to kick in enough to get a few solid referrals going before I had the doors ready to open. I also am good at supporting and working well with other professionals so a psych nurse practitioner joined me so that has helped significantly. I am in my second month and on track to “profit“ about 5k this month after base expenses so I have at least slowed the bleeding.

My timeline was came up with plans in August, filed for business license in September, met with our accountant in October, put in 90 day notice Nov 1, let go earl on Nov 30, Dec 1 kicked everything into high gear. Secured office space toward end of Dec. Worked on infrastructure next two months and opened up March 1. Psych NP joined two weeks later and I met with potential intern today to add to practice. One thing that was on my todo list that I haven’t done yet is testing materials, but my clinical emphasis is opposite yours so you‘ll probably get that done pretty quick. I also switched software two weeks after opening, was with Simplepractice and now with Therapynotes. Glad I made the switch and will likely stick with therapynotes for now although I do have a few complaints.

i do believe it is important to have a vision of what you want to do and that will help guide you. My vision was to create a group practice utilizing my proven skill set to generate revenue effectively with psychotherapy to ensure profitability as I grow. I also want to use my teaching/supervisor skills to foster the development of new clinicians and then use the practice as the foundation for a residential program. My vision starts to get a little blurry at that point but that is what will be clarified over the next year or and I have time because of the non-compete from my last job.

Don’t know if any of this was helpful for others, but it is helpful for me to structure my thoughts so thanks for listening to my Ted talk.

 

[calimich]

I also switched software two weeks after opening, was with Simplepractice and now with Therapynotes. Glad I made the switch and will likely stick with therapynotes for now although I do have a few complaints.

Thanks for sharing, and glad you are back! I’m considering the same change and would love to hear more about this piece specifically.

 

[smalltownpsych]

Thanks for sharing, and glad you are back! I’m considering the same change and would love to hear more about this piece specifically.

Therapynotes has a better interface overall and is much easier to use for setting up accounts. They are also a little less expensive, especially if you’re not doing a lot of insurance billing. I also like that they seem to be customizing and improving their platform more. One criticism of many software platforms is how far behind the times they can be and how slow to add features that are relatively simple customer requests. Therapynotes will also be implementing an integrated e-scripts which is key for my practice with a psych NP. It’s in beta and they said a few more weeks till live about a month ago and I need it like yesterday. The insurance interface works very well as far as my limited testing and it is setup so I can submit the claim with a click. None of my clients have received any reimbursement yet but they appreciate that we are trying. I also like the credit card integration and they can provide an optional swipe machine which I ordered because it will just help improve the professional feel of the practice. Client portal works well and provides more functionality than I have used yet but will likely implement more aspects as we get busier. clients can schedule, access super bills, enter demo information, pre-pay for services, sign privacy and confidentiality forms. some of it I haven’t integrated yet because filling out the forms in the waiting area seems to make sense for providing a sense of security and stability so certain things I am keeping intentionally old-fashioned for now. I also think that scheduling with a person might improve commitment to show up. When psych NP is running, her patients will be scheduling online and paying up front. Much different dynamic.

Features I don’t like are that it doesn’t have as much customization of document templates as I might like; however, the Templates they do have for standard intake and sessions are pretty robust and not too far from what I would do. A pet peeve is that since it’s a SOAP format I have to put in a subjective and an objective part of the note and I can never figure out a clear difference in my mind between the two. So I just sort of split my note in half, but I’m pretty sure that’s more of a me problem. Also, it doesn’t have a simple flag to show if I have completed billing or note for an appointment. Notes show up in my todo list and that works but I like to see it at a glance on my calendar. To verify everything is billed I have to pull up an aging report so that is a little clunky, but since I am very focused on revenue, it’s not like I will forget to check on this.

 

[BuckeyeLove]

and I can never figure out a clear difference in my mind between the two.

I've been doing them for 8 years and honestly I still can't tell you the difference. I'm pretty sure they were designed for nursing maybe?

 

[Sanman]

I've been doing them for 8 years and honestly I still can't tell you the difference. I'm pretty sure they were designed for nursing maybe?

Subjective: Patient appears angry

Objective: Patient is throwing a stapler at my head

 

[summerbabe]

Subjective: Patient appears angry

Objective: Patient is throwing a stapler at my head

Assessment: 7/10 pain for said stapler hitting my head

Plan: discharge patient

 

[smalltownpsych]

Subjective: Patient appears angry

Objective: Patient is throwing a stapler at my head

That helps a bit, maybe part of my issue is that I would write, "Patient presented as angry as evidenced by throwing stapler at my head."

 

[Sanman]

That helps a bit, maybe part of my issue is that I would write, "Patient presented as angry as evidenced by throwing stapler at my head."

Yeah, most of us were trained to write in more of a prose style for reports and session notes. SOAP notes and medical note taking is often written more briefly. Most of the subjective would be patient report ("I feel less depressed") while evidence like grooming, psychomotor agitation or pressured speech would be objective evidence for or against said report.

 

[smalltownpsych]

Yeah, most of us were trained to write in more of a prose style for reports and session notes. SOAP notes and medical note taking is often written more briefly. Most of the subjective would be patient report ("I feel less depressed") while evidence like grooming, psychomotor agitation or pressured speech would be objective evidence for or against said report.

I also tend to put that evidence into the assessment portion and I never like to do duplicate work. Truth is that DAP works alot better for me. Maybe I'll send an email to Therapynotes asking for that option. Simplepractice had SOAP, DAP, and several other templates available to choose from and all could be customized. If you really like customizable note templates, then that is definitely the platform to go with. I am good at writing a sentence that can capture the data, the assessment and the plan. Some of that is because I have always been prone to write in long run-on sentences and even my paragraphs could go on for days. When I'm doing real writing, I go back and break everything up into logical chunks.

 

[clausewitz2]

I've been doing them for 8 years and honestly I still can't tell you the difference. I'm pretty sure they were designed for nursing maybe?

They come from medicine, so I apologize on our behalf. The basic idea is that anything somebody tells you about the situation, experiences, and symptoms of whoever you are treating goes in the subjective part. If you can't preface it with "s/he/they said" without being a reasonable paraphrase don't put it in the subjective. I don't put anything I said or exchanges between us in this section. If the patient's report varies from the sort of formal register most notes end up adopting it is generally going to involve a verbatim quote. Ex. "Patient reports they felt 'some type of way' about this event."

The objective part is our direct observations of their behavior during the interview, test results, imaging results, and, confusingly, usually any information directly copied from notes from other healthcare folks. Yes, my inner Foucault also stirs at the epistemic injustice inherent in this.

When my judgments and thoughts get involved it goes in the assessment. I am also guilty of the run-on para-sentence but I always try to separate out a section from the running case conceptualization I have specifically discussing what happened "TODAY, ..." I see people with a different frequency than most of y'all so it may make more sense for me to do this. I deliberately put sentences into my assessment section directly stating my opinions about things I have been told and how we arrived at a decision that was reached at the appointment. Again, when meds are on the line, at some point it does matter whether someone agrees or disagrees about taking something and this needs recorded. Back and forth discussion between us ends up in my "TODAY, ..." section.

I sometimes sneak bits of our discussion into the subjective in the form of specifying the circumstances under which the patient said something very telling. Ex. "When asked to identify his biggest challenge, patient stated that it was 'all these ***holes all over the g***amn road all the time'".

the plan is the boring bit most other people actually care about, of course.

 

[AcronymAllergy]

They come from medicine, so I apologize on our behalf. The basic idea is that anything somebody tells you about the situation, experiences, and symptoms of whoever you are treating goes in the subjective part. If you can't preface it with "s/he/they said" without being a reasonable paraphrase don't put it in the subjective. I don't put anything I said or exchanges between us in this section. If the patient's report varies from the sort of formal register most notes end up adopting it is generally going to involve a verbatim quote. Ex. "Patient reports they felt 'some type of way' about this event."

The objective part is our direct observations of their behavior during the interview, test results, imaging results, and, confusingly, usually any information directly copied from notes from other healthcare folks. Yes, my inner Foucault also stirs at the epistemic injustice inherent in this.

When my judgments and thoughts get involved it goes in the assessment. I am also guilty of the run-on para-sentence but I always try to separate out a section from the running case conceptualization I have specifically discussing what happened "TODAY, ..." I see people with a different frequency than most of y'all so it may make more sense for me to do this. I deliberately put sentences into my assessment section directly stating my opinions about things I have been told and how we arrived at a decision that was reached at the appointment. Again, when meds are on the line, at some point it does matter whether someone agrees or disagrees about taking something and this needs recorded. Back and forth discussion between us ends up in my "TODAY, ..." section.

I sometimes sneak bits of our discussion into the subjective in the form of specifying the circumstances under which the patient said something very telling. Ex. "When asked to identify his biggest challenge, patient stated that it was 'all these ***holes all over the g***amn road all the time'".

the plan is the boring bit most other people actually care about, of course.

When I was reviewing chart notes at VA, I very much appreciated folks who included the equivalent of a "Today" section in their notes. Some would copy-and-paste content from prior notes (or summaries of such) below that and label it in chronological order, which also helped me to very quickly get an idea of what had been going on with this person for the past X years.

And yeah, I'm a fan of direct quotations of the patient when it's particularly poignant and/or colorful. Or when they made vaguely threatening statements that I didn't want to label as threatening myself.

 

[smalltownpsych]

Was feeling a little frustrated last week because one of my clients that I thought was going to be a solid longer-term case left me. Hate the feeling of rejection and even more so when finances are iffy right now. Just got a call from a new client that will more than make up for that. Solid referral from a community contact and the client is right in my wheelhouse and was more than happy to pay cash. So still hanging in there.