dealing with the stresses of day-to-day work

[elbandito1]

I'm 1 year out from residency and currently working inpatient. I feel as though I cycle through busy and frustrating weeks followed by days or weeks where things are less stressful. Most of it, at least on my reflection, seems to be dictated by the severity and pathology of patients we admit. I've isolated several factors that frustrate me the most - family pressures to effectively change a person's life, drug-seeking patients that continue to ask for escalating controlled medications, and the sheer volume of documentation. I've found ways to more-or-less feel okay with my handling of the above scenarios, but it just does not feel satisfying. Additionally, our service is going through a turn-over and we're all being asked to cover other units, more consistently than I would like. Carrying on average 10-12 inpatients daily, not including when I need to cover other units, without any additional support besides our social worker has not been enjoyable lately.

Early on at this job, I was finding it easier to compartmentalize work from my day-to-day life. I've found lately that I am just quite burnt out and subtle things like borderline patient's family (who also seem to have traits / have very unrealistic expectations) bothering me more than I'd like. I'm wondering, for those that are seasoned at working inpatient, or anyone in general, what is your approach in compartmentalizing the day-to-day stressors that come with the job. what is your approach to feeling content with the work you do?

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[nexus73]

These are similar frustrations I've had with inpatient, and it's interesting there are some days and weeks that just flow, and others that don't. If you have older more seasoned colleagues, I'd hope they could give you some advice.

On the borderline front, or family wanting you to "fix" someone. Being clear about what's possible, that hospital is to stabilize and definitive care is for outpatient (psych, therapist, IOP, etc). Inpatient is short and to stabilize, not for weeks to fix someone's life, which we all know isn't possible. I recall several times a family member wants the person committed for months to the state hospital to fix their borderline pd. It makes sense from a lay perspective, the family thinks the hospital is where you go when you're really sick (need surgery, ICU, septic, etc etc) so why wouldn't someone with BPD not go to the hospital because obviously they are super sick and unstable and making everyone else's life complete chaos, and they've been to the hospital 18 times already for a few days to a couple weeks and they're still not fixed. So wouldn't you then escalate to a months long stay at a state hospital? Well clearly we know this will only make things worse. The person needs to be out in real life outside the hospital, working in therapy to build skills to better manage their emotions and how to interact with people. Being in an artificial controlled environment of a hospital isn't going to help them manage their emotions in the world any better. And prolonging hospitalization will increase unhealthy dependence on the hospital.

 

[Fan_of_Meehl]

I'm 1 year out from residency and currently working inpatient. I feel as though I cycle through busy and frustrating weeks followed by days or weeks where things are less stressful. Most of it, at least on my reflection, seems to be dictated by the severity and pathology of patients we admit. I've isolated several factors that frustrate me the most - family pressures to effectively change a person's life, drug-seeking patients that continue to ask for escalating controlled medications, and the sheer volume of documentation. I've found ways to more-or-less feel okay with my handling of the above scenarios, but it just does not feel satisfying. Additionally, our service is going through a turn-over and we're all being asked to cover other units, more consistently than I would like. Carrying on average 10-12 inpatients daily, not including when I need to cover other units, without any additional support besides our social worker has not been enjoyable lately.

Early on at this job, I was finding it easier to compartmentalize work from my day-to-day life. I've found lately that I am just quite burnt out and subtle things like borderline patient's family (who also seem to have traits / have very unrealistic expectations) bothering me more than I'd like. I'm wondering, for those that are seasoned at working inpatient, or anyone in general, what is your approach in compartmentalizing the day-to-day stressors that come with the job. what is your approach to feeling content with the work you do?

At the risk of being controversial (but I don't think it will be), this is part of the hazard of over-'medicalizing' psychiatric/psychological problems. One of the untoward, ahem, side effects of such a model is that it tends to set up people (and their families) into a conceptual framework of these problems consistent with the expectation that they will just bring their family member you for you to 'diagnose --> treat --> and fix--?' them with your brilliance and definitively efficacious 'medical'/somatic treatment technologies. You sound like you're on the right track (and I think others have and will encourage you to continue down this track) of properly educating them 'out' of this lay paradigm of placing undue responsibility solely on you as the 'treating' provider or on the 'technology' that we have to 'treat' their 'disease.' I think that with more time and experience this type of psychoeducation of patients will become second-hand, automatic, and routine. Sad thing is...it's a form of psychoeducation that has been increasingly urgent to deliver to co-workers and administrative staff as well.

 

[painballer27]

Are you required to speak to family members?

 

[elbandito1]

Not obligated to, but often will receive calls from them. It can help with collateral. Sometimes it turns into “my loved one has been in the hospital for 3 days and I haven’t heard from anyone.”

 

[painballer27]

I see. It seems like there could be social workers or someone to talk to the families so that you can focus on being a doctor and treating patients.

 

[JKinSC]

Are you required to speak to family members?

This is why God made social workers....

 

[painballer27]

This is why God made social workers....

Yeah my point exactly. As a psychiatrist your job should be doing what you're trained to do, making the diagnosis and treatment plan, not sitting down with family members for hours. Other people with less training can do that

 

[J ROD]

This is why God made social workers....

Mine always say they want to talk to a provider.....that's why God made NP's as well!

 

[Marasmus1]

Yeah my point exactly. As a psychiatrist your job should be doing what you're trained to do, making the diagnosis and treatment plan, not sitting down with family members for hours. Other people with less training can do that

But the problem is many times sitting down with the family for hours is crucial for the treatment of patients and what gets them better more than the meds. (especially if you are dealing with children and adolescents but even for majority adults).

Considering NPs increasingly staffing hospitals and clinics, one can argue that ''expensive'' MDs who only do evals and med checks will be replaced by an NP who can do pretty much the same with ''much cheaper'' price. I can hear you saying ''Well how about the quality care and patient outcomes?''. In capitalist mental healthcare system, the quality patient care can not win the fight against ''productivity'' and ''profits''. And never, ever underestimate NPs when it comes to productivity and profits because my eyes witnessed NPs billing 99215 + 90833 20 times a day for 5 minutes medication checks.

In my current state, I constantly observe MD`s replaced by NP`s in the CMHC`s and hospitals. If we do not act collectively, in near future we will likely lose significant leverage against corporate/capitalist mental healthcare.

Now some say ''Well if it comes to that point, I will open my own shop''. I would say good luck with dealing insurance companies and their ridiculous mental health service reimbursements. If you want to do cash practice though, you will much more than evals and med checks to attract patients with capital because there will be two other private clinic right across the street. In either case, no psychiatrist will be hitting 400k +

 

[deleted456421]

But the problem is many times sitting down with the family for hours is crucial for the treatment of patients and what gets them better more than the meds. (especially if you are dealing with children and adolescents but even for majority adults).

Considering NPs increasingly staffing hospitals and clinics, one can argue that ''expensive'' MDs who only do evals and med checks will be replaced by an NP who can do pretty much the same with ''much cheaper'' price. I can hear you saying ''Well how about the quality care and patient outcomes?''. In capitalist mental healthcare system, the quality patient care can not win the fight against ''productivity'' and ''profits''. And never, ever underestimate NPs when it comes to productivity and profits because my eyes witnessed NPs billing 99215 + 90833 20 times a day for 5 minutes medication checks.

In my current state, I constantly observe MD`s replaced by NP`s in the CMHC`s and hospitals. If we do not act collectively, in near future we will likely lose significant leverage against corporate/capitalist mental healthcare.

Now some say ''Well if it comes to that point, I will open my own shop''. I would say good luck with dealing insurance companies and their ridiculous mental health service reimbursements. If you want to do cash practice though, you will much more than evals and med checks to attract patients with capital because there will be two other private clinic right across the street. In either case, no psychiatrist will be hitting 400k +

I'm honestly perplexed about the lack of concern by many (maybe even a majority) of psychiatrists on this forum about the future of psychiatry. I constantly vacillate between feeling quite positive and despondent about our field, but it's clear that midlevels add serious stress to our work. Two jobs have now asked that I provide training and supervision to clearly deficient NPs without pay or academic appointment. Some of them are "seasoned" and cocky prescribers, but the new ones are totally incompetent yet often still cocky.

I feel the pain even while moonlighting. Somehow NPs are allowed to dispo patients from the ED and admit them to the floor without discussion with me even though I'm the admitting attending. I encounter major errors during the admission process with terrifying regularity.

Don't rely on NPs to decrease the stress of your job. They'll eat you alive.

Instead, clearly articulate your training and value to whatever health system you work within. Or, like most of those I envy, start a private practice and hope for the best.

 

[painballer27]

But the problem is many times sitting down with the family for hours is crucial for the treatment of patients and what gets them better more than the meds. (especially if you are dealing with children and adolescents but even for majority adults).

Considering NPs increasingly staffing hospitals and clinics, one can argue that ''expensive'' MDs who only do evals and med checks will be replaced by an NP who can do pretty much the same with ''much cheaper'' price. I can hear you saying ''Well how about the quality care and patient outcomes?''. In capitalist mental healthcare system, the quality patient care can not win the fight against ''productivity'' and ''profits''. And never, ever underestimate NPs when it comes to productivity and profits because my eyes witnessed NPs billing 99215 + 90833 20 times a day for 5 minutes medication checks.

In my current state, I constantly observe MD`s replaced by NP`s in the CMHC`s and hospitals. If we do not act collectively, in near future we will likely lose significant leverage against corporate/capitalist mental healthcare.

Now some say ''Well if it comes to that point, I will open my own shop''. I would say good luck with dealing insurance companies and their ridiculous mental health service reimbursements. If you want to do cash practice though, you will much more than evals and med checks to attract patients with capital because there will be two other private clinic right across the street. In either case, no psychiatrist will be hitting 400k +

So the field of psychiatry is essentially doomed?

 

[smalltownpsych]

Put your energy where it matters most. Often the frustration is when we feel like we are wasting our time and energy. Agree completely with both sentiments about family communication. When a family is open to being part of the solution, I’ll talk to them and strategize and educate. If not, they get the brief report and directions to communicate about everything else with the RN, social worker, case manager, outpatient clinic, etc. Anybody but me. Same can be said with patients. One advantage of inpatient vs. outpatient is that you can more easily choose which cases to put your energy into you have others on the team to ensure patient gets needs met.

With substance abusers, even more so than other patients, clear boundaries are essential. If you have to be the bad person and they are pissed about that, then let the others deal with it. Don’t get sucked into their pattern of manipulation/debate by trying to explain to them. Broken record technique can be effective with this. “I understand what you are saying; but the answer is still no.” After they respond and it doesn’t typically matter what they say if it is part of that pattern, “As I said, we will not do x, y, or z. I will check in with you tomorrow.“ If they try again, “This conversation is unproductive and I have other patients to see, good bye.” and walk out the door letting staff know that patient is riled up again and what plan is if the patient can’t emotionally regulate.

Part of inpatient treatment is to set that ultimate boundary or limit. The best time to directly hit on that pattern is when they can be restrained. I have had many sessions where I go in to tell them a hard truth, knowing that it might blow them up. Staff appreciates knowing about it beforehand and what I have found is that often the patient appreciates knowing the boundary or truth and we can move forward to discharge. If the inpatient treatment avoids whatever the crux of the matter is, then we’ll get more of the revolving door.

Also, if learning to master the above interactions aren’t what you enjoy, then other settings might be better for you. Main reason why I chimed in is that I love that kind of stuff.

 

[deleted1100659]

maybe you should consider a diff job/setting. If you're not happy where you are, the only two options are to become content with it or seek elsewhere. Theres always a risk it can be worse somewhere else, however, no risk= no potential for reward. You dont have to love your job, but ideally finding something you like more days tahn you dislike.

 

[comp1]

I'm not sure you can be talking to the families of 12 people a day. Of course that would burn you out. You're the leader of a team. You need to be delegating. It's unfortunate that you're not at an academic site, but I can tell you that that is what keeps me going in inpatient. I'm a conductor. I don't play all of the instruments and quite honestly I'd be pretty bad at some of them, but I understand the roles. The OP seems to be moving from chair to chair trying to perform every part of the orchestra. It's not doable.

 

[SubzDoc]

I am rarely happy to hear that family members want to speak to me although I am not insensitive to these requests and take some of them seriously. I have done it in a variety of settings when there is a clear reason to do so (collateral is needed, pt has dementia, etc). If there is clear dysfunction in the relationships I can discuss an MFT referral with the patient, I let them know all parties will need to consent. I do not respond to every request to communicate with family, providing therapy to distressed family members is just not our job. I have on occasion encouraged patients to discuss concerns with their family and then I discuss those concerns with the patient directly. They can then communicate our discussion with the family if they wish.

 

[whopper]

I've noticed my own set of weaknesses of what gets me frustrated with my job. It differs depending on setting of practice. In inpatient the pet-peeve was dealing with insurance company physician hookers telling me that my patient was safe for discharge despite it was very clear they were not. I figured a way to fight back but by the time this happened I was already on my way out of inpatient. (The idea being of having the patient or their family report the physician to the state medical board of their own state).

In private practice it's the patient being intentionally insulting. I figured out a solution-you terminate the patient, but then here comes the problem if you actually have a conscience. If you terminate the patient relationship and you actually give a damn about good care you're going to second guess if you terminated too prematurely and if you gave this person enough chances.

To deal with this issue I've made an algorithm. Give the person 3 chances where you did the following 1) observed and documented the person being intentionally emotionally abusive to myself or anyone working in my office 2) address the issue with the patient in a non-confrontational manner and ask how this could've been avoided. 3) Double check to make sure the inappropriate behavior was not from a treatable Axis I Disorder.

If the patient doesn't act in a good-faith manner then after 3 chances terminate them. One of her lines: "Why do you care if this medication works or not? The only thing you are to me is the idiot who prescribes this medication and I have to see you only because otherwise I can't get this medicine. Otherwise you're a zero to me." I terminated her. I gave it one last chance "Was that line necessary?" "Would you have accepted that type of behavior from one of your own clients?" (She's a lawyer).

Just terminated her last week. My first year of private practice I was terminating at least 1 patient a month. Sometimes several in a week. Now it's about one every 3-4 months.

The next most bothersome thing, as mentioned above, is intrusive family members calling my office. That problem, however, hasn't happened at my office for months.

 

[lockian]

I've noticed my own set of weaknesses of what gets me frustrated with my job. It differs depending on setting of practice. In inpatient the pet-peeve was dealing with insurance company physician hookers telling me that my patient was safe for discharge despite it was very clear they were not. I figured a way to fight back but by the time this happened I was already on my way out of inpatient. (The idea being of having the patient or their family report the physician to the state medical board of their own state).

In private practice it's the patient being intentionally insulting. I figured out a solution-you terminate the patient, but then here comes the problem if you actually have a conscience. If you terminate the patient relationship and you actually give a damn about good care you're going to second guess if you terminated too prematurely and if you gave this person enough chances.

To deal with this issue I've made an algorithm. Give the person 3 chances where you did the following 1) observed and documented the person being intentionally emotionally abusive to myself or anyone working in my office 2) address the issue with the patient in a non-confrontational manner and ask how this could've been avoided. 3) Double check to make sure the inappropriate behavior was not from a treatable Axis I Disorder.

If the patient doesn't act in a good-faith manner then after 3 chances terminate them. One of her lines: "Why do you care if this medication works or not? The only thing you are to me is the idiot who prescribes this medication and I have to see you only because otherwise I can't get this medicine. Otherwise you're a zero to me." I terminated her. I gave it one last chance "Was that line necessary?" "Would you have accepted that type of behavior from one of your own clients?" (She's a lawyer).

Just terminated her last week. My first year of private practice I was terminating at least 1 patient a month. Sometimes several in a week. Now it's about one every 3-4 months.

The next most bothersome thing, as mentioned above, is intrusive family members calling my office. That problem, however, hasn't happened at my office for months.

Question, what in your mind counts as emotionally abusive? Where I live, no one typically calls anyone names to their face (cultural thing), but I often find patients blaming me for their distress in a guilt-tripping sort of way. I’ve taught myself to not instinctively apologize, because if I know I’m providing good care there is no reason to apologize, but those are often the patients who seem to occupy my mind outside of work, and it’s a very unpleasant feeling.

 

[Candidate2017]

1. Inpt psychiatrists aren't family therapists. It's ok for families to briefly vent, but don't get caught in their triangulation. Also, tell the nurse to tell family to call or message the patient directly. A patient with capacity should be encouraged to speak with their family regarding their progress and plan. That is part of the therapeutic process. Family contact should ideally be limited to day of discharge to discuss diagnosis, prognosis, safety plan, meds, follow up recs.

2. Drug seeking? Just say no, walk away.

3. Documentation too long? Well, read about billing and medicolegal requirements. The deeper your understanding, the shorter your notes can be.

4. Employer pressure to work for free? They're just doing their job. Just say no. Be ready to walk. Tell them to hash it out with your lawyer, work part time, quit, do 1099 or locums, start your own practice, do cash melatonin enemas, etc.

All of the above is mostly to say don't reward maladaptive behaviors, otherwise you encourage more of it. Just say no.

Also, it also helps to stick to psychiatry. Med school/training rewards being right and knowing the answer to every problem. But no, we aren't gods or wizards with magical incantations, potions, or crystal balls. Avoid the temptation to solve others' problems or write ESA letters. Radically accept that your role is very specific and limited, and actually tell patients/families, you have limited knowledge, limited tools, limited meds, and that the solution is within them. Just shrug and tolerate uncertainty. And patients/families will learn to do the same. Or not.

 

[lockian]

Yeah my point exactly. As a psychiatrist your job should be doing what you're trained to do, making the diagnosis and treatment plan, not sitting down with family members for hours. Other people with less training can do that

Do you practice medicine? Because comments surprise me. A treatment plan without buy-in is nothing but a worthless piece of paper. Face time with doctors who care to explain what’s going on and why they’re doing what you’re doing improves buy in. Buy in makes change. It also protects against liability. People are less likely to sue a doctor who was available and personable than a faceless entity. Obviously your time is not infinite and you have to pick and choose. There is a fine art with conveying care and investment while spending relatively little time, minute for minute. Some of my colleagues are amazing at it. I am not yet, but I’m learning.

 

[Fan_of_Meehl]

Do you practice medicine? Because comments surprise me. A treatment plan without buy-in is nothing but a worthless piece of paper. Face time with doctors who care to explain what’s going on and why they’re doing what you’re doing improves buy in. Buy in makes change. It also protects against liability. People are less likely to sue a doctor who was available and personable than a faceless entity. Obviously your time is not infinite and you have to pick and choose. There is a fine art with conveying care and investment while spending relatively little time, minute for minute. Some of my colleagues are amazing at it. I am not yet, but I’m learning.

I hope my following comment in on topic/point (and my comment is more of a general comment on the thread topic rather than a direct response to the prior post).

I think there is a critical distinction to be made between: a) providing a plan (or course of care) that is consistent with widely accepted standards of care or standards of practice within the field for a particular diagnosis or problem versus b) attempting to (or conceptualizing your role as) effecting some specific outcome for the patient/ family (e.g., patient is 'cured,' depression is remitted, father no longer drinks/ uses drugs, patient has no more anxiety).

Over the years, it has become apparent to me that some patients (and their families) and even some administrators appear to operate under the expectation that I must provide a specific clinical outcome rather than providing widely accepted standard of care/practice treatment. Whenever patients/parents (or healthcare organizations) expect routine provider practice to greatly exceed standard of care/practice in the field (as some may argue, for example, the VA has done on the topics of PTSD or suicide or engagement in psychotherapy process), it causes a lot of headaches and I see it often as my role to continuously educate everyone on what the standard of care for the condition/problem is and this may be found in any number of reputable professional texts or consensus guidelines.

 

[SubzDoc]

VA has done on...suicide...it causes a lot of headaches

This. So much this.

 

[Sushirolls]

OP, time for outpatient. Drop the inpatient.

 

[elbandito1]

I appreciate everyone’s responses, and it’s been quite helpful. I agree that at its basic, my role is to assess, formulate a TP and follow through with it and makes changes as needed. I have an academic appointment and have medical students and can delegate tasks to them, but often times it becomes more time consuming than just doing it myself.

More frequently than I’d like, and as someone said, a lot of times it’s social work or nursing saying “oh they want to speak with the doctor,” and it turning out to be something the team could easily handle without needing my input.

I’ve given some consideration to look for alternative jobs and passively looking, but not sure yet if I’m ready to abandon ship, and that has more to do with the logistics of switching jobs. But it’s certainly crossed my mind and getting constant emails about local institutions and openings with much higher salary. Like someone said above, my worry is the new job being worse, but I guess I wouldn’t know unless I try.

The ultimate goal is outpatient but I have student loans and hoping PSLF will help me out and I’d rather not be employed by an institution working outpatient. I imagine if I’m salaried and working for someone, their incentive is to get as much out of me as they possibly can.

all the comments above have been very helpful and I’ve attempted to implement some of them and has helped with my workflow and my level of frustration. It’s interesting because the institution I work for is well known, from an outside perspective, as a solid institution for providing mental health treatment, but a year in and I can how mismanaged everything is, which also explains the high turnover rate

 

[FrustratedFamDoc]

I'm primary care, but speaking with concerned family members is a big part of what I do. My approach is pragmatic, with hopes of removing emotional aspects from the conversation, as it doesn't really help with anything.

Hello, I'm Dr. Mark V. I'm so glad you wanted to speak with me about pt X.

"What specifically are your concerns with pt?"

1. Here's what we have going on and my concerns.
2. Here's what we're doing and our plans.
3. Here's what YOU need to do going forward.
4. Here's what I need to do going forward.
5. Here are the things to expect going forward.

Questions?

Redirect any tangent to this process, back to this process. It's logical, not emotional, which many find to be challenging. Learn to recognize the rabbit holes early and find the nearest off ramp. This will come with time. You will find the conversations much shorter and more rewarding. Family members will leave with a plan in place that they will hopefully will remember. Expectations will be set.

 

[smalltownpsych]

I appreciate everyone’s responses, and it’s been quite helpful. I agree that at its basic, my role is to assess, formulate a TP and follow through with it and makes changes as needed. I have an academic appointment and have medical students and can delegate tasks to them, but often times it becomes more time consuming than just doing it myself.

More frequently than I’d like, and as someone said, a lot of times it’s social work or nursing saying “oh they want to speak with the doctor,” and it turning out to be something the team could easily handle without needing my input.

I’ve given some consideration to look for alternative jobs and passively looking, but not sure yet if I’m ready to abandon ship, and that has more to do with the logistics of switching jobs. But it’s certainly crossed my mind and getting constant emails about local institutions and openings with much higher salary. Like someone said above, my worry is the new job being worse, but I guess I wouldn’t know unless I try.

The ultimate goal is outpatient but I have student loans and hoping PSLF will help me out and I’d rather not be employed by an institution working outpatient. I imagine if I’m salaried and working for someone, their incentive is to get as much out of me as they possibly can.

all the comments above have been very helpful and I’ve attempted to implement some of them and has helped with my workflow and my level of frustration. It’s interesting because the institution I work for is well known, from an outside perspective, as a solid institution for providing mental health treatment, but a year in and I can how mismanaged everything is, which also explains the high turnover rate

Sounds like the problem is with nursing and social work more than with the families. Regardless, it is still about how to set boundaries. A big mistake that we all can make is to think that if you fixed “them” or anything else external that things would be better. The only thing you have control over is you and how you handle situations. With staff, I am very accessible and I direct them on how to handle these things themselves when they should, but I am very patient about it because sometimes what I am actually thinking is not exactly going to lead to effective teamwork. I will also be quick to take over when it is over their head or just too difficult for them for whatever reason. When they appreciate you they will work harder for you.

 

[Merovinge]

for example, the VA has done on the topics of ... suicide

The "Zero suicide" initiatives are so frustratingly titled. We certainly need more awareness and open confrontation of the problem of suicide both as a population and also as health care providers. However, suicide is not the same as leaving a scalpel inside someone or missing a switch on airplane that can solved by an administrator making you complete a checklist .

 

[FrustratedFamDoc]

When they appreciate you they will work harder for you.

This.

 

[Fan_of_Meehl]

The "Zero suicide" initiatives are so frustratingly titled. We certainly need more awareness and open confrontation of the problem of suicide both as a population and also as health care providers. However, suicide is not the same as leaving a scalpel inside someone or missing a switch on airplane that can solved by an administrator making you complete a checklist .

I'm curious...do cardiologists have a 'Zero Heart Attacks' initiative? Do internal medicine docs have a 'Zero Mortality (ever)' initiative? Do administrators / bureaucrats have a 'Zero Mistakes (ever)' Initiative?

Obviously, those are all rhetorical questions but the point is that this is the only area I can think of where they've put forth the ridiculous (though ideologically laudable, if hopelessly utopian) goal of 'Zero Suicide' or 'Elimination of Suicide' initiative. I know it's a cringey phrase but it seems apt in this case...it seems to be extreme 'virtue signaling', e.g., 'I'm SO serious about saving lives that I'm going to have you pledge that we are going to have ZERO suicides...ever... It's an ideological pledge, not a rational/reasonable one. It stinks of political maneuvering/peacocking.

Mental healthcare is challenging enough as is and, importantly, some of the rituals/procedures that they insist upon insisting upon not only do not necessarily help to further reduce suicide risk, some of them may actually, empirically, increase suicide risk via a number of potential pathways, for example, some of the procedures / THOROUGHLY THOROUGH INTENSIVE evaluations that have been mandated for every single session in some cases actually soak up much of the time in session (even though the veteran begins the session saying, nope, no suicidal ideation, intent, or behaviors since the last session...so it 'squeezes out' time/resources to be able to actually address REAL issues that may be contributing to hopelessness and, ultimately, suicide. (e.g., substance use, depression, relationship issues, anxiety, etc.). So, quite likely, it can have the opposite effect than intended but because people can't get beyond concrete thinking (e.g., if we just make the 'evaluations' LENGTHIER, MORE FREQUENT, STANDARDIZED/INFLEXIBLE--the MORE lengthy, frequent, and inflexible we make them, the more we will reduce suicide risk (wrong). It also potentially really impedes the therapeutic alliance/relationship (also crucial to outcome) and sends the impression to the patient that the 'doctor' is just a lowly technician with no authority/skill to exercise clinical judgment at all. There are SO many ways that the implementation of these initiatives are often beyond useless and actually backfire in terms of their intended effects.

 

[mistafab]

I'm curious...do cardiologists have a 'Zero Heart Attacks' initiative? Do internal medicine docs have a 'Zero Mortality (ever)' initiative? Do administrators / bureaucrats have a 'Zero Mistakes (ever)' Initiative?

Obviously, those are all rhetorical questions but the point is that this is the only area I can think of where they've put forth the ridiculous (though ideologically laudable, if hopelessly utopian) goal of 'Zero Suicide' or 'Elimination of Suicide' initiative. I know it's a cringey phrase but it seems apt in this case...it seems to be extreme 'virtue signaling', e.g., 'I'm SO serious about saving lives that I'm going to have you pledge that we are going to have ZERO suicides...ever... It's an ideological pledge, not a rational/reasonable one. It stinks of political maneuvering/peacocking.

Mental healthcare is challenging enough as is and, importantly, some of the rituals/procedures that they insist upon insisting upon not only do not necessarily help to further reduce suicide risk, some of them may actually, empirically, increase suicide risk via a number of potential pathways, for example, some of the procedures / THOROUGHLY THOROUGH INTENSIVE evaluations that have been mandated for every single session in some cases actually soak up much of the time in session (even though the veteran begins the session saying, nope, no suicidal ideation, intent, or behaviors since the last session...so it 'squeezes out' time/resources to be able to actually address REAL issues that may be contributing to hopelessness and, ultimately, suicide. (e.g., substance use, depression, relationship issues, anxiety, etc.). So, quite likely, it can have the opposite effect than intended but because people can't get beyond concrete thinking (e.g., if we just make the 'evaluations' LENGTHIER, MORE FREQUENT, STANDARDIZED/INFLEXIBLE--the MORE lengthy, frequent, and inflexible we make them, the more we will reduce suicide risk (wrong). It also potentially really impedes the therapeutic alliance/relationship (also crucial to outcome) and sends the impression to the patient that the 'doctor' is just a lowly technician with no authority/skill to exercise clinical judgment at all. There are SO many ways that the implementation of these initiatives are often beyond useless and actually backfire in terms of their intended effects.

At a dmh we rotate at, every opt visit requires phq9 and ccrs. It detracts from the care provided for these already lower functioning folks by chewing up valuable time with their psychiatrist.

What a joke. These screeners are treated as diagnostic, and placed on a pedestal. In no way was this what they were designed to do. Additionally, you can see how an institution/administration with good intentions would institute as many brain-dead instruments as possible to say “we’re doing our part.”

 

[Fan_of_Meehl]

The "Zero suicide" initiatives are so frustratingly titled. We certainly need more awareness and open confrontation of the problem of suicide both as a population and also as health care providers. However, suicide is not the same as leaving a scalpel inside someone or missing a switch on airplane that can solved by an administrator making you complete a checklist .

Several months ago, when the VA 'rolled out' yet ANOTHER top-down authoritarian set of mandates to 'eliminate suicide' (a.k.a. the 'Zero Suicide' pledge and action plan), a social worker program manager asked me what I thought of it. I looked her dead in the eye and replied, "What it clearly communicates to me is that they are NOT SERIOUS about actually addressing the issue."

I think that gets to the heart of my frustration. EVERYBODY wants to do everything within reason (and within their power) to avoid the tragic outcome of patient suicide. It's frustrating that the apparent degree of PUBLICLY ANNOUNCED ZEAL that a person (generally, hell, exclusively, a non-provider administrator type) expresses is INVERSELY proportional to the actual amount of time/effort that they spend in daily contact with actual patients actually trying to reduce depression/hopelessness to actually do anything about their actual suicide risk. "{put on game face for the cameras/public; pound fist on podium} Here at [insert organization], we are doing everything humanly possible to eliminate the horrific SCOURGE of patient suicide once and for all; I tell you now...no sacrifice is too much to ask, no obstacle too great, no barrier too high to be overcome...we WILL end suicide once and for all under MY leadership...we can do this together, #WEAREALLINTHISTOGETHER---blahh blahh blahhety blahh blahhh"). Or--and I love this one--"In order to aggressively combat the scourge of patient suicide and end it once and for all, we will be sponsoring a 'March for Suicide Awareness' this Friday on the quad from 8am - 2pm; please be there to show your support for reducing suicide risk in our veteran population!' Yeah...well...about that, chief...I'd be HAPPY to attend your 'march' (which will do jack and s___ to actually reduce suicide risk to the 100+ veterans in my caseload). I'm going to have to send my regrets that I cannot attend your public march because I, unfortunately, am booked solid with appointments to see actual veterans and actually work face-to-face and one-on-one with them...you know...directly providing professional mental health assessment and treatment to them. I know it'd be better if I could 'march' and all with you and the secretaries (who won't be available to check patients in or reschedule them), the canteen workers, the butchers, bakers and candlestick-makers...but, hey, them's the breaks.

And I am so tired of receiving emails with the obligatory '#BETHERE' sticker on them. Thankfully, they have rotated in additional 'catch phrases' and the 'bethere' one is more scarce these days, but it always particularly struck a nerve with me. Some admin sending the admonition for me--a full-time mental health provider with an enormous caseload--to 'hashtag BE THERE'--? I wanted to say...'BE there??? Bit--, I ***LIVE*** 'there!.' I'm 'there' (spending time in face to face MH service/care delivery) all shift long, every workday, all week, all month and all year. When was the last time that YA'LL spent face to face time with veterans actually trying to talk them off 'the cliff' of suicide risk? Sorry for the rant, it's just SO frustrating.

 

[mistafab]

Several months ago, when the VA 'rolled out' yet ANOTHER top-down authoritarian set of mandates to 'eliminate suicide' (a.k.a. the 'Zero Suicide' pledge and action plan), a social worker program manager asked me what I thought of it. I looked her dead in the eye and replied, "What it clearly communicates to me is that they are NOT SERIOUS about actually addressing the issue."

I think that gets to the heart of my frustration. EVERYBODY wants to do everything within reason (and within their power) to avoid the tragic outcome of patient suicide. It's frustrating that the apparent degree of PUBLICLY ANNOUNCED ZEAL that a person (generally, hell, exclusively, a non-provider administrator type) expresses is INVERSELY proportional to the actual amount of time/effort that they spend in daily contact with actual patients actually trying to reduce depression/hopelessness to actually do anything about their actual suicide risk. "{put on game face for the cameras/public; pound fist on podium} Here at [insert organization], we are doing everything humanly possible to eliminate the horrific SCOURGE of patient suicide once and for all; I tell you now...no sacrifice is to much to ask, no obstacle to great, no barrier to high to be overcome...we WILL end suicide once and for all under MY leadership...we can do this together, #WEAREALLINTHISTOGETHER---blahh blahh blahhety blahh blahhh"). Or--and I love this one--"In order to aggressively combat the scourge of patient suicide and end it once and for all, we will be sponsoring a 'March for Suicide Awareness' this Friday on the quad from 8am - 2pm; please be there to show your support for reducing suicide risk in our veteran population!' Yeah...well...about that, chief...I'd be HAPPY to attend your 'march' (which will do jack and s___ to actually reduce suicide risk to the 100+ veterans in my caseload). I'm going to have to send my regrets that I cannot attend your public march because I, unfortunately, am booked solid with appointments to see actual veterans and actually work face-to-face and one-on-one with them...you know...directly providing professional mental health assessment and treatment to them. I know it'd be better if I could 'march' and all with you and the secretaries (who won't be available to check patients in or reschedule them), the canteen workers, the butchers, bakers and candlestick-makers...but, hey, them's the breaks.

And I am so tired of receiving emails with the obligatory '#BETHERE' sticker on them. Thankfully, they have rotated in additional 'catch phrases' and the 'bethere' one is more scarce these days, but it always particularly struck a nerve with me. Some admin sending the admonition for me--a full-time mental health provider with an enormous caseload--to 'hashtag BE THERE'--? I wanted to say...'BE there??? Bit--, I ***LIVE*** 'there!.' I'm 'there' (spending time in face to face MH service/care delivery) all shift long, every workday, all week, all month and all year. When was the last time that YA'LL spend face to face time with veterans actually trying to talk them off 'the cliff' of suicide risk? Sorry for the rant, it's just SO frustrating.

Felt this in my soul.

 

[birchswing]

Other people with less training can do that

I don't know a lot about it, but isn't it more entirely different training rather than less? Like social workers would know more about to cut through the red tape of the ten gazillion federal, state, and local agencies that provide assistance in our byzantine system, whereas I don't think doctors know much about that. In my experience. I don't have experience with social workers, but more so with psychiatrists/psychologists not seeming to know, at least outpatient, about various forms of assistance. And people I know who have social workers seem to find them helpful in those regards.

 

[painballer27]

I don't know a lot about it, but isn't it more entirely different training rather than less? Like social workers would know more about to cut through the red tape of the ten gazillion federal, state, and local agencies that provide assistance in our byzantine system, whereas I don't think doctors know much about that. In my experience. I don't have experience with social workers, but more so with psychiatrists/psychologists not seeming to know, at least outpatient, about various forms of assistance. And people I know who have social workers seem to find them helpful in those regards.

You're right. You don't know a lot about it. You're "non-medical" and I don't know why you continue to give your input. Psychiatrists do 4 years of undergrad, followed by 4 years of rigorous medical school training, followed by 4 more years of rigorous residency training. Tbh I don't know what the training for a social worker consists of but I know its nowhere near the level of a physician. So to answer your question, no, it is more training, not just different.

 

[nexus73]

I don't know a lot about it, but isn't it more entirely different training rather than less? Like social workers would know more about to cut through the red tape of the ten gazillion federal, state, and local agencies that provide assistance in our byzantine system, whereas I don't think doctors know much about that. In my experience. I don't have experience with social workers, but more so with psychiatrists/psychologists not seeming to know, at least outpatient, about various forms of assistance. And people I know who have social workers seem to find them helpful in those regards.

if you ask a social worker how much training they get cutting through red tape and arguing with insurance companies, the answer is usually none, it’s not why they became social workers. But they are highly educated and cost a lot less than a doctor or nurse even usually so it falls to them and over time they learn it on the job. And it doesn’t mean they like doing it. It’s kind of like working with borderline personality disorder, psychiatrists are trained to do it, but it doesn’t mean I want to to it all day every day, or even at all.

 

[birchswing]

You're right. You don't know a lot about it. You're "non-medical" and I don't know why you continue to give your input. Psychiatrists do 4 years of undergrad, followed by 4 years of rigorous medical school training, followed by 4 more years of rigorous residency training. Tbh I don't know what the training for a social worker consists of but I know its nowhere near the level of a physician. So to answer your question, no, it is more training, not just different.

Did you see Dr. Oz on Jeopardy?

He's probably (I guess?) good at cardiothoracic surgery which he had training in, but he's a dim bulb. Came in dead last after harassing his fellow contestants. Must be a type. A money-grubbing type. An elitist, money-grubbing type.

Edit: Also psychiatrists don't do 4 years of residency in every state. Not required in mine. There is no state board definition of psychiatrist in my state. I'm very familiar with how licensing works.

 

[birchswing]

if you ask a social worker how much training they get cutting through red tape and arguing with insurance companies, the answer is usually none, it’s not why they became social workers. But they are highly educated and cost a lot less than a doctor or nurse even usually so it falls to them and over time they learn it on the job. And it doesn’t mean they like doing it. It’s kind of like working with borderline personality disorder, psychiatrists are trained to do it, but it doesn’t mean I want to to it all day every day, or even at all.

That sounds like the school nurse. She did everything in that school for everyone. It was like the catch-all job.

Browsing Quora, it does seem like there are some psychiatrists and psychologists who enjoying treating people with BPD. It seems like BPD has taken on broader and broader meaning, though, so what people mean when they say it might be completely different from someone else. It seems like more and more well-adjusted people are using that term.

 

[hamstergang]

At a dmh we rotate at, every opt visit requires phq9 and ccrs. It detracts from the care provided for these already lower functioning folks by chewing up valuable time with their psychiatrist.

What a joke. These screeners are treated as diagnostic, and placed on a pedestal. In no way was this what they were designed to do. Additionally, you can see how an institution/administration with good intentions would institute as many brain-dead instruments as possible to say “we’re doing our part.”

A few years ago, my hospital decided we should do Stanley-Brown safety plans for all outpatients. Not the worst idea, but I had some 5 or 6 year olds I was seeing for ADHD, and the safety plan just didn't make sense for them -- they weren't suicidal and had no indication that they would be, and they didn't understand it anyway. Management said to have them fill out the safety plan then not for suicidality, but instead for like getting angry or something.

I pushed back. If the whole point was to address suicide, then what's the point of filling these out for other concerns? Oh right, it was because they wanted to say we did the form with every patient so it'd seem like we took suicide seriously.

Management didn't care what I had to say, but I cared what they had to say even less and just did what was clinically appropriate. They had a policy that we'd do the safety plan with every patient but never checked to see if there was follow through.

 

[lockian]

You're right. You don't know a lot about it. You're "non-medical" and I don't know why you continue to give your input. Psychiatrists do 4 years of undergrad, followed by 4 years of rigorous medical school training, followed by 4 more years of rigorous residency training. Tbh I don't know what the training for a social worker consists of but I know its nowhere near the level of a physician. So to answer your question, no, it is more training, not just different.

To be honest, very little of what I learned in undergrad (it can be completely unrelated to medicine, really, except the premed classes), or even the first half of med school prepared me specifically for the psychiatric field. In med school you learn a lot of minutiae about the heart and bowel, for instance, and you need to be aware of those things to monitor for side effects and choose the right medication, but when it came to specifically being able to evaluate a patient with schizophrenia or borderline PD, that was mostly the last 4, maybe 5 if you include medical school psychiatry rotation, years of my training, and I'm *still* learning on the job.

 

[smalltownpsych]

Several months ago, when the VA 'rolled out' yet ANOTHER top-down authoritarian set of mandates to 'eliminate suicide' (a.k.a. the 'Zero Suicide' pledge and action plan), a social worker program manager asked me what I thought of it. I looked her dead in the eye and replied, "What it clearly communicates to me is that they are NOT SERIOUS about actually addressing the issue."

I think that gets to the heart of my frustration. EVERYBODY wants to do everything within reason (and within their power) to avoid the tragic outcome of patient suicide. It's frustrating that the apparent degree of PUBLICLY ANNOUNCED ZEAL that a person (generally, hell, exclusively, a non-provider administrator type) expresses is INVERSELY proportional to the actual amount of time/effort that they spend in daily contact with actual patients actually trying to reduce depression/hopelessness to actually do anything about their actual suicide risk. "{put on game face for the cameras/public; pound fist on podium} Here at [insert organization], we are doing everything humanly possible to eliminate the horrific SCOURGE of patient suicide once and for all; I tell you now...no sacrifice is too much to ask, no obstacle too great, no barrier too high to be overcome...we WILL end suicide once and for all under MY leadership...we can do this together, #WEAREALLINTHISTOGETHER---blahh blahh blahhety blahh blahhh"). Or--and I love this one--"In order to aggressively combat the scourge of patient suicide and end it once and for all, we will be sponsoring a 'March for Suicide Awareness' this Friday on the quad from 8am - 2pm; please be there to show your support for reducing suicide risk in our veteran population!' Yeah...well...about that, chief...I'd be HAPPY to attend your 'march' (which will do jack and s___ to actually reduce suicide risk to the 100+ veterans in my caseload). I'm going to have to send my regrets that I cannot attend your public march because I, unfortunately, am booked solid with appointments to see actual veterans and actually work face-to-face and one-on-one with them...you know...directly providing professional mental health assessment and treatment to them. I know it'd be better if I could 'march' and all with you and the secretaries (who won't be available to check patients in or reschedule them), the canteen workers, the butchers, bakers and candlestick-makers...but, hey, them's the breaks.

And I am so tired of receiving emails with the obligatory '#BETHERE' sticker on them. Thankfully, they have rotated in additional 'catch phrases' and the 'bethere' one is more scarce these days, but it always particularly struck a nerve with me. Some admin sending the admonition for me--a full-time mental health provider with an enormous caseload--to 'hashtag BE THERE'--? I wanted to say...'BE there??? Bit--, I ***LIVE*** 'there!.' I'm 'there' (spending time in face to face MH service/care delivery) all shift long, every workday, all week, all month and all year. When was the last time that YA'LL spent face to face time with veterans actually trying to talk them off 'the cliff' of suicide risk? Sorry for the rant, it's just SO frustrating.

Keep on ranting. You clarified very well some of my own frustrations with these dynamics. I do enjoy the marches though just because I enjoy walking with people and do it for fun regardless of whether there is cause.

Another frustration is the whole concept of everyone being just as important to this as everyone else. I am good at assessing for and treating the causes of suicide you aren’t. Just do your job so that I can do mine. I don’t go down to the hall of records and tell you how to file or down to the kitchen and tell people how to organize the meal delivery system or how to track patient accounts to make sure the bills are paid. This dynamic of everyone being involved and thinking they have an idea of how to help aka tell us how to do our jobs seems much more prevalent in our field of mental health than others in medicine.

 

[Fan_of_Meehl]

Keep on ranting. You clarified very well some of my own frustrations with these dynamics. I do enjoy the marches though just because I enjoy walking with people and do it for fun regardless of whether there is cause.

Another frustration is the whole concept of everyone being just as important to this as everyone else. I am good at assessing for and treating the causes of suicide you aren’t. Just do your job so that I can do mine. I don’t go down to the hall of records and tell you how to file or down to the kitchen and tell people how to organize the meal delivery system or how to track patient accounts to make sure the bills are paid. This dynamic of everyone being involved and thinking they have an idea of how to help aka tell us how to do our jobs seems much more prevalent in our field of mental health than others in medicine.

I really appreciate this reply (and back and forth). I think it helps us process and categorize our concerns and frustrations.

You make a really good point in your second paragraph (in terms of how these types of things sap us of energy and demoralize us). People (especially higher within the hierarchy) love employing the phrase/concept 'stay in your lane' but these days EVERYBODY wants to LARP as a mental health professional (without actually ever seeing patients). Meanwhile, we keep our mouths shut and heads down and just grind through seeing heavy-duty mental health cases day in and day out while receiving endless emails, trainings, videos, cliches, slogans, etc. from people who don't have a clue how to actually do any of the things they are imploring everyone to 'do more' of.

 

[forchinet121]

Did you see Dr. Oz on Jeopardy?

He's probably (I guess?) good at cardiothoracic surgery which he had training in, but he's a dim bulb. Came in dead last after harassing his fellow contestants. Must be a type. A money-grubbing type. An elitist, money-grubbing type.

Edit: Also psychiatrists don't do 4 years of residency in every state. Not required in mine. There is no state board definition of psychiatrist in my state. I'm very familiar with how licensing works.

Can you elaborate on what you mean by psychiatrists don’t do 4 years of residency in every state?

 

[birchswing]

Can you elaborate on what you mean by psychiatrists don’t do 4 years of residency in every state?

I've told this story before here so it's probably grating to some, but when I was looking for a new psychiatrist I came across a cash-only psychiatrist who advertised himself as a "residency-trained psychiatrist" on his web-site.

I thought it a bit peculiar.

Why would you go out of your way to say residency trained?

So I looked him up on the state board of medicine web-site that has information that has to be publicly disclosed. He had trained at two different psychiatric residencies and had been kicked out of both, for similar reasons each time. He hadn't finished either.

I contacted the board to ask about the word psychiatrist being used, and they said that psychiatrist was not a term that they regulate. So, I guess in my state at least you can call yourself a psychiatrist somewhat loosely.

 

[smalltownpsych]

I really appreciate this reply (and back and forth). I think it helps us process and categorize our concerns and frustrations.

You make a really good point in your second paragraph (in terms of how these types of things sap us of energy and demoralize us). People (especially higher within the hierarchy) love employing the phrase/concept 'stay in your lane' but these days EVERYBODY wants to LARP as a mental health professional (without actually ever seeing patients). Meanwhile, we keep our mouths shut and heads down and just grind through seeing heavy-duty mental health cases day in and day out while receiving endless emails, trainings, videos, cliches, slogans, etc. from people who don't have a clue how to actually do any of the things they are imploring everyone to 'do more' of.

That phrase “stay in your lane” in my mind is a clear signal for a unproductive and potentially toxic dynamic. It is akin to unhealthy family dynamics around boundaries such as when a child of an addicted parent takes on a parentified or caretaker role and even more toxic, emotional support role of the other parent. In other words, when you have competent leadership, people don’t need to be told to stay in their lanes. Competent leadership recognizes that they don’t need to micromanage. I used to oversee truckers in a previous job, a good dispatcher gives the general parameters of what needs to be done and the order of deliveries. They don’t worry about how they drive the truck unless they are micromanagers and then they waste a lot of energy trying to have safety slogans which assumes that your professional drivers are rampaging lunatics if you don’t tell them how to drive.

 

[Fan_of_Meehl]

That phrase “stay in your lane” in my mind is a clear signal for a unproductive and potentially toxic dynamic. It is akin to unhealthy family dynamics around boundaries such as when a child of an addicted parent takes on a parentified or caretaker role and even more toxic, emotional support role of the other parent. In other words, when you have competent leadership, people don’t need to be told to stay in their lanes. Competent leadership recognizes that they don’t need to micromanage. I used to oversee truckers in a previous job, a good dispatcher gives the general parameters of what needs to be done and the order of deliveries. They don’t worry about how they drive the truck unless they are micromanagers and then they waste a lot of energy trying to have safety slogans which assumes that your professional drivers are rampaging lunatics if you don’t tell them how to drive.

Agree. You can tell a lot about the functional meaning of a phrase (its intended influence on others' behavior) by noticing the contexts within which it is ordinarily invoked as well as the expected behavior (or inhibition of behavior) it is intended to reliably elicit.

I have most often encountered the 'stay in your lane' phrase to be invoked in situations in which someone has made an uncomfortable or rather embarrassing (to those in power, or their associates) observational truth and the clear intention of the use of the phrase is to completely shut down any further discussion/inquiry into the topic.

In all fairness, I think that there are situations in which the use of the concept ('stay in your lane') is appropriate and adaptive. I have even used in on myself covertly from time to time as a self-delivered admonition...almost along the lines of practicing radical acceptance for that which I do not control.

 

[SeniorWrangler]

Responding to the OP, take those early signs of burnout seriously, it only gets worse and it’s hard to heal.