Declining outpatient referrals

[WisNeuro]

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Yeah well this is a reason why I don't think they should've gotten rid of the GAF.

In situations like this it clearly explains something very succinctly. Also from personal experience if you took the GAF seriously the numbers were accurate. What happened most of the time IMHO was that clinicians weren't referencing the chart when making the number and allowing the insurance directive to mandate the number. E.g. "do we want to keep her inpatient longer? If so make GAF 15 even if it's really a 45.

As you hint at, the GAF was used in a way that rendered the numbers meaningless. Either someone fudged the numbers for insurance reasons, or providers really had no idea what the anchor points were and just threw in a number that sounded fine to them. I don't know how many people I saw with GAF scores of about 40 in treatment for what I would say were mild to moderate anxiety/depression, working full-time/going to school etc. In theory, it sounded useful. In actual practice, just another meaningless piece of information in the chart.

 

[randomdoc1]

Hmm... I'm not sure what to think of this. I've NEVER EVER felt to be in danger in an outpatient practice setting. And I treat out of control addicts on a daily basis. People who are truly dangerous don't present in this kind of context. I feel much more at risk in the ER/inpatient.



I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

The adult ADHD thing has been discussed extensively on these forums numerous times. My line has been that this is something that didn't exist at all when I was in residency, and I was blindsided by when starting a job in the worried well outpatient world. I suppose you might say that just shows I went to a crappy residency program, but based on what I've gleaned from prior discussions, it's a perfectly reasonable and evidence-consistent opinion that adults do not need stimulants in order to function. If adult ADHD is now 20% of general psychiatry, that in and of itself is evidence that psychiatry is fake medicine--is ADHD a new virus, like HIV? If not, how can something that didn't exist 50 years ago now constitute 20% of the practice? On the contrary, I would much prefer to see suicidal patients and prescribe lithium, antipsychotics, and MAOIs, than spend one more day dealing with the damn worried well and their fake, first world problems of supposedly being unable to function without Adderal or Xanax.

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I have my 2 cents to add too. Sluox, I really enjoy your input on the forums and it has been extremely helpful. I too admit that I do not have much interest in ADHD and I'm more subspecializing towards anxiety and treatment resistant depression. I'm exploring MAOIs and have more experience with them than most psychiatrists in my area. However, many of the adults presenting to my office historically for adult ADHD, they mostly just wanted to walk out with stimulants. They declined the standard of care which includes often UDS (high comorbid substance use and often times it is AODA and no ADHD) and TSH. They actually got mad. Even when I tried to get a thorough assessment done, most of the time it turned out to not be ADHD and yet they still argue with the diagnosis (e.g. no evidence of pediatric symptoms whatsoever). I believe the American Journal of Psychiatry touched on the adult ADHD topic quite a bit, and there was one article, can't remember off the top of my head, that said especially adults presenting with reports of onset of symptoms or predominance of symptoms in adulthood, very few turned out to actually have ADHD. I'm also not a fan of mechanism of action of the amphetamines, it leads to tolerance quite quickly as it causes a flood of dopamine and feedback ensues that leads to the tolerance. Also, I work with one of the biggest names (a neuropsychologist) in ADHD who published many of the major texts, she's also quite frustrated with the massive flux of adults inquiring about ADHD who turn out to not have ADHD. Even the ones who do have ADHD, comorbidity especially tends to be the norm than the exception and even many of the patients I've worked with in this category just kept perseverating that they just need more stims and really don't try to address their other disorders. In addition, this neuropsycohlogist also feels non-pharmacologic adjuncts are highly underutilized and a big piece of treating ADHD. Which I fully agree as well and this is equally as frustrating.

Anyways, sorry to let off what sounds like a rant, it's not meant to be, really, but that's been my experience. I understand Trismegistus4's feelings about this one.

Just a general statistic, when I first started PP, 85% of the new patient calls were about adult ADHD, which is an interesting statistic. I started seeing these patients but almost all of them never came back. One even went so far as to troll on the internet and left me a fake bad review of how I was trying to take away this golden and vital medication and did an incomplete assessment. This dropped my new patient traffic until I got healthgrades to take that bogus review down. Of the people that stayed, there was often comorbidity which they did not want to address for the most part and they just kept asking for more stims. At least with the population here, a lot more trouble than it is worth. If statistically most do not care to have a good quality assessment or to hear what I have to say, I decided let's not waste both our times, let alone risk more trolling and fake reviews of me on the internet.

 

[whopper]

ADHD exists, but the methods to diagnose it are highly questionable, the diagnosis and treatment lends itself to many people faking it (more time on exams, people who were kicked out of college get to go back in), and psychiatry itself is a field where many practicing clinicians are prone to the easy quick diagnosis making even diagnosis of something that is highly accepted as real at times also highly questionable. (E.g. at some VAs EVERYONE has PTSD, I mean EVERYONE without any of the clinicians actually going through the diagnostic criteria for real. If I ever got someone with a PTSD dx from a VA like that I'm not going to initially believe it's a valid diagnosis until I vet the patient myself).

Add to that, if you practice in a very low psychosocial environment, even if the patient really has it they might just sell their meds under bad circumstances. E.g. if you're working in a depressed area, that patient might just be worrying about their next meal and sell a few pills here and there, even if they really have ADHD, making treating it with stimulants that much more of a headache. So you happen to even believe they have ADHD but now you won't give them anymore stimulants. So what happens then if they try Wellbutrin or Strattera and those meds don't work well (which is highly realistic). They're SOOL, you tell them this and the freak out on you all the while truly having the disorder that you now refuse to treat.

Another freaking headache especially if you're in an organization where you know some of your colleagues don't practice with high standards and let's be honest this does happen quite a bit. E.g. you cover for another doctor for one day that you don't trust and all of his ADHD patients happen to come in that day. Of course I'm not going to like prescribing them stimulants. Heck I might even be a little ticked off about it. So you're trapped into this position of not prescribing them and when the patient asks you, you don't want to be fully honest and tell them you think their usual clinician is an idiot, or you could prescribe them and not feel comfortable about it either.

In my own private practice I feel much more comfortable treating people for ADHD cause I've thoroughly gone through the cases and I trust myself.

It just goes to show you something that's very sad in our field but is going on quite commonly and no one addresses the elephant in the room/Emperor's new clothes. You pick up a chart, see a diagnosis and treatment from a colleague, and you have almost no faith the diagnosis or treatment is valid, but no one wants to address the real issue, cause there's a shortage of psychiatrists and the institution is forced to keep this person that sucks and you're trapped into working with this guy.

 

[dl2dp2]

It just goes to show you something that's very sad in our field but is going on quite commonly and no one addresses the elephant in the room/Emperor's new clothes. You pick up a chart, see a diagnosis and treatment from a colleague, and you have almost no faith the diagnosis or treatment is valid, but no one wants to address the real issue, cause there's a shortage of psychiatrists and the institution is forced to keep this person that sucks and you're trapped into working with this guy.

Pretty much exactly what he says. Interestingly, psychiatric diagnoses if done correctly are actually pretty reliable across different clinicians, is the irony. But things like structured interviews and thorough review of symptoms take a lot of time, and few has time to do them except in a private setting.

But, the point is, in principle, screening people out will not HELP any of this ONE bit. That's my point. Sure, in the real world, perhaps you just don't want to/have the sources to deal, and I'm sympathetic to that argument. But I'm saying as a standard of care, I don't think "screening out" has any clinical utility. It's a purely logistic maneuver.

 

[randomdoc1]

Pretty much exactly what he says. Interestingly, psychiatric diagnoses if done correctly are actually pretty reliable across different clinicians, is the irony. But things like structured interviews and thorough review of symptoms take a lot of time, and few has time to do them except in a private setting.

But, the point is, in principle, screening people out will not HELP any of this ONE bit. That's my point. Sure, in the real world, perhaps you just don't want to/have the sources to deal, and I'm sympathetic to that argument. But I'm saying as a standard of care, I don't think "screening out" has any clinical utility. It's a purely logistic maneuver.

I agree that diagnoses tend to be consistent if each clinician takes the time to do a good quality assessment. Especially in residency when we reviewed cases, we generally had a very good consensus of the working diagnosis. It would be nice if there weren't so many crappy clinicians out there too that just makes it worse. Even this week, I've seen so many new MDD patients and the lines of treatment they went through were pathetic. It was not systematic or evidence based and some patients just had the impressions that treatment stopped at montherapy with SSRIs and "supportive talk therapy." I said I was so glad they came to be seen, I've got a lot of options for them both pharm and non-pharm. As for the adult ADHD matter in my area, soon as that internet trolling started and the effects on my traffic were noted...that was the breaking point for my tolerance. It's ok if patients decide not to follow my recommendations 100% but that was something I was unable to accept. =/.

 

[Ceke2002]

I cannot answer for another person but can say that the majority of eating disorders and their sx aren't treatable with meds. The majority of them are psychotherapy-only cases unless the ED is severe requiring hospitalization.

The only solid data with eating disorders and meds are SSRIs reduce purging (and some binging) behavior. Topiramate helps with binging in some studies but it never got an indication. Although Vyvanse got an indication for treating binge-eating many psychiatrists aren't comfortable with this treatment because ED patients typically have cluster B traits, stimulants are controlled substances with addiction potential, and it's a while it will treat the sx it doesn't treat any fundamental physiology that will lead to health benefits other than sx improvement.. (In comparison most antidepressants, for example cause physiological changes more fundamental than simply just treating the sx such as change in the regulation of neurotransmitters, increased brain-derived neurotrophic factor, decreased pathological cytokine release, all of which are healthy benefits more fundamental than simply improving sx, and they aren't addictive. Also several long-term studies show antidepressants for the most part are safe and can yield disease preventing benefits).

I'm blanking on her name, she's Paul Keck's wife, and one of the top authorities on eating disorders. She gave a presentation and showed the dozens of studies of various meds on various eating disorders. The overwhelming majority when you looked at them as a whole showed no direction with using psychotropics for most eating disorders. While some of them showed some benefits, simply look at a few more and you'll see the same med in another studying when repeated didn't show benefits or even adverse effects and almost all of them had very small sample sizes. E.g. less than 20 in many of them.

So before someone responds back saying there's dozens of studies, yeah there are, and most of them aren't good studies with contradicting results when you look at the other ones likely cause of the small sample sizes. E.g. there's a study showing Ondansetron can reduce binge eating and purging but it only had 29 patients.

Further, while private companies don't have to release their own research data, I'm 99% convinced many of them did do some thorough studying on eating disorders and psychotropic meds such as SSRIs cause this is an untapped goldmine in terms of pharmaceutical treatment. Imagine, having an already existing med so you don't have to research a new one, treating a disorder nothing else treats, and it adding a new indication? I'm sure they've tried...and failed but won't release the failure data.

Topirimate, now there's a real popular medication with the anorexics. It was amazing how many restricting anorexics in my support groups suddenly discovered their new found 'bulimia' when that medication came out and reported side effects included weight loss. But yes I agree with everything here, the research isn't great in support of medication to treat EDs, and I've known far too many people who do end up on a merry go round of different meds (none warranted) in a misguided attempt by Doctors to 'do something'.

And from a patient's point of view I would have to say unless you are prepared to go the therapy route, and unless you are experienced with treating (or at least have a genuine interest in the treatment of) eating disorders, then you do us little in the way of service by taking us on and could end up doing more harm than good as well. I do think we are a specialised population, so unless you have a specialisation in eating disorders, or that's where you're looking to head to, just take a step back and consider all the variables before just accepting eating disorder patients.

 

[Trismegistus4]

But, the point is, in principle, screening people out will not HELP any of this ONE bit. That's my point. Sure, in the real world, perhaps you just don't want to/have the sources to deal, and I'm sympathetic to that argument. But I'm saying as a standard of care, I don't think "screening out" has any clinical utility. It's a purely logistic maneuver.

True, it is a logistic maneuver, but I think it's one that makes sense. I mean, if you want to say that diagnosing and treating ADHD in adults should be within any psychiatrist's skill set, I personally disagree, but I at least think that's a reasonable view to hold. But as @randomdoc1 said, 85% of her new patient referrals were for adult ADHD. In such a setting, when you combine that with the fact that, in my experience so far, a solid majority--I'd estimate 75% of the ones I've seen--do not have a childhood history, if you take all comers, you're basically prevented from doing almost anything else. You're a de facto ADHD specialist. That is just not why I went into psychiatry. Especially when, while a minority of these people who don't meet diagnostic criteria will take no for an answer, however reluctantly, and not come back, enough of them will keep coming back, scheduling follow-ups, trying to wear me down, claiming that nothing else is working and their inability to "focus" is debilitating, to make my life hell. I want to see people with schizophrenia, bipolar disorder, treatment-resistant depression, OCD, and the only way to do that is to tell the stimulant seekers (truthfully, as I've said, I received no training or experience in this in residency, and don't care to obtain any now) "that's just not my area of expertise. Here are the names and phone numbers of some other docs who may be able to help."

 

[dl2dp2]

True, it is a logistic maneuver, but I think it's one that makes sense. I mean, if you want to say that diagnosing and treating ADHD in adults should be within any psychiatrist's skill set, I personally disagree, but I at least think that's a reasonable view to hold. But as @randomdoc1 said, 85% of her new patient referrals were for adult ADHD. In such a setting, when you combine that with the fact that, in my experience so far, a solid majority--I'd estimate 75% of the ones I've seen--do not have a childhood history, if you take all comers, you're basically prevented from doing almost anything else. You're a de facto ADHD specialist. That is just not why I went into psychiatry. Especially when, while a minority of these people who don't meet diagnostic criteria will take no for an answer, however reluctantly, and not come back, enough of them will keep coming back, scheduling follow-ups, trying to wear me down, claiming that nothing else is working and their inability to "focus" is debilitating, to make my life hell. I want to see people with schizophrenia, bipolar disorder, treatment-resistant depression, OCD, and the only way to do that is to tell the stimulant seekers (truthfully, as I've said, I received no training or experience in this in residency, and don't care to obtain any now) "that's just not my area of expertise. Here are the names and phone numbers of some other docs who may be able to help."

Sure, that's a legit argument. I'll buy that.

Still, if you think about it, it's an odd concept and very peculiar in medicine. What you are describing is the right trend, which is that even within what is known as "general psychiatry", due to complexities in care, things started to naturally sub-specialize. It used to be primary care docs would write insulin and manage CHF all the time, but now everyone gets an echo and a cards consult. Theoretically, if you are getting lots of ADHD calls, and you are a general psychiatrist and the "correct" system is in place, you should still be doing the "screening" yourself in person and make a diagnosis, and perhaps then refer to a specialist. In practice, of course, this is impossible because the evaluation itself is lengthy and your time is limited. I'm not sure what's more ideal, you refer the patient out completely assuming that the said ADHD specialist is capable of handling the other "general psychiatry" tasks (hey, what if the patient has ADHD *and* depression, god forbid, like 30-50% of them), vs. you keeping the patient and having the specialist making a definitive diagnosis and send the patient back to you.

It would be kind of like a cardiologist who sets up a practice, and he ends up getting 85% people with repetitive infectious endocarditis due to prevalence of IVDU in the community. I can see how that would be very frustrating. Still, I doubt that this said cardiologist would start to "screen out" these patients at the secretarial level. I can't imagine that...

I don't personally like eating disorders, but on some infrequent basis I do an eval and it is revealed that the patient has a severe eating disorder. I don't "screen out" eating disorder. Similarly, I don't "screen out" peripartum patients, even though I don't feel 100% comfortable treating them. How far do you go with "screening" exactly? To a certain extent, what you call "screening out" is really a general bias against seeing a particular kind of patients, which as an addiction specialist I find troubling: the possibly addicted, vaguely antisocial "difficult" patient. Of course, some of them end up dying in droves of overdose. I'm sympathetic to the dilemma--I get it, for example, it's tough for a female clinician (esp. one with less exposure to this type in training) to handle this type of patients, especially at some volume, but still... The solution is unclear. For example, it's fairly clear to me that this population is wildly heterogenous, and the concerns you have that may be pretty real for some group is not applicable at all to other groups based on some other covariates (i.e. income, family support, education level etc.), so screening out does everyone harm (i.e. you might have found some people who you'd love to work with and you could have made more money, but by "screening" you deny them the care they need and you lose out on having a good case). Keep in mind the effect size for stimulants is some of the biggest in medicine. People who actually have real bad ADHD, a good stimulant could be literally life altering and very quickly too. This is not like giving someone Celexa and wait 12 weeks to see possibly subtle effects...

 

[whopper]

I've considered strategies to somehow screen patients before they can establish a doctor-patient relationship such as only take referrals from other therapists who know not to refer to you for certain things.

And I have received referrals from idiot therapists that were completely inappropriate.

This strategy only works if you have a nice source of people who can refer to you that you trust and they understand what type of patient they should refer.

But you do that your practice will grow at rate of what I'd estimate to be less than 10% of what it otherwise would've been. While psychiatrists tend to fill up much faster vs other fields of medicine, it's not worth the slow rate of growth especially when the amount of people you get that are too severe for your office will be very small. I've had about 50 completely inappropriate patients my first year out of what was around 1000. Is it worth it to slow our practice growth for that small an amount? And out of that about 40 of them were easy inappropirate patients. E.g. the patient came in, already had a GAF in the 60s+ and really just needed a psychotherapist and I referred them to one. Easy. No problem. They thought psychiatry these days was couch therapy cause they watched too much Frasier.

Of what was around the 10 inappropriate patients that weren't easy, wow, I could tell you some stories. Severe intellectual disability patient who got violent in my office (she had a long history of violence, parents lied to me about her history and said she was never violent), person on Clozapine who never reliably got his labs done and then his mother would scream at us for her son's lack of responsibility, woman with borderline PD from a wealthy family tells me her family is being sexist for not letting her take over their extremely successful business all the while having severe borderline sx and not connecting that this is the exact reason, and when I tell her she has emotional dysregulation she responds, "you're my doctor you're supposed to support me no matter what and get my family to give me their business!," alcoholic comes to my office and doesn't want to go sober, he's there cause his wife is making him show up, and he won't do any of the treatment recommendations, and then when he drinks his wife calls us up and screams at us, kid who being enabled by his grandmother (and the kid and the mother lived in the grandmother's home) and allowed to do anything he wanted including playing video games all day long, using mother's credit card, his mother tried to get me to intervene, and after figuring it out after several visits I told her he's not going to get better cause this is all a behavioral reinforcement problem the grandmother is creating and neither he-the patient or she-the grandmother wanted to fix the problem, so I told her and her son to move out, but the mother refuses to move out.....voila checkmate, this situation will not improve and I do not have the means to improve it, I could go on.

As I said before, have the patient themself, not their family or friends arrange the appt, don't directly take from a hospital unless the hospital tells you about the patient's case and you can have a discussion with them, don't let brand new patients come in the same day (or very quickly like the next day) as they arrange an appt unless you're willing to take the risk, but that risk will be low. Those are the only strategies I've figured out so far that won't significantly curb your intake flow.

 

[whopper]

then you do us little in the way of service by taking us on and could end up doing more harm than good as well. I

There's psychiatrists out there who take in patients who have disorders that don't improve with meds and don't tell their patients this then try med after med. Worse, some of them add a med, it doesn't work, then the doc keeps adding more meds. Later on the patient is on a stew of several psychotropic meds, none of which are causing improvement. Then add to that some of these docs tell their patient to continue to take the meds that aren't working even if they're causing significant side effects such as 100 lbs weight gain.

And this is not rare. Unfortunately this has been from my experience quite common.

I have taken some patients and medicated disorders that dont' respond well to meds but upfront told the patient they should get a therapist, try the non-med treatments and what I do will only be adjunctive and not the main treatment. I do this upfront. I don't know why the other docs don't when they damned-well know the meds don't work well. (I actually do know but it's not an appropriate reason).

 

[MedMan80]

I've considered strategies to somehow screen patients before they can establish a doctor-patient relationship such as only take referrals from other therapists who know not to refer to you for certain things.

And I have received referrals from idiot therapists that were completely inappropriate.

This strategy only works if you have a nice source of people who can refer to you that you trust and they understand what type of patient they should refer.

But you do that your practice will grow at rate of what I'd estimate to be less than 10% of what it otherwise would've been. While psychiatrists tend to fill up much faster vs other fields of medicine, it's not worth the slow rate of growth especially when the amount of people you get that are too severe for your office will be very small. I've had about 50 completely inappropriate patients my first year out of what was around 1000. Is it worth it to slow our practice growth for that small an amount? And out of that about 40 of them were easy inappropirate patients. E.g. the patient came in, already had a GAF in the 60s+ and really just needed a psychotherapist and I referred them to one. Easy. No problem. They thought psychiatry these days was couch therapy cause they watched too much Frasier.

Of what was around the 10 inappropriate patients that weren't easy, wow, I could tell you some stories. Severe intellectual disability patient who got violent in my office (she had a long history of violence, parents lied to me about her history and said she was never violent), person on Clozapine who never reliably got his labs done and then his mother would scream at us for her son's lack of responsibility, woman with borderline PD from a wealthy family tells me her family is being sexist for not letting her take over their extremely successful business all the while having severe borderline sx and not connecting that this is the exact reason, and when I tell her she has emotional dysregulation she responds, "you're my doctor you're supposed to support me no matter what and get my family to give me their business!," alcoholic comes to my office and doesn't want to go sober, he's there cause his wife is making him show up, and he won't do any of the treatment recommendations, and then when he drinks his wife calls us up and screams at us, kid who being enabled by his grandmother (and the kid and the mother lived in the grandmother's home) and allowed to do anything he wanted including playing video games all day long, using mother's credit card, his mother tried to get me to intervene, and after figuring it out after several visits I told her he's not going to get better cause this is all a behavioral reinforcement problem the grandmother is creating and neither he-the patient or she-the grandmother wanted to fix the problem, so I told her and her son to move out, but the mother refuses to move out.....voila checkmate, this situation will not improve and I do not have the means to improve it, I could go on.

As I said before, have the patient themself, not their family or friends arrange the appt, don't directly take from a hospital unless the hospital tells you about the patient's case and you can have a discussion with them, don't let brand new patients come in the same day (or very quickly like the next day) as they arrange an appt unless you're willing to take the risk, but that risk will be low. Those are the only strategies I've figured out so far that won't significantly curb your intake flow.

I think child fellowship teaches you how to deal with many of these family systems problems. One must learn how to limit set, calling and bitching won't be tolerated, if you do that you won't get a call back. The patient's family must agree to both the diagnosis and treatment to be successful, they can refuse to either one if they want and that gives you all the more reason to discharge them from your practice with appropriate followup..

 

[MedMan80]

There's psychiatrists out there who take in patients who have disorders that don't improve with meds and don't tell their patients this then try med after med. Worse, some of them add a med, it doesn't work, then the doc keeps adding more meds. Later on the patient is on a stew of several psychotropic meds, none of which are causing improvement. Then add to that some of these docs tell their patient to continue to take the meds that aren't working even if they're causing significant side effects such as 100 lbs weight gain.

And this is not rare. Unfortunately this has been from my experience quite common.

I have taken some patients and medicated disorders that dont' respond well to meds but upfront told the patient they should get a therapist, try the non-med treatments and what I do will only be adjunctive and not the main treatment. I do this upfront. I don't know why the other docs don't when they damned-well know the meds don't work well. (I actually do know but it's not an appropriate reason).

To the last part of your post, "lazy psychiatry"

 

[Indodo]

Navel gazer?

Self meditation or narcissism depending on how you do it and how you perceive it.

 

[PikminOC]

Hmm... I'm not sure what to think of this. I've NEVER EVER felt to be in danger in an outpatient practice setting. And I treat out of control addicts on a daily basis. People who are truly dangerous don't present in this kind of context. I feel much more at risk in the ER/inpatient.



I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

I have had benzo seekers get very mad in the office, and psychotic patients who can get violent. Everyone's tolerance is different. Its just me and one staff member.

 

[PikminOC]

While not at all the point, this is wildly variable from state to state. Some states with independent practice authority for NPs certainly do make them liable for medical malpractice torts.

Liability aside, if your practice pattern resembles a mid-level's, why did you waste so many years of your life in training?

Yes but nurses are still held to nursing standard, not Physician

 

[PikminOC]

To the last part of your post, "lazy psychiatry"

Many Psychiatrists don't do therapy so they refer out

 

[Mass Effect]

All you say would be correct. But in real life this doesn't happen very often: only if the patient says I'm suicidal with a plan on the phone, or says I'm actively in alcohol withdrawal. You refer to ER. Or if you are getting a hospital discharge where it's clear the outpatient plan is not appropriately set up.

On the other hand, in order to get enough clinical information to say confidently that a person needs a higher level of care and determine what that care level would be, it often takes a full evaluation. For example, in substance abuse, the ASAM placement criteria is fairly detailed and has lots of pieces. In public psychiatry it would the same: does the patient have enough negative symptom to require a specialized program? Is it a prodromal case? Does the patient need a state hospital admission? How do you know what to refer to until you have a comprehensive treatment plan designed? The space issue is a non-issue. In private practice, you often need to do an evaluation first before "accepting" the patient into your practice. This is considered standard of care. You would bill every time someone shows up, regardless of whether they would stay.

Think of this another way: if you are any other medical specialist, would you do such screening? No. It's nonsensical. People show up to your outpatient practice for a chief complaint or a referral from PCP, and they might end up with cancer, or lupus, or MS, and might need to be 1) hospitalized 2) get procedures, but this doesn't mean that they get "screened" out from the get go because routine outpatient follow-up is determined, after a work up, to be clinically inappropriate. "Screening people out" is a weird archaic psychoanalytic remnant that's really no longer relevant in modern psychiatric practice.

I'm going to push back on this. There are a lot of patients in psychiatry that you know you can't help (assuming private solo practice) just by reading their file or records from the referring doc. One that was already mentioned is patients with a hx of violence. I don't do too much PP (a one-time consult here or there), but I won't see folks with hx of violence. We had a hospital that was notorious for discharging patients if they were violent (inpatient unit) and they tried to send them to me because they assaulted a nurse. I said no way. If you don't feel the violent behavior is due to an Axis I dx (dx was antisocial personality), you figure out the dispo, but pt isn't coming to me from inpt just because you couldn't handle the outburst.

On that same note, adults with dx of severe ASD with behavioral dysregulation who the child psychiatrist is no longer treating, I'd be hesitant to take given how little PP I do and the services some of these patients need.

Also, I don't feel comfortable treating patients over 75 so when I got a referral for a 93 year old pt who's granddaughter felt she was depressed, I asked the PCP to get her a therapist and refer to a geri-psychiatrist if meds are necessary on the opposite side of town. If the patient couldn't get in to geri, I would have seen her to evaluate.

There are some psychiatrists who won't see pregnant women. Many who won't see EDs. There are also those who prefer to just see women or just see men. Nothing wrong with that. To suggest we all have to see and treat everyone in PP is ridiculous.

 

[Mass Effect]

Hmm... I'm not sure what to think of this. I've NEVER EVER felt to be in danger in an outpatient practice setting. And I treat out of control addicts on a daily basis. People who are truly dangerous don't present in this kind of context. I feel much more at risk in the ER/inpatient.

I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

Your statement that people who are truly dangerous don't present in this context is completely false. There are many cases of outpatient docs being assaulted or killed by patients.

As said above, I don't think people should be shamed for deciding what they want for their private practice. That poster never said he was only going to prescribe some meds, but there are doctors who don't like certain meds or a class of meds.

 

[Mass Effect]

Hmm... I'm not sure what to think of this. I've NEVER EVER felt to be in danger in an outpatient practice setting. And I treat out of control addicts on a daily basis. People who are truly dangerous don't present in this kind of context. I feel much more at risk in the ER/inpatient.

I guess if you don't write stimulants period then there's no point seeing you if someone has ADHD. Which would be a very odd stance to take as a psychiatrist, since this is like at least 20% of general psychiatry, and 50-60% of some subspecialties (child, addiction). Of course you probably also don't do lithium and antipsychotics, and definitely no MAOIs. And you don't deal with suicidal patients, right? Where do we draw the line here in "screening people out"? Are you even a real doctor? I guess plenty of people in our specialty basically went into it so as to avoid practicing actual medicine as much as possible. Hey, whatever works for you if you want to screen people out so you can focus on giving unnecessary SSRIs to the worried well. Don't say I told you so when your job gets taken by mid levels...

Your statement that people who are truly dangerous don't present in this context is completely false. There are many cases of outpatient docs being assaulted or killed by patients.

As said above, I don't think people should be shamed for deciding what they want for their private practice. That poster never said he was only going to prescribe some meds, but there are doctors who don't like certain meds or a class of meds so if a pt is on them, they may decline to take them on.

 

[Mass Effect]

The adult ADHD thing has been discussed extensively on these forums numerous times. My line has been that this is something that didn't exist at all when I was in residency, and I was blindsided by when starting a job in the worried well outpatient world. I suppose you might say that just shows I went to a crappy residency program, but based on what I've gleaned from prior discussions, it's a perfectly reasonable and evidence-consistent opinion that adults do not need stimulants in order to function. If adult ADHD is now 20% of general psychiatry, that in and of itself is evidence that psychiatry is fake medicine--is ADHD a new virus, like HIV? If not, how can something that didn't exist 50 years ago now constitute 20% of the practice? On the contrary, I would much prefer to see suicidal patients and prescribe lithium, antipsychotics, and MAOIs, than spend one more day dealing with the damn worried well and their fake, first world problems of supposedly being unable to function without Adderal or Xanax.

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Whoa hold up. I can't believe no one mentioned this, but where is this evidence you speak of that adults with ADHD don't need stimulants? You're not specifying if you mean "adult onset" so I don't know what you're saying, but if you're saying that kids with legitimate ADHD who grow up to be adults with ADHD don't need stimulants, I'm going to push back. I would really differentiate. There's a difference between ADHD in adults and adult-onset ADHD.

I also think that while you get annoyed at those who don't want to see the seriously mentally ill, you're showing a pretty remarkable level of disrespect to patients who suffer from disorders you're not fond of. And frankly, I find that far more disturbing than the poster you're quoting.

 

[Mass Effect]

This is a complex argument. IMHO if one doesn't do a specific type of treatment that is within the standard of care you are possibly negligent, but just as medicine is highly complex, this isn't black and white.

The LAW does specifically state if that you must offer the patient treatment options and you cannot limit the patient to the only types of treatment you like to give.

E.g. one patient was told to walk as his form of antidepressant treatment. He underwent this treatment for years with little success, even to the point of wearing out shoes within just days cause he walked so much cause he was so desperate to treat his depression.

After undergoing years with no improvement he finally decided to see another doctor who put him on an antidepressant and he got better within weeks. He sued his first psychiatrist for never offering this treatment which was then within the standard of care, and won, with the court finding it ridiculous that the first psychiatrist never offered him this option to begin with especially since it was within the standard an

This is disingenuous and I'm pretty sure you know that since you were very careful with your language while still intentionally giving the impression that people could be in trouble legally for not doing whatever the patient requires. It's false. You need to refer to someone who does, but you're not negligent for not doing it yourself.

 

[Stagg737]

The LAW does specifically state if that you must offer the patient treatment options and you cannot limit the patient to the only types of treatment you like to give.

This is assuming you've established a relationship with the patient, correct? If I'm seeing someone for an outpatient consult and the situation isn't urgent/emergent you wouldn't have to provide the treatment, would you? Especially if you explain that it's an option but that you won't do it and they need to seek care elsewhere if they want it. Guess the real question is "Can you abandon a patient that you're only seeing as a one-time consult?"

 

[Sushirolls]

Nope.