Does this kind of job exist?

[Desired Member]

Does this job exist
-working mostly with patients who have schizophrenia, schizoaffective, bipolar 1, and/or OCD. May sound selfish/awful, but these are disorders I'm interested in and everything else I find exhausting
-working with patients in a secure living environment
- seeing about 5-10 patients per day and working about 3 days per week

Money not very important, I would work for as little as 90,000$ per year. I don't care much about money.

I feel so burned out in residency. I'm tired of seeing patients with personality disorders and horrible life circumstances where no permutation of medication makes them feel better. It's like a charade.

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[hallowmann]

Criterion 1 and 2 seem very incompatible together in the US without it being some type of facility. In many jobs you can work as little as you want provided you are willing to forgo benefits.

If you're willing to be flexible with #2, you could easily find a job with CMHC or ACT group where you only work 3 days a week and see 10 pts a day.

 

[PikminOC]

Working with ngri patients like Mendota

 

[hebel]

Yeah, look for a part time state/county gig.

 

[dl2dp2]

State hospital. DUH.

 

[Stagg737]

Yeah, look for a part time state/county gig.

Was going to say the first two criteria sound a bit like a forensics unit. Thought the 3rd part seems incompatible unless you just work part-time.

 

[Merovinge]

ACT team or state mental health hospital would be my recommendations depending on if you prefer OP or IP. SMI only can definitely be done and luckily for you it usually pays poorly and that won't bother you too much.

 

[sloop]

Working with ngri patients like Mendota

State hospital. DUH.

I mean, these patients usually don’t have a “secure living environment” outside the hospital. It turns out that your level of social support rapidly diminishes after you rape or kill a family member, set fire to a building, or do something similar.

The hospital is not these patients’ home. If you’re working with these types of patients, your goal should be to figure out a way to transition them back into the community. There are some people for whom that’s not possible, but it is still the goal. To that end, working with state hospital patients committed following an insanity adjudication is going to wind up involving a lot of social interventions like trying to establish housing for people who many facilities will reject due to their charges.

 

[PikminOC]

I mean, these patients usually don’t have a “secure living environment” outside the hospital. It turns out that your level of social support rapidly diminishes after you rape or kill a family member, set fire to a building, or do something similar.

The hospital is not these patients’ home. If you’re working with these types of patients, your goal should be to figure out a way to transition them back into the community. There are some people for whom that’s not possible, but it is still the goal. To that end, working with state hospital patients committed following an insanity adjudication is going to wind up involving a lot of social interventions like trying to establish housing for people who many facilities will reject due to their charges.

Yes Ive worked at one. The social workers take care of the housing needs etc

 

[sloop]

Yes Ive worked at one. The social workers take care of the housing needs etc

Yeah, that’s true. Also, you could presumably work on a high security unit where most of the patients are like years away from potentially being presented for release.

I was just pointing out that we don’t really know what OP was concerned about when he was talking about a “secure living environment.” When he mentioned that alongside his preference for a part time, three days per week job, I guess I kind of imagined an outpatient practice where the patients are not at risk of homelessness and have good social supports, which is obviously different from a state hospital. If what he really meant was “I don’t personally have to worry about fixing issues with their their living situation,” then you’re right that a state hospital could qualify.

I also think his criterion for “working with patients in a secure living environment” is a bit ambiguous. I didn’t necessarily interpret it this way, but I can also see how that might be construed as “I want to work in a hospital or locked unit” rather than “I want my patients to be at low risk of homelessness.” In which case, I would also say that a state hospital job would make a lot more sense, provided you can find one that is part-time.

 

[FlowRate]

One of my attendings in residency specialized in MIPSP (mentally ill w/ problematic sexual behavior). He has a pretty slow day clinic at the CMHC from what I could tell. At lot of patients fully integrated into CMHC systems in well resourced cities will probably have housing but the nature of their SMI usually leads to that remaining unstable (letting random homeless people stay in their apartment, messing up apartment due to decompensated paranoia, not sticking with various programs quite long enough to get the secured housing arrangement.) It's probably the folks in group homes who have the best mix of social supports and housing stability. I don't know if there are jobs that would select for that population exclusively but it would be a reasonable amount of CMHC pts again in a well-resourced city.

 

[comp1]

Yes, these positions should be available. Corrections is one option, particularly state mental hospitals which deal with civil in addition to criminal long term commitments. You'd make a lot more than $90k if you could put up with a touch of antisocial. Outside of that, I only know California, but you'd be looking to work for/at a Crestwood type facility here, also known as an Institute of Mental Disorders which are where conserved patients live long term (with the theoretical goal of recovery). You see patients about once a month and they are generally large facilities so your rough ideas on patient care definitely could work. These are not popular jobs as recovery often remains theoretical when a person has progressed so far as to need conservatorship.

 

[Desired Member]

Thanks everyone for the responses.
When I said "secure living environment" I meant that the person has some stable living place with social support.
I really don't want to do a forensic fellowship nor do I want to be directly involved with the legal system. Can a psychiatrist work in a state hospital without having to testify in court , write affidavits, etc?
Does CMHC mean that the person lives in a long-term facility?

I'm so exhausted from seeing people with borderline traits/BPD, abysmal social situations where pretty much anybody would be depressed, and/or substance use disorders. Medications don't help and they need interventions which I'm not equipped to provide as a psychiatrist. I constantly get patients who really need a DBT program and/or rehab. But they can't access these because of transportation issues, motivation issues, very long waitlists, financial constraints, etc.
I would work inpatient as I find mania/psychosis fascinating, but there is also an extremely high level of borderlines and malingerers admitted to psych units which are 2 groups I never want to work with again! I suppose I'm looking for a way to only see patients with the diseases that I'm interested in which is probably not possible.

 

[FlowRate]

I really don't want to do a forensic fellowship nor do I want to be directly involved with the legal system. Can a psychiatrist work in a state hospital without having to testify in court , write affidavits, etc?

Pretty much any inpatient work requires testifying in court and/or writing physicians reports for legal/bureaucratic documents.

Does CMHC mean that the person lives in a long-term facility?

Community mental health center = usually state funded mental health facility (usually outpatient +- IOP/PHP, historically some also have their own inpatient units) taking care of pts with severe mental illness. It's actually a way of getting patients more wraparound outpatient services than what might be typical through specialty groups or hospital systems. Often associated with ACT teams and more social work / case management support.

 

[soporific]

there are some private-pay ACT teams, which might fit what you're looking for

 

[Orgone]

Thanks everyone for the responses.
When I said "secure living environment" I meant that the person has some stable living place with social support.
I really don't want to do a forensic fellowship nor do I want to be directly involved with the legal system. Can a psychiatrist work in a state hospital without having to testify in court , write affidavits, etc?
Does CMHC mean that the person lives in a long-term facility?

I'm so exhausted from seeing people with borderline traits/BPD, abysmal social situations where pretty much anybody would be depressed, and/or substance use disorders. Medications don't help and they need interventions which I'm not equipped to provide as a psychiatrist. I constantly get patients who really need a DBT program and/or rehab. But they can't access these because of transportation issues, motivation issues, very long waitlists, financial constraints, etc.
I would work inpatient as I find mania/psychosis fascinating, but there is also an extremely high level of borderlines and malingerers admitted to psych units which are 2 groups I never want to work with again! I suppose I'm looking for a way to only see patients with the diseases that I'm interested in which is probably not possible.

I have great news for you. Your current reality, as expressed in bold, is not the reality for all of psychiatry. Or even most of psychiatry. Residency clinics tend to collect and hold on to a disproportionately high percentage of these types of patients. They are not reflective of all community mental health centers, and certainly not reflective of a private practice whether taking cash-pay or "good" insurance. I remember moonlighting as a 4th year resident in a private clinic, and experiencing the shock of seeing actual results from medication intervention, the shock because I was so used to only having patients with the untreatable cluster of problems you describe. And a good, well-organized CMHC will have the types of interventions you are missing.

That's not to say that you will ever be able to completely avoid patients with BPD, substance use, or "shi*ty life syndrome". But after your training you will have many options, inpatient and outpatient, to minimize the type of caseload that has you feeling exhausted.

 

[uname943]

Thanks everyone for the responses.
When I said "secure living environment" I meant that the person has some stable living place with social support.
I really don't want to do a forensic fellowship nor do I want to be directly involved with the legal system. Can a psychiatrist work in a state hospital without having to testify in court , write affidavits, etc?
Does CMHC mean that the person lives in a long-term facility?

I'm so exhausted from seeing people with borderline traits/BPD, abysmal social situations where pretty much anybody would be depressed, and/or substance use disorders. Medications don't help and they need interventions which I'm not equipped to provide as a psychiatrist. I constantly get patients who really need a DBT program and/or rehab. But they can't access these because of transportation issues, motivation issues, very long waitlists, financial constraints, etc.
I would work inpatient as I find mania/psychosis fascinating, but there is also an extremely high level of borderlines and malingerers admitted to psych units which are 2 groups I never want to work with again! I suppose I'm looking for a way to only see patients with the diseases that I'm interested in which is probably not possible.

-Board and cares.
-Dementia care? Stable housing. Usually little substance use or personality disorder.

 

[splik]

you probably cannot avoid these pts altogether but you can find something where you can make things work for you. For example working in an early psychosis clinic. There are still a bunch of emerging personality disorders that get dx as psychosis but it is probably more what you are looking for.

You could also start a private practice focusing on specific disorders. Most private practitioners focus on depression, anxiety, ADHD etc but there are certainly pts with bipolar I, schizophrenia and other psychotic disorders who are private pay and functional enough not to need case management services. I have also seen pts in the past who receive case management services from the CMHC and saw me for their psychiatric care. The CMHCs are usually very happy with that set up. Some more affluent patients have families who pay privately for case management and other supportive services too. There are some cool programs that focus on the kind of pts you want (e.g. Residential Treatment for Schizophrenia - Comprehensive Treatment & Care) however these jobs are not easy to come by.

I am the opposite of you. i see lots of pts with personality pathology and love working with them. Different people are interested and effective working with different patients. Additionally, your program may not have prepared you to effectively work with and treat these patients. Finally, as mentioned above, residency clinics are full of train wreck patients. In the real world you will see patients who get better and very appreciative of your care. I don't see patients with anxiety or ADHD and don't deal with much bipolar or schizophrenia either. I focus on providing my niche services. If there is a need for what you want to do, then it's not being selfish to focus on that.

 

[clozareal]

Another option is to work part time in an academic center or community program that has an OCD or psychosis specialty clinic. You'll only get those patients and can refer all the other ones out. I would be wary about a bipolar clinic because it'll be filled with borderline personality disorder (whether co-morbid or self-/misdiagnosed as bipolar).

 

[thepoopologist]

I'm in personality disorder land, a psychosis specialty clinic sounds great

 

[Desired Member]

you probably cannot avoid these pts altogether but you can find something where you can make things work for you. For example working in an early psychosis clinic. There are still a bunch of emerging personality disorders that get dx as psychosis but it is probably more what you are looking for.

You could also start a private practice focusing on specific disorders. Most private practitioners focus on depression, anxiety, ADHD etc but there are certainly pts with bipolar I, schizophrenia and other psychotic disorders who are private pay and functional enough not to need case management services. I have also seen pts in the past who receive case management services from the CMHC and saw me for their psychiatric care. The CMHCs are usually very happy with that set up. Some more affluent patients have families who pay privately for case management and other supportive services too. There are some cool programs that focus on the kind of pts you want (e.g. Residential Treatment for Schizophrenia - Comprehensive Treatment & Care) however these jobs are not easy to come by.

I am the opposite of you. i see lots of pts with personality pathology and love working with them. Different people are interested and effective working with different patients. Additionally, your program may not have prepared you to effectively work with and treat these patients. Finally, as mentioned above, residency clinics are full of train wreck patients. In the real world you will see patients who get better and very appreciative of your care. I don't see patients with anxiety or ADHD and don't deal with much bipolar or schizophrenia either. I focus on providing my niche services. If there is a need for what you want to do, then it's not being selfish to focus on that.

Thanks for your response. You're right, my program doesn't teach me how to treat patients with personality disorders. I only know how to prescribe medication. I would love to work at a clinic or residential treatment center focusing on psychotic disorders.

 

[clozareal]

Thanks for your response. You're right, my program doesn't teach me how to treat patients with personality disorders. I only know how to prescribe medication. I would love to work at a clinic or residential treatment center focusing on psychotic disorders.

If you're not getting it from your program, it would behoove you to seek this elsewhere. Here's a free trainee conference directed toward treatment of patients like these that's going on next month.

Login | Austen Riggs Online Education

education.austenriggs.org

 

[Desired Member]

If you're not getting it from your program, it would behoove you to seek this elsewhere. Here's a free trainee conference directed toward treatment of patients like these that's going on next month.

Login | Austen Riggs Online Education

education.austenriggs.org

Thank you I signed up.

 

[DOBound2019]

If you're not getting it from your program, it would behoove you to seek this elsewhere. Here's a free trainee conference directed toward treatment of patients like these that's going on next month.

Login | Austen Riggs Online Education

education.austenriggs.org

I attended the first one they did in case anyone was wondering it’s an excellent conference. I learned a lot from it.

 

[Stagg737]

Thanks for your response. You're right, my program doesn't teach me how to treat patients with personality disorders. I only know how to prescribe medication. I would love to work at a clinic or residential treatment center focusing on psychotic disorders.

Can you clarify this? I honestly don't understand what you mean by they didn't teach you to treat patients with PDs. How is this possible?

 

[splik]

Can you clarify this? I honestly don't understand what you mean by they didn't teach you to treat patients with PDs. How is this possible?

This is the majority of psych residency programs!!

 

[Stagg737]

Not the person you were talking to but in my residency they don't teach us anything really. Supervision is minimal, feedback is minimal, and didactics are just a rehashing of DSM criteria. It does not surprise my at all that there's programs that don't teach how to treat pt's with PDs, I feel like my program doesn't teach me anything. I have to look for anything I want to learn. This is at an "academic" program too

This is the majority of psych residency programs!!

I honestly cannot imagine a program like this. I can see didactics and supervision being mediocre, but not teaching how to address personality disorders at all? It baffles me that decent programs would not be directly educating and teaching about such pervasive and problematic conditions...

 

[splik]

I honestly cannot imagine a program like this. I can see didactics and supervision being mediocre, but not teaching how to address personality disorders at all? It baffles me that decent programs would not be directly educating and teaching about such pervasive and problematic conditions...

decent programs DO but most programs are not up to scratch. The ACGME is fairly bad at enforcing its own program requirements.

 

[clozareal]

I honestly cannot imagine a program like this. I can see didactics and supervision being mediocre, but not teaching how to address personality disorders at all? It baffles me that decent programs would not be directly educating and teaching about such pervasive and problematic conditions...

Personality disorder treatment education in residency programs:

• BPD? Refer to DBT.
• Antisocial?Jail
• Every other personality disorder? Send to therapist.

 

[Stagg737]

Personality disorder treatment education in residency programs:

• BPD? Refer to DBT.
• Antisocial?Jail
• Every other personality disorder? Send to therapist.

I mean, what else is there? Lol

 

[michaelrack]

I mean, what else is there? Lol

I have seen xanax used quite frequently

 

[hallowmann]

I have seen xanax used quite frequently

And Adderall for when they feel down or tired.

This reminds me of a young patient I saw recently come in on a moodstabilizer, SRI, SGA, NDRI, high doses of long acting and immediate release stimulant and large amounts of gabapentin carrying reported diagnoses of anxiety, bipolar 1, and ADHD all diagnosed in the last few years.

 

[Stagg737]

And Adderall for when they feel down or tired.

This reminds me of a young patient I saw recently come in on a moodstabilizer, SRI, SGA, NDRI, high doses of long acting and immediate release stimulant and large amounts of gabapentin carrying reported diagnoses of anxiety, bipolar 1, and ADHD all diagnosed in the last few years.

So when was the benzo discontinued?

 

[Attending1985]

I attended the first one they did in case anyone was wondering it’s an excellent conference. I learned a lot from it.

I wish I could go

 

[Desired Member]

Can you clarify this? I honestly don't understand what you mean by they didn't teach you to treat patients with PDs. How is this possible?

I have prescribed lamictal off-label for BPD but I know there is little evidence for this. I was taught that DBT is gold standard treatment for BPD, and if you can't get them into DBT then another therapy modality will have to suffice. I have not been trained to do DBT. I have 3 therapy patients but try to teach myself how to do therapy via listening to YouTube videos on my way to work.
There seems to be BPD everywhere. Rarely I come across ASPD or NPD patient, and from what I've read they are typically resistant to any type of therapy or medication.