Early practice update, 6 mos out

[meow1985]

I am now 6+ mos into my first attending job, and a few things have improved, but I'm seriously thinking of getting a different job. In fact, after a particularly frustrating week I applied for some jobs and lo and behold, I am now sitting on an offer.

What's better:
I am no longer freaking out so much about bad things happening.
I weirdly regressed in confidence when I graduated from residency, but I'm getting some of it back. Functionally, I am no longer changing my mind about treatment plan all the time or calling patients because "I've thought more about the situation/done some further reading/chart review and I think..." No, it can wait until an appointment.
I am calling social workers, caregivers, legal people, collateral, and other MD's as little as I possibly can, and I'm learning to be ok with that.
I've gotten better at I've automated a lot of processes, including dot phrases. I know the system a bit better and how know to make things happen with less effort.

What's not so good:
Notes
I can't write a note in less time than 15 minutes to save my life, and completing notes before I walk out the door at the end of day is still way beyond me. This is with typing the subjective section in the visit, more carry-forward functions, and dictation. I've recently analyzed where the time goes while writing notes and a lot of it is:

--updating a running past psychiatric history that keeps getting carried forward, including med trials, higher level of care episodes, important studies, etc.
--in connection with the above, scrolling through the chart because what happened in the ER visit again and what exactly did the imaging show and what was the QTC or thyroid value so I can put it in my note since the template never pulls things in right
--updating a running case formulation in the beginning of the assessment
--with the new billing changes - checking which diagnoses we actually addressed this visit and which we didn't
--having emotions about my patients
--looking up papers etc to answer questions I may have on the case
--second-guessing my decisions (see above, getting better)
--going down rabbit holes in connection with the above

Patient population
I am getting lots of secondary trauma from listening to my patients, simply because of the kind of community my practice serves.
There is lots of chemical dependency and dual diagnosis, and I am realizing that this is not the population for me. Not without the right resources, anyway. More on that later.
I'm starting to realize I've always wanted to want to be someone who serves the underserved, but I don't think I am nor ever will be.
Lots of bio-psycho-socially complex cases, self-referrals for strange reasons, PCP's passing the buck when they are "no longer comfortable" managing someone's controlled substances, when in fact that person probably shouldn't even *be* on a controlled substance.

The system
Some of this has been contributed to by the pandemic and some recent institution-specific issues.
Triage of intakes is minimal, if any.
Things as basic as getting through to the front desk and a reliable mail system are fraught
MA's doing RN work. Not enough support staff, period. This results in me doing my own triage and care coordination whenever I can. I am also constantly fearful that something will fall through the cracks and end poorly.
Staff turnover among docs and support staff. In the last few months, 3 docs have left. One of them is the local... liberal prescriber.
No care coordinator or social worker in house.
My coverage partner hardly does anything when I'm gone.

The only way to survive in said job, I've realized, is to stop caring and do less, or get a different job. Not caring and doing less has never been my strong suit. I kind of hate to do it when I've only been there for 6 mos and they've lost 3 other docs. I also realize there will be tough patients everywhere, and my note-writing woes and do-too-much tendencies will not go away without some really hard work on myself.

Thoughts on how to address my documentation further? Stories on switching jobs after a short period of time?

---

Members don't see this ad.

 

[AD04]

Do you have 1 hour for new patients and 30 minutes for follow ups? If not, negotiate for more time as the fore-mentioned time is standard. They lost 3 doctors and you have a job offer so your negotiating position is stronger. If you still have trouble finishing your notes with the standard time, you will have to be more efficient with notes. My notes are templates and I rarely type out full sentences for HPI and MSE. I don't think too much about assessment as it should be the same as last visit. I do flesh out my plan as that is good for patient care and for CYA and for billing.

To function well in your position, you have to get used to saying no to patients. When I first started my current position, I almost cursed out the previous psychiatrist as I inherited so many patients on high doses / multiple controlled substances. But I tapered them down and almost all of my patients are on minimal controlled substances. If your patients have continuity of care, it will get easier and the difficult work you do in the beginning will pay off.

I knew I wanted out of my first gig after 3 months. I tried to learn as much as I could before I left. It took another 8 months to transition to my second gig. I wouldn't be as successful as I am now if I didn't have the knowledge from the first gig. If you want to switch, go ahead. Make sure you apply what you've learned and grow from there.

 

[meow1985]

Do you have 1 hour for new patients and 30 minutes for follow ups? If not, negotiate for more time as the fore-mentioned time is standard. They lost 3 doctors and you have a job offer so your negotiating position is stronger. If you still have trouble finishing your notes with the standard time, you will have to be more efficient with notes. My notes are templates and I rarely type out full sentences for HPI and MSE. I don't think too much about assessment as it should be the same as last visit. I do flesh out my plan as that is good for patient care and for CYA and for billing.

To function well in your position, you have to get used to saying no to patients. When I first started my current position, I almost cursed out the previous psychiatrist as I inherited so many patients on high doses / multiple controlled substances. But I tapered them down and almost all of my patients are on minimal controlled substances. If your patients have continuity of care, it will get easier and the difficult work you do in the beginning will pay off.

I knew I wanted out of my first gig after 3 months. I tried to learn as much as I could before I left. It took another 8 months to transition to my second gig. I wouldn't be as successful as I am now if I didn't have the knowledge from the first gig. If you want to switch, go ahead. Make sure you apply what you've learned and grow from there.

I do have that amount of time for intakes and follow ups. Truthfully, what I need is an RN I can trust who is experienced and works with just me and at most one other doc, a care coordinator/social worker for the department, and a general infrastructure that works. I think I can get that at the other place that gave me an offer because I specifically asked about all those things.

Setting limits is indeed hard for me. I know this is a risk for giving out too many meds and too many controlled substances, so I actively work to remain a conservative prescriber and tell patients that up front. When it comes to other stuff, like, *no* I will not be your therapist or your social worker because I don't have thet time - those lines can easily get more blurred. I can set those limits, but it's stepping on myself every time.

 

[Sushirolls]

The only way to survive in said job, I've realized, is to stop caring and do less, or get a different job.

LOL, this lessen didn't take long.

Not caring and doing less has never been my strong suit. I kind of hate to do it when I've only been there for 6 mos and they've lost 3 other docs.

If you still have a well of caring to draw upon, your best respite will likely be your own private practice. Big Box shops have a way to suck the care out of you.

As far as documenting, good luck. Some people hone it down to a fine blade. I'm still an over documenter.

If the job is bad and you want to move on, move on. Don't delay.

 

[meow1985]

LOL, this lessen didn't take long.

If you still have a well of caring to draw upon, your best respite will likely be your own private practice. Big Box shops have a way to suck the care out of you.

As far as documenting, good luck. Some people hone it down to a fine blade. I'm still an over documenter.

If the job is bad and you want to move on, move on. Don't delay.

I know this forum is a big proponent of private practices, so I have a question. I am finding I need either more time to do care coordination and triage, or someone else who can reliably do it. In private practice, I'd either have to hire support staff or act as my own support staff. How feasible is it to do either and still make decent money?

 

[splik]

I know this forum is a big proponent of private practices, so I have a question. I am finding I need either more time to do care coordination and triage, or someone else who can reliably do it. In private practice, I'd either have to hire support staff or act as my own support staff. How feasible is it to do either and still make decent money?

Solo private practices by their nature have to screen for patients who do not need these kinds of case management services. You have to be up front about what you can and cannot provide. Patients will need to privately obtain such services out of pocket or through their PCP or community clinic. There are lots of patients who don't need those kinds of services and that would be ideal (e.g. many patient with depression, bipolar, PTSD, anxiety disorders, ADHD). It is also not uncommon for private practice psychiatrists to require patients (other than stable patients) to be in therapy either with themselves or a different therapist. It makes a huge difference if they are being seen regularly by someone.

 

[WisNeuro]

Private practice or not, your note/documentation time will still hinder your hourly net income. If the time spent on this is still onerous after you've settled in, I would consider seeking someone out to consult with, even if it is paid. The name of the game is cutting down the time spent on non-reimbursed work and maximizing the reimbursed part. Fixing that now will pay dividends for the rest of your career.

 

[Merovinge]

Private practice or not, your note/documentation time will still hinder your hourly net income. If the time spent on this is still onerous after you've settled in, I would consider seeking someone out to consult with, even if it is paid. The name of the game is cutting down the time spent on non-reimbursed work and maximizing the reimbursed part. Fixing that now will pay dividends for the rest of your career.

I think for this OP it's actually beyond just reimbursement. The time spent documenting and worrying about each case is clearly going to lead to quick burnout and make being a practicing clinical psychiatrist an unstainable path. Definitely would find it reasonable to work with a mentor or consultant to help out in this arena.

 

[robellis]

Therapy

 

[dl2dp2]

I know this forum is a big proponent of private practices, so I have a question. I am finding I need either more time to do care coordination and triage, or someone else who can reliably do it. In private practice, I'd either have to hire support staff or act as my own support staff. How feasible is it to do either and still make decent money?

I'm confused about your concerns. Imagine that you do the work that involves your "support staff" (i.e. family meetings, etc), but you bill $300 per hour of any patient/family interaction, and bill 99213+90833 per half hour unit of management ($150), and document accordingly. Which part of this is not clear? If you have more difficult patients, just arrange to see them more often and do "care coordination" while they are in the office.

The only part that's difficult, to me, is that the $300 per hour $150 per 99213+90833 number can vary, and to increase it as high as you can is an art not a science. However, personally I think people like you (i.e. "not good about not caring or working less") tend to be a good fit for private practice because it allows you to deliver the highest quality of care and get paid well for it. I'm almost certain that $150 per 99213+90833 can be sustained quickly anywhere in the US.

 

[Stagg737]

--updating a running past psychiatric history that keeps getting carried forward, including med trials, higher level of care episodes, important studies, etc.
--in connection with the above, scrolling through the chart because what happened in the ER visit again and what exactly did the imaging show and what was the QTC or thyroid value so I can put it in my note since the template never pulls things in right
--updating a running case formulation in the beginning of the assessment

Sounds like you're over-documenting. It's good to be thorough and update things, but it really sounds like your notes would be somewhat cumbersome to read. I'm still pretty inexperienced, but covering other residents has given me a good idea of what I actually care about versus what is just fluff or needs to be there for billing.

Think about other notes you've read in the past. What was missing that you wanted to know? What was there that you didn't care about? If it was there and you didn't care, was it needed for billing? If not then don't worry about it. If nothing else PGY-3 has helped me become much more efficient in my note-writing and how to cut out the irrelevant (or less relevant) fluff.

I weirdly regressed in confidence when I graduated from residency, but I'm getting some of it back. Functionally, I am no longer changing my mind about treatment plan all the time or calling patients because "I've thought more about the situation/done some further reading/chart review and I think..." No, it can wait until an appointment.


--having emotions about my patients
--going down rabbit holes in connection with the above
I am getting lots of secondary trauma from listening to my patients, simply because of the kind of community my practice serves.

The first part seems like a natural part of not having the safety net of supervising attendings there. I'm guessing that will get better with time. The later 3 things sound like great topics to discuss with a therapist of your own.

The system
Some of this has been contributed to by the pandemic and some recent institution-specific issues.
Triage of intakes is minimal, if any.
Things as basic as getting through to the front desk and a reliable mail system are fraught
MA's doing RN work. Not enough support staff, period. This results in me doing my own triage and care coordination whenever I can. I am also constantly fearful that something will fall through the cracks and end poorly.
Staff turnover among docs and support staff. In the last few months, 3 docs have left. One of them is the local... liberal prescriber.
No care coordinator or social worker in house.
My coverage partner hardly does anything when I'm gone.

This sounds pretty bad. It sucks enough being alone on an island in general. In a CMHC setting with high-acuity patients it sounds unsustainable, especially for someone prioritizing standard of care or someone who is emotionally invested.

There is lots of chemical dependency and dual diagnosis, and I am realizing that this is not the population for me. Not without the right resources, anyway. More on that later.
I'm starting to realize I've always wanted to want to be someone who serves the underserved, but I don't think I am nor ever will be.

This sounds like the most insightful thing you've said. Don't beat yourself up about not being able to treat this population. There are plenty of people in all populations who need care, and burning yourself out or providing care you believe to be substandard (even if due to the system and not your fault) isn't good for anyone. I'd move on if I were in your position, I say this to patients all the time but you can't take care of others if you aren't taking care of yourself first.

 

[nrmp]

Is your over documentation likely due to fear of getting law suit? If your documentation is very short and 2 liner what the worse thing you think will happen? I wonder people who are doing SOAP notes, how detailed are your plans? Do you guys document risk-assessment for all patients? I agree with Staggs comment on there are sections which are mostly irrelevant or for billing purpose only and could get rid off so you don't have keep updating every visit. You could also do psych re-eval once a year when you could actually update all those sections and bill as 90792.

 

[nexus73]

What do you think about an inpatient job where you don't have to worry about the patient between appointments. You see them in the hospital for an episode of care, and then discharge to the community. The risk there is what happens between discharge and outpatient followup, but at least when they're admitted you have maximum control of risk.

 

[FlowRate]

These are just suggestions, in case you might find it helpful to hear how other people document.

--updating a running past psychiatric history that keeps getting carried forward, including med trials, higher level of care episodes, important studies, etc.

This can be done very efficiently. I'm guessing you go into way too much detail. Meds tried, highest dose, adverse reactions. Number of hospitalizations, date of most recent one.

--in connection with the above, scrolling through the chart because what happened in the ER visit again and what exactly did the imaging show and what was the QTC or thyroid value so I can put it in my note since the template never pulls things in right

Summarize as TSH normal, high, or low. Summarize as ECG nonconcerning or QTC elevated.

--updating a running case formulation in the beginning of the assessment

I only write a proper formulation when I think it will really matter for other people who will see my note in the future. It only gets updated if there's a major change.

--with the new billing changes - checking which diagnoses we actually addressed this visit and which we didn't

You addressed all of the psychiatric diagnoses.

I am getting lots of secondary trauma from listening to my patients, simply because of the kind of community my practice serves.

I don't know if you do this already, but my trauma screening questions start with "we don't have to talk about specifics or details." Some people actually find it containing if you interrupt to keep them from spilling everything.

If you still have a well of caring to draw upon, your best respite will likely be your own private practice. Big Box shops have a way to suck the care out of you.

Honestly I don't see how starting a PP makes most of what meow was talking about any easier. The lack of good support staff and colleagues is specific to that job but not to being employed generally.

 

[robellis]

These are just suggestions, in case you might find it helpful to hear how other people document.

This can be done very efficiently. I'm guessing you go into way too much detail. Meds tried, highest dose, adverse reactions. Number of hospitalizations, date of most recent one.

Summarize as TSH normal, high, or low. Summarize as ECG nonconcerning or QTC elevated.

I only write a proper formulation when I think it will really matter for other people who will see my note in the future. It only gets updated if there's a major change.

You addressed all of the psychiatric diagnoses.

I don't know if you do this already, but my trauma screening questions start with "we don't have to talk about specifics or details." Some people actually find it containing if you interrupt to keep them from spilling everything.

Honestly I don't see how starting a PP makes most of what meow was talking about any easier. The lack of good support staff and colleagues is specific to that job but not to being employed generally.

What you suggested is even over documenting around these parts haha

 

[FlowRate]

What you suggested is even over documenting around these parts haha

Interesting, so you don't include med history or hospitalizations etc?

 

[Stagg737]

Interesting, so you don't include med history or hospitalizations etc?

I don't do this in every note, only if something happened between the last appointment or if I know the patient is moving/someone else will need the records I'll be more detailed. I'll also add meds tried if I'm doing something really off-label or trying to get something insurance won't want to pay for to show what hasn't worked as justification. I don't mind when other docs do it, but not something I do regularly.

 

[FlowRate]

I don't do this in every note, only if something happened between the last appointment or if I know the patient is moving/someone else will need the records I'll be more detailed. I'll also add meds tried if I'm doing something really off-label or trying to get something insurance won't want to pay for to show what hasn't worked as justification. I don't mind when other docs do it, but not something I do regularly.

The hospitalizations thing is just in the initial note. Past med trials is part of the required elements of our notes at this place because it makes coverage and transfers easy and I've also found it really helpful because otherwise I'd be constantly looking that info up anyway when I need to make a med change. It just pulls forward from the last note so not like I have to retype it every time.

 

[Monocles]

There is lots of chemical dependency and dual diagnosis, and I am realizing that this is not the population for me. Not without the right resources, anyway. More on that later.
I'm starting to realize I've always wanted to want to be someone who serves the underserved, but I don't think I am nor ever will be.

OP why not try the other end of the socioeconomic spectrum now and do cash only? You might find yourself with more affinity for the wealthy professional class.

 

[Attending1985]

Working with that population is so tough. Only possible with excellent community and therapeutic supports. Most people don’t necessarily need medications but you’re expected to “help” them.

 

[hallowmann]

Interesting, so you don't include med history or hospitalizations etc?

That stuff all gets copy-forwarded honestly. I only update it if it changes, and it often doesn't. I work hard on the intake or my first follow-up (i.e. spend extra time on it) so that I minimize what I have to do in the future.