Early practice update

[meow1985]

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Hello all, update post.

I think I have simultaneously the cushiest and most stressful outpatient job in the city. I have 30 minute appointments and 90 minute intakes, 35 hours a week and no call, and I think I'm making more than anyone else does for comparable work in this geographic area.

That said, a good chunk is hazard pay.

In my short tenure so far, I've referred multiple people to the ER for both psych and non-psych reasons, seen a death and a suicide attempt, generated police welfare checks and adult protective services reports, and have been involved in guardianship proceedings.

I have no issue, as I feared, of telling people on inappropriate regimens that things need to change. Usually, people either work with me or go elsewhere. If there's one good thing about no longer being a resident, is that I've lost my fear of being fired... By patients, anyway.

I document super-defensively still, but am gradually cutting down on documentation time.

What I have an issue with is the large swath of patients who are unreliable narrators, have SMI, and/or are in institutions. I am constantly questioning whether they have capacity to make this or that decision, whether they need a higher level of community support and if so which one, if they are being abused, and where the truth really lies. I do way too much case management that I am not equipped to do because at the moment the clinic doesn't have anyone to do that job. Sometimes the entire care team is my patient. I worry I'll do too much or too little. Legal and neuropsych are my new best friends.

I live in fear of doing something wrong due to either lack of clinical knowledge, missing something on info-gathering, or simply wanting to do something well-meaning and it blowing up in my face. I lose sleep over fears of board and administrative action. Sometimes I wonder if I should quit and find myself a more worried well population, but I'm not sure it's a good idea to go searching for a new job right now.

Question for the audience. Some of my practice partners say they don't get involved much outside of appointments in patient issues. And I just don't understand.... how? They have the same patient population. How do you not become a reluctant case manager as a psychiatrist? This is starting to feel unsustainable. I am at work 2 hours past closing time every day, and then I come home and crunch notes for 3-5 more hours. I can't live my whole life like that.

 

[AD04]

Hello all, update post.

I think I have simultaneously the cushiest and most stressful outpatient job in the city. I have 30 minute appointments and 90 minute intakes, 35 hours a week and no call, and I think I'm making more than anyone else does for comparable work in this geographic area.

That said, a good chunk is hazard pay.

In my short tenure so far, I've referred multiple people to the ER for both psych and non-psych reasons, seen a death and a suicide attempt, generated police welfare checks and adult protective services reports, and have been involved in guardianship proceedings.

I have no issue, as I feared, of telling people on inappropriate regimens that things need to change. Usually, people either work with me or go elsewhere. If there's one good thing about no longer being a resident, is that I've lost my fear of being fired... By patients, anyway.

I document super-defensively still, but am gradually cutting down on documentation time.

What I have an issue with is the large swath of patients who are unreliable narrators, have SMI, and/or are in institutions. I am constantly questioning whether they have capacity to make this or that decision, whether they need a higher level of community support and if so which one, if they are being abused, and where the truth really lies. I do way too much case management that I am not equipped to do because at the moment the clinic doesn't have anyone to do that job. Sometimes the entire care team is my patient. I worry I'll do too much or too little. Legal and neuropsych are my new best friends.

I live in fear of doing something wrong due to either lack of clinical knowledge, missing something on info-gathering, or simply wanting to do something well-meaning and it blowing up in my face. I lose sleep over fears of board and administrative action. Sometimes I wonder if I should quit and find myself a more worried well population, but I'm not sure it's a good idea to go searching for a new job right now.

Question for the audience. Some of my practice partners say they don't get involved much outside of appointments in patient issues. And I just don't understand.... how? They have the same patient population. How do you not become a reluctant case manager as a psychiatrist? This is starting to feel unsustainable. I am at work 2 hours past closing time every day, and then I come home and crunch notes for 3-5 more hours. I can't live my whole life like that.

Ask your partners. See how much they do for their patients. See how they document. Ask them if and how many malpractice lawsuits they had while working there. If it is 0 or very minimal over a good chunk of time, mimic what they do. It sounds like you are causing your own stress / burn out.

 

[dl2dp2]

Are you cash? There's a very simple way to improve your life if you are cash: raise your fees by 50-100% or to the median OON FAIRHealth rates.

If you are not cash, sorry--you are SOL. It'll be challenging--you are paid more because you are doing other people's jobs. I think you should look for a new job or start a cash side gig---assuming no non-compete.

 

[TexasPhysician]

No matter who you are, you can’t do everything to save everyone. It’s impossible. Case management is not your job. Spend your time lobbying for a case manager. Many agencies will see your willingness to do the work as reason not to hire one - you are volunteering to save them money.

My clinic notes for the entire day don’t take more than 1 hour, and I do them during appointments. Create templates, smart phrases, or whatever. If you prep for it, it is easy to meet legal and billing requirements. It’ll be even easier in 2021 with billing changes.

 

[psych_0]

I have 30 minute appointments and 90 minute intakes, 35 hours a week and no call, and I think I'm making more than anyone else does for comparable work in this geographic area.

I am at work 2 hours past closing time every day, and then I come home and crunch notes for 3-5 more hours. I can't live my whole life like that.

Sounds like you work much more than 35 hours a week. 5 days x 3-5 hours = 15-25 hours a week AFTER work....

My 2 cents as a random internet psychiatrist who knows nothing else about you besides what you wrote in your post: Sounds like you're convincing yourself you love this job when in reality it's dominating your life outside of work (extra time on notes, losing sleep, etc). Also, you're not making more than anyone else for "comparable work" if you're working full time M-F plus 15-25 hours a week after work.

 

[meow1985]

Sounds like you work much more than 35 hours a week. 5 days x 3-5 hours = 15-25 hours a week AFTER work....

My 2 cents as a random internet psychiatrist who knows nothing else about you besides what you wrote in your post: Sounds like you're convincing yourself you love this job when in reality it's dominating your life outside of work (extra time on notes, losing sleep, etc). Also, you're not making more than anyone else for "comparable work" if you're working full time M-F plus 15-25 hours a week after work.

Well, it's 35 hours of patient appointment time that I am contracted and paid for. I don't get paid for any of the other stuff -- but nobody is paid for answering Mycharts, fielding calls, coordinating care, calling other providers/collateral/group homes/case managers/legal people, filling out forms, faxing orders to facilities, consulting with legal and colleagues on the WTH/I'm-out-of-my-depth cases, and making reports to state agencies. Unless they are in private practice. And then they usually have high functioning patients who don't need as much of that kind of stuff.

I definitely don't love the job, but I am conflicted about finding a new one. Other corporate places I looked at in the area also had grumblings about how they could use better social work support, and appointments were 20 minutes or so, and there was call and worse pay. And at a certain level I feel like going to a suburban small group private practice with stable, high-functioning patient would be a copout... Pride and masochism, I guess. 🙂

 

[meow1985]

No matter who you are, you can’t do everything to save everyone. It’s impossible. Case management is not your job. Spend your time lobbying for a case manager. Many agencies will see your willingness to do the work as reason not to hire one - you are volunteering to save them money.

My clinic notes for the entire day don’t take more than 1 hour, and I do them during appointments. Create templates, smart phrases, or whatever. If you prep for it, it is easy to meet legal and billing requirements. It’ll be even easier in 2021 with billing changes.

Good advice. I actually do already have templates, smart phrases, *and* I dictate.

Where I get bogged down is the assessment, though. I feel like I need to justify why I did what I did and why all the terrible things that could happen are unlikely to happen, as if I'm always already on the stand in a malpractice case.

 

[meow1985]

It sounds like you are causing your own stress / burn out.

Story of my life 😀

Are you cash? There's a very simple way to improve your life if you are cash: raise your fees by 50-100% or to the median OON FAIRHealth rates.

If you are not cash, sorry--you are SOL. It'll be challenging--you are paid more because you are doing other people's jobs. I think you should look for a new job or start a cash side gig---assuming no non-compete.

Lol, if I were cash, would I have low-functioning, institutionalized patients with SMI? Most of those sorts of people are on public assistance, no?

Honestly, I don't mind the acuity and SMI/ACT is one of my strengths. I just don't have the support I need to provide the kind of care that I think is appropriate. My fellow MDs have been lobbying for the same thing but with limited success.

Idk if this is a stereotype, but I know literally no one, members of the lower end of the 1% included, who would pay cash for medical care. It may be a personal bias, but I feel like if you have enough money to cash pay a psychiatrist, you probably are very, very privileged and that's not the sort of population I got into this business to take care of.

Not saying I don't want to change, it would just be a sacrifice of my values. There are certainly no easy answers.

 

[Mass Effect]

Story of my life 😀


Lol, if I were cash, would I have low-functioning, institutionalized patients with SMI? Most of those sorts of people are on public assistance, no?

Honestly, I don't mind the acuity and SMI/ACT is one of my strengths. I just don't have the support I need to provide the kind of care that I think is appropriate. My fellow MDs have been lobbying for the same thing but with limited success.

Idk if this is a stereotype, but I know literally no one, members of the lower end of the 1% included, who would pay cash for medical care. It may be a personal bias, but I feel like if you have enough money to cash pay a psychiatrist, you probably are very, very privileged and that's not the sort of population I got into this business to take care of.

Not saying I don't want to change, it would just be a sacrifice of my values. There are certainly no easy answers.

I think there are limited options, none of which are perfect:

1. Stay where you are in the big corporate practice. You need to learn to be more efficient though or stop trying to save everyone. You're on a crash course to burnout.
2. Leave and join a cash only practice or a small private practice (or your own) with the worried well. I get your point about sacrificing your values, but you may have a happier life overall if you're taking on so much work because of your level of empathy for your patients.
3. Leave and go into one of the Ivory Tower academics where there's social work galore. They still need more help, but the places I'm familiar with do not expect MDs to do any of this. You would be taking a pay cut though. Depending on how much you're making, it'll likely be a substantial pay cut. But your life will be easier.

 

[TexasPhysician]

Good advice. I actually do already have templates, smart phrases, *and* I dictate.

Where I get bogged down is the assessment, though. I feel like I need to justify why I did what I did and why all the terrible things that could happen are unlikely to happen, as if I'm always already on the stand in a malpractice case.

Why not have the assessment be the diagnoses and just cut/paste generic cya stuff? The majority of preventative legal issues are generic. There are not tons of issues to individually prevent against.

 

[hallowmann]

Question for the audience. Some of my practice partners say they don't get involved much outside of appointments in patient issues. And I just don't understand.... how? They have the same patient population. How do you not become a reluctant case manager as a psychiatrist? This is starting to feel unsustainable. I am at work 2 hours past closing time every day, and then I come home and crunch notes for 3-5 more hours. I can't live my whole life like that.

You are documenting 3-5 hours for 7 patient hours? That is a glaring problem. You are overdocumenting. The goal of the CYA explanations are to argue that you are meeting standard of care, not that you have thought of and prevented every possible outcome that could happen. You're not a pharmaceutical company listing the side effects in the <1% category. You're also not a god, expected to anticipate every possible problem that might come up with your treatment.

You can do better than this for yourself. Keep in mind that if you're burnt out, you will start to truly make mistakes or you will not be able to take care of the population you are trying to help.

Life is to some degree about risk mitigation. You could die in a car accident, but that doesn't mean you don't drive. You could die in a plane crash, but it doesn't mean you don't ever fly. You could get killed by a patient, but it doesn't mean you don't treat them. You estimate the risk and act accordingly. If something has a low likelihood of happening, like an obscure side effect, and you are meeting standard of care, which give a relatively broad range for the "art" of medicine, you will be OK.

Also, some advice for documentation, there is one thing I was told by an attending early in training: "make a mistake on your notes". I was so focused on formatting and phrasing things in such a way, spending a ton of time on documentation (still a problem, but less so) he told me to make a purposeful typo. Nothing that would affect anything, obviously, but something that allowed the note to not be "perfect". It doesn't need to be. Don't let the best be the enemy of the good.

Well, it's 35 hours of patient appointment time that I am contracted and paid for. I don't get paid for any of the other stuff -- but nobody is paid for answering Mycharts, fielding calls, coordinating care, calling other providers/collateral/group homes/case managers/legal people, filling out forms, faxing orders to facilities, consulting with legal and colleagues on the WTH/I'm-out-of-my-depth cases, and making reports to state agencies. Unless they are in private practice. And then they usually have high functioning patients who don't need as much of that kind of stuff.

I definitely don't love the job, but I am conflicted about finding a new one. Other corporate places I looked at in the area also had grumblings about how they could use better social work support, and appointments were 20 minutes or so, and there was call and worse pay. And at a certain level I feel like going to a suburban small group private practice with stable, high-functioning patient would be a copout... Pride and masochism, I guess. 🙂

You are letting your anxiety cause you to not only do more work, but potentially do it wrong. You are not trained to be a social worker or case manager. You don't know the best, fastest, or most accurate way of doing these things because you are not trained to do it. It takes you longer because you are starting from limited knowledge of it and you run the risk of making bigger mistakes that way.

You need to take a step back. You need to see what others around you are doing. You don't have to do exactly as they do, but use it as a guide. If you aren't trained to do something, don't let yourself get sucked into doing it, or better yet, give yourself some time. Maybe you'll find that there are others who are better equipped to do those things for the patient.

Why not have the assessment be the diagnoses and just cut/paste generic cya stuff? The majority of preventative legal issues are generic. There are not tons of issues to individually prevent against.

I think they are literally worried about almost anything happening. That's the problem.

 

[loannightmares]

As a resident, I'm wondering how overly defensive I am with my documentation too, because I have a similar problem to OP's. Some random examples that I'm making up (in the outpatient setting):

- Start Cymbalta 30 mg daily for treatment of MDD. LFTs wnl. Encouraged patient to avoid excessive alcohol intake while taking this medication.
- Start Risperdal 0.5 mg QHS for treatment of new-onset auditory hallucinations. Lipid profile and HgbA1c wnl; will order prolactin level. Discussed with patient benefits and risks including but not limited to EPS and TD.

It seems like attendings will usually just say, "Start Cymbalta 30 mg" or "Start Risperdal 0.5 mg" and leave it at that. Maybe they'll include a generic block phrase that says, "I reviewed all benefits, side effects, risks of medications with patients", but usually not. Is that really the way to do it, or are they under-documenting?

OP, I think we've talked about this before, but I share many of your anxieties. I would just echo others' sentiments above that you can't take on an inordinate amount of responsibility for others; it will just burn you out. Doing your best doesn't mean taking on additional roles and tasks you aren't trained for, even though you might by default feel guilty for not doing them.

 

[VA Hopeful Dr]

As a resident, I'm wondering how overly defensive I am with my documentation too, because I have a similar problem to OP's. Some random examples that I'm making up (in the outpatient setting):

- Start Cymbalta 30 mg daily for treatment of MDD. LFTs wnl. Encouraged patient to avoid excessive alcohol intake while taking this medication.
- Start Risperdal 0.5 mg QHS for treatment of new-onset auditory hallucinations. Lipid profile and HgbA1c wnl; will order prolactin level. Discussed with patient benefits and risks including but not limited to EPS and TD.

It seems like attendings will usually just say, "Start Cymbalta 30 mg" or "Start Risperdal 0.5 mg" and leave it at that. Maybe they'll include a generic block phrase that says, "I reviewed all benefits, side effects, risks of medications with patients", but usually not. Is that really the way to do it, or are they under-documenting?

My notes are similar to your attendings' notes. I will put more for high risk stuff (antidepressants in under 25, for example) or if a patient is refusing something.

But otherwise, pretty brief.

 

[Mass Effect]

As a resident, I'm wondering how overly defensive I am with my documentation too, because I have a similar problem to OP's. Some random examples that I'm making up (in the outpatient setting):

- Start Cymbalta 30 mg daily for treatment of MDD. LFTs wnl. Encouraged patient to avoid excessive alcohol intake while taking this medication.
- Start Risperdal 0.5 mg QHS for treatment of new-onset auditory hallucinations. Lipid profile and HgbA1c wnl; will order prolactin level. Discussed with patient benefits and risks including but not limited to EPS and TD.

It seems like attendings will usually just say, "Start Cymbalta 30 mg" or "Start Risperdal 0.5 mg" and leave it at that. Maybe they'll include a generic block phrase that says, "I reviewed all benefits, side effects, risks of medications with patients", but usually not. Is that really the way to do it, or are they under-documenting?

OP, I think we've talked about this before, but I share many of your anxieties. I would just echo others' sentiments above that you can't take on an inordinate amount of responsibility for others; it will just burn you out. Doing your best doesn't mean taking on additional roles and tasks you aren't trained for, even though you might by default feel guilty for not doing them.

It's great that you're so thorough. But what you should probably do is create a dot-phrase for these things.

Create a dot-phrases for:
SSRIs
SNRIs
TCAs
Wellbutrin
Mirtazapine
BuSpar
Meds in pregnancy
Stimulants
Antipsychotics
Mood stabilizers
Benzos
Sleep aids
ECT counseling
TMS counseling
Various psychiatric conditions you see a lot

Now, every time you start a patient on Cymbalta, you know you've discussed the risks, so just insert the dot-phrase at the end of your note. When you start someone in risperidone, do the same. If both, use both dot-phrases. As long as you are actually reviewing the risks with every patient, you don't need to spell it out every single time. That's what dot-phrases are meant for.

 

[meow1985]

You are documenting 3-5 hours for 7 patient hours? That is a glaring problem. You are overdocumenting. The goal of the CYA explanations are to argue that you are meeting standard of care, not that you have thought of and prevented every possible outcome that could happen. You're not a pharmaceutical company listing the side effects in the <1% category. You're also not a god, expected to anticipate every possible problem that might come up with your treatment.

You can do better than this for yourself. Keep in mind that if you're burnt out, you will start to truly make mistakes or you will not be able to take care of the population you are trying to help.

Life is to some degree about risk mitigation. You could die in a car accident, but that doesn't mean you don't drive. You could die in a plane crash, but it doesn't mean you don't ever fly. You could get killed by a patient, but it doesn't mean you don't treat them. You estimate the risk and act accordingly. If something has a low likelihood of happening, like an obscure side effect, and you are meeting standard of care, which give a relatively broad range for the "art" of medicine, you will be OK.

Also, some advice for documentation, there is one thing I was told by an attending early in training: "make a mistake on your notes". I was so focused on formatting and phrasing things in such a way, spending a ton of time on documentation (still a problem, but less so) he told me to make a purposeful typo. Nothing that would affect anything, obviously, but something that allowed the note to not be "perfect". It doesn't need to be. Don't let the best be the enemy of the good.


You are letting your anxiety cause you to not only do more work, but potentially do it wrong. You are not trained to be a social worker or case manager. You don't know the best, fastest, or most accurate way of doing these things because you are not trained to do it. It takes you longer because you are starting from limited knowledge of it and you run the risk of making bigger mistakes that way.

You need to take a step back. You need to see what others around you are doing. You don't have to do exactly as they do, but use it as a guide. If you aren't trained to do something, don't let yourself get sucked into doing it, or better yet, give yourself some time. Maybe you'll find that there are others who are better equipped to do those things for the patient.

I think they are literally worried about almost anything happening. That's the problem.

Maybe case management isn't quite the right word. It might be more care coordination that I'm doing, and care coordination is something you can technically bill for, if the dot phrases my colleagues use are any indication.

A typical example:

I recommend that a patient needs a certain level of care, let's say DBT or SUD treatment, and let's say it doesn't exist in-house.

My colleagues would generally just tell the patient to search online or call insurance, and if the patient is too easily confused or dysregulated to get far in that process, that's too bad. If I have a patient who is likely to have trouble with getting connected to a resource on their own, I will consult colleagues and the clinic manager on where to refer, then get that info to the patient. Seems easy, but if the patient doesn't use Mychart, I either have to call, or send a letter, or both. All told that can be 30 minutes of my time.

I also spend a lot of time thinking and angsting about legal and ethical issues, like patients refusing care and me thinking they may not have the capacity to do so - it happens often in patients with SMI, TBI, dementia. If no proxy or guardianship exists, what's my duty to protect the patient and society, and more importantly, what are concrete options for how I can put the process in motion? Again, I spend time consulting with colleagues, the legal department, and the patient's care team, if they have one. Then I document that I did all that and what we talked about.

One thought I had is that as the MD, my job is to focus on medication management. But medications are only a small part of treatment. One mentor I had told me that my job begins and ends with formulating the best treatment plan that I can. But how much is formulating a treatment plan worth if it can't be put in motion?

Regarding assessment in notes.

I have some dot phrases for common drug types and issues, such as mania, sedation, FDA warnings. I also type in session for the HPI. Question, though. Do you have to document all the options for care that you discussed? My sense is probably not and that you can get away with just saying "discussed treatment options," but I list all the options discussed anyway.

Then there are the medically and psychiatrically complex patients where there are not easy or risk-free options. I.e. the medically complex elderly person where you're trying to decide what's worse - benzos, anticholinergics, causing hypotension with antiadrenergics?

 

[robellis]

As a resident, I'm wondering how overly defensive I am with my documentation too, because I have a similar problem to OP's. Some random examples that I'm making up (in the outpatient setting):

- Start Cymbalta 30 mg daily for treatment of MDD. LFTs wnl. Encouraged patient to avoid excessive alcohol intake while taking this medication.
- Start Risperdal 0.5 mg QHS for treatment of new-onset auditory hallucinations. Lipid profile and HgbA1c wnl; will order prolactin level. Discussed with patient benefits and risks including but not limited to EPS and TD.

It seems like attendings will usually just say, "Start Cymbalta 30 mg" or "Start Risperdal 0.5 mg" and leave it at that. Maybe they'll include a generic block phrase that says, "I reviewed all benefits, side effects, risks of medications with patients", but usually not. Is that really the way to do it, or are they under-documenting?

OP, I think we've talked about this before, but I share many of your anxieties. I would just echo others' sentiments above that you can't take on an inordinate amount of responsibility for others; it will just burn you out. Doing your best doesn't mean taking on additional roles and tasks you aren't trained for, even though you might by default feel guilty for not doing them.

You’re probably over documenting but that’s a good thing but the cons are obvious

 

[meow1985]

You are documenting 3-5 hours for 7 patient hours? That is a glaring problem. You are overdocumenting. The goal of the CYA explanations are to argue that you are meeting standard of care, not that you have thought of and prevented every possible outcome that could happen. You're not a pharmaceutical company listing the side effects in the <1% category. You're also not a god, expected to anticipate every possible problem that might come up with your treatment.

I sat down to document today and it took 3 times as long as I wanted to. I noticed a few things.

The notes that made me second guess myself and worry about wording were ones where the patients have capacity issues.

Some attending in the past told me that treating without proper consent can be prosecuted as assault, and that stuck with me. Also, notes can be used in court settings to determine things like guardianship and in CAP cases custody. Those are materially important things in people's lives.

 

[TexasPhysician]

I sat down to document today and it took 3 times as long as I wanted to. I noticed a few things.

The notes that made me second guess myself and worry about wording were ones where the patients have capacity issues.

Some attending in the past told me that treating without proper consent can be prosecuted as assault, and that stuck with me. Also, notes can be used in court settings to determine things like guardianship and in CAP cases custody. Those are materially important things in people's lives.

It is not easy to prove a lack of capacity at a past specific point in a court of law. If you document that you discussed the risks, benefits, and alternatives and the patient voiced understanding while asking intelligible follow-up questions (assuming true), it is hard to argue that the patient didn’t have capacity. That dot phrase takes 2 seconds and lowers the risk of such a charge to almost 0.

 

[Mass Effect]

It is not easy to prove a lack of capacity at a past specific point in a court of law. If you document that you discussed the risks, benefits, and alternatives and the patient voiced understanding while asking intelligible follow-up questions (assuming true), it is hard to argue that the patient didn’t have capacity. That dot phrase takes 2 seconds and lowers the risk of such a charge to almost 0.

This is correct. My dot phrase says exactly that - discussed risks and benefits, patient participated in a meaningful way in discussion, asked questions and voiced understanding (when it's true). If it goes to court two years from now, I don't see how someone can argue that patient didn't have capacity two years ago.

 

[justfolks]

Just a patient here, but OP's posts seem more about OP's own anxiety than about good patient care. Spending hours writing a narrative about the specific treatment options discussed, instead of just saying "discussed treatment options," which could be automated to a couple of key strokes, seems, well, crazy.

 

[calvnandhobbs68]

I sat down to document today and it took 3 times as long as I wanted to. I noticed a few things.

The notes that made me second guess myself and worry about wording were ones where the patients have capacity issues.

Some attending in the past told me that treating without proper consent can be prosecuted as assault, and that stuck with me. Also, notes can be used in court settings to determine things like guardianship and in CAP cases custody. Those are materially important things in people's lives.

You know how often surgeons do surgeries on people with mild dementia who probably don’t have capacity half the time either?

A solid chunk of the patients in a typical FQHC likely lack true demonstrable capacity at any given point (I can count off the top of my head and number of my patients with schizophrenia who probably need guardians). What are we supposed to do, do nothing for them? Not treat their psychosis/mania/depression/anxiety/etc? Hunt down their second cousin to be their surrogate decision maker? Wait a year for a guardianship hearing? You’re over thinking it.

We’ve found out from your previous posts here that you tend to be unrealistically anxious about clinical situations. You obviously know this too or else you wouldn’t have posted this to begin with. This is like with the lawsuit thread...you’re basically posting “make me feel better/tell me I should change what I’m doing” and then arguing why you shouldn’t change what you’re doing even though that’s what you actually want to be able to do. If the real problem is you don’t like the job, then bail.

 

[meow1985]

This is correct. My dot phrase says exactly that - discussed risks and benefits, patient participated in a meaningful way in discussion, asked questions and voiced understanding (when it's true). If it goes to court two years from now, I don't see how someone can argue that patient didn't have capacity two years ago.

I feel like I have more than my share of patients that can't or don't participate in a meaningful discussion, though. And then they refuse care. Those are the cases I lose sleep over, over-document on, and try to budge the needle on case management-wise.

I still over-document and do too much on the other cases, but that's easier to address.

You know how often surgeons do surgeries on people with mild dementia who probably don’t have capacity half the time either?

A solid chunk of the patients in a typical FQHC likely lack true demonstrable capacity at any given point (I can count off the top of my head and number of my patients with schizophrenia who probably need guardians). What are we supposed to do, do nothing for them? Not treat their psychosis/mania/depression/anxiety/etc? Hunt down their second cousin to be their surrogate decision maker? Wait a year for a guardianship hearing? You’re over thinking it.

Believe it or not, that's a hump I did get over. At first I was afraid of treating those people, but ultimately it helped to hear from someone exactly what you said. I might need to create a dot phrase about how "the patient is accepting treatment, and this is the safe choice, therefore in the interest of beneficence..." Like I said, though, it's when those patients refuse care that things get dicey.

We’ve found out from your previous posts here that you tend to be unrealistically anxious about clinical situations. You obviously know this too or else you wouldn’t have posted this to begin with. This is like with the lawsuit thread...you’re basically posting “make me feel better/tell me I should change what I’m doing” and then arguing why you shouldn’t change what you’re doing even though that’s what you actually want to be able to do. If the real problem is you don’t like the job, then bail.

You're 100% correct. I want to change, but my fear of something bad happening is a powerful barrier. Technically, anxious is not quite the right word, traumatized is more like it. I've felt like my medical training and career so far have been constant low-grade trauma, but the details of that are beyond the scope of this discussion.

This thread is helpful, futile though it may feel for respondents, because it adds grains to the side of the scale of "just let it go already."

Regarding the job, I could try and find a job where I will have fewer SMI/dementia patients, but it's not like I would be able to completely avoid them. Can you do that, in private practice? Say, "you have this or that diagnosis, but I am not comfortable treating that, so let me send you elsewhere?"

 

[meow1985]

Just a patient here, but OP's posts seem more about OP's own anxiety than about good patient care. Spending hours writing a narrative about the specific treatment options discussed, instead of just saying "discussed treatment options," which could be automated to a couple of key strokes, seems, well, crazy.

Sometimes patients are very complicated and you're choosing between several high risk options.

Also, sometimes you discuss a number of treatments, choose option A, and it doesn't work. Patient calls between appointments and asks if something else can be tried. You can see them for another appointment, but depending on you and the patient's schedules, that may or may not be possible in a timely manner. You can call the patient (but you're not paid for that) and document another risk-benefit discussion of option B (even though you already discussed option B at the appointment, you just didn't document it, so legally it didn't happen). Or you can tell your nurse to tell them to try option B and that risks and benefits were already discussed and documented at the appointment. Your nurse calls the patient to pass along the message, and everyone's happy. All because you did a little more work up front.

Keep in mind that treatment options can have vastly different side effects that need to be specifically documented in the interest of CYA. If option A has a s/e of mania, you have to document that you discussed that. If option B has a side effect of low BP, falls, and sedation, to CYA you have to discuss that too.

If anyone has a better way to address the above situation, let me know.

 

[Mass Effect]

I feel like I have more than my share of patients that can't or don't participate in a meaningful discussion, though. And then they refuse care. Those are the cases I lose sleep over, over-document on, and try to budge the needle on case management-wise.

What do you mean they can't participate? As for the ones who refuse care, just document that. Say you went over all the options, discussed side effects and benefits, but patient refused care over my recommendation.

I don't understand the types of patients you're getting that can't participate or refuse care. They may refuse one med over another, but you're the doctor and you're there to guide them. For instance, your bipolar patients shouldn't be getting SSRIs instead of mood stabilizers, but in addition to mood stabilizers. If they're refusing mood stabilizers, then you make a risk/benefit analysis of giving them an SSRI unopposed. But the patient shouldn't get to decide that's what they want end of story.

Also you don't have to list every side effect to CYA. You list the most common and the most dangerous. These drugs have a ton more side effects and you will never be able to account for every single thing (that's why pharmacy hands them a packet). For instance, ALL my SSRIs have the exact same dot phrase. It even says SSRI meds rather than the specific medication. They all get the common s/e's like weight gain, sexual dysfunction, serotonin syndrome, increased suicidal thoughts in patients under the age of 25, and a couple other things. It took me 5 minutes to write that dot phrase when I started and I use it at the end of every note in which I prescribed an SSRI. It literally takes 5 seconds to do that.

 

[meow1985]

What do you mean they can't participate? As for the ones who refuse care, just document that. Say you went over all the options, discussed side effects and benefits, but patient refused care over my recommendation.

I don't understand the types of patients you're getting that can't participate or refuse care. They may refuse one med over another, but you're the doctor and you're there to guide them. For instance, your bipolar patients shouldn't be getting SSRIs instead of mood stabilizers, but in addition to mood stabilizers. If they're refusing mood stabilizers, then you make a risk/benefit analysis of giving them an SSRI unopposed. But the patient shouldn't get to decide that's what they want end of story.

Also you don't have to list every side effect to CYA. You list the most common and the most dangerous. These drugs have a ton more side effects and you will never be able to account for every single thing (that's why pharmacy hands them a packet). For instance, ALL my SSRIs have the exact same dot phrase. It even says SSRI meds rather than the specific medication. They all get the common s/e's like weight gain, sexual dysfunction, serotonin syndrome, increased suicidal thoughts in patients under the age of 25, and a couple other things. It took me 5 minutes to write that dot phrase when I started and I use it at the end of every note in which I prescribed an SSRI. It literally takes 5 seconds to do that.

Patients who have SMI or cognitive impairment and don't have proxies or guardians. Examples include: They can barely repeat back the name of the medication back to me, much less risks and benefits. They reasons they refuse meds are psychotic ones. They have poor insight into their illness and their need for treatment. They angrily dismiss everything you say.

I do have dot phrases for my side effect discussions, though I've been needing to tweak them some. It still doesn't help, somehow. Maybe it's because I feel the need to explain that yes, a risk exists and this patient has risk factors for developing this side effect, but the benefits outweigh the risks and yes, the patient understands that.

I have a lot of emotions about my patients, and while I can bracket them in session, they seem to come out when I am trying to do notes. 🙁 That's another issue that slows me down.

 

[dl2dp2]

My colleagues would generally just tell the patient to search online or call insurance, and if the patient is too easily confused or dysregulated to get far in that process, that's too bad. If I have a patient who is likely to have trouble with getting connected to a resource on their own, I will consult colleagues and the clinic manager on where to refer, then get that info to the patient. Seems easy, but if the patient doesn't use Mychart, I either have to call, or send a letter, or both. All told that can be 30 minutes of my time.

This level of case management is not being paid for my commercial insurance, let alone Medicaid/Medicare. In a system like yours, t's actually stipulated from day 1 to be not your job. If you don't have a dedicated case manager to do this at your facility, then it's the patient's responsibility. I do this sometimes for my private patients, but I also get paid 3-5x your rate per minute net. Also, it's not true that private patients don't have SMI--they do. It's just that their parents are wealthier, and often not by much. I have plenty of middle-class patients/families willing to pay for high-quality care for their SMI offspring on SSI/Medicaid, including dedicated case management, which they cannot get at a facility such as yours. I frankly think private practice is the SOLUTION, not the problem.

Regarding the job, I could try and find a job where I will have fewer SMI/dementia patients, but it's not like I would be able to completely avoid them. Can you do that, in private practice? Say, "you have this or that diagnosis, but I am not comfortable treating that, so let me send you elsewhere?"

You can. But this will lead to not being able to fill as quickly. I deal with complex and difficult cases all the time in PP, but unlike in your case, I provide very high-quality care and get paid for it, and have no ethical qualms about any of my work. Is it really better for the system doing a half ass job AND get paid ****ty for it? Who's really winning here?

 

[clausewitz2]

@sluox speaks truth on this. I too had the idea that going into private practice meant it would be garden variety high-functioning depranxious people all day, every day, but you'd be surprised how many professionals and relatively functional people do pretty well for themselves except for when they stop sleeping and begin telling people they're the Anti-Christ or when they start getting worried that their two year-old nephew is conspiring against them with the government.

Also, I've said it before, but: if you get a few patients early on who are local therapists or physicians, do good work and word gets around, and you suddenly have a whole bunch of people who would prefer to pay cash and will figure out a way to afford it almost independent of income.

 

[FN9]

I will admit that while I write concise notes, when covering for a pt, i'd rather read a note from OP than mine, much more juicy details 🙂

 

[Candidate2017]

I want to change, but my fear of something bad happening is a powerful barrier. Technically, anxious is not quite the right word, traumatized is more like it. I've felt like my medical training and career so far have been constant low-grade trauma, but the details of that are beyond the scope of this discussion.

This thread is helpful, futile though it may feel for respondents, because it adds grains to the side of the scale of "just let it go already."

That's precisely the point.

Med school/residency constantly tells us we are responsible for everything. For years and years. They derive great benefit keeping us stuck in an infantile stage of fear, shame, and magical thinking where we believe anything good or bad that happens is caused by our actions. But at some point, we have to realize we are adults with identities and boundaries separate from the system. So, like a toddler, we need to exercise our newfound power and say, "No." Repeatedly. No, I am not the case manager. No, I am not responsible for noncompliant patients. No, I don't write surgical clearance letters. Etc, etc.

 

[meow1985]

As a resident, I'm wondering how overly defensive I am with my documentation too, because I have a similar problem to OP's. Some random examples that I'm making up (in the outpatient setting):

- Start Cymbalta 30 mg daily for treatment of MDD. LFTs wnl. Encouraged patient to avoid excessive alcohol intake while taking this medication.
- Start Risperdal 0.5 mg QHS for treatment of new-onset auditory hallucinations. Lipid profile and HgbA1c wnl; will order prolactin level. Discussed with patient benefits and risks including but not limited to EPS and TD.

It seems like attendings will usually just say, "Start Cymbalta 30 mg" or "Start Risperdal 0.5 mg" and leave it at that. Maybe they'll include a generic block phrase that says, "I reviewed all benefits, side effects, risks of medications with patients", but usually not. Is that really the way to do it, or are they under-documenting?

OP, I think we've talked about this before, but I share many of your anxieties. I would just echo others' sentiments above that you can't take on an inordinate amount of responsibility for others; it will just burn you out. Doing your best doesn't mean taking on additional roles and tasks you aren't trained for, even though you might by default feel guilty for not doing them.

I have a section in my notes where I list any relevant labs, but I usually don't comment on them in the assessment unless they are abnormal or trending in a concerning direction.

For Cymbalta, I'd put what you put if there was an actual concern of excessive alcohol use in that patient, in which case I'd justify why benefits outweigh the risks and what was done to modify risk (i.e. advised to limit alcohol use). For your 1-2 drinks a week people, what you put is probably excessive.

For risperidone, I wouldn't comment on the normal metabolic labs either. I do have a blanket dot phrase about educating patients on EPS, TD, metabolic side effects and required monitoring. On abnormal metabolic labs, I comment on what I did to address the abnormality (I may loop in pcp, start metformin myself, discuss transitioning to a different agent, etc.)

 

[DuskPhilosophy]

Again, I spend time consulting with colleagues, the legal department, and the patient's care team, if they have one. Then I document that I did all that and what we talked about.

In my training we were explicitly told not to document that we had spoken to risk management or legal because it could be used against us if ever a legal situation arose. Was anyone taught the same or different?

 

[robellis]

In my training we were explicitly told not to document that we had spoken to risk management or legal because it could be used against us if ever a legal situation arose. Was anyone taught the same or different?

How could talking to legal be used against you?

 

[FlowRate]

I don't get paid for any of the other stuff -- but nobody is paid for answering Mycharts, fielding calls, coordinating care, calling other providers/collateral/group homes/case managers/legal people, filling out forms, faxing orders to facilities, consulting with legal and colleagues on the WTH/I'm-out-of-my-depth cases, and making reports to state agencies.

I start with 1 hour per day built in to my schedule and move up to 1.5 hours at 9 months and 2 hours at 18 months. That does not include my hour lunch. We also have decent therapy / case management resources. (I am an employed doc)

Where I get bogged down is the assessment, though. I feel like I need to justify why I did what I did and why all the terrible things that could happen are unlikely to happen, as if I'm always already on the stand in a malpractice case.

FWIW my discussion of med options is usually 1-2 short sentences about 1-3 med options and why they're reasonable. I don't always specifically document specific ADE discussions (I should probably make some dot phrases) although I do always discuss w/ the pt and there's a generic "discussed adverse effects" part in the note template.

Straightforward cases the assessment is 3 sentences. Very complex cases or justifying iterative progress on a very suboptimal treatment regimen (usually from another doc) maybe two-three 5-sentence paragraphs MAX. Even the lengthiest documentation takes 20 minutes for a new patient, max. Follow-ups are usually 5-10 and finished during/between appointments.

Idk if this is a stereotype, but I know literally no one, members of the lower end of the 1% included, who would pay cash for medical care. It may be a personal bias, but I feel like if you have enough money to cash pay a psychiatrist, you probably are very, very privileged and that's not the sort of population I got into this business to take care of.

By definition, all of my patients have health insurance. Some are on HDHP, some are on usual HMO/PPO option. Maybe 5-10% of my patients pay cash for psychotherpy and I also intermittently work with pts who are bringing their care into our system after having worked with cash psychiatrists. This is not a particularly well-off patient population.

Also, the quality of care from some of these cash psychiatrists is surprising. It makes me increasingly convinced that I'd have no issues getting pts once I had a few professional patients telling others about me, as @clausewitz2 mentioned, if I ever made the switch.

 

[splik]

In my training we were explicitly told not to document that we had spoken to risk management or legal because it could be used against us if ever a legal situation arose. Was anyone taught the same or different?

Correct these conversations should not be documented in the medical record.however it is unlikely it would be used against you. More to the point documenting these conversations is not likely to protect you (though following legal guidance may) and patients (who you should assume will read everything you write) may react negatively seeing such things documented. It might look like you are more interested in covering your own ašs than patient care.

 

[clausewitz2]

FWIW my discussion of med options is usually 1-2 short sentences about 1-3 med options and why they're reasonable. I don't always specifically document specific ADE discussions (I should probably make some dot phrases) although I do always discuss w/ the pt and there's a generic "discussed adverse effects" part in the note template.

I ended up creating dot phrases for pretty much all of the medications I use on a regular basis that are specific to each medication. Obviously for some they are extremely similar between dot phrases (risperidone and haldol, f'rinstance). Occasionally I have to add in a not-so-common AE that might be very relevant in a particular complex case or end up having to delete one of my common AEs because I realize I forgot to mention that one but as long as you have a spiel about these effects that is pretty consistent there's no reason this should be a difficult thing to document.

I prescribe a fair number of MAOIs and have longer dotphrases for those, including detailed information about actual empirically motivated dietary restrictions (as opposed to the insane, "you get to live on gruel now" dietary precautions that are more straightforward to find on the internet), a run down on potential signs of a hypertensive crisis and exactly what to do, etc. The conversation takes some time but the documentation does not.

Straightforward cases the assessment is 3 sentences. Very complex cases or justifying iterative progress on a very suboptimal treatment regimen (usually from another doc) maybe two-three 5-sentence paragraphs MAX. Even the lengthiest documentation takes 20 minutes for a new patient, max. Follow-ups are usually 5-10 and finished during/between appointments.

My assessments are always written in pluperfect to allow them to slowly keep accreting over the course of treatment, mostly with brief statements about responses to treatment or major changes in symptoms/life circumstances. I start with a brief case formulation covering major symptom areas tersely and perhaps aspects of personality dysfunction that are apparent. When i do it right I end up with a potted summary of the entirety of my work with the person in question, which means when I see one of my folks who I don't see that often I am way less likely to have a "who the hell is [NAME], again?"

When I started back in August I was spending so much freaking time on intakes until I realized that these were not records that anyone besides me, insurance, patient, and maybe a court were going to see and I didn't need to impress anyone with my erudition or anticipate literally any possible outcome. Get in what I need for billing, probably a bit more history than needed to help me have a better sense of their life/have something to ask them about at the next appointment, say what I'm thinking/doing about anything that would be an utter disaster to miss, and briefly update psych ROS. I have also been very aggressive about identifying things I spend a lot of time on asking detailed questions about and making questionnaires I can push to patient portal before appointments and just plug into my notes.

At the end of the day I decided if I was spending as long on documenting an encounter as I would on an actual appointment, I was documenting too much. It will be interesting to see how things shake out with new rules about to go into effect on being able to bill on time including documentation time; I imagine many employers will suddenly become way more understanding about the need for admin time.

 

[meow1985]

I think I just generally have an issue with overthinking, overdoing, and a lack of confidence in my decisions. Documentation is only a symptom, where it shows up as overexplaining and second-guessing what I write. So despite dot phrases, templates, dictation and typing in session, I still can't seem to get it done quickly.

Case in point, I am on vacation, with coverage, New Year's is important to me and my family, and I am struggling not to open up my Mychart messages to see if there's any fires I need to put out. I am simultaneously afraid of opening up Mychart and seeing said fires. I need to get some notes done, but on some subconscious level, stressful appointment where I'm not sure if I did the right thing = stressful note.

I am also angsting over whether I should report a patient to adult protective services for making bad life choices they may or may not have capacity to make.

For extra fun, I am constantly in fear that I will get sued/get board action and lose my career and this nice house I now have.

This is an easy road to burnout for sure.

A friend recently has a piece of advice. Think, what would a mediocre psychiatrist do? Because plenty of mediocre psychiatrists are happily in practice for years.

 

[robellis]

I think I just generally have an issue with overthinking, overdoing, and a lack of confidence in my decisions. Documentation is only a symptom, where it shows up as overexplaining and second-guessing what I write. So despite dot phrases, templates, dictation and typing in session, I still can't seem to get it done quickly.

Case in point, I am on vacation, with coverage, New Year's is important to me and my family, and I am struggling not to open up my Mychart messages to see if there's any fires I need to put out. I am simultaneously afraid of opening up Mychart and seeing said fires. I need to get some notes done, but on some subconscious level, stressful appointment where I'm not sure if I did the right thing = stressful note.

I am also angsting over whether I should report a patient to adult protective services for making bad life choices they may or may not have capacity to make.

This is an easy road to burnout for sure.

A friend recently has a piece of advice. Think, what would a mediocre psychiatrist do? Because plenty of mediocre psychiatrists are happily in practice for years.

Therapy

 

[meow1985]

Therapy

100%. But with leaving work at 7 and 3 hours of notes, where in my schedule do you propose I put it, lol?

 

[robellis]

100%. But with leaving work at 7 and 3 hours of notes, where in my schedule do you propose I put it, lol?

Pay cash and find someone open on the weekends

 

[psych_0]

I think I just generally have an issue with overthinking, overdoing, and a lack of confidence in my decisions. Documentation is only a symptom, where it shows up as overexplaining and second-guessing what I write. So despite dot phrases, templates, dictation and typing in session, I still can't seem to get it done quickly.

Case in point, I am on vacation, with coverage, New Year's is important to me and my family, and I am struggling not to open up my Mychart messages to see if there's any fires I need to put out. I am simultaneously afraid of opening up Mychart and seeing said fires. I need to get some notes done, but on some subconscious level, stressful appointment where I'm not sure if I did the right thing = stressful note.

I am also angsting over whether I should report a patient to adult protective services for making bad life choices they may or may not have capacity to make.

For extra fun, I am constantly in fear that I will get sued/get board action and lose my career and this nice house I now have.

This is an easy road to burnout for sure.

A friend recently has a piece of advice. Think, what would a mediocre psychiatrist do? Because plenty of mediocre psychiatrists are happily in practice for years.

It is so incredibly hard to lose your license it's kind of a joke to be honest. In my short career I have worked with people who have been CAUGHT doing things such as :
- Writing notes on patients that they have never physically seen. Not like one or two, I'm talking writing notes on an entire inpatient unit without ever physically seeing anyone. Caught with video tape proof.
- Soliciting patients (yes, plural) for sexual favors in each for higher doses of stimulants/benzos
- Having sex with prostitutes while on call
- Coming to work high on meth (not Adderall, legit street meth).

These people were not fired. They were all allowed to resign and are still in practice, granted they work in small undesirable areas BUT THEY ALL STILL PRACTICE PSYCHIATRY.

Breathe. Sign your notes. Enjoy the holiday with your family.

 

[robellis]

It is so incredibly hard to lose your license it's kind of a joke to be honest. In my short career I have worked with people who have been CAUGHT doing things such as :
- Writing notes on patients that they have never physically seen. Not like one or two, I'm talking writing notes on an entire inpatient unit without ever physically seeing anyone. Caught with video tape proof.
- Soliciting patients (yes, plural) for sexual favors in each for higher doses of stimulants/benzos
- Having sex with prostitutes while on call
- Coming to work high on meth (not Adderall, legit street meth).

These people were not fired. They were all allowed to resign and are still in practice, granted they work in small undesirable areas BUT THEY ALL STILL PRACTICE PSYCHIATRY.

Breathe. Sign your notes. Enjoy the holiday with your family.

This is good perspective for the OP but also haha wtf

 

[Bartelby]

A few thoughts: first, it sounds like you are new to attendinghood and new to your system. Congrats! This does mean, though, that you are experiencing another steep learning curve. Your system seems to have thrown you in full-speed, which is fine. When new psychiatrists come to work in my system I (and my colleagues) make sure they have a light load for the first 2-3 months exactly so that they can familiarize themselves with many of the issues you are struggling with while still getting out of the door on time. As you settle into the job, though, I anticipate you will become much more comfortable with what options exist for your patients. What might have taken you a couple hours figuring out on the phone this week could be a three-minute email next year as things come together for you. That should work in your favor.

Re: decision making capacity / competency, the patient is presumed to have it unless they are clearly demonstrating a lack of capacity, so the default is that they do have decision making capacity. Even if they are demonstrating serious deficits, you have to know what specific legal options you have. Getting a conservatorship (or its equivalent) likely requires dangerousness, and many of your patients may be in a gray zone of questionable capacity and yet assent to (and benefit from) recommended treatment. I think it is extremely unlikely that someone (who?) would later go through your patients' charts and start declaring that they lacked capacity and you missed it. If you are very concerned and there is no clear case for guardianship / conservatorship, consider seeing if the patient is comfortable involving a next of kin (or equivalent) in their medical decision making and run medical decision making by both the patient and next of kin.

The bottom line is you should not be doing hours of documentation after-hours, I feel confident you will burn out. You can probably tame that with some more experience and a growth mindset, though. And as others have mentioned above, if you feel yourself really getting hung up despite more experience on the job you should consider exploring those issues in your own therapy.