Establishing boundaries in private practice

[MrFlyGuy]

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Hi everyone,

How does everyone establish clinical boundaries in a cash pay private practice?

I am straight out of fellowship and there have been multiple situations with patients where I feel like under my fellowship clinic I would have ended the appointment before it even really began.

For instance I've had two patients driving during video appointments. I have had patients make up things that I said to make me look bad to the front desk staff.

Also at least 70% of my patients are looking for a diagnosis of ADHD with stimulant treatment.

I have established boundaries with a few key patients but they have all ended up canceling because "it was not the right fit."

Is it just a hard fact of life that providing care in a cash based practice means pandering to patients in a way?

MrFlyGuy

 

[Sushirolls]

Hard fact of life. It's a hard hustle.

Driving patients? I tell them pull over, and re-log in once they are parked. Click, I exit.

ADHD? That's why we have like 3+ recent ADHD rants on this forum.

Not fit? Yeah, that's an ARNP with a big smile, and says yes to whatever the patient wants.

@randomdoc1 is still maintaining pep in her step, and zeal for the goat rodeo. Not a cash doc, but still has fight. And will have some commentary to offer I suspect.

I'm getting more crusty, and looking forward to the day I can just farm full time.

 

[Stagg737]

This is the problem with new cash pay PP. There is likely going to either be a significant amount of time to reach a full, sustainable clinic full of reasonable patients or the clinic will need to pander to problem patients looking to be their own doctor and have the psychiatrist write them whatever they want.

This is part of why geography and staying near where you train can be so important as Comp1 likes to preach, as those you trained with can be a great referral source to help get patients who aren't just looking for their next candy shop or trying to direct care inappropriately.

 

[randomdoc1]

cash pay patients will carry a degree of entitlement. They see themselves as the customer in a burger king. "I'm paying you big, you give me what I think is worth that money." You may want to start collecting at time of service. If you are not and you don't give "my adderall", they will stiff you and maybe leave a fake review as your tip. I screen patients before they even make it to an appointment. I'm so fed up with the bs. My practice is marketed as specializing in depression, anxiety, trauma with a psychotherapy heavy focus. I use the convenient excuse that all prescribers are part time, so we're not adequately staffed to safely managed controlled subs (and make it painfully clear, they will not get an rx for ANY controlled substance here ever). I also drug database check all intakes before they make it in. You will find a lot of lying on the phone intake and see a paper trial of being fired from clinics. I just cancel any appointment they had and don't bother to see them. I have a handy list of APNPs to refer to who will take the referral and get 'em in quickly for much cheaper.

Insured patients act this way too, but to a lesser degree. Working with insurance is better than not because patients these days are very unwilling or unable to pay a dam thing. Insurance gives you a reliable income stream and is over 95% of our clinic revenue. And it is far more lucrative than cash.

Having a child adolescent fellowship training behind your name in a cash practice is seen these days as bright neon sign of "get your adderall here" to a lot of general population folk. I would even consider removing that from my bio if I were you. Maybe temporarily. Because it'll attract drug seeking like flies to a...a....

 

[randomdoc1]

Hard fact of life. It's a hard hustle.

Driving patients? I tell them pull over, and re-log in once they are parked. Click, I exit.

ADHD? That's why we have like 3+ recent ADHD rants on this forum.

Not fit? Yeah, that's an ARNP with a big smile, and says yes to whatever the patient wants.

@randomdoc1 is still maintaining pep in her step, and zeal for the goat rodeo. Not a cash doc, but still has fight. And will have some commentary to offer I suspect.

I'm getting more crusty, and looking forward to the day I can just farm full time.

we need to fight the battle together bruh

 

[FatherPsychiatry]

Having a child adolescent fellowship training behind your name in a cash practice is seen these days as bright neon sign of "get your adderall here" to a lot of general population folk. I would even consider removing that from my bio if I were you. Maybe temporarily. Because it'll attract drug seeking like flies to a...a....

Wow interesting point. Why do you think that is? Do the patients think that their perceived ADHD was missed during childhood so a C&A trained psychiatrist would be able to catch it better? I figured most people who just wanted some stims would go straight to any of the NP mills in my area.

 

[randomdoc1]

Wow interesting point. Why do you think that is? Do the patients think that their perceived ADHD was missed during childhood so a C&A trained psychiatrist would be able to catch it better? I figured most people who just wanted some stims would go straight to any of the NP mills in my area.

I think it's a multitude of things
-fulfills a narcissistic desire to have an expert validate their diagnosis and lifelong struggles
-many PCPs, psychiatrists, PAs, NPs will also try to punt the hot potato back and say the real expert on stims is C&A psych. they are the best person to consult
-many people know on some level what they are doing is not right, so they feel less wrong if a C&A agrees with them to entrench the denial

Going back to OPs topic
-your allies will be networking with good evidence based providers and therapists who have similar philosophies as you to send you quality referrals
-I'm not saying to shun your training as indeed you should be proud of it. But if an undesirable case was trying to get on my panel, I downplay my entire practice (and try to make it look undesirable) and say we're not well versed in something. If there is a case I'm interested in, that's where I flash my credentials.
-what you are encountering is people converting to appointments with the wrong intention. There's science behind marketing and referral funnels. A lot of the population you described don't want to get better, they just want what they want. The effective resolution will be increasing your visibility to those with the intention compatible with your philosophy--so it needs to be even further upstream, at the appointment is too late. Find those who want the evidence based route. They are out there. It will take some work to make your brand and following but it is still possible.
-->my office is known as a no nonsense brand that is very lifestyle focused. So there is now a curated referral stream. Is there still drug seeking that want their drugs handed on a silver platter from a luxury office because of likely some NPD? You bet! Diversion to NPs is your best weapon.

Actually, I don't even display the bios of any prescribers at my office anymore. I found that since I removed it, far less drug seeking and calls from people that won't take no for an answer (they just wanted to steam roll their way in and force a xanax or adderall script out of someone). And often it got creepy because the prettiest providers, some patients (men and women) almost had this sexualized/fantasized fixation about a pretty physician giving controlled subs. They were already getting somewhat obsessed with a provider they never met. The cluster B was oozing through. My website just says, we have psychiatry available but it depends on what the schedules look like, call to inquire. The emphasis and SEO is far heavier on the psychotherapy providers. That curates for a more motivated patient following and those who are seeking med management for the right reasons, when non-pharm is not sufficient and they are not looking to medicate their problems away. Just only for what is medically necessary.

 

[TheRightMedication]

Regarding the "how" of boundaries -

1. Write 'em down, so both you and the patient know what they are. I put them in my consent to treatment. This includes duration of appointments, the payment situation, the ways we will and will not communicate, and cancellation policies, to name a few.

2. Discuss every boundary pressing, and especially every boundary crossing, as soon as possible. You might have to say its important to address it before carrying on with other business, if resisted.

3. Consider Automation - For years I resisted having patients enter credit card info for automatic billing in my EMR. Ive since tried it and it has made life so much easier. The psychodynamic importance of payment can still be dealt with with insurance changes and so forth.

4. Supervision - a time honored way to stay effective, healthy, and sane.

5. Faith - when you keep to your boundaries, you'll find your practice grows increasing populated by patients who are better suited to them. Could take a while.

Same rules apply for cash practices as insurance, though those patients have a reputation for pushing against some of them more than others.

Edit for egregious spelling errors

 

[randomdoc1]

1. Write 'em down, so both you and the patient know what they are. I put them in my consent to treatment. This includes duration of appointments, the payment situation, the ways we will and will not communicate, and cancellation policies, to name a few.

This! I have bumped this up a little more even. Learned this from a psychologist at the practice. I print it out, physically hand it to them myself and patient signs it in front of me. Things like
-appt duration
-what is late
-fees
-cancellation policy
-if a text reminder "didn't go through" you are still responsible for knowing your appts, lack of a reminder does not mean exemption from fees, we're big boys and girls now
-refill policy
-etc.

Made a world of difference and reduced a LOT of bs. Never eliminated it but helped tremendously. Those who were not in agreement never returned and made room for individuals more worth the time and energy.

 

[psydocc]

Being firm on boundaries is the reason it took me 1.5 years to become full in a location that could have had me full in 4 months, but to me it was worth the wait. I can say about 99% of my established patients are pleasant individuals who just want to improve their mental health. A "better fit" for the drug seekers would be NPs who almost universally seem to think an adderall and xanax cocktail solves all mental health issues.

 

[randomdoc1]

@shoomer there's something to be said about you never know what skills will come in handy. Makes me think of the Karate Kid "wax on wax off." Grew up in poverty in the service industry. My mother brought me to work with her. We dealt with angry drunk people all the time that would not leave at closing time and our income relied on their tips. You learn a lot of finesse.

 

[lol.psych]

I have a very psychotherapy heavy practice, 60/40 insurance/cash. My intake process is… maybe excessive. I do a 15min zoom meet-and-greet to see if our vibes work well together, and my pre-appointment history form is… a lot. I think this weeds out a lot of the drug seekers, it’s not worth the hassle to have to talk to me for like 5 hours before I even entertain the thought of prescribing something more exciting than propranolol. I am not for folks who are looking for a retail “I want this, this, and this” type experience.

It probably also helps that I make it very clear that I want to know all the feelings and internal mechanics and details, I’m not someone they can just list diagnostic criteria to and walk out with a script. Because boy howdy will I have follow up questions.

I have not had a patient try to have an appointment while driving. In their car, parked, sure. But driving?! Why would *they* want that? Especially if they’re cash pay — what a waste of money!

If someone cancels after you set clear boundaries, then sounds like they’re right… it’s not a good fit. They want someone with wobbly boundaries, and that’s not you. Saves you a lot of future headaches.

 

[randomdoc1]

I know people get scared of PP. But I say do not give up, at least, not easily. It's high risk, slow to build up, but the income ceiling is high. It is definitely feasible to exceed 600k a year as an evidence based and ethical psychiatrist. And also enjoy the autonomy, comfortable schedule, and getting all the credit you earned.

Or even more simply put, best of all worlds. Good lifestyle, meaningful work, time for family.

 

[Merovinge]

I have a very psychotherapy heavy practice, 60/40 insurance/cash. My intake process is… maybe excessive. I do a 15min zoom meet-and-greet to see if our vibes work well together, and my pre-appointment history form is… a lot. I think this weeds out a lot of the drug seekers, it’s not worth the hassle to have to talk to me for like 5 hours before I even entertain the thought of prescribing something more exciting than propranolol. I am not for folks who are looking for a retail “I want this, this, and this” type experience.

It probably also helps that I make it very clear that I want to know all the feelings and internal mechanics and details, I’m not someone they can just list diagnostic criteria to and walk out with a script. Because boy howdy will I have follow up questions.

I have not had a patient try to have an appointment while driving. In their car, parked, sure. But driving?! Why would *they* want that? Especially if they’re cash pay — what a waste of money!

If someone cancels after you set clear boundaries, then sounds like they’re right… it’s not a good fit. They want someone with wobbly boundaries, and that’s not you. Saves you a lot of future headaches.

Does not sound excessive to me at all, my friends/colleagues in cash private practice all have a 10-15 minute zoom or phone call before considering bringing someone in to establish a doctor/patient relationship as well as significant intake paperwork.