For those who do inpatient quickly - how?

[yanks26dmb]

I'm not asking how, as in, how is it possible? Just wondering how you do it. I know a lot of people can do it. But I'm out here moonlighting and it's taking me forever to get through a patient panel of 12. Like a full work day of 7-8 hours. What are you guys doing who see 15 patients then bounce to get to PP by noon? Between court, nurses stopping you, etc I just can't get myself to move faster. Any tips?

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[mistafab]

What’s your actual work flow?

As in, see patients 7-830, write notes 830-10, field nurses as they come, teams at 11, court at 1.

What is the flow of what you actually are doing with all that time.

 

[Jules A]

It depends on the type of unit too. Inner city where majority are manic or psychotic is quick vs affluent burbs with no shortage of clusterB traits takes considerably longer.

 

[yanks26dmb]

What’s your actual work flow?

As in, see patients 7-830, write notes 830-10, field nurses as they come, teams at 11, court at 1.

What is the flow of what you actually are doing with all that time.

I feel like I spend too much time chart reviewing, trying to figure out what the team the previous week did, etc.

I also think I get too obsessed with trying to get the right diagnosis, get all the history, etc. Like I feel some discomfort if I can't get to the bottom of whether this is unipolar + bpd vs bipolar vs bipolar + bpd

 

[G Sheb]

It's probably because you're doing a decent job.
There's no way you will see 12 patients and finish in a 3/4 hours without cutting corners.
12 patients is a full time job even in academic hospitals where residents pick up the majority of the work.
You should "obsess" over diagnosis, treatment..etc.

 

[nexus73]

I saw 11 patients today and was there 830-5, 2 admits, 1 discharge, 8 follow ups. It is my first day back on service so most are brand new. Subsequent days will usually be finishing around 3.

 

[yanks26dmb]

It's probably because you're doing a decent job.
There's no way you will see 12 patients and finish in a 3/4 hours without cutting corners.
12 patients is a full time job even in academic hospitals where residents pick up the majority of the work.
You should "obsess" over diagnosis, treatment..etc.

3/4 seems fast. But I was hoping I could get done in 5. I wanted to do both inpatient and outpatient after I finished this summer..but I don't know how people do it..

 

[clozareal]

Admit/discharge = support from good nurses and good social workers. One place I moonlight, the social worker handles all the discharge planning, where the medication goes afterwards, follow-up appointments, and family meetings.

Good signout from the weekday docs. Diagnosis, treatment plan, contingencies, legal issues to contend with. Orders cleaned up by Friday. The better the weekday docs, the smoother the weekend goes. The best moonlighting gigs you go in, figure out if you want to increase, decrease, or keep the meds the same, then be on your way. Do a targeted ROS to make sure there are no side effects from the previous day's med dose change. I try not to change the plan from the week too drastically otherwise you'll piss off the weekday docs unless it's really indicated (adverse reaction to treatment needing change in med). This also depends on good support from the milieu and programming.

When more is less = psychotic/manic patients who keep wanting to talk but all of that doesn't change your treatment plan. Doesn't take more than a few minutes to tell if a patient is still manic or psychotic and still meets hold criteria. The more psychotherapy you do, the less you get paid per hour if you are getting paid by number of patients seen and not CPT codes/RVU targets.

There are like 5 conditions on the inpatient unit: depression/suicidality, mania, psychosis, and rocks (those needing placement but can't get it). The more you do inpt, the faster you get at recognizing and managing each one.

 

[allantois]

I can’t remember the last time a saw a useful inpatient diagnosis.. lol

 

[SmallBird]

I think there are two components that determine how long things take: your efficiency, and the number of tasks you address. I think calling it a 'good or bad' job generates defensiveness and misses the point as people may do a good job quickly and a bad job slowly.

In terms of efficiency: you need to make sure that you redirect patients who provide repetitive narratives, you need to generate hypothesis as to the formulation very early in your interview, then test them and refine your questioning, rather than gathering all the data in the world and ending the interview without a sense of what is going on. Your documentation should be focused but also sufficient so that you aren't asked to supplement it for billing/legal purposes. You should manage the discussions during rounds and multidisciplinary meetings to ensure that your time is being used to provide the insights you are best suited to provide, and avoid simply being an observer to information sharing or care management sessions that don't require your input. In my current position, I arrive at 7am, spend an average of 15 minutes/patient seeing 11 patients, attend 30 minute rounds, document for an hour (I get in the 'zone' and dictate fast and avoid all distractions) and then on average spend an hour facilitating care through multidisciplinary engagement. Then there is a variable amount of time on other things - some days I cover consults so that adds an hour or two. Some days I really do leave at 1pm. Some days I am covering admits and try and see anybody that arrives before 2pm.

In terms of the tasks of the admission: I see my role as refining the formulation (eg diagnosis but often much more utility is derived by helping define more of the patients personality structure and psychosocial context then switching them from unspecified mood disorder to unspecified unspecified disorder or whatever); ensuring biomedical treatment is optimized; providing guidance to the social work team on the best focus for subsequent psychological and social treatment; providing brief therapy focused on addressing crisis-sustaining factors; and providing psychoeducation to the patient and AT MOST one family member if this is requested or appropriate because of their age.

I have covered 35 patients on a day once when my function was entirely redifined as simply identifying and responding to acute new events without doing any of the other tasks.

I have colleagues who are efficient but spend much longer on the unit because they include additional tasks in their role, including: working with social work on family systems issues that may be contributing to ongoing morbidity; doing more detailed therapy with patients focused on skill acquisition and understanding insights less related to the acute issue; participating in meetings with outpatient organizations to develop collaborative care plans for more difficult patients; taking a deep dive into non-psychiatric medical issues and connecting with outpatient specialists and PCPs to optimize these medications (this is the biggest time sink and I sometimes feel bad knowing someone is probably on the wrong anithypertensives but unless they are unstable its a case of 'refer back to PCP').

I think its unfortunate that people who see 7 patients a day assume that those seeing 20 are doing bad care. It is also unfortunate that people who see 20 a day can't acknowledge that there are probably helpful things they could be doing for a patient but are not doing and just own that rather than making fun of people who take longer.

 

[psychmd03]

It depends on the type of unit too. Inner city where majority are manic or psychotic is quick vs affluent burbs with no shortage of clusterB traits takes considerably longer.

This is quite important. High functioning +\- personality patients will eat up much more time than sick.

Work flow is very important. Efficient documentation is extremely important. You need good support staff set up that help with a lot of the work that isn’t direct patient care. IE sw that manages most family calls. Nursing that will call in meds or manage pharmacy issues the list goes on.

You need the experience as well to quickly diagnose people ie take in as much info as possible like as you walk to the patient what are they doing? Pacing? Shaking? Their walk? Are they talking to themselves? Can you hear them rambling about delusional odd things? Or are they isolated? Not doing ADLs? Rooms a mess barely eating? You can get all that info to start your differential before even talking. Then as soon as they start talking you gather more info. You should get very quick at this. Also in coverage personally I’m looking to cover not be their full doctor. They bring up dc I immediately defer and move the discussion. I want to know is there an effective plan right now? Are their SE? If they are a few days in have they been dispo planning? Do they have concerns that I will address or if they have concerns for the team I will take them down and document and forward that.

I was the same way when I started moonlighting in 3rd year. Now about 2.5 years out that type of coverage is a fun relaxing day.

Just some initial thoughts.

 

[Merovinge]

I can’t remember the last time a saw a useful inpatient diagnosis.. lol

I'd say for mania and psychosis IP units can be very helpful if there are decent docs to really describe the sx noted by themselves and by the staff. Knowing how bad someone can get when the wheels fall off is extremely useful information. There are a lot of other useful things to know like -personality issues arising in a new environment, conflicts with family, medical concerns, catatonia, etc. Is any of this going to be conveyed by most meat grinder IP units? Certainly not. Would it matter for someone's overall treatment and life if it did? It certainly could.

 

[Merovinge]

I think there are two components that determine how long things take: your efficiency, and the number of tasks you address. I think calling it a 'good or bad' job generates defensiveness and misses the point as people may do a good job quickly and a bad job slowly.

In terms of efficiency: you need to make sure that you redirect patients who provide repetitive narratives, you need to generate hypothesis as to the formulation very early in your interview, then test them and refine your questioning, rather than gathering all the data in the world and ending the interview without a sense of what is going on. Your documentation should be focused but also sufficient so that you aren't asked to supplement it for billing/legal purposes. You should manage the discussions during rounds and multidisciplinary meetings to ensure that your time is being used to provide the insights you are best suited to provide, and avoid simply being an observer to information sharing or care management sessions that don't require your input. In my current position, I arrive at 7am, spend an average of 15 minutes/patient seeing 11 patients, attend 30 minute rounds, document for an hour (I get in the 'zone' and dictate fast and avoid all distractions) and then on average spend an hour facilitating care through multidisciplinary engagement. Then there is a variable amount of time on other things - some days I cover consults so that adds an hour or two. Some days I really do leave at 1pm. Some days I am covering admits and try and see anybody that arrives before 2pm.

In terms of the tasks of the admission: I see my role as refining the formulation (eg diagnosis but often much more utility is derived by helping define more of the patients personality structure and psychosocial context then switching them from unspecified mood disorder to unspecified unspecified disorder or whatever); ensuring biomedical treatment is optimized; providing guidance to the social work team on the best focus for subsequent psychological and social treatment; providing brief therapy focused on addressing crisis-sustaining factors; and providing psychoeducation to the patient and AT MOST one family member if this is requested or appropriate because of their age.

I have covered 35 patients on a day once when my function was entirely redifined as simply identifying and responding to acute new events without doing any of the other tasks.

I have colleagues who are efficient but spend much longer on the unit because they include additional tasks in their role, including: working with social work on family systems issues that may be contributing to ongoing morbidity; doing more detailed therapy with patients focused on skill acquisition and understanding insights less related to the acute issue; participating in meetings with outpatient organizations to develop collaborative care plans for more difficult patients; taking a deep dive into non-psychiatric medical issues and connecting with outpatient specialists and PCPs to optimize these medications (this is the biggest time sink and I sometimes feel bad knowing someone is probably on the wrong anithypertensives but unless they are unstable its a case of 'refer back to PCP').

I think its unfortunate that people who see 7 patients a day assume that those seeing 20 are doing bad care. It is also unfortunate that people who see 20 a day can't acknowledge that there are probably helpful things they could be doing for a patient but are not doing and just own that rather than making fun of people who take longer.

Great post. I will say that the people seeing 50 patients/day as the primary doc do just almost universally provide bad care. 20 is definitely doable in the right setting and still doing good work. Having worked with the docs and the patient's of the docs who are part of the 50ish pts/day bucket in two different settings is quite the experience.

 

[TheRightMedication]

I do psychotherapy and can readily spend 50 minutes with a patient, yet I am confused by this question. If you have an inpatient that you're seeing for followup, and the diagnostic question is settled, and the treatment plan is made, how on earth does that take longer than 15 minutes? I see those patients for less time than that.

Unless you're bogged down with cases that require thorough diagnostics and collateral every day, or you have a ton of cases where building an alliance will make the difference in the case, I just don't see 15 or so patients taking all day.

 

[SmallBird]

I do psychotherapy and can readily spend 50 minutes with a patient, yet I am confused by this question. If you have an inpatient that you're seeing for followup, and the diagnostic question is settled, and the treatment plan is made, how on earth does that take longer than 15 minutes? I see those patients for less time than that.

Unless you're bogged down with cases that require thorough diagnostics and collateral every day, or you have a ton of cases where building an alliance will make the difference in the case, I just don't see 15 or so patients taking all day.

If you have 15 you could assume 3 new, 3 DC and 9 follow ups. The admits can take 30 min to see, and the discharges 20 min, so that's 2.5hrs in direct patient time. Another 2.5 hours to see the other 9 at 15 min each, and then rounds, documentation, and you are at 7 hours.

 

[TheRightMedication]

If you have 15 you could assume 3 new, 3 DC and 9 follow ups. The admits can take 30 min to see, and the discharges 20 min, so that's 2.5hrs in direct patient time. Another 2.5 hours to see the other 9 at 15 min each, and then rounds, documentation, and you are at 7 hours.

You gotta pump those numbers down, those are rookie numbers

Edit - see psychmd03 for tips in that regard.

 

[Stagg737]

I'm not asking how, as in, how is it possible? Just wondering how you do it. I know a lot of people can do it. But I'm out here moonlighting and it's taking me forever to get through a patient panel of 12. Like a full work day of 7-8 hours. What are you guys doing who see 15 patients then bounce to get to PP by noon? Between court, nurses stopping you, etc I just can't get myself to move faster. Any tips?

Get your workday schedule down and figure out how much time you need for each. For me a time table looks like the following:

Team huddle: <30 minutes
H&P and f/up notes: <60 minutes
Discharges/dispo: 30-60 mins (usually closer to 30)
Average time spent with patients: 30-60 mins/H&P, f/ups highly variable though typically 5-15 minutes unless you're adding on psychotherapy. for 10-12 patients this will probably come out to around 2-4 hours.

This should come out to less than a 6 hour day for the above. As others have said, patient population can make a huge difference. If 90% of your patients are laughing maniacally with their hallucinations and answer the question "How are you feeling today?" with responses like "Hot dogs are blue radio", the time spent with patients is dramatically cut down. Support staff is also essential, as good staff can take care of 95% of issues while babysitting poor staff or having to do a lot of collateral work can eat away your time. I rarely do extensive therapy when covering inpatient as our unit has PhD fellows and therapists seeing patients daily and CM is pretty solid.

On my "efficient" days when I cover ~8 patients my day looks like this:

7-8:30: See f/up and discharge patients
8:30-9:15: Treatment team and d/c orders
9:15-11: See new patients
11-1 or 2: Lunch and notes then done

This can vary significantly, but a lot of "new" patients will have already been evaluated by our ER (where I mainly work) or have been on the unit before, so I can usually start writing notes by 10:30. On good days I could easily be done by noon, but I like to work at a bit more relaxed pace and talk with therapists and CM, so I'm usually there a little longer. There's plenty of ways to increase efficiency, but imo the best way to work quickly and maintain good patient care is having a good support staff.

 

[hamstergang]

I feel like I spend too much time chart reviewing, trying to figure out what the team the previous week did, etc.

When just covering, this was a huge source of time for me as well. I'm not sure how to fix it without getting the primary team to do something different to help you.

 

[TheRightMedication]

When just covering, this was a huge source of time for me as well. I'm not sure how to fix it without getting the primary team to do something different to help you.

Call them up and get a sign out - otherwise you are indeed stuck with a big chart review for every patient.

 

[Sushirolls]

The fastests docs I've seen, are the ones who care less; and exhibit the following:
1) dictate notes
2) dictate almost every note the same with the same canned garbage lines
3) don't actually care about getting collateral, or outside records
4) Do the most terse intake notes, then still diagnose as bipolar, and start seroquel
5) freely give benzos
6) Dictate discharge summary note with same canned terse phrases without actually caring and putting details of what really happened in admission.
7) be sure to fluctuate from intake, to progress and discharge summary diagnosis, never be consistent, nor explain why a change
8) once you are off unit, don't return any phone calls or do any thing. The unit will figure it out...

 

[yanks26dmb]

Today went a bit better. was able to finish notes, round, discharge in about 4 hrs on 11 patients. It does seem to make a huge difference when I am familiar with the patients already.

Court seems like its an almost daily thing though (based on a few days experience I have in this hospital and state) and its not til early afternoon. How often are you all having to testify in court?

 

[Stagg737]

Court seems like its an almost daily thing though (based on a few days experience I have in this hospital and state) and its not til early afternoon. How often are you all having to testify in court?

Almost never, this is weird that court is a daily thing unless you're managing many patients on a state unit. How often are are patient's being made involuntary?

 

[allantois]

Twice weekly court here

 

[forchinet121]

Court is like once a month, why would court be weekly that would be horrible

 

[clozareal]

Most the units I've been it have courts once or twice weekly.

I think there are two components that determine how long things take: your efficiency, and the number of tasks you address. I think calling it a 'good or bad' job generates defensiveness and misses the point as people may do a good job quickly and a bad job slowly.

In terms of efficiency: you need to make sure that you redirect patients who provide repetitive narratives, you need to generate hypothesis as to the formulation very early in your interview, then test them and refine your questioning, rather than gathering all the data in the world and ending the interview without a sense of what is going on. Your documentation should be focused but also sufficient so that you aren't asked to supplement it for billing/legal purposes. You should manage the discussions during rounds and multidisciplinary meetings to ensure that your time is being used to provide the insights you are best suited to provide, and avoid simply being an observer to information sharing or care management sessions that don't require your input. In my current position, I arrive at 7am, spend an average of 15 minutes/patient seeing 11 patients, attend 30 minute rounds, document for an hour (I get in the 'zone' and dictate fast and avoid all distractions) and then on average spend an hour facilitating care through multidisciplinary engagement. Then there is a variable amount of time on other things - some days I cover consults so that adds an hour or two. Some days I really do leave at 1pm. Some days I am covering admits and try and see anybody that arrives before 2pm.

In terms of the tasks of the admission: I see my role as refining the formulation (eg diagnosis but often much more utility is derived by helping define more of the patients personality structure and psychosocial context then switching them from unspecified mood disorder to unspecified unspecified disorder or whatever); ensuring biomedical treatment is optimized; providing guidance to the social work team on the best focus for subsequent psychological and social treatment; providing brief therapy focused on addressing crisis-sustaining factors; and providing psychoeducation to the patient and AT MOST one family member if this is requested or appropriate because of their age.

I have covered 35 patients on a day once when my function was entirely redifined as simply identifying and responding to acute new events without doing any of the other tasks.

I have colleagues who are efficient but spend much longer on the unit because they include additional tasks in their role, including: working with social work on family systems issues that may be contributing to ongoing morbidity; doing more detailed therapy with patients focused on skill acquisition and understanding insights less related to the acute issue; participating in meetings with outpatient organizations to develop collaborative care plans for more difficult patients; taking a deep dive into non-psychiatric medical issues and connecting with outpatient specialists and PCPs to optimize these medications (this is the biggest time sink and I sometimes feel bad knowing someone is probably on the wrong anithypertensives but unless they are unstable its a case of 'refer back to PCP').

I think its unfortunate that people who see 7 patients a day assume that those seeing 20 are doing bad care. It is also unfortunate that people who see 20 a day can't acknowledge that there are probably helpful things they could be doing for a patient but are not doing and just own that rather than making fun of people who take longer.

This is a great post. Amount of time spent is not necessarily representative of the quality of care given on an inpatient unit. Doing all that extra fluff (obtaining collateral, family meetings, talking with nurses and therapists, writing extremely detailed notes in the subjective despite it not being used for billing, etc) may not contribute to the overall plan and contribution you can make as a weekend moonlighter. It's also important to note that there is limited treatment alliance over the weekend anyways.

Here are how my meetings go with the patient, which usually take all of 10 minutes per patient:
"Hi. I'm Dr. Clozareal, the psychiatrist covering for today and tomorrow. I'm here to talk to you about your medications. It looks like Seroquel was increased last night to 300mg. How did you sleep last night? Any headaches? Lightheadedness? Dizziness on standing up? [side effects from medication] How is your mood? Can you get up and walk around the room for me? [test for EPS and orthostatic hypotensive symptoms] How is it going with [hallucinations/delusional thoughts]? Is it better, worse, or about the same as yesterday? What's the plan on where you will go after discharge? [checking for hold criteria on why they still need to be admitted]. You won't be discharged over the weekend. The plan is to continue the Seroquel at this dose for another day and then increase it to 400mg tomorrow night if you're tolerating it well and it's helping. If there are any issues that come up with your medications, you can always ask your nurse about them. See you tomorrow."

Documentation [shortened]:
S: slept 8 hours, no orthostatic hypotensive symptoms after increasing Seroquel to 400mg as he denies dizziness or lightheadedness when standing. Hallucinations slightly better but continues to hear them intermittently throughout the day, telling him to do things but nothing violent, which he reports a hard time resisting half the time. Says he wants to leave but when asked where he would go, he says will sleep on the ground outside next to bus stop. When asked about keeping warm from the snow, he curses me out saying that there is no snow even when I pointed it outside the window.
O: no parkinsonism or cogwheeling rigidity, no akathisia, auditory hallucinations improved but continue to be present, mood is "good," insight limited given inability to verbalize plan for shelter in keeping warm from snow outside. [pull in vitals]
A: 40M with schizophrenia, admitted for acute decompensation off medications. Today, slight improvement of hallucinations after increasing dose of Seorquel. Continue same dose as he is tolerating it without adverse effects such as EPS. Patient requires continued hospitalization for inability to care for self in terms of shelter due to psychotic symptoms.
P:
#1 Unspecified psychosis
- Continue Seroquel 400mg PO at bedtime, plan to increase tomorrow
- Baseline metabolic labs normal, EKG not indicated at this time
- Continue to monitor for side effects of EPS and orthostasis with Seroquel
- Continue involuntary hold/civil commitment

There's a lot of redirection and ignoring manic/psychotic content once my formulation hypothesis has been confirmed.

 

[Doctorows]

On my "efficient" days when I cover ~8 patients my day looks like this:

7-8:30: See f/up and discharge patients
8:30-9:15: Treatment team and d/c orders
9:15-11: See new patients
11-1 or 2: Lunch and notes then done

Do you go right into seeing new patients without any chart review? When do you call their outpatient psychiatrists? Return phone calls from family? Family meetings? These things take a huge chunk of my day, but I can't imagine treating patients on the inpatient unit (not talking about weekend coverage) without doing them.

 

[calvnandhobbs68]

Do you go right into seeing new patients without any chart review? When do you call their outpatient psychiatrists? Return phone calls from family? Family meetings? These things take a huge chunk of my day, but I can't imagine treating patients on the inpatient unit (not talking about weekend coverage) without doing them.

lol I have never once gotten a call from an inpatient psychiatrist or even resident when a patient of mine has been admitted. I often don't even find out about an admission until I get the discharge paperwork (50/50 if that gets sent over) and the patient shows up with a "oh yeah I was in the hospital for 2 weeks last month". I did once get a call from a great resident in the ER about one of my patients who I was happy to talk to but that's been it for the last 1.5 years.

So from my experience calling outpatient psychiatrists doesn't seem to be the standard of care.

 

[psychmd03]

When just covering, this was a huge source of time for me as well. I'm not sure how to fix it without getting the primary team to do something different to help you.

I do a lot of coverage still and agree that you might need a sign-out. Personally to me, if I am covering on the weekend IE two days the weekday crew better have their work buttoned up and plan set. DCs over the weekend need to be prepped, meds sent, dispo plan (IMO that is a sw job not us anyway) better be set. I am not here on the weekend to do those things. I am here to make sure the wheels aren't falling off and make changes if there are SE or issues popping up. Personally, I don't really chart review unless I am seeing something that looks grossly off IE catatonic person taking a boatload of typicals, someone looks delirious to me. Now I will need to dive in to see what has been going on and what has been done. Otherwise, the manic patient that is still rambling a million miles a minute I will check meds see if they are being taken, check doses, last inc and if any levels are coming up that need to be done. For new patients normally I can pick up on the person's prescribing patterns so I can start meds and plans that will line up with each particular treatment team so as to set up a smooth transition to the week but that doesn't really take time just pattern recognition. Just my thought and take on coverage. I get feedback from those I cover and adapt if someone doesn't like the coverage.

 

[psychmd03]

Almost never, this is weird that court is a daily thing unless you're managing many patients on a state unit. How often are are patient's being made involuntary?

I am also blown away at the idea of court daily. I involuntarily med petition more patients than most in my metro area it seems because 4 judges and 4 state attorneys know me quite well and make jokes about seeing me but even at my worst time when I had multiple petitions going at once. I average going to court once every other month but still likely less than that.

Agreed with Stagg unless this is a state hospital and even more likely a forensic I did training in a state hospital and court still was nowhere near that often. I would be very curious as to the reason for each court hearing?

 

[Doctorows]

lol I have never once gotten a call from an inpatient psychiatrist or even resident when a patient of mine has been admitted. I often don't even find out about an admission until I get the discharge paperwork (50/50 if that gets sent over) and the patient shows up with a "oh yeah I was in the hospital for 2 weeks last month". I did once get a call from a great resident in the ER about one of my patients who I was happy to talk to but that's been it for the last 1.5 years.

So from my experience calling outpatient psychiatrists doesn't seem to be the standard of care.

Hmm I've had a very different experience both in residency and now. I've heard horror stories about the quality of care in a couple of private hospitals in town and know that not everyone makes the effort to communicate with outpatient providers, but I thought those were the crappy places, not academic psychiatrists who strive to provide better than crappy care... I don't know, I wouldn't feel good about prescribing the first mood stabilizer that comes to mind to a manic patient who cannot provide a clear history of previous med trials without calling the person who has been managing their care for years. Or putting a depressed patient with vague history (many previous admissions for a "nervous breakdown") on an SSRI without checking for history of mania. Not to mention the fact that many manic/psychotic patients often don't even know what meds they are supposed to be on at the time of admission, let alone meds they've trialed in the past.

 

[SmallBird]

You gotta pump those numbers down, those are rookie numbers

Edit - see psychmd03 for tips in that regard.

I'm good, thanks though.

 

[Tangerine123]

once you are off unit, don't return any phone calls or do any thing. The unit will figure it out...

You mean once you clock out?
If you did your hand-off correctly this should be a non-issue. Acute problems will be solved by the nightshift, anything else can wait until the next day. It's unhealthy if you can't disconnect from work.

 

[calvnandhobbs68]

You mean once you clock out?
If you did your hand-off correctly this should be a non-issue. Acute problems will be solved by the nightshift, anything else can wait until the next day. It's unhealthy if you can't disconnect from work.

Lol no like take off at 12PM and don’t return any phone calls from the nurses or social workers or anything despite the fact that you’re technically “on” still (usually because you’re over at your second job or doing your private practice outpatient clinic or out surfing….). This absolutely happens.

 

[Trismegistus4]

The fastests docs I've seen, are the ones who care less; and exhibit the following:
1) dictate notes
2) dictate almost every note the same with the same canned garbage lines
3) don't actually care about getting collateral, or outside records
4) Do the most terse intake notes, then still diagnose as bipolar, and start seroquel
5) freely give benzos
6) Dictate discharge summary note with same canned terse phrases without actually caring and putting details of what really happened in admission.
7) be sure to fluctuate from intake, to progress and discharge summary diagnosis, never be consistent, nor explain why a change
8) once you are off unit, don't return any phone calls or do any thing. The unit will figure it out...

LOL, so true. The one "psychiatrist" (if you can call him that) at my institution who leaves earliest is like this. Spends less than 2 hours seeing all patients (even if that includes several new admits,) puts everybody on the same meds, notes are nothing but copy-and-paste from other people's notes and copy-forward (leading to blatant falsehoods like "I assumed care of the patient today" being in the daily note for 3 days straight,) and if anyone asks him to do anything more, indignantly huff "I don't have time" despite being out the door at noon.

 

[forchinet121]

LOL, so true. The one "psychiatrist" (if you can call him that) at my institution who leaves earliest is like this. Spends less than 2 hours seeing all patients (even if that includes several new admits,) puts everybody on the same meds, notes are nothing but copy-and-paste from other people's notes and copy-forward (leading to blatant falsehoods like "I assumed care of the patient today" being in the daily note for 3 days straight,) and if anyone asks him to do anything more, indignantly huff "I don't have time" despite being out the door at noon.

Is this the VA? How old is the doc?

 

[luckybuck]

LOL, so true. The one "psychiatrist" (if you can call him that) at my institution who leaves earliest is like this. Spends less than 2 hours seeing all patients (even if that includes several new admits,) puts everybody on the same meds, notes are nothing but copy-and-paste from other people's notes and copy-forward (leading to blatant falsehoods like "I assumed care of the patient today" being in the daily note for 3 days straight,) and if anyone asks him to do anything more, indignantly huff "I don't have time" despite being out the door at noon.

Honestly thats the way to do it

 

[yanks26dmb]

Almost never, this is weird that court is a daily thing unless you're managing many patients on a state unit. How often are are patient's being made involuntary?

This is a community hospital. Court meets 4/5 days a week. It feels like 80% of my patients are on some kind of legal hold and there some kind of hearing that pops up for them.

 

[GoSpursGo]

Let's please leave the off-topic discussion about affirmative action out of this thread. That's been a debate since the dawn of SDN, and this isn't really the underlying question being asked in this thread.

 

[FlowRate]

lol I have never once gotten a call from an inpatient psychiatrist or even resident when a patient of mine has been admitted. I often don't even find out about an admission until I get the discharge paperwork (50/50 if that gets sent over) and the patient shows up with a "oh yeah I was in the hospital for 2 weeks last month". I did once get a call from a great resident in the ER about one of my patients who I was happy to talk to but that's been it for the last 1.5 years.

So from my experience calling outpatient psychiatrists doesn't seem to be the standard of care.

It's funny, when I was in residency it was absolutely standard of care to at least call the outpatient doc once (and coordinate a conversation if you don't reach them and they reach out to you). I've only received outreach from inpatient teams maybe 5% of the time I've had patients admitted here and that's probably being generous, including the units with residents, as well.

 

[forchinet121]

It's funny, when I was in residency it was absolutely standard of care to at least call the outpatient doc once (and coordinate a conversation if you don't reach them and they reach out to you). I've only received outreach from inpatient teams maybe 5% of the time I've had patients admitted here and that's probably being generous, including the units with residents, as well.

That’s been my experience as well we don’t routinely or ever really call the outpatient doc

 

[Sushirolls]

It's funny, when I was in residency it was absolutely standard of care to at least call the outpatient doc once (and coordinate a conversation if you don't reach them and they reach out to you). I've only received outreach from inpatient teams maybe 5% of the time I've had patients admitted here and that's probably being generous, including the units with residents, as well.

I have had 0 calls. 0 records requests.
I have at least 3 patients adamantly tell their inpatient "team" be it nurse, doc, SW, etc call my OP psychiatrist (me) and get my records, get my history, etc. This was from a for profit free standing psych hospital.

Another non-profit, large health system, smaller fraction of patient admission from my panel, no contact either.

I have a long rant on this topic. Don't get me started.

 

[FlowRate]

That’s been my experience as well we don’t routinely or ever really call the outpatient doc

TBH that's really poor form and should change, especially if your listed status as resident is accurate. (At most programs, residents have ample time to do this.)

I have had 0 calls. 0 records requests.
I have at least 3 patients adamantly tell their inpatient "team" be it nurse, doc, SW, etc call my OP psychiatrist (me) and get my records, get my history, etc. This was from a for profit free standing psych hospital.

Another non-profit, large health system, smaller fraction of patient admission from my panel, no contact either.

I have a long rant on this topic. Don't get me started.

Really frustrating. Nothing like your patient being admitted with all of the meds changed (including benzo added), contingencies/plans ignored from your documentation, and an inappropriate diagnosis given, with zero outreach from the inpatient team about any of it.

 

[forchinet121]

TBH that's really poor form and should change, especially if your listed status as resident is accurate. (At most programs, residents have ample time to do this.)

Really frustrating. Nothing like your patient being admitted with all of the meds changed (including benzo added), contingencies/plans ignored from your documentation, and an inappropriate diagnosis given, with zero outreach from the inpatient team about any of it.

I mean I think everyone has ample time to do this if they want to it’s not limited to residents or med students, if you want to make less money as an attending you could do this as well but no one does and that’s how we are trained unfortunately

 

[FlowRate]

I mean I think everyone has ample time to do this if they want to it’s not limited to residents or med students, if you want to make less money as an attending you could do this as well but no one does and that’s how we are trained unfortunately

For sure, I think it's standard of care and professional courtesy for any level to do it, I'm just highlighting there are learning and quality of care opportunities as a resident that are being missed while you actually have somewhat more protected bandwidth (at most programs) to do it.

This is coming from someone who hates the game of phone tag with outside therapists and inpatient units but I do it anyway.

 

[Candidate2017]

Outpatient psychiatrists are a real touchy bunch about inpatient doctors not reaching out to them.

Really frustrating. Nothing like your patient being admitted with all of the meds changed (including benzo added), contingencies/plans ignored from your documentation, and an inappropriate diagnosis given, with zero outreach from the inpatient team about any of it.

I really don't care if inpatient psych changes my patient's meds. I'm not tied to the meds I prescribe, and if really want, I can just change them back. Or wait and see if the new med changes will do them good.

In every non-psych specialty, the inpatient physician or consultant rarely contacts the PCP or outpatient specialist. They often change meds wholesale and do what needs to be done to stabilize a seriously ill patient that's in front of them. Then they discharge the patient with a summary and list of meds. And I've never seen any PCP or outpatient specialist get their knickers in a bunch over med changes.

The most troubling thing about inpatient psych, is that some psych hospitals never send a discharge summary, and take 1-2 weeks to do so after you request it.

 

[Candidate2017]

The other side is that outpatient psychiatrists rarely return calls from inpatient psychiatrists, and rarely send requested records. Any records that are sent arrive 1-2 weeks after the patient has been discharged.

If we don't want to relinquish control, then we need to be old school doctors that admit and round on our own patients. Some PCPs and medical specialists do this. Some very old psychiatrists also do this. But again, if we want an inpatient/outpatient dichotomy, then we have to be ok with another psychiatrist doing what needs to be done right here, right now to treat the patient in front of them, including changing meds or diagnoses.

 

[ObsequiousAplomb]

TBH that's really poor form and should change, especially if your listed status as resident is accurate. (At most programs, residents have ample time to do this.)

Really frustrating. Nothing like your patient being admitted with all of the meds changed (including benzo added), contingencies/plans ignored from your documentation, and an inappropriate diagnosis given, with zero outreach from the inpatient team about any of it.

Regarding the IP docs adding a benzodiazepine: does that actually happen to you with frequency? I've never once seen an inpatient doc do that, even when a benzodiazepine or other controlled substance would be clearly indicated. Not that they call me first, but that they just don't do it. Even obviously catatonic patients are given two or three antipsychotics by the IP docs I've worked with because they're so staunchly head-in-the-sand anti-benzodiazepine.

I've absolutely seen the reverse, where a patient was taking Klonopin 0.5 mg qhsprn and the inpatient team immediately replaced it with gabapentin 100 mg tidprn, Vistaril 50 Q6H standing, melatonin 10 mg qhsprn, trazodone 25 mg qhsprn AND switching their maintenance medication to something their insurance doesn't cover all because they were involuntarily hospitalized for saying things like "I just get so anxious I wish it would all just go away" or some other vague BS. They make sure to document that the Klonopin was severely too highly dosed, etc.

 

[FlowRate]

Outpatient psychiatrists are a real touchy bunch about inpatient doctors not reaching out to them.


I really don't care if inpatient psych changes my patient's meds. I'm not tied to the meds I prescribe, and if really want, I can just change them back. Or wait and see if the new med changes will do them good.

In every non-psych specialty, the inpatient physician or consultant rarely contacts the PCP or outpatient specialist. They often change meds wholesale and do what needs to be done to stabilize a seriously ill patient that's in front of them. Then they discharge the patient with a summary and list of meds. And I've never seen any PCP or outpatient specialist get their knickers in a bunch over med changes.

The most troubling thing about inpatient psych, is that some psych hospitals never send a discharge summary, and take 1-2 weeks to do so after you request it.

If you don't see how what we do is different from what internists do--and thus the utility of a brief call with the outpatient doc or therapist in at least some cases--then I don't think there's much to discuss. It's not about being "tied to the meds you prescribe"--I'm not, either.

Regarding the IP docs adding a benzodiazepine: does that actually happen to you with frequency?

With frequency? I'd be lying if I said yes. But it has come up multiple times in the last year or so. I'm not like universally anti-benzo, these were just cases where it was an odd addition. One didn't even get it while on the unit, just given it "to go."

 

[comp1]

So I definitely concur that 12 patients is a full time job WITH residents. If you're doing it without residents, it's more than a full time job and hopefully you are being compensated appropriately. As far as how you do inpatient fast, well, it does have to do with chart review. In my experience, the chart is often a better reporter for inpatient than the patient is. Fast providers will work somewhere that has detailed inpatient and outpatient charting on patients going back decades that you can quickly skim to form a history. Fast providers will also always be working at the top of their license, meaning that they won't generally be doing discharge planning, which is by far the hardest part of managing inpatients. The FASTEST providers will have other people doing things like collecting collateral for them.

 

[psychmd03]

I have had 0 calls. 0 records requests.
I have at least 3 patients adamantly tell their inpatient "team" be it nurse, doc, SW, etc call my OP psychiatrist (me) and get my records, get my history, etc. This was from a for profit free standing psych hospital.

Another non-profit, large health system, smaller fraction of patient admission from my panel, no contact either.

I have a long rant on this topic. Don't get me started.

At risk of getting you started I will play devils advocate......other than helping make sure a very poor doctor doesn't give a garbage schizophrenia diagnosis and prescribe a start antipsychotic bid without ever truly taking into account what the patient is saying about past medications trials and diagnosis (I would argue that doctor could be given records to their face and that wont change their poor treatment plan) what will the OS records do to assist with IP care? Since the plan is not working if the patient landed IP and a treatment regimen will be started whether it will be a restart of OP medication and an assumption the patient wasn't taking them or new meds if the patient is gonna hold to their compliance. But no matter what the treatment plan is they will be monitored for stability and discharged once stable and a new appt is made for follow up. They should not be discharged on a medication plan that is not working and the OP records really wont modify that in any meaningful way.

When I was doing OP I dont think I ever got contacted but when my patient would come back and say they were IP we would discuss how they were doing with the new meds and then start adjusting based on how they were doing. I never would have told an IP doc what meds to use or not used as I was not seeing my patient in an IP state and that is quite different than they present OP.