How consistent are your private practice hours?

[Psychresy]

I'm just starting out on my own. I'm currently going through the paneling process with a big payor in my area. I am also taking cash and have a couple patients lined up so far. In my ideal world, I would be doing 18 hours of outpatient a week (3x6 hour days - anything more than 6 hours of outpatient and I'm too drained).

For those further down the path, how consistent are your weekly hours week over week? Are you generally around your ideal work load or is it a week of 5 hours followed by a week of 25?

Once I fill up (I'm imagining 6-9 months) should I expect to be able to get pretty close to my desired weekly hours each week? To that point, how do you correlate desired weekly hours to the practice being full and closed to new patients? As in, how many patients will I need to have on my panel to fill 18 hours each week?

Any other tips to manage work flow and overall work load? I would rather over schedule than under schedule and not be filling enough hours each week but I don't want to go overkill either.

---

Members don't see this ad.

 

[TexasPhysician]

I’ve never closed to new patients. Patients move, change insurance, taper off meds, transfer to PCP, etc. Availability to be seen within 1-2 months just fluctuates.

If my clinical hours was set at 18 per week, I’d expect to work 16-22/week after ramping up. There are cancellations or random slow weeks that drop the number a bit. Then there are “full moons” where I’ve got 4+ urgent cases to fit in that week. Sometimes a good local referral source asks me to fit in a new patient. Working an extra hour here and there keeps the referral sources happy.

 

[FlowRate]

Are you taking on any more traditional therapy patients or are you aiming for a more purely 30-min f/u E/M and 90833 type practice?

 

[Psychresy]

Are you taking on any more traditional therapy patients or are you aiming for a more purely 30-min f/u E/M and 90833 type practice?

Aiming for the 30min f/u em+90833

 

[calvnandhobbs68]

Aiming for the 30min f/u em+90833

This has come up before but basically multiply your weekly patients you'd expect to see when "full" by what you think your average followup time would be (usually generally anywhere from 1-3 months in psychiatry, sometimes 6 months). Give some wiggle room to keep accepting intakes and recognize that there's gonna be a certain percentage of turnover (people leaving, going back to PCP, getting d/c'd by you).

I'm like @TexasPhysician, I've never been "closed" to new patients and it'll be 2 years now in about a month. I do tend to space people out when stable to 2-3 months fairly quickly but even most of my really stable patients are still every 3 months max....if longer than that I send back to the PCP unless it's a college kid coming back during breaks or something. Generally weeks are pretty consistent but there are days when like 4/14 patients will no show or something (usually during the summer lol).

 

[jbomba]

This has come up before but basically multiply your weekly patients you'd expect to see when "full" by what you think your average followup time would be (usually generally anywhere from 1-3 months in psychiatry, sometimes 6 months). Give some wiggle room to keep accepting intakes and recognize that there's gonna be a certain percentage of turnover (people leaving, going back to PCP, getting d/c'd by you).

I'm like @TexasPhysician, I've never been "closed" to new patients and it'll be 2 years now in about a month. I do tend to space people out when stable to 2-3 months fairly quickly but even most of my really stable patients are still every 3 months max....if longer than that I send back to the PCP unless it's a college kid coming back during breaks or something. Generally weeks are pretty consistent but there are days when like 4/14 patients will no show or something (usually during the summer lol).

Should you multiply your weekly patients when full by 4 (if doing 1 month visits on average)?

In op case, 36 weekly patients x 4 weeks would mean 144 patients to be full if each came back once a month.

 

[calvnandhobbs68]

Should you multiply your weekly patients when full by 4 (if doing 1 month visits on average)?

In op case, 36 weekly patients x 4 weeks would mean 144 patients to be full if each came back once a month.

Yeah just in my experience there aren't a ton of patients that want to keep coming back every 4 weeks forever, especially if they have an outside therapist as well. Even if they don't, most people don't want to keep coming back every month just for you to refill their Lexapro and Concerta if there's not a lot going on.

 

[TexasPhysician]

Should you multiply your weekly patients when full by 4 (if doing 1 month visits on average)?

In op case, 36 weekly patients x 4 weeks would mean 144 patients to be full if each came back once a month.

Most patients should improve and move out to q3 months. Then eventually taper off meds or transfer back to PCP. You’ll always have patients moving in and out of rotation. If patients are coming back monthly forever, there is a problem.

 

[jbomba]

Most patients should improve and move out to q3 months. Then eventually taper off meds or transfer back to PCP. You’ll always have patients moving in and out of rotation. If patients are coming back monthly forever, there is a problem.

Even if you're doing therapy with them?

 

[TexasPhysician]

Even if you're doing therapy with them?

Patients that do 30 min med follow-ups with some therapy rarely want monthly appointments unless they are struggling.

 

[Sushirolls]

I have an excel spread sheet that I started when I opened.
Rows are the 52 weeks of the year. Color coded for each Quarter.

Column 1 "week"
Column 2 "consults"
Column 3 "follow ups"
Column 4 Date, basically the Monday of that week 7/17, 7/24, etc
Column 5 is for data, I have one spot that sums the consults, sums the follow ups, and averages the consults, and averages the follow ups.
Column 6 "clinical hours" Is where you do this math (1.5 x avg consult) + (0.5 x avg follow up) = avg clinical hours per week

*If you take a vacation week, you enter 0 and 0 and it pulls your average. But even if you worked less days, it still pulls your average. Is what it is.
*I do 90 minute consults, hence the 1.5 multiplier. I do 30 min followups, hence the 0.5 multiplier.

See my cut paste of this year Q2:

	4	11	3-Apr	Q2
15	4	6	10-Apr
	3	18	17-Apr
	2	9	24-Apr
	4	6	1-May
	3	13	8-May
20	4	5	15-May
	3	9	22-May
	1	11	29-May
	1	14	5-Jun
	4	11	12-Jun
25	4	5	19-Jun	39	135
	2	17	26-Jun	3.0	10.4	9.7

 

[jbomba]

I have an excel spread sheet that I started when I opened.
Rows are the 52 weeks of the year. Color coded for each Quarter.

Column 1 "week"
Column 2 "consults"
Column 3 "follow ups"
Column 4 Date, basically the Monday of that week 7/17, 7/24, etc
Column 5 is for data, I have one spot that sums the consults, sums the follow ups, and averages the consults, and averages the follow ups.
Column 6 "clinical hours" Is where you do this math (1.5 x avg consult) + (0.5 x avg follow up) = avg clinical hours per week

*If you take a vacation week, you enter 0 and 0 and it pulls your average. But even if you worked less days, it still pulls your average. Is what it is.
*I do 90 minute consults, hence the 1.5 multiplier. I do 30 min followups, hence the 0.5 multiplier.

See my cut paste of this year Q2:

	4	11	3-Apr	Q2
15	4	6	10-Apr
	3	18	17-Apr
	2	9	24-Apr
	4	6	1-May
	3	13	8-May
20	4	5	15-May
	3	9	22-May
	1	11	29-May
	1	14	5-Jun
	4	11	12-Jun
25	4	5	19-Jun	39	135
	2	17	26-Jun	3.0	10.4	9.7

That's great thanks for sharing. Are you taking insurance? Could you do more weekly consults if you wanted?

I'm curious how fast I may fill if I were to get on with one to two big panels in a major city. I've had people in residency tell me 3-4 months but that seems like an awful lot of new consults if we're calculating a need for a patient panel of 240ish for 15 hours a week.

 

[clozareal]

For me, it fluctuates between 12-20 clinical hours per week, my max being 24 which I've only hit like a few weeks out of the year and those were my most exhausting weeks. Luminello tells me I'm averaging 15.31 hours per week. It mostly depends on my vacation schedule. Because of this, my income also fluctuates around ± $10k per month. My goal is to get to 16-18 clinical hours per week to meet my financial goals.

 

[rjs2131]

If you want to consistently be full after 3-4 months (I filled 30 clinical hours of an insurance practice by month 4 and have never dropped below 28-29 clinical hrs/week outside of vacation/holiday - just hit the 2 year mark), here are things that helped me:

- Marketing well from the start (psychology today, letters to PCP and peds, letters to local therapists)
- 90 min news, 30 min follow-ups (I see CAP + adults)
- See new patients back within a few weeks (sooner if needed) and then space out after that (I don’t go longer than 3 months between visits)
- Quick access to communicating with patients - not everyone likes this, but I use email almost exclusively and this makes me efficient + allows me to keep a running cancellation/waitlist so I can very quickly pull a patient into an empty slot if needed…I’ve had times where I’ve scheduled someone the same day


Hope that helps!

 

[Sushirolls]

That's great thanks for sharing. Are you taking insurance? Could you do more weekly consults if you wanted?

I'm curious how fast I may fill if I were to get on with one to two big panels in a major city. I've had people in residency tell me 3-4 months but that seems like an awful lot of new consults if we're calculating a need for a patient panel of 240ish for 15 hours a week.

I am taking insurance.
I use Thursdays to some times do just a few extra consults, like a release valve if necessary.

 

[clausewitz2]

If you want to consistently be full after 3-4 months (I filled 30 clinical hours of an insurance practice by month 4 and have never dropped below 28-29 clinical hrs/week outside of vacation/holiday - just hit the 2 year mark), here are things that helped me:

- Marketing well from the start (psychology today, letters to PCP and peds, letters to local therapists)
- 90 min news, 30 min follow-ups (I see CAP + adults)
- See new patients back within a few weeks (sooner if needed) and then space out after that (I don’t go longer than 3 months between visits)
- Quick access to communicating with patients - not everyone likes this, but I use email almost exclusively and this makes me efficient + allows me to keep a running cancellation/waitlist so I can very quickly pull a patient into an empty slot if needed…I’ve had times where I’ve scheduled someone the same day


Hope that helps!

I think communicating quickly with patients (but in a way with clear and consistent boundaries) plus being able to see people relatively quickly as needed, plus no-show/late cancel fees are the way to go. My modal patient is probably seen every 6 weeks; I do 3 months in rare cases and usually don't do more than 8-10 weeks for anyone I'm prescribing controlled substances to. I have a lot who have been doing qmonth for years now, just no longer a majority. I am honestly getting antsy that it is getting hard to find slots for follow-ups less than a month out. I recognize not everyone wants to follow people as closely as all this.

 

[whopper]

I'm like @TexasPhysician, I've never been "closed" to new patients and it'll be 2 years now in about a month. I do tend to space people out when stable to 2-3 months fairly quickly but even most of my really stable patients are still every 3 months max....if longer than that I send back to the PCP unless it's a college kid coming back during breaks or something. Generally weeks are pretty consistent but there are days when like 4/14 patients will no show or something (usually during the summer lol).

Same here but I now only take referrals. Why? Cause I've noticed about 5-10% of brand new patients turn out to be a-holes. I don't mean they're sick, I mean they're downright rude, give me and my assistant unneeded grief and are highly entitled. E.g. guy changes his phone number, doesn't tell us, and then gets mad at us when we haven't called him. "You're a professional. I expect you to know my phone number even if I don't inform you I changed it."

Also I've noticed about 5% of brand new patients who weren't referred shouldn't have seen me in the first place. "Since you're a psychiatrist can you tell me if I'll have a good future?"

I've noticed with referrals less than 1% are a-holes and they usually have already been filtered as having a real problem a psychiatrist could help.

I also make patients self-schedule. Don't let their family members do so. Could be a HIPAA violation but this way if they don't show up they can't claim you can't hold them responsible. Also it eliminates the type of patient who doesn't want help who's only there cause their family member "thinks something's wrong with me."

 

[Sushirolls]

I have noticed any correlations of referral versus self referral regarding patient demeanor. Just a role of the dice each encounter.

I concur on the patient scheduling, and patient filling out questionnaires and not family. If some patients truly aren't capable of online forms themselves and family do it, I've defaulted to truly treating it as consult, send it back to PCP. I don't have the staff, time (resources), to manage extra barriers of patients who can't fully direct their care.

 

[Merovinge]

I think communicating quickly with patients (but in a way with clear and consistent boundaries) plus being able to see people relatively quickly as needed, plus no-show/late cancel fees are the way to go. My modal patient is probably seen every 6 weeks; I do 3 months in rare cases and usually don't do more than 8-10 weeks for anyone I'm prescribing controlled substances to. I have a lot who have been doing qmonth for years now, just no longer a majority. I am honestly getting antsy that it is getting hard to find slots for follow-ups less than a month out. I recognize not everyone wants to follow people as closely as all this.

I think that's basically model OP CAP care, if someone is more stable than that they should be going back to their PCP. A panel full of psychostimulant q3 month checks is just not keeping up with the times, we have so much burden of illness in the CAP age range these days that we need to be seeing the quite sick kids that could not be managed at the PCP level.

 

[Sushirolls]

I think that's basically model OP CAP care, if someone is more stable than that they should be going back to their PCP. A panel full of psychostimulant q3 month checks is just not keeping up with the times, we have so much burden of illness in the CAP age range these days that we need to be seeing the quite sick kids that could not be managed at the PCP level.

From a societal resource perspective, or thinking in terms of health system level of care sure, perhaps.

But at the individual professional level, and level of the patient, I don't fault or criticize any doc who opts for this. Allows for a more balanced work/life. Patient also gets stability, continuity, and positive experience that echos into their later years of having a positive experience with psychiatry.

I've been trained to deal wide variety of mental health from my quality residency program, but now, I've scaled things way back. Way back. Not concerned with shouldering society failures/burdens or optimizing my skillset for the better of society. Nope. Just biting off a little, and helping who I do. That's good enough.

I'll mention to my adult Q3 patients option to go back to their PCP once, after their stable, and some do pursue that. But I'm fine seeing stable Q3.

Oh, and if my practice ever bursts with stable Q3, I'll start doing shared medical appointments to accommodate the population.

*Do we tell roofers you must only do the most steep pitched, angled, roofs? Or those most rotten, moss covered and hail damaged?
*Do we tell CPAs they must refer their clients to DIY accounting tax prep kits, and they only do the difficult cases?
*Do we tell JDs only take challenging cases, and refer the rest ChatGPT?

 

[calvnandhobbs68]

I think that's basically model OP CAP care, if someone is more stable than that they should be going back to their PCP. A panel full of psychostimulant q3 month checks is just not keeping up with the times, we have so much burden of illness in the CAP age range these days that we need to be seeing the quite sick kids that could not be managed at the PCP level.

I think it just depends on who your patient population is in general. I dont have a “panel full” of q3 month patients but you can look at it from the other perspective too, that spacing more stable patients out more quickly if able actually allows me to see more intakes or fit in more acute patients more easily. There’s arguments to be made in all directions in terms of frequency and necessity of patients on your panel. I also agree with points @Sushirolls made above.

I do generally offer to patients to have their PCP manage things esp if they’re just on one med and we’ve been at q3 month visits for a couple visits but many parents would prefer to stay with me or many young adult patients don’t HAVE a PCP (which I always talk to them about anyway but I can’t exactly make them get a pcp….).

I’ve also definitely found that parents are not eager to have their kids come back every 6 weeks during the school year anyway…

In child much more than adult there are also many pediatricians who don’t want to or would rather not manage a kid even on a stable SSRI and stimulant for instance or a kid on trileptal or lamictal or Abilify etc or a kid who has a history of being hospitalized, especially if they already have an outpatient psychiatrist they’re seeing. I mean I recently had a pediatric practice balk at me sending a kid back to them who’s been on the same dose of Zoloft for years (and a similarly stable real low dose amitriptyline for abd pain which is what they were getting all hung up on) so I was just like whatever I’ll just keep seeing them I guess.

 

[PikminOC]

I think it just depends on who your patient population is in general. I dont have a “panel full” of q3 month patients but you can look at it from the other perspective too, that spacing more stable patients out more quickly if able actually allows me to see more intakes or fit in more acute patients more easily. There’s arguments to be made in all directions in terms of frequency and necessity of patients on your panel. I also agree with points @Sushirolls made above.

I do generally offer to patients to have their PCP manage things esp if they’re just on one med and we’ve been at q3 month visits for a couple visits but many parents would prefer to stay with me or many young adult patients don’t HAVE a PCP (which I always talk to them about anyway but I can’t exactly make them get a pcp….).

I’ve also definitely found that parents are not eager to have their kids come back every 6 weeks during the school year anyway…

In child much more than adult there are also many pediatricians who don’t want to or would rather not manage a kid even on a stable SSRI and stimulant for instance or a kid on trileptal or lamictal or Abilify etc or a kid who has a history of being hospitalized, especially if they already have an outpatient psychiatrist they’re seeing. I mean I recently had a pediatric practice balk at me sending a kid back to them who’s been on the same dose of Zoloft for years (and a similarly stable real low dose amitriptyline for abd pain which is what they were getting all hung up on) so I was just like whatever I’ll just keep seeing them I guess.

More primary care doctors don't want to manage any psych cases due to liability. I've seen this

 

[splik]

More primary care doctors don't want to manage any psych cases due to liability. I've seen this

In my area, it's the opposite. Lots wanting to cherry pick certain stuff like ADHD, addiction/suboxone, ketamine. Many PCPs finding psych a good way to have cash only or concierge based practices.

There's a clinic down the road from me run by family physicians - they specialize in Xanax, Adderall, marijuana, and emotional support animals.

 

[VA Hopeful Dr]

I think it just depends on who your patient population is in general. I dont have a “panel full” of q3 month patients but you can look at it from the other perspective too, that spacing more stable patients out more quickly if able actually allows me to see more intakes or fit in more acute patients more easily. There’s arguments to be made in all directions in terms of frequency and necessity of patients on your panel. I also agree with points @Sushirolls made above.

I do generally offer to patients to have their PCP manage things esp if they’re just on one med and we’ve been at q3 month visits for a couple visits but many parents would prefer to stay with me or many young adult patients don’t HAVE a PCP (which I always talk to them about anyway but I can’t exactly make them get a pcp….).

I’ve also definitely found that parents are not eager to have their kids come back every 6 weeks during the school year anyway…

In child much more than adult there are also many pediatricians who don’t want to or would rather not manage a kid even on a stable SSRI and stimulant for instance or a kid on trileptal or lamictal or Abilify etc or a kid who has a history of being hospitalized, especially if they already have an outpatient psychiatrist they’re seeing. I mean I recently had a pediatric practice balk at me sending a kid back to them who’s been on the same dose of Zoloft for years (and a similarly stable real low dose amitriptyline for abd pain which is what they were getting all hung up on) so I was just like whatever I’ll just keep seeing them I guess.

My general preferences for treating kids and adults as an outpatient PCP:

ADHD - I'll do that with no complaints.

Depression/anxiety - usually no issues. If a patient is on or needs meds beyond the usual stuff (SSRI/SNRI, buspar, Wellbutrin, low-ish dose TCAs) I would generally prefer they see psych. I don't like managing trileptal, anti-psychotics, or anything like that.

More severe pathology like schizophrenia, true bipolar, and significant PDs need a psychiatrist most of the time.

 

[Merovinge]

I think it just depends on who your patient population is in general. I dont have a “panel full” of q3 month patients but you can look at it from the other perspective too, that spacing more stable patients out more quickly if able actually allows me to see more intakes or fit in more acute patients more easily. There’s arguments to be made in all directions in terms of frequency and necessity of patients on your panel. I also agree with points @Sushirolls made above.

I do generally offer to patients to have their PCP manage things esp if they’re just on one med and we’ve been at q3 month visits for a couple visits but many parents would prefer to stay with me or many young adult patients don’t HAVE a PCP (which I always talk to them about anyway but I can’t exactly make them get a pcp….).

I’ve also definitely found that parents are not eager to have their kids come back every 6 weeks during the school year anyway…

In child much more than adult there are also many pediatricians who don’t want to or would rather not manage a kid even on a stable SSRI and stimulant for instance or a kid on trileptal or lamictal or Abilify etc or a kid who has a history of being hospitalized, especially if they already have an outpatient psychiatrist they’re seeing. I mean I recently had a pediatric practice balk at me sending a kid back to them who’s been on the same dose of Zoloft for years (and a similarly stable real low dose amitriptyline for abd pain which is what they were getting all hung up on) so I was just like whatever I’ll just keep seeing them I guess.

Totally would not be sending those kids back to a PCP (bolded above) but also don't feel like hardly any should be falling in q3 month visit population.

I absolutely have had patients who have the rapport and just want to keep you around, I am not advocating for kicking those patients out by any stretch, but our field and patient population are not furthered by having the limited supply of our slots on stable 1 diagnosis SSRI or psychostimulant patients even if we were instrumental in getting the accurate diagnosis. I'm certainly not suggesting seeing patient's more frequently then needed, but I still continue to see folks who have outpatient doctors who haven't a clue about what's happening with their patients who are very high severity (e.g. several IP/PHP stays) because they only see them every 3 months and when they do it's a short visit to briefly review the meds. These kids are lacking a "quarterback" overseeing their mental health care which is such a critical role that we can provide.

 

[calvnandhobbs68]

Totally would not be sending those kids back to a PCP (bolded above) but also don't feel like hardly any should be falling in q3 month visit population.

I absolutely have had patients who have the rapport and just want to keep you around, I am not advocating for kicking those patients out by any stretch, but our field and patient population are not furthered by having the limited supply of our slots on stable 1 diagnosis SSRI or psychostimulant patients even if we were instrumental in getting the accurate diagnosis. I'm certainly not suggest seeing patient's more frequently then needed, but I still continue to see folks who have outpatient doctors who haven't a clue about what's happening with their patients who are very high severity (e.g. several IP/PHP stays) because they only see them every 3 months and when they do it's a short visit to briefly review the meds. These kids are lacking a "quarterback" overseeing their mental health care which is such a critical role that we can provide.

I think that’s likely a result of the type of doctors they’re seeing rather than a function of frequency of visits. There is no reason I need to be seeing a kid on any of those meds above frequently indefinitely without actual instability and that would actually contribute to my inability to see new patients. And again, I have parents giving me a hard time about 3 month visits at times.

I agree that we should try to match patient followup with patient severity but the fact that you’re on any of those medications doesn’t in and of itself mean you’re inappropriately spacing out these patients when they’re stable. So you end up with this pretty decent chunk of patients who were unstable at some point, are now stabilized on medications that are probably outside of the PCP comfort level (understandably) and we just want them to keep coming back every 1-2 months forever?

I mean I could line up patients doing q4 week 15 minute “med checks”….I’d be seeing them every 4 weeks but probably wouldn’t know much about what’s going on with them. So again this is likely much more a result of the type of psychiatrist they’re seeing if they don’t know anything about their patient vs a function of visit frequency.

I think different people also have a different idea of how much frequency is “needed” which is totally fair but what I would say to that is see your patients as frequently as you feel is needed and I’ll see mine as frequently as I feel is needed. With that I agree with @Sushirolls. There are systems that pay/incentivize shunting patients back to primary care.

 

[Merovinge]

I think that’s likely a result of the type of doctors they’re seeing rather than a function of frequency of visits. There is no reason I need to be seeing a kid on any of those meds above frequently indefinitely without actual instability and that would actually contribute to my inability to see new patients. And again, I have parents giving me a hard time about 3 month visits at times.

I agree that we should try to match patient followup with patient severity but the fact that you’re on any of those medications doesn’t in and of itself mean you’re inappropriately spacing out these patients when they’re stable. So you end up with this pretty decent chunk of patients who were unstable at some point, are now stabilized on medications that are probably outside of the PCP comfort level (understandably) and we just want them to keep coming back every 1-2 months forever?

I mean I could line up patients doing q4 week 15 minute “med checks”….I’d be seeing them every 4 weeks but probably wouldn’t know much about what’s going on with them. So again this is likely much more a result of the type of psychiatrist they’re seeing if they don’t know anything about their patient vs a function of visit frequency.

I think different people also have a different idea of how much frequency is “needed” which is totally fair but what I would say to that is see your patients as frequently as you feel is needed and I’ll see mine as frequently as I feel is needed. With that I agree with @Sushirolls. There are systems that pay/incentivize shunting patients back to primary care.

I think you're a good doc, I would send my own child to see you, If I inadvertedly described your OP practice it was not an effort to put you on blast.

Context matters a great deal here. Is the patient on Abilify as an augmenting agent for TRD following an IP stay? Then absolutely they need more than q3 month visits and need to work to get off the medication at a reasonable time. Was it the miracle med for ASD aggression they've been on for 3 years and are very stable, than they could certainly be seen q3 months. I'd argue with the frequency of mood episodes for adolescents with bipolar disorder, even "stable" on Lamictal would not be best served on q3 month visits.

I will say I was forced to do q3 month visits for almost the entirety of my last hospital employed practice over 3 years. It was the best that could be done given my panel size but there were clearly patients for whom it was not enough. That is how I derive my thoughts on the matter. Also clearly patient panels will differ with the severity of illness and that will impact the frequency of needed appointments.

Overall I am glad there are varying viewpoints on the practice and that trainees can see different models to be aware of as options when they become attendings.

 

[calvnandhobbs68]

I remembered this thread again and felt like bringing up a couple more examples of why it's tough to shift people back to primary care sometimes even though they might be seen as "too easy" for psychiatry.

Teenager on Effexor 150mg, has been stable for like a year now, I give them the option of going back to PCP since they're so stable and they say yes, they will schedule appt with PCP and let me know so I can send records over, including my last progress note that says she's been stable forever now. PCP office just straight up tells them they don't prescribe Effexor for teenagers...so they ask if they can just keep seeing me. Sure, I'm not going to take more time out of my day to try to train the PCP on prescribing Effexor....

Grade school kid on Ritalin LA + afternoon booster dose (that's it), sent back to PCP due to stability, starts getting worse over the summer, PCP bumps dose once and does nothing else, family wants to get back in with me because they're not doing anything...

I'm not hating on pediatricians in any way but again the level of lack of comfort with like basic psychiatric meds is tough sometimes and leads me back to having a decent amount of these kinds of patients on my panel.

 

[clozareal]

I agree. I will only shift back to PCP when they are off medications for 6-12 months and have had no relapse.

I've also been wary of thinking that patients who see me enter this magical thing called "stability." I've been surprised by the most stable patients when life changes happen (going off to college, death of a friend/family, etc)

 

[VA Hopeful Dr]

I remembered this thread again and felt like bringing up a couple more examples of why it's tough to shift people back to primary care sometimes even though they might be seen as "too easy" for psychiatry.

Teenager on Effexor 150mg, has been stable for like a year now, I give them the option of going back to PCP since they're so stable and they say yes, they will schedule appt with PCP and let me know so I can send records over, including my last progress note that says she's been stable forever now. PCP office just straight up tells them they don't prescribe Effexor for teenagers...so they ask if they can just keep seeing me. Sure, I'm not going to take more time out of my day to try to train the PCP on prescribing Effexor....

Grade school kid on Ritalin LA + afternoon booster dose (that's it), sent back to PCP due to stability, starts getting worse over the summer, PCP bumps dose once and does nothing else, family wants to get back in with me because they're not doing anything...

I'm not hating on pediatricians in any way but again the level of lack of comfort with like basic psychiatric meds is tough sometimes and leads me back to having a decent amount of these kinds of patients on my panel.

Its been my experience that a significant number of pediatricians start to have trouble around the time puberty starts.

 

[Ironspy]

It’s been my experience that a significant number of pediatricians start to have trouble around the time puberty starts.

This made me chuckle a bit and reminded me of the following:

I worked with a pediatrician who was seeing a college student for a physical with the patient’s mom. The mom asked how long the pediatrician would continue seeing him and pediatrician responded with “until he develops adult problems “.

Minutes later, the patient mentioned he used cannabis and the pediatrician said “that’s an adult problem. You need to see an adult doctor “

 

[VenusinFurs]

Totally would not be sending those kids back to a PCP (bolded above) but also don't feel like hardly any should be falling in q3 month visit population.

I absolutely have had patients who have the rapport and just want to keep you around, I am not advocating for kicking those patients out by any stretch, but our field and patient population are not furthered by having the limited supply of our slots on stable 1 diagnosis SSRI or psychostimulant patients even if we were instrumental in getting the accurate diagnosis. I'm certainly not suggesting seeing patient's more frequently then needed, but I still continue to see folks who have outpatient doctors who haven't a clue about what's happening with their patients who are very high severity (e.g. several IP/PHP stays) because they only see them every 3 months and when they do it's a short visit to briefly review the meds. These kids are lacking a "quarterback" overseeing their mental health care which is such a critical role that we can provide.

As a family doctor who trained in the state of Maine and worked there for many years, we don’t really have many psychiatrists up there and if I had a kid who is doing well on an antipsychotic or mood stabilizing antiepileptic with no established psychiatrist, I feel it would be malpractice for me to refuse to prescribe these medications, and I would respect the wishes of the family if they really were unwilling or unable to see a specialist, which they likely would have to wait over 6 months to see anyway. I know this is not the same discussion, I just have to point out that as a PCP in an underserved area I have had to manage some pretty freaking complex regimens. I have also started adult patients on antipsychotics, I am surprised there are family doctors who feel an antipsychotic regimen absolutely necessitates a psychiatrist consult, in rural Maine I can’t let patients suffer because UpToDate or whatever says I need to consult a psychiatrist. It’s kind of hard to argue someone must see a psychiatrist if there are no psychiatrists.

So yeah if I was in you guys’ area I would not empty my bowels at having your patients returned to my care for psychiatric medication management. I’d be very happy they even got to see a psychiatrist in the first place.

 

[VenusinFurs]

Same here but I now only take referrals. Why? Cause I've noticed about 5-10% of brand new patients turn out to be a-holes. I don't mean they're sick, I mean they're downright rude, give me and my assistant unneeded grief and are highly entitled. E.g. guy changes his phone number, doesn't tell us, and then gets mad at us when we haven't called him. "You're a professional. I expect you to know my phone number even if I don't inform you I changed it."

Also I've noticed about 5% of brand new patients who weren't referred shouldn't have seen me in the first place. "Since you're a psychiatrist can you tell me if I'll have a good future?"

I've noticed with referrals less than 1% are a-holes and they usually have already been filtered as having a real problem a psychiatrist could help.

I also make patients self-schedule. Don't let their family members do so. Could be a HIPAA violation but this way if they don't show up they can't claim you can't hold them responsible. Also it eliminates the type of patient who doesn't want help who's only there cause their family member "thinks something's wrong with me."

Haven’t you studied the tarot section of the dsm?