Inpatient resident workload

[DisorderedDoc417]

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Hey all! I’m posting to discuss what should reasonably be expected of a pgy 2 and feeling burnout. Please tell me what you guys think...

Usual case load is +/- 3 new evaluations, usually 1-2 discharges, and 6-8 patients for follow-up depending on number of discharges. I typically have no problem finishing this by 4:30 in the afternoon. However, I find that reviewing documentation outside of usual work hours is slowly creeping more and more into my free time. Making calls to family and reviewing notes is also quite time consuming, especially on Mondays, as many “follow ups” are new to the team.

We also see patients in continuity clinic once weekly as pgy-2s.

I feel very little motivation to study outside of this work-load. I’m not quite as able to spend the quality time at the bedside as I like, and I feel the information taking is more robotic. It can feel at times that the attending “has it much easier” as they attest our note with a short addendum, but they get to spend more “quality” time addressing the patients concerns with nuanced questioning.

Overall, I feel like I enjoy the job less, I’m not enjoying or don’t have time for activities outside of work that I used to, and my workday feels more generic and less thoughtful when it comes to diagnosis, treatment, and disposition than I would like. I’m more or less achieving the same level of performance as other residents in the same spot with no performance concerns. Is it silly I feel a little burned out? I know I’m not working the 100 hours a surgeon does, but call and this schedule above certainly take their toll.

Thanks!

 

[hallowmann]

Sounds like a standard inpatient mood or child unit to me. You do sound burned out to me though. That's probably not helping your efficiency and productivity, and its probably why you're noticing the documentation/chart review creep. You probably need a day or two off and maybe something to break the monotony.

Sometimes you can't help but let things get a little more robotic, especially on call, but it might help to take a step back and think about the things you really enjoy about the work. If you work with students, sometimes its fun to see how excited they are and remember that you were there at some point. Bottom line is find the handful of actions/interactions that you love in your day and focus on those.

As far as attendings having it better, yeah that sounds about right. They also have more responsibility though, and those things usually go hand in hand. Residency doesn't really exist to be enjoyed, it exists to train you for practice. I have yet to meet a single attending that wishes they were a resident again.

 

[clausewitz2]

Hey all! I’m posting to discuss what should reasonably be expected of a pgy 2 and feeling burnout. Please tell me what you guys think...

Usual case load is +/- 3 new evaluations, usually 1-2 discharges, and 6-8 patients for follow-up depending on number of discharges. I typically have no problem finishing this by 4:30 in the afternoon. However, I find that reviewing documentation outside of usual work hours is slowly creeping more and more into my free time. Making calls to family and reviewing notes is also quite time consuming, especially on Mondays, as many “follow ups” are new to the team.

We also see patients in continuity clinic once weekly as pgy-2s.

I feel very little motivation to study outside of this work-load. I’m not quite as able to spend the quality time at the bedside as I like, and I feel the information taking is more robotic. It can feel at times that the attending “has it much easier” as they attest our note with a short addendum, but they get to spend more “quality” time addressing the patients concerns with nuanced questioning.

Overall, I feel like I enjoy the job less, I’m not enjoying or don’t have time for activities outside of work that I used to, and my workday feels more generic and less thoughtful when it comes to diagnosis, treatment, and disposition than I would like. I’m more or less achieving the same level of performance as other residents in the same spot with no performance concerns. Is it silly I feel a little burned out? I know I’m not working the 100 hours a surgeon does, but call and this schedule above certainly take their toll.

Thanks!

So you are routinely carrying 13 patients a day? How much time do you actually get to spend with each patient? How long is the intake interview? When on Earth do you learn anything or have time to discuss a puzzling case with your attending?

Are most of the patients chronic, well-known to the system rocks? What is the typical LOS? I just get an image of waving from the hallway at most follow-up patients. How does it work, logistically? When do you get the chance to do the digging into the history or do the kind of subtle probing of psychopathology that clarifies a murky picture?

I get that inpatient units in most places have sort of become very temporary holding environments for the acutely suicidal and nothing more (or short-term orphanages in the case of many child units), but I feel like academic centers should be better than this and should not miss the opportunity to clarify the picture with observations the outpatient team is never going to be able to collect.

It occurs to me that not all programs are academic programs but I feel like they should still aspire to more than "IP admission indicated for precisely the LOS covered by patient's insurance and not one day more or less."

 

[Old&InTheWay]

I don't think it's silly that you are feeling the way you are feeling; your workload sounds pretty tough/unrelenting compared to what I have seen so far and I would guess that you're not the only one in your program struggling with it. That said, there's probably not much you can do about your work situation right now. I also feel like it's much easier to admit to ourselves and others that we may be experiencing burnout rather than depression. There is so much overlap and both conditions can lead to or worsen the other. I would think about what you would suggest to a patient who came to you with your complaints. I'm not sure what MH resources are available to residents where you are, but I feel like that could be a reasonable place to start.

 

[hallowmann]

So you are routinely carrying 13 patients a day? How much time do you actually get to spend with each patient? How long is the intake interview? When on Earth do you learn anything or have time to discuss a puzzling case with your attending?

Are most of the patients chronic, well-known to the system rocks? What is the typical LOS? I just get an image of waving from the hallway at most follow-up patients. How does it work, logistically? When do you get the chance to do the digging into the history or do the kind of subtle probing of psychopathology that clarifies a murky picture?

I get that inpatient units in most places have sort of become very temporary holding environments for the acutely suicidal and nothing more (or short-term orphanages in the case of many child units), but I feel like academic centers should be better than this and should not miss the opportunity to clarify the picture with observations the outpatient team is never going to be able to collect.

It occurs to me that not all programs are academic programs but I feel like they should still aspire to more than "IP admission indicated for precisely the LOS covered by patient's insurance and not one day more or less."

There is a reason I qualified my statement with mood or child unit. You generally have more turn around on those units than say on a psychosis or Geri unit. You don't need as much time to worry about placement or to have someone clear.

Parents/kids often want to go home quick and usually have a home to go to. I'm also rarely filing on kids. People in acute mood crises usually do pretty well if you can develop a plan, have good follow-up, and build up some social support. As far as LOS goes, on average people stay on those units about 5-7 days. The bipolar patients or people getting index ECT obviously stay on longer.

When the picture is murky, you put in the extra time at my institution. At least that's what you do when you want to treat your patients well.

I guess I also interpreted the numbers in the OP a bit different because it never occurred to me as seeing 13 different people, so maybe I'm off. I interpreted it as 8 pts consisting of 2 DCs and 6 non-DCing "old patients," and then there's 2-3 admissions to replace the people that DCed. I'm at an academic institution, and honestly that sounds like an average day (again on those units). There's almost always people waiting in the wings for admissions. If you have a Psych ED, call can be even worse with multiple new evals/consults, but we're only on call once a week.

When psych beds are in demand, you have to become a steward of that resource. That means you're not admitting people that could be safe with other alternatives and close OP follow-up, and it means you are trying your best to DC people as soon as they are safe and a plan of care is in place. Every day that you don't is a day someone else who needs inpatient care isn't getting it.

Like I said, I'm at an academic institution, but I'm also in a state with not nearly enough psych beds to match the population, in the only hospital in the state that takes the uninsured. Maybe you have the luxury of having plenty of beds and resources available to patients where you're training, where you can keep someone on a locked unit just to see if you can gleam a new psychopathological pearl, but you're not going to find that in my state.

I also personally find it a bit ridiculous that you equate turn around solely with the bottomline, and honestly I don't know of any academic psych units functioning in the black.

 

[clausewitz2]

There is a reason I qualified my statement with mood or child unit. You generally have more turn around on those units than say on a psychosis or Geri unit. You don't need as much time to worry about placement or to have someone clear.

Parents/kids often want to go home quick and usually have a home to go to. People in acute mood crises usually do pretty well if you can develop a plan, have good follow-up, and build up some social support. As far as LOS goes, on average people stay on those units about 5-7 days. The bipolar patients or people getting index ECT obviously stay on longer.

When the picture is murky, you put in the extra time at my institution. At least that's what you do when you want to treat your patients well.

I guess I also interpreted the numbers in the OP a bit different because it never occurred to me as seeing 13 different people, so maybe I'm off. I interpreted it as 8 pts consisting of 2 DCs and 6 non-DCing "old patients," and then there's 2-3 admissions to replace the people that DCed. I'm at an academic institution, and honestly that sounds like an average day (again on those units). There's almost always people waiting in the wings for admissions. If you have a Psych ED, call can be even worse with multiple new evals/consults, but we're only on call once a week.

When psych beds are in demand, you have to become a steward of that resource. That means you're not admitting people that could be safe with other alternatives and close OP follow-up, and it means you are trying your best to DC people as soon as they are safe and a plan of care is in place. Every day that you don't is a day someone else who needs inpatient care isn't getting it.

Like I said, I'm at an academic institution, but I'm also in a state with not nearly enough psych beds to match the population, in the only hospital in the state that takes the uninsured. Maybe you have the luxury of having plenty of beds and resources available to patients where you're training, where you can keep someone on a locked unit just to see if you can gleam a new psychopathological pearl, but you're not going to find that in my state.

I also personally find it a bit ridiculous that you equate turn around solely with the bottomline, and honestly I don't know of any academic psych units functioning in the black.

OP said ~3 admissions a day, 6-8 follow-ups, and 2 discharges. That sounds like 11 - 13 census wise to me. I agree with you that 8 is perfectly reasonable.

Our child experiences were obviously very different; our kiddo units get a lot of children who can't go home for various reasons and the median LOS is closer to 14 days than the 5-7 that is typical of our high turnover adult gen pop units. Probably shortest LOS is on our dual diagnosis unit (substance, not ID) which is closer to 3-4 for a number of reasons. Longest is probably ID/autism units where we do occasionally have people hang out for like a year.

My point is not that short stays don't make sense given the circumstances and realities of modern mental health system. My point is that even with those stays there is a lot you can be doing to assist in the future care of these folks, but if you have the kind of census OP describes this is not really possible. IP hospitalization doesn't really reduce risk of suicide so we ought to be doing something.

The fact that short stays are the name of the game these days is entirely a financial issue. The shift from hospitalizations lasting many weeks to a few days was not because of magical evidence that this was a more effective approach. You are right that academic centers are more likely to hold people even if insurance isn't coughing up but I strongly question your assertion about inpatient units running at a perpetual loss everywhere. Our IP services largely subsidize our OP network. We are very good about getting uninsured people MA during their stay but we definitely admit people who are not currently insured.

I am not talking about holding people in hospital for intellectual curiosity. I am talking about making a short hospitalization into something more valuable to the patient than a very expensive and glorified respite. How are you going to do that without time to breathe?

 

[hallowmann]

OP said ~3 admissions a day, 6-8 follow-ups, and 2 discharges. That sounds like 11 - 13 census wise to me. I agree with you that 8 is perfectly reasonable.

Our child experiences were obviously very different; our kiddo units get a lot of children who can't go home for various reasons and the median LOS is closer to 14 days than the 5-7 that is typical of our high turnover adult gen pop units. Probably shortest LOS is on our dual diagnosis unit (substance, not ID) which is closer to 3-4 for a number of reasons. Longest is probably ID/autism units where we do occasionally have people hang out for like a year.

My point is not that short stays don't make sense given the circumstances and realities of modern mental health system. My point is that even with those stays there is a lot you can be doing to assist in the future care of these folks, but if you have the kind of census OP describes this is not really possible. IP hospitalization doesn't really reduce risk of suicide so we ought to be doing something.

The fact that short stays are the name of the game these days is entirely a financial issue. The shift from hospitalizations lasting many weeks to a few days was not because of magical evidence that this was a more effective approach. You are right that academic centers are more likely to hold people even if insurance isn't coughing up but I strongly question your assertion about inpatient units running at a perpetual loss everywhere. Our IP services largely subsidize our OP network. We are very good about getting uninsured people MA during their stay but we definitely admit people who are not currently insured.

I am not talking about holding people in hospital for intellectual curiosity. I am talking about making a short hospitalization into something more valuable to the patient than a very expensive and glorified respite. How are you going to do that without time to breathe?

Fair enough. I agree that if we're talking about 13 with 10 being established, that seems like a bit much to me. That's probably something I would only see on-call, which again is only a once a week kind of thing.

There certainly are kids that have to stay because of placement concerns, but the majority we see have a place to go to, whether that's home or foster care.

SW at our institution certainly works hard to get Medicaid coverage for everyone as well, but there's still a lot of coverage issues. Last I checked our whole department is in the red. Partials usually make some money depending on the population, ID and Geri are bleeding money, I think Child does OK, and mood and psychosis units tend to be neutral with the exception of EDO, which makes money. I'm honestly not sure about outpatient, but as a state we have had such massive cuts to all forms of MH funding over the last decade that we as a whole aren't functioning in the black.

A bunch of inpatient units in the state have shutdown due to funding issues over that time. I'm not as in tune with other state MH funding, but even where I rotated for med school, the psych units struggled to be net positive.

As far as the experience of our patients, we have a very large staff, have interdisciplinary rounds every AM, and we usually have a clear plan for most patients from time of admission. A lot of people work very hard to make the hospitalization valuable. Honestly, that's something that I thought was happening at most good psych units.

 

[clausewitz2]

Fair enough. I agree that if we're talking about 13 with 10 being established, that seems like a bit much to me. That's probably something I would only see on-call, which again is only a once a week kind of thing.

There certainly are kids that have to stay because of placement concerns, but the majority we see have a place to go to, whether that's home or foster care.

SW at our institution certainly works hard to get Medicaid coverage for everyone as well, but there's still a lot of coverage issues. Last I checked our whole department is in the red. Partials usually make some money depending on the population, ID and Geri are bleeding money, I think Child does OK, and mood and psychosis units tend to be neutral with the exception of EDO, which makes money. I'm honestly not sure about outpatient, but as a state we have had such massive cuts to all forms of MH funding over the last decade that we as a whole aren't functioning in the black.

A bunch of inpatient units in the state have shutdown due to funding issues over that time. I'm not as in tune with other state MH funding, but even where I rotated for med school, the psych units struggled to be net positive.

As far as the experience of our patients, we have a very large staff, have interdisciplinary rounds every AM, and we usually have a clear plan for most patients from time of admission. A lot of people work very hard to make the hospitalization valuable. Honestly, that's something that I thought was happening at most good psych units.

I think we will have to agree to disagree about the kinds of things that make short acute hospitalizations valuable.

 

[whopper]

Even if the numbers suggest a stable and reasonable workload the resident could still be behind due to factors such as turnaround on the unit, general rejection/acceptance of malingers and cluster B patients, and other factors.

If, for example the unit generally accepts malingerers, it could make life much more difficult cause when they leave it'll be a lot of draining work with the person acting out.

The 6 months I did residency we had attendings too chicken to stand up to malingerers. Then we got one who put his foot down to them and about 6-12 months later the malingers coming in went from about 1/2 the unit to almost none of them. Life got a heck of a lot easier.

 

[DisorderedDoc417]

Sounds like a standard inpatient mood or child unit to me. You do sound burned out to me though. That's probably not helping your efficiency and productivity, and its probably why you're noticing the documentation/chart review creep. You probably need a day or two off and maybe something to break the monotony.

Sometimes you can't help but let things get a little more robotic, especially on call, but it might help to take a step back and think about the things you really enjoy about the work. If you work with students, sometimes its fun to see how excited they are and remember that you were there at some point. Bottom line is find the handful of actions/interactions that you love in your day and focus on those.

As far as attendings having it better, yeah that sounds about right. They also have more responsibility though, and those things usually go hand in hand. Residency doesn't really exist to be enjoyed, it exists to train you for practice. I have yet to meet a single attending that wishes they were a resident again.

Agree with this. I don’t think they have it “better” per se. They have a load of their own responsibilities and larger patient loads. The say also stops with them. Residency is very manageable, I’m mostly looking to continue to try and find ways to enjoy it. Compared to surgery, it’s not nearly so demanding, but I’d like to maximize the opportunity.

 

[DisorderedDoc417]

Even if the numbers suggest a stable and reasonable workload the resident could still be behind due to factors such as turnaround on the unit, general rejection/acceptance of malingers and cluster B patients, and other factors.

If, for example the unit generally accepts malingerers, it could make life much more difficult cause when they leave it'll be a lot of draining work with the person acting out.

The 6 months I did residency we had attendings too chicken to stand up to malingerers. Then we got one who put his foot down to them and about 6-12 months later the malingers coming in went from about 1/2 the unit to almost none of them. Life got a heck of a lot easier.

Average turnaround is 3-6 days, plenty of malingering, BLPD, we see a mix of everything from psychosis to depression/mood d/o to the SI with personality.

 

[DisorderedDoc417]

Some very thoughtful points are being raised and I appreciate your replies, thank you! I recognize personally that the larger proportion of personality disorder and suspected malingering the more I feel how I’ve highlighted above. A day or two off would be nice but not in my immediate future unfortunately.

 

[DisorderedDoc417]

I don't think it's silly that you are feeling the way you are feeling; your workload sounds pretty tough/unrelenting compared to what I have seen so far and I would guess that you're not the only one in your program struggling with it. That said, there's probably not much you can do about your work situation right now. I also feel like it's much easier to admit to ourselves and others that we may be experiencing burnout rather than depression. There is so much overlap and both conditions can lead to or worsen the other. I would think about what you would suggest to a patient who came to you with your complaints. I'm not sure what MH resources are available to residents where you are, but I feel like that could be a reasonable place to start.

As others have posted I think a few days off would probably do the trick. Another piece of it is the documentation creep or studying outside of work. On long weekends or on brief periods of time off I enjoy doing the things I always have enjoyed so I’m not too concerned about depression.

 

[hallowmann]

I think we will have to agree to disagree about the kinds of things that make short acute hospitalizations valuable.

I didn't make a ton of assertions regarding what makes a short stay valuable, so I'm not entirely sure we are even disagreeing.

Making nuanced diagnoses with background and collateral digging is something we try to do from the outset, but we're also seeing these patients in crises, a lot of how they present to us in the inpatient setting does not necessarily dictate what treatment modalities will ultimately be best for them a year down the line. Some of that has to be dictated by the provider that's going to see them every 3 mos for the next few years as well as their therapist.

Maybe we're talking past each other and your outpatient services are simply different than ours, making the priorities on the inpatient stay a bit different. Or maybe we're just not talking about the same populations.

 

[Shufflin]

There's a little bit of malingerer in every patient, and a little bit of patient in every malingerer.

 

[clausewitz2]

There's a little bit of malingerer in every patient, and a little bit of patient in every malingerer.

One of the most frustrating cases I was ever involved with was a someone who clearly had something going on that was quite limiting and severe but did not fit very well into a clear diagnostic category but who also repetitively sought admission when, say, he did not like the apartment his ACT team got him or felt threatened by his roommate making a sandwich. At one point during one of his (many) admissions he identified that we had become a "revolving door" for him and this was clearly quite upsetting to him but it did not prevent him from seeking admission on a weekly basis. Never had a positive UDS and like I said, always had housing, not a lot of cluster B; I think we ultimately went with "dependent PD" in addition to his historical dx.

So there was kind of a lot of both in that one.

I didn't make a ton of assertions regarding what makes a short stay valuable, so I'm not entirely sure we are even disagreeing.

Making nuanced diagnoses with background and collateral digging is something we try to do from the outset, but we're also seeing these patients in crises, a lot of how they present to us in the inpatient setting does not necessarily dictate what treatment modalities will ultimately be best for them a year down the line. Some of that has to be dictated by the provider that's going to see them every 3 mos for the next few years as well as their therapist.

Maybe we're talking past each other and your outpatient services are simply different than ours, making the priorities on the inpatient stay a bit different. Or maybe we're just not talking about the same populations.

All I am saying is that I did not fully appreciate until starting my first outpatient year how -limited- the information outpatient providers have about many of their clients in many respects. you see them for 0.5-1 hours a couple times a month at best and usually less than that. You frequently see people bringing their A-game and it can be hard to get a clear sense of what happens when things aren't going well. Someone being inpatient gives you 24 hour, round the clock data on what they're like when things go wrong and how they deal with it. It is hard to keep up apparent competence all day for days at a time. This is massively helpful for the outpatient providers to hear about for conceptualizing the client better. Plus, personality dysfunction is often much more apparent under stress, and few things are more stressful than IP hospitalization.

Our outpatient services are very integrated with our IP services and there is a lot of cross-talk, so I have become used to being able to read an IP note and get a sense of what the hospitalization was like, the clinical picture, and the IP team's thoughts about what was going on. IP obviously frequently lacks the longitudinal perspective, but they are unparalleled in their ability to amass a cross-sectional picture. I would say this is even more important in people who function at a relatively high level most of the time but then have periods where everything goes off the rails (i.e. most of the people on a mood unit). If someone has a sealed-over recovery style then you are going to struggle to get many details about what happened when things are going well. I am low-key enraged as a result when I get hospital discharge summaries that are a mess of autopopulated and templated nonsense with minimal detailed description of pathology or a formulation beyond a MSE and a DSM diagnosis.

What population are you referring to where this is not one of the basic functions of IP?

 

[hallowmann]

One of the most frustrating cases I was ever involved with was a someone who clearly had something going on that was quite limiting and severe but did not fit very well into a clear diagnostic category but who also repetitively sought admission when, say, he did not like the apartment his ACT team got him or felt threatened by his roommate making a sandwich. At one point during one of his (many) admissions he identified that we had become a "revolving door" for him and this was clearly quite upsetting to him but it did not prevent him from seeking admission on a weekly basis. Never had a positive UDS and like I said, always had housing, not a lot of cluster B; I think we ultimately went with "dependent PD" in addition to his historical dx.

So there was kind of a lot of both in that one.

Ahh yes, sounds very familiar.

...All I am saying is that I did not fully appreciate until starting my first outpatient year how -limited- the information outpatient providers have about many of their clients in many respects. you see them for 0.5-1 hours a couple times a month at best and usually less than that. You frequently see people bringing their A-game and it can be hard to get a clear sense of what happens when things aren't going well. Someone being inpatient gives you 24 hour, round the clock data on what they're like when things go wrong and how they deal with it. It is hard to keep up apparent competence all day for days at a time. This is massively helpful for the outpatient providers to hear about for conceptualizing the client better. Plus, personality dysfunction is often much more apparent under stress, and few things are more stressful than IP hospitalization.

Our outpatient services are very integrated with our IP services and there is a lot of cross-talk, so I have become used to being able to read an IP note and get a sense of what the hospitalization was like, the clinical picture, and the IP team's thoughts about what was going on. IP obviously frequently lacks the longitudinal perspective, but they are unparalleled in their ability to amass a cross-sectional picture. I would say this is even more important in people who function at a relatively high level most of the time but then have periods where everything goes off the rails (i.e. most of the people on a mood unit). If someone has a sealed-over recovery style then you are going to struggle to get many details about what happened when things are going well. I am low-key enraged as a result when I get hospital discharge summaries that are a mess of autopopulated and templated nonsense with minimal detailed description of pathology or a formulation beyond a MSE and a DSM diagnosis.

What population are you referring to where this is not one of the basic functions of IP?

Our units and communication are very similar to what you described. It seems we were likely talking past each other. Perhaps I wasn't clear in my previous posts. I agree for the most part with your post. We fortunately get clinic exposure starting at 2nd year in my program, so we have some sense of it prior to the full outpatient year - but I'm just not there yet in terms of seeing nothing but clinic patients a day.

I think I conceptually find it less than ideal to diagnose a true personality disorder based on tendencies people have when they are in crisis (as opposed to trends, behavior, and perceptions that persist even when out of crisis). While I agree that it can give you insight into their care and perhaps their past, I guess I don't like the idea of basing a personality diagnosis solely on a short interaction when someone experiences that level of stress.

With regards to the population comment, I meant more in terms of the makeup of the individual units. Most (all) patients can benefit from the care you described in the above post. For me what you described is typical of IP care at my program (or at very least the goal of it) for all patients. Prior to the above post I could only guess what you meant by references to making the IP stay "more valuable to the patient." Now I know what you mean.

 

[FlowRate]

We typically have 6 patients of varying degrees of medical and psychiatric complexity and from the entire spectrum of DSM disorders. Depending on attending, usually 1-2 discharges and 1-2 admissions per day. There are some inefficiencies to the way the unit is run which make it harder to finish the minimum work of the day to give yourself leeway to engage in more thoughtful/involved aspects of care. Overall I found it very manageable.