Inpatient versus outpatient psych

[tinyhandsbob]

Can some give me an idea of what a typical day looks like in inpatient psych for an attending? Specifically, what are the main activities and how much time do you spend doing each approximately (rounding, charting, other etc) . Also how does the amount of face to face time with patients compare to working in an outpatient setting. For those who have worked in both settings what were your impressions of pro/cons working in each and what type of person generally enjoys inpatient over outpatient (or vice versa).

Thanks!

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[robellis]

Where are you in your training?

 

[comp1]

Concur with wanting to know where you are in training. You'll get experience with both in residency. There are extreme variations from inpatient attendings who just round and leave for the day to more of a shift type hospitalist. Similarly, outpatient clinics might be all telehealth. They might be at a county setting with seriously mentally ill indigent individuals. It might be an all cash private practice in a high rise. I would say GENERALLY inpatients spend less face to face time with patients. This has to do with the often limited benefit of spending a large amount of time talking with grossly disorganized individuals. However, it's so widely varied. You can find an inpatient job that has more face to face time than outpatient job if that's really your thing.

 

[OldPsychDoc]

Depends somewhat on the patient population that day, turnover, number and quality of residents on service 😉, and number of meetings.
So a "typical day on a unit of 20 with a PA and one good resident: 1 hour interdisciplinary team, round on 2-3 discharges, round on overnight admissions, round on PA's patients of concern, round with resident and chat about cases & teaching points, grab some lunch, have an hour of random administrative meeting, finish seeing the rest of my stay-over patients, admit 1-2 new patients or hospital transfers if they arrive to the beds vacated this morning, finish charting round with resident again, sign off on resident charts, sign out, get out of there by 5. Troubleshooting discharges, pharmacy problems, prior auths, seclusion events, family meetings--all that's extra spice in the day. Best part about it is the team aspect of practice.

As far as pro/con--outpatient can be quite isolating, even in a group practice, and feel like shuttling people in and out of your office all day long (pre-COVID obviously--now it's a constant procession of phone and video calls...). OTOH, you tend to have more control over your day's and week's schedule.

 

[robellis]

Depends somewhat on the patient population that day, turnover, number and quality of residents on service 😉, and number of meetings.
So a "typical day on a unit of 20 with a PA and one good resident: 1 hour interdisciplinary team, round on 2-3 discharges, round on overnight admissions, round on PA's patients of concern, round with resident and chat about cases & teaching points, grab some lunch, have an hour of random administrative meeting, finish seeing the rest of my stay-over patients, admit 1-2 new patients or hospital transfers if they arrive to the beds vacated this morning, finish charting round with resident again, sign off on resident charts, sign out, get out of there by 5. Troubleshooting discharges, pharmacy problems, prior auths, seclusion events, family meetings--all that's extra spice in the day. Best part about it is the team aspect of practice.

As far as pro/con--outpatient can be quite isolating, even in a group practice, and feel like shuttling people in and out of your office all day long (pre-COVID obviously--now it's a constant procession of phone and video calls...). OTOH, you tend to have more control over your day's and week's schedule.

So you let the PA see patients on their own without seeing them as well?

 

[comp1]

So you let the PA see patients on their own without seeing them as well?

PAs aren't scribes...depending on the setting, they would definitely be rounding on their own and reporting back to a supervising physician as needed.

 

[robellis]

PAs aren't scribes...depending on the setting, they would definitely be rounding on their own and reporting back to a supervising physician as needed.

If the PA sees their own patients without you seeing them isn’t that you implying the PA provides equivalent care to patients

 

[OldPsychDoc]

If the PA sees their own patients without you seeing them isn’t that you implying the PA provides equivalent care to patients

I guess that's one way to look at it--and it's pretty much correct.
Look at it this way--our PAs with 5-8 years of FT inpatient experience have seen more patients than any of the residents have.

And to clarify, I'm responsible for every patient that comes to our floor. I see all admissions and transfers, all discharges, and continuing patients as indicated. If I delegate the continuing care of patients to a PA, I may not see them (or bill for them) every day, but I still know what's going on with them.

 

[hamstergang]

If the PA sees their own patients without you seeing them isn’t that you implying the PA provides equivalent care to patients

But if the PA has the psychiatrist as back up when things get more difficult/complicated, then they aren't really providing the same value.

 

[Psychresy]

But if the PA has the psychiatrist as back up when things get more difficult/complicated, then they aren't really providing the same value.

It's like saying a resident has the same value as the attending.

 

[robellis]

It's like saying a resident has the same value as the attending.

No it’s actually not because every single patient a resident sees is then seen by an attending

 

[NickNaylor]

I work as an inpatient attending at a teaching site with residents and medical students. I make it clear to the resident that our patients are his/her patients primarily and that my role, ideally, is to simply talk through their plans to make sure that they make sense and that their diagnostic impressions are accurate and reasonable. I see patients separately and do not round with the trainees most days unless I have concerns about their ability to actually do an interview. I'll spend a few days rounding with them to make sure I have data to provide feedback on when it comes to interviewing. Our volume is relatively low (usually no more than 6 patients). Here's a typical day for me:

5:30am: wake up, make coffee, pre-round on patients at home while getting caffeinated and/or finishing attestations from the day before
7:30am: head out to the hospital
8:30-8:45am: start seeing patients

I'm typically able to finish seeing patients by 1pm at the latest, often earlier than that. I'll sit down with the trainees, staff patients, do some teaching, and head home from there. I do all of my charting and any other ancillary tasks (e.g., calling collateral, speaking with outpatient docs, etc.) from home. If I actually sat down to do all my work, I would be able to easily finish my work by 3pm or so most days. In general, though, I do other things when I get home and do my documentation later in the evening after my wife/baby go to bed. I often have meetings and other academic work to do, so I'll do that in the afternoon as well. If I really wanted to compress everything and prioritize efficiency above all else, I could easily finish all of my work by 1-2pm on most days.

The pay is less than at other hospitals and in other settings, but the workload is very manageable, I have residents that deal with the majority of issues without needing my help (especially if they're solid), and I generally don't have to worry about dealing with things once I'm off-campus. I like not having a set "schedule" for my work, which offers a sense of freedom that is totally lacking with a packed schedule for clinic. If I'm tired and decide to sleep in a little later than usual, I can do that because no one is waiting for me at a specific time. Alternatively, if I have something I know I need to do in the afternoon and need to get out of the hospital a little earlier than usual, I can simply come in earlier, get everyone seen, staff with the resident, and I'm good to go. I really like that flexibility.

 

[SpinDktr]

I haven't really been on these boards in quite awhile, but dissatisfaction with my current attending position has brought me back here. I do inpatient work on a geriatric psychiatry unit. It is a 15 bed unit, and I am the sole provider during the week, and there is (crappy) telepsych coverage on weekends. Much of my time during the week is spent undoing bad decisions by weekend coverage. The in person MD who who was providing vacation coverage just quit.

While I enjoy geriatrics and what I do, it is emotionally draining, and I do not feel supported by the administration of the hospital. I am just starting year 3 of a 5 year term, and am between either giving notice immediately or sticking out to the end of my term. The only thing really keeping me here is that there is such a dearth of adequate care in geriatric psychiatry. Most psychiatrists in my experience do not handle this phase of life well; doing so takes a lot of time, emotional commitment (to do right), and many, MANY discussions with difficult families.

Good luck, make sure you have some balance in whatever position you take. For me, I am either looking at going back to outpatient or maybe do some locums to get a better feel for what various positions have to offer. I am 9 years out of residency and 8 out of gero fellowship. There is no shortage of positions, but feeling unsupported is a recipe for burnout.

 

[comp1]

It's so important to have a good team on inpatient, preferably with multiple MDs. The great upside of inpatient work is that you should never feel alone in your decisions. I try to make sure that everything is decided by group consensus and not fiat.

 

[robellis]

I haven't really been on these boards in quite awhile, but dissatisfaction with my current attending position has brought me back here. I do inpatient work on a geriatric psychiatry unit. It is a 15 bed unit, and I am the sole provider during the week, and there is (crappy) telepsych coverage on weekends. Much of my time during the week is spent undoing bad decisions by weekend coverage. The in person MD who who was providing vacation coverage just quit.

While I enjoy geriatrics and what I do, it is emotionally draining, and I do not feel supported by the administration of the hospital. I am just starting year 3 of a 5 year term, and am between either giving notice immediately or sticking out to the end of my term. The only thing really keeping me here is that there is such a dearth of adequate care in geriatric psychiatry. Most psychiatrists in my experience do not handle this phase of life well; doing so takes a lot of time, emotional commitment (to do right), and many, MANY discussions with difficult families.

Good luck, make sure you have some balance in whatever position you take. For me, I am either looking at going back to outpatient or maybe do some locums to get a better feel for what various positions have to offer. I am 9 years out of residency and 8 out of gero fellowship. There is no shortage of positions, but feeling unsupported is a recipe for burnout.

Leave now don’t wait it out and endure suffering

 

[SpinDktr]

I have put a cap on the census at 10, and given them an ultimatum to find adequate vacation and weekend coverage. They are not happy about it, saying that is "not viable". I really dislike the CEO, he has been emailing me frantically. He still doesn't know how to spell my name. 3 years here, I am really trying to look at it as a learning opportunity. Getting back to OP though, for me, outpatient was less emotionally taxing but it got to be boring. I would prefer to do IP with a solid staff and support.

 

[robellis]

I have put a cap on the census at 10, and given them an ultimatum to find adequate vacation and weekend coverage. They are not happy about it, saying that is "not viable". I really dislike the CEO, he has been emailing me frantically. He still doesn't know how to spell my name. 3 years here, I am really trying to look at it as a learning opportunity. Getting back to OP though, for me, outpatient was less emotionally taxing but it got to be boring. I would prefer to do IP with a solid staff and support.

I hope you’re being paid well to put up with this…

 

[futuredo32]

Inpatient- a mix of people who are suicidal, manic, psychotic and want help and those who are there on an involuntary basis. Those on an involuntary basis don't like you because they know you are the one keeping them there, for the rest, they are generally appreciative and it's not so bad, it feels like you are putting a band aid on them and sending them on their way, although a lot are frequent fliers. Patients on the inpatient unit, in my experience can be extremely violent.
Outpatient, (in my experience) patient's who want treatment. They tend to be more insightful and pleasant. You have a longer-term relationship with them. I strongly prefer outpatient to inpatient.

 

[futuredo32]

It's so important to have a good team on inpatient, preferably with multiple MDs. The great upside of inpatient work is that you should never feel alone in your decisions. I try to make sure that everything is decided by group consensus and not fiat.

Interesting. Where I have worked inpatient all of the physicians saw their own patients and there was no discussion , no group consensus. I see my patients , treat, the other psychiatrists see their patients and do the same..

 

[NickNaylor]

Interesting. Where I have worked inpatient all of the physicians saw their own patients and there was no discussion , no group consensus. I see my patients , treat, the other psychiatrists see their patients and do the same..

That's unfortunate. Our faculty group is very collaborative, we often talk about our patients with each other, and we will go to each other for advice regarding diagnostic impressions, management, etc. - particularly if it's a patient we've seen before. Makes the environment a lot more enjoyable.

 

[SpinDktr]

Agree with the above. Having a good collegial atmosphere with other psychiatrists to bounce ideas off is very helpful, and something I really miss with the job I've got. Even if I don't agree with the other psychiatrist (which frequently happens), actually having that discussion is helpful and facilitates a better understanding of the patient and their problems. I've seen both types of environments as far as inpatient work goes.

 

[clausewitz2]

Agree with the above. Having a good collegial atmosphere with other psychiatrists to bounce ideas off is very helpful, and something I really miss with the job I've got. Even if I don't agree with the other psychiatrist (which frequently happens), actually having that discussion is helpful and facilitates a better understanding of the patient and their problems. I've seen both types of environments as far as inpatient work goes.

While outpatient I am probably going to swap out some of my more lucrative private practice hours for a few more hours in the grant-funded specialty clinic I work with precisely because a competent and collegial interdisciplinary team is so valuable to me. Still wish there was another psychiatrist in the mix, though.

 

[comp1]

Oh yeah...don't work anywhere that all of the doctors practice in silos. It's not good for staff or patients, particularly long term. If you want to make sure you avoid a situation like that, it helps to have residents and/or medical students, even if you aren't at a university hospital.

 

[futuredo32]

We're friendly, but we don't work together. We all see our own patients individually. We say hi how are you etc.

 

[erg923]

We're friendly, but we don't work together. We all see our own patients individually. We say hi how are you etc.

What do you think this is about? You? Others? Hospital CEO/admin stuff?

All psychiatrists that work on same unit consistently in which patients are, PROBABLY, going shared over time and come from the same geographic region and/or culture should have some sense of a team? Or at least feel that they have a reasonable means of collaboration/consultation if they want to? No reason to be siloed in care in that situation unless you really want to be.

 

[futuredo32]

What do you think this is about? You? Others? Hospital CEO/admin stuff?

All psychiatrists that work on same unit consistently in which patients are, PROBABLY, going shared over time and come from the same geographic region and/or culture should have some sense of a team? Or at least feel that they have a reasonable means of collaboration/consultation if they want to? No reason to be siloed in care in that situation unless you really want to be.

Two of the PA's who do outpatient only chat a lot, I dont know about what. I don't think it's about anything, me, others, hospital, I think most of us want to go to work, get our work done and go home. I am a locums, I don't normally live in this area, I am leaving in two months. I don't see us as a team. We are individual psychiatrists seeing our own patients. I would rather do my job and leave for the day than chat about patients. We say hi to each other, If I didn't know what to do about a patient, I could ask. I won't supervise the PAs. If one of the psychiatrists had a question, I would be happy to help, but we are all competent. I did refer one patient to the psychiatrist who does ECT, but other than that, I really don't see a need. We're friendly when we see each other in the facility. I really like to keep my private life separate from work. Some have worked here for years, maybe they discuss patients, I don't know. I'm friendly with them when I see them and vice versa but I don't feel the need for collaboration. That reminds me of residency, which was good. I paid a former attending for supervision for therapy for awhile after residency, but I am set now. I do see a psychiatrist for analysis and ask him a clinical question occasionally during my therapy session.

 

[mmms85]

Commenting on the above: I speak with other attendings in the hospital where I work fairly often. As a group we go to each other if we're having troubles figuring out the diagnosis for a patient, we ask each other for advice, etc. For example, I have limited experience with typical antipsychotics outside of Haloperidol and Chlorpromazine. If I want to use another typical on a patient, I can go to one of my fellow attendings who is extremely experienced in them, and get advice with regards to dosing, titration, side effects to look for, etc. I'm very glad and lucky to be able to utilize such a resource. Also, feeling like you are friends with your coworkers can make the often tasking inpatient work a bit more bearable.

With regards to the question asked, though, I do both inpatient and outpatient work so I can comment on what my days look like.

Inpatient: I generally wake up at 530am and show up at the hospital at 7am. Once I arrive I converse with the nurses about if anything notable happened the night before, the main thing I look for is if anyone needed PRN's. I also check if anyone was admitted overnight, if so I'll need to evaluate them today. I generally start rounds 7:30-8am, and finish rounds around 11, sometimes it takes until noon. The patients I see in hospital are generally those acutely suicidal, manic patients, and psychotic patients.

Outpatient: I see patients outpatient at the local clinic associated with the hospital. I generally arrive at 1pm (after I leave the inpatient ward and grab a quick bite for lunch) and finish around 4pm. I do med-checks and also new evals. The med checks generally are rather short, the new evals take about 45 minutes to an hour, sometimes it can take 90 minutes. The patients I see in clinic are - of course - more stable than those in hospital. I still see patients with Severe Mental Illness - people with bipolar, schizophrenia, schizoaffective, etc - but most of the patients I see have MDD, GAD, or Panic d/o. There are therapists at the clinic, so I can easily refer a patient to them if therapy is necessary (which it is, far more often than not.)

With regards to charting, I do all that at home. I generally get home about 5pm, and I'll do my charting after I relax for a few hours, eat dinner, etc.

 

[deleted1100659]

I work as an inpatient attending at a teaching site with residents and medical students. I make it clear to the resident that our patients are his/her patients primarily and that my role, ideally, is to simply talk through their plans to make sure that they make sense and that their diagnostic impressions are accurate and reasonable. I see patients separately and do not round with the trainees most days unless I have concerns about their ability to actually do an interview. I'll spend a few days rounding with them to make sure I have data to provide feedback on when it comes to interviewing. Our volume is relatively low (usually no more than 6 patients). Here's a typical day for me:

5:30am: wake up, make coffee, pre-round on patients at home while getting caffeinated and/or finishing attestations from the day before
7:30am: head out to the hospital
8:30-8:45am: start seeing patients

I'm typically able to finish seeing patients by 1pm at the latest, often earlier than that. I'll sit down with the trainees, staff patients, do some teaching, and head home from there. I do all of my charting and any other ancillary tasks (e.g., calling collateral, speaking with outpatient docs, etc.) from home. If I actually sat down to do all my work, I would be able to easily finish my work by 3pm or so most days. In general, though, I do other things when I get home and do my documentation later in the evening after my wife/baby go to bed. I often have meetings and other academic work to do, so I'll do that in the afternoon as well. If I really wanted to compress everything and prioritize efficiency above all else, I could easily finish all of my work by 1-2pm on most days.

The pay is less than at other hospitals and in other settings, but the workload is very manageable, I have residents that deal with the majority of issues without needing my help (especially if they're solid), and I generally don't have to worry about dealing with things once I'm off-campus. I like not having a set "schedule" for my work, which offers a sense of freedom that is totally lacking with a packed schedule for clinic. If I'm tired and decide to sleep in a little later than usual, I can do that because no one is waiting for me at a specific time. Alternatively, if I have something I know I need to do in the afternoon and need to get out of the hospital a little earlier than usual, I can simply come in earlier, get everyone seen, staff with the resident, and I'm good to go. I really like that flexibility.

This sounds like a pretty sweet gig, im curious what the pay range is for it.

 

[NickNaylor]

This sounds like a pretty sweet gig, im curious what the pay range is for it.

About $225k base salary. Overnight call (which is just backing up the resident), weekend coverage, and holiday coverage is additional pay beyond the base salary.

 

[Stagg737]

Commenting on the above: I speak with other attendings in the hospital where I work fairly often. As a group we go to each other if we're having troubles figuring out the diagnosis for a patient, we ask each other for advice, etc. For example, I have limited experience with typical antipsychotics outside of Haloperidol and Chlorpromazine. If I want to use another typical on a patient, I can go to one of my fellow attendings who is extremely experienced in them, and get advice with regards to dosing, titration, side effects to look for, etc. I'm very glad and lucky to be able to utilize such a resource. Also, feeling like you are friends with your coworkers can make the often tasking inpatient work a bit more bearable.

With regards to the question asked, though, I do both inpatient and outpatient work so I can comment on what my days look like.

Inpatient: I generally wake up at 530am and show up at the hospital at 7am. Once I arrive I converse with the nurses about if anything notable happened the night before, the main thing I look for is if anyone needed PRN's. I also check if anyone was admitted overnight, if so I'll need to evaluate them today. I generally start rounds 7:30-8am, and finish rounds around 11, sometimes it takes until noon. The patients I see in hospital are generally those acutely suicidal, manic patients, and psychotic patients.

Outpatient: I see patients outpatient at the local clinic associated with the hospital. I generally arrive at 1pm (after I leave the inpatient ward and grab a quick bite for lunch) and finish around 4pm. I do med-checks and also new evals. The med checks generally are rather short, the new evals take about 45 minutes to an hour, sometimes it can take 90 minutes. The patients I see in clinic are - of course - more stable than those in hospital. I still see patients with Severe Mental Illness - people with bipolar, schizophrenia, schizoaffective, etc - but most of the patients I see have MDD, GAD, or Panic d/o. There are therapists at the clinic, so I can easily refer a patient to them if therapy is necessary (which it is, far more often than not.)

With regards to charting, I do all that at home. I generally get home about 5pm, and I'll do my charting after I relax for a few hours, eat dinner, etc.

How many inpatients and outpatients are you typically seeing per day?

 

[thomasina]

Agree with the above. Having a good collegial atmosphere with other psychiatrists to bounce ideas off is very helpful, and something I really miss with the job I've got. Even if I don't agree with the other psychiatrist (which frequently happens), actually having that discussion is helpful and facilitates a better understanding of the patient and their problems. I've seen both types of environments as far as inpatient work goes.

How is that facilitated? Do you guys have regularly scheduled peer supervision meetings, is the workroom structured such that it makes for easy water cooler / patient discussion talk, ...?

 

[Monocles]

About $225k base salary. Overnight call (which is just backing up the resident), weekend coverage, and holiday coverage is additional pay beyond the base salary.

Not bad for a census of 6!

 

[comp1]

This is at a VA, so we are all salaried and our daily schedule is set. We come and leave at scheduled times. Nobody is ever rushing to get out. We all round together including the attendings, residents, medical students, NPs, social workers, charge nurse, addiction therapists, etc. Sometimes outpatient providers even pop in. This gives everyone a chance to ask any questions they have and to really come to a joint consensus about all patient care decisions. It's pretty amazing and I'd never trade it for any sort of siloed work, inpatient or outpatient. You end up feeling really confident about everything you do because it wasn't all just your decision alone. If one attending is feeling worried about something, we'll even addendum each other's notes documenting our support for the joint decision as a second opinion. Patients can try to split, but because we all decided on something together, it's pretty darn hard.

 

[Candidate2017]

This is at a VA... Nobody is ever rushing to get out. We all round together including the attendings, residents, medical students, NPs, social workers, charge nurse, addiction therapists, etc. Sometimes outpatient providers even pop in. This gives everyone a chance to ask any questions

This sounds... terrible. I bet the residents and students are secretly dying to rush out but can't leave. Also, there's always that one SW or RN who hijacks the rounds because they need to give their 2 cents on every patient, as well as the latest soap opera recap on each patient. It's more efficient to quickly run the list with the charge RN, do a pit stop with the SWs on what needs to be done today, round and curbside staff as needed, wrap up and move on the next unit or clinic.

 

[comp1]

I guess to each their own. I'd feel kind of alone in my decision making if it was all just quick curbsiding. We can still round on 16 patients in 90 minutes, so I wouldn't call it inefficient exactly. Some patients take 2 minutes, some take 30....

 

[Sushirolls]

All it takes is one 'weak' link in the IP pool of docs, ARNPs, PAs etc. The frequent patients come back again and the one (or several) drastically change the meds up in a way that creates future problems for when they come back again. The inpatient pool is only as strong as the weakest professional link and it gets old fast turning off the benzo Rx, or the multiple antipsychotics, or the 'depakote for everyone' or 'seroquel for everyone'. Outpatient private practice you have at least the illusion of control to guide more optimal med regiments.

Recently had a DNP tell an obese depression/anxiety/SUDs patient of mine they have bipolar and started a little Depakote + Lamictal + Seroquel. Thankfully I get to undue this potentially devastating impact of further debilitating weight gain in a patient that needs to emphasize other interventions over an erroneous bipolar II diagnosis.

 

[tinyhandsbob]

Commenting on the above: I speak with other attendings in the hospital where I work fairly often. As a group we go to each other if we're having troubles figuring out the diagnosis for a patient, we ask each other for advice, etc. For example, I have limited experience with typical antipsychotics outside of Haloperidol and Chlorpromazine. If I want to use another typical on a patient, I can go to one of my fellow attendings who is extremely experienced in them, and get advice with regards to dosing, titration, side effects to look for, etc. I'm very glad and lucky to be able to utilize such a resource. Also, feeling like you are friends with your coworkers can make the often tasking inpatient work a bit more bearable.

With regards to the question asked, though, I do both inpatient and outpatient work so I can comment on what my days look like.

Inpatient: I generally wake up at 530am and show up at the hospital at 7am. Once I arrive I converse with the nurses about if anything notable happened the night before, the main thing I look for is if anyone needed PRN's. I also check if anyone was admitted overnight, if so I'll need to evaluate them today. I generally start rounds 7:30-8am, and finish rounds around 11, sometimes it takes until noon. The patients I see in hospital are generally those acutely suicidal, manic patients, and psychotic patients.

Outpatient: I see patients outpatient at the local clinic associated with the hospital. I generally arrive at 1pm (after I leave the inpatient ward and grab a quick bite for lunch) and finish around 4pm. I do med-checks and also new evals. The med checks generally are rather short, the new evals take about 45 minutes to an hour, sometimes it can take 90 minutes. The patients I see in clinic are - of course - more stable than those in hospital. I still see patients with Severe Mental Illness - people with bipolar, schizophrenia, schizoaffective, etc - but most of the patients I see have MDD, GAD, or Panic d/o. There are therapists at the clinic, so I can easily refer a patient to them if therapy is necessary (which it is, far more often than not.)

With regards to charting, I do all that at home. I generally get home about 5pm, and I'll do my charting after I relax for a few hours, eat dinner,

Out of curiosity, how long does charting take for you at home generally? And do you find charting for inpatient and outpatient to be similar in time intensiveness or is inpatient more time consuming?