Is This...Malignant?

[clement]

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So psych residency and malignant don't often go together. If you were in a situation where your outpatient clinic was a county clinic run by your department and they start presenting residents with "productivity reports" by resident in terms of how many of your appts YOU are allegedly filling, would you view that as coercion? the county itself requires pts to be seen at least once 120 days. however residents are pressured to schedule ppl as frequently as possible (even q 2 weeks) including for those who are totally stable and either don't wish to be seen super frequently or aren't appropriate to be seen frequently. the report itself makes the assumption that you take ownership over ppl not showing up, not wanting to be seen as frequently as it is convenient for revenue to be generated, and so on. I can't think of any other department that does this.

 

[3882370]

It is simply data. ACGME requires residents be provided data to assess clinical effectiveness, or something like that, and this is data. If you can learn something from it - e.g. You have the lowest no-show rate, which might possibly indicate you have a particularly good therapeutic alliance, great. If your frequency of appointments is significantly different than others, it's something to think about. Look at the data and see how it might be useful to you. You will be judged on such metrics throughout your career. Even in private practice, being aware of your no-show rate is very important. In a community clinic, it may boost your RVUs.

 

[clement]

It is simply data. ACGME requires residents be provided data to assess clinical effectiveness, or something like that, and this is data. If you can learn something from it - e.g. You have the lowest no-show rate, which might possibly indicate you have a particularly good therapeutic alliance, great. If your frequency of appointments is significantly different than others, it's something to think about. Look at the data and see how it might be useful to you. You will be judged on such metrics throughout your career. Even in private practice, being aware of your no-show rate is very important. In a community clinic, it may boost your RVUs.

No it's not an acgme thing. It's strictly a clinic revenue based thing and you get
reprimanded on it sweat shop style.

 

[OldPsychDoc]

The tracking of productivity is a "real world" training issue, relevant to your "Systems-Based Practice" competency, but the reprimanding and "sweat shop style" of it smacks of some degree of misplaced priorities, if not malignancy.
I'll cynically ask though, have previous generations of residents treated this rotation as a "working vacation", such that you're experiencing some backlash related to the sins of your forebears?

 

[clement]

The tracking of productivity is a "real world" training issue, relevant to your "Systems-Based Practice" competency, but the reprimanding and "sweat shop style" of it smacks of some degree of misplaced priorities, if not malignancy.
I'll cynically ask though, have previous generations of residents treated this rotation as a "working vacation", such that you're experiencing some backlash related to the sins of your forebears?

I believe this is the first year they've started "tracking numbers" but things were actually worse for my forebears in terms of outpatient case loads of up to 150+ each I'm told. I totally get the "real-world part," but as you say, we're in a training program where revenue shouldn't take precedence over teaching regardless of how our clinic is funded. They literally generate a list by resident of who sees how much, as we are to schedule our own pts while being held accountable when people who have been seen every 8 weeks for years, now refuse to be seen monthly. There are so many variables that go into it with a county setting. You have people with uber high acuity caseloads that see people weekly and others where most patients are stable enough that they were told by prior residents to start seeing their pcp (but don't have funding, which is bound to change?). This setting has had a high no-show rate going back years however. It may be the nature of its patients.

 

[vistaril]

No it's not an acgme thing. It's strictly a clinic revenue based thing and you get
reprimanded on it sweat shop style.

How many pts are we talking about here? 25 for a resident in a morning? or 8-10 for a resident in a morning?

clinic revenue(and productivity) is a very very important part of residency. perhaps the most important part. Especially with these populations(im assuming outpt smi). You can be the best psychiatrist in the world, but if you're seeing insurance/medicare/medicaid patient med mgt followups and being a slow poke, you won't generate much revenue. And not generating much revenue means a decent salary can't(and won't) be supported, unless you are excellent in some other capacity(real role is an administrator or in research or education for example).....

Except for small pockets of people in mental health, none of us are truly 'on salary'. We may get a salary or wage, but that's going to be some % of what we actually generate in revenue to our employer.

 

[clement]

How many pts are we talking about here? 25 for a resident in a morning? or 8-10 for a resident in a morning?

clinic revenue(and productivity) is a very very important part of residency. perhaps the most important part. Especially with these populations(im assuming outpt smi). You can be the best psychiatrist in the world, but if you're seeing insurance/medicare/medicaid patient med mgt followups and being a slow poke, you won't generate much revenue. And not generating much revenue means a decent salary can't(and won't) be supported, unless you are excellent in some other capacity(real role is an administrator or in research or education for example).....

Except for small pockets of people in mental health, none of us are truly 'on salary'. We may get a salary or wage, but that's going to be some % of what we actually generate in revenue to our employer.

assuming you can definitively correlate revenue to residents not scheduling ppl in, then this should not interfere with education, which is the priority of a TRAINING program. the more expensive but less shady alternative is to hire more admin ppl who will schedule pts and remind them of their appts.

 

[whopper]

Sounds to me it is malignant, but on the patients more so than the residents. Residents can be worked up to 80 hrs a week. If you read the fine print, you could work someone over 80, so long as at the end of the month it averages out to 80. So you could make them work 120 hours (and yes that is ridiculous) so long as the rest of the weeks it's less than 80 and averages out to 80.

But getting to the point, I think it's unfair to a patient to make them show up if they don't have to do it. Further, if you make patients show up that are doing well, it could blow up in your face cause they'll get ticked off with that and try to go elsewhere. It is a waste of insurance (or state money) to push services that aren't needed.

 

[Doctor Bagel]

I believe this is the first year they've started "tracking numbers" but things were actually worse for my forebears in terms of outpatient case loads of up to 150+ each I'm told. I totally get the "real-world part," but as you say, we're in a training program where revenue shouldn't take precedence over teaching regardless of how our clinic is funded. They literally generate a list by resident of who sees how much, as we are to schedule our own pts while being held accountable when people who have been seen every 8 weeks for years, now refuse to be seen monthly. There are so many variables that go into it with a county setting. You have people with uber high acuity caseloads that see people weekly and others where most patients are stable enough that they were told by prior residents to start seeing their pcp (but don't have funding, which is bound to change?). This setting has had a high no-show rate going back years however. It may be the nature of its patients.

Are there consequences associated with your productivity? Would something bad happen if your hours are low because of no shows or whatever? Tracking your hours can be perceived as annoying (or seen as trying to pit residents against each other), but I think programs have some interest in knowing how many patients you're seeing because that's part of your training. Also, productivity is part of our real life world after we leave residency, and those clinics do need to stay afloat.

 

[clement]

Are there consequences associated with your productivity? Would something bad happen if your hours are low because of no shows or whatever? Tracking your hours can be perceived as annoying (or seen as trying to pit residents against each other), but I think programs have some interest in knowing how many patients you're seeing because that's part of your training. Also, productivity is part of our real life world after we leave residency, and those clinics do need to stay afloat.

No formal consequence has been outlined yet. That would really take the cake. This was just rolled out, but it's conducted in a way that assumes you take full ownership with a list that literally ranks us by productivity.

 

[heyjack70]

It sounds like used car lot: tracking numbers and listing ranks.

 

[myPsychAlt]

Well my program tracks therapy hours, though we're responsible for scheduling and filling out the billing codes for our weekly therapy patients. I suppose we are technically tracked in our medication clinics, but we have such a huge supply of patients needing to be seen that it's actually difficult to see those patients too often given a limited number of spots in the day, and I've never heard anything about residents docked for not seeing enough MedMon. I'm usually encouraged to transfer care to PCPs if patients have been stable for a long time to get more patients in with more complicated needs. If anything it's a hit to our attendings' RVUs when our patients don't show up, but the residents aren't really responsible

(our tracking system is FUBAR right now because of the transition to Cerner eletronic billing... so even that isn't really well-followed. Basically the program is just interested in knowing that you're not completely using your therapy afternoons sitting on your ass not seeing people).

 

[pre med 2014]

Hmmm this thread got me wondering. Does anybody know if airline pilots receiving treatment for mental illness have to see their psychiatrist more frequently than appropriate, or more often than they would prefer?

 

[Doctor Bagel]

Hmmm this thread got me wondering. Does anybody know if airline pilots receiving treatment for mental illness have to see their psychiatrist more frequently than appropriate, or more often than they would prefer?

From what I've heard, airlines don't allow you to fly if you're taking any psychotropics, including SSRIs.

 

[pre med 2014]

From what I've heard, airlines don't allow you to fly if you're taking any psychotropics, including SSRIs.

No. That has changed. Your pilot may be on anti-depressants, it was a hot issue.

 

[Shikima]

So psych residency and malignant don't often go together. If you were in a situation where your outpatient clinic was a county clinic run by your department and they start presenting residents with "productivity reports" by resident in terms of how many of your appts YOU are allegedly filling, would you view that as coercion? the county itself requires pts to be seen at least once 120 days. however residents are pressured to schedule ppl as frequently as possible (even q 2 weeks) including for those who are totally stable and either don't wish to be seen super frequently or aren't appropriate to be seen frequently. the report itself makes the assumption that you take ownership over ppl not showing up, not wanting to be seen as frequently as it is convenient for revenue to be generated, and so on. I can't think of any other department that does this.

There are a lot of residency which are malignant in the realm of Psychiatry.

 

[Psychotic]

.

 

[whopper]

There are a lot of residency which are malignant in the realm of Psychiatry.

Problem with that can of worms is you do that, you can be opening yourself up to a libel suit and a flame war here.

There are malignant programs out there but several, and understandably so, keep their mouths shut when they see them.

 

[Psychotic]

.

 

[MacDonaldTriad]

The problem with developing a “malignancy” list is who is to be trusted to provide such data? An applicant who heard that a program was malignant from a resident during an interview? Maybe a disgruntled resident who has only worked in one program? This would be better determined by duty hour violations, average hours worked, amounts of call. These questions are answered and collected, I’m not sure how publicly available they are.

 

[Psychotic]

.

 

[nancysinatra]

Flame war, sure. Libel lawsuit? Not really considering that libel is a personal attack, on an individual, not an entity or, in this case, a psychiatry program. Someone can give an honest opinion on the work environment of a program without libeling any person(s) at the program."

Right - to be libel, the statement has to be factually untrue. It can't be merely an unflattering opinion. Otherwise, wouldn't every program director in America sue every disgruntled resident who ever voiced their opinion for libel? Wouldn't they use the threat of a libel lawsuit as incentive to extort good "feedback" on all the useless evals the ACGME or whoever runs things is perpetually demanding of residents nowadays in the constant paperwork flow that is psychiatry training?

Additionally, the untrue statement has to be damaging to its victim's reputation (which means the reputation had to be at least somewhat good to begin with). There are some people (and perhaps some residency programs) whose reputations are so bad already, that they can't be libeled. It's not possible to libel Hitler, for example.

 

[whopper]

Right - to be libel, the statement has to be factually untrue.

Oh yeah sure, just like if you're a bariatric surgeon that does competent work, shouldn't you not be sued? The reality is such a surgeon loses more money fighting to prove the real story. Several lawyers have this down to a science and their intent is simply to create a settlement against a doctor because for the doctor that's $10,000, but fighting in court is >$45K.

You're talking about the theoretical and how it's supposed to be on paper.

There's hardly anything to gain for someone already in a program to announce on a forum. They're already trapped. When someone blabs, people in the programs try to figure out who it was and then cream the guy --> that's why it's a malignant program. Most programs only have a few PGYs per year, and from a post, it's often easy to narrow down which year they are. Also, some have figured out ways to tell who is who. I've gotten PMs from users who told me they were able to narrow a specific user either down to the person or down to maybe two people (even supplying me a link with a pic of all the residents on it). Most residents I've seen in a malignant program are too scared to announce they're in one, even if it's with an anonymous username.

Also factor in, if you're in a malignant program, getting in a new class that is good makes it easier for you, so why scare people away? If you're a PGY-II and you're already trapped, a new PGY-I class that's terrible will only shift more work to you. Why? In a malignant program attendings dont' care about making the work fair. They just want it to get done. The PGY I's can't do it? Make the IIs do it.

And what Macdonald said. Some are simply just disgruntled, and others are those that don't want to look that way even if their program is malignant.

Medstudents and residents as a whole aren't exactly going to burn some bras, surround the evil dean's office while singing kumbaya, and claim whatever -ism you can think of in a demand for social justice. Journalists and law students tend to be that way. Medstudents and residents tend to shut up and take it.

My point is not that I agree with this, but the general culture and attitude I've seen from residents is they simply want to graduate and move on and they're not into trying to make it better for the next guy. This is a contradiction of what we physicians should be practicing. Think about it. Residents were maligned for decades. Only after decades of abuse there's finally some reforms? Most of those residents that were abused became attendings that wanted to continue it instead of fixing it. If anything, I figure our profession should be one of the top ones for people that want to push social justice. I do think several on the forum here are exceptions to that rule, but they are....exceptions.